Water as Therapy

“Thousands have lived without love, not one without water.”

― W. H. Auden

The human adult body is made up of approximately 60% water (Mitchell et al, 1945); we may survive for up to three weeks without food but can survive only days without water. While over 70% of the world’s surface is covered by water and approximately one-third of our world’s population lives around coastal ecosystems (Neumann et al., 2015), billions lack access to safe drinking water (UN Water, 2021). Even in the developed world, where most of us have easy access to clean water to meet our basic physical health needs, water remains a valuable commodity. Homes and hotels in proximity of water or with water views tend to be more expensive, demonstrating that beyond meeting our basic physical needs, we derive a utility from being in relation with water. To date however, this value has not been elucidated or formally quantified and is not well understood (White et al., 2020).

In 1992, Gesler developed the concept of the ‘therapeutic landscape’ to refer to a natural environment with powers to heal one physically, mentally, and spiritually. Healing was thought to derive not only from physical materials provided by nature - such as medicinal plants, fresh air or water - but also the humanistic, cultural elements of geography. Landscapes provided symbolic value to mediate between biophysical, psychological, and social-cultural roots of medicine for holistic healing. The curative power of water, a symbol of “purification and absolution”, has been sought from as early as classical times through to the nineteenth century in Western civilisations when hydropathic medicine was formulated in Germany and the search for health saw the growth of springs-towns across the United States (Vance, 1972, p. 737). This ceded only as the germ theory of disease became dominant and proliferation of effective biological therapies shifted the focus from psychological or social-cultural therapies towards pharmacological cures.

The benefits of blue space to mental health

The current body of literature on blue space and its salutogenic properties is rather disparate, with conceptual ambiguity regarding the definition of ‘blue space’. Broadly, blue spaces may promote health, prevent illness and facilitate recovery in distinct populations and contribute towards a diverse range of mental, physical, psychosocial and even public health outcomes (Britton et al., 2018). There is clear emerging evidence of the potential for blue space to have a positive influence on health, and especially mental health, in a range of settings (Britton et al., 2020; Gascon et al., 2017). 

Modern day studies into the therapeutic landscape have typically focused on the importance of ‘green spaces’ such as urban parks, trails, and open spaces (Barton & Rogerson, 2017), with ‘blue spaces’ sometimes subsumed within. However, the definition of blue space typically encompasses a far broader category of water bodies including all visible outdoor surface waters (Grellier et al. 2017). Blue spaces are thought to offer distinct sensory experiences and accordingly, have distinct outcomes and benefits that remain relatively understudied (Haeffener et al., 2017).

Exposure to blue space has been demonstrated to be beneficial for mental health in a diverse range of settings, including where one is immersed in water (Gibert et al., 2022), in physical proximity of water, or has real or virtual views of natural or artificial bodies of water (White et al., 2020). For instance, studies have demonstrated the beneficial effects of aquatic views in supporting recovery from stressful situations (Cracknell et al., 2017) including electroconvulsive therapy (Barker et al., 2003). A randomized controlled trial utilising virtual reality technology during dental treatment found lower levels of pain and anxiety in patients who walked along a coast relative to patients who walked around a well-maintained and pleasant virtual city incorporating some natural elements such as trees and a fountain; thus establishing the psychological benefits of blue space beyond that of simply providing a distraction (Tanja-Dijkstra et al., 2018).

In recent years, there have been a proliferation of programs utilising blue space as a setting for therapeutic interventions for mental health conditions.  A systematic review including 33 contemporary studies of therapeutic interventions conducted in blue space noted that in contrast to studies of interventions in green space settings, interventions conducted in blue space settings were more frequently active (e.g. surfing, dragon boat racing, sailing, fly-fishing, kayaking, canoeing, swimming and scuba diving) rather than passive (e.g. walking along a beach) but tended to focus on studying mental rather than physical outcomes (Britton et al., 2020). This may be due to the capacity of blue space to “take one outside oneself” (p. 160) with a more mentally immersive engagement than that prompted by green space (Foley & Kistemann, 2015). Overall, the systematic review found that interventions in blue space were noted to have a clear benefit for health, especially mental health, and psychosocial wellbeing (Britton et al., 2020).

Blue space as a public health resource

While exposure to blue space has been demonstrated to lower psychological distress in some areas where green space has not, the precise mechanisms through which these benefits are attained have yet to be identified (Nutsford et al., 2016). Most studies to date have been conducted in middle to high income countries where urbanisation poses demands on our emotional and cognitive resources while simultaneously creating a disconnect from the natural environment and one another. Indeed, rapid urbanization worldwide has been associated with increasing prevalence of common mental syndromes and psychopathology (Ventriglio et al., 2021). Thus, the salutogenic effects of exposure to blue space may, at least in part, be attributed to its role in supporting our restoration from modern day stressors while reconnecting us to nature and at times, one another (White et al., 2010).

As urbanisation continues to accelerate worldwide, with an estimated 80% of the world’s population projected to live in megacities by 2060 (Bhugra et al., 2019), there are concerns regarding associated rises in rates of depression, anxiety, and other mental disorders (World Health Organisation, 2021). As White et al. (2020) state, improved access to and use of blue spaces, may “play a role in tackling some of the major public health challenges of middle to high-income countries in the 21st century”, including common mental health disorders (p. 2).

Noting the relevance of blue space as a health resource with implications for public health policy, Foley and Kistemann (2015) coined the term “healthy blue space” to refer to health-enabling environments including coastal areas and “urban blue” inland waters in which “water is at the center of a range of environments with identifiable potential for the promotion of human wellbeing” (p. 157). Interestingly, the beneficial effects of blue space has been noted to be largest for persons from lower socioeconomic areas, suggesting that water may also have an equigenic (social levelling) potential (Wheeler et al., 2015). However, blue space environments also embody well-documented risks, such as that of drowning, water-borne diseases and flooding, all of which are exacerbated by the increasing threats of climate change and rising sea levels and may be more pronounced in developing countries (White et al., 2020).

Conclusion

The proliferation of nature-based interventions in recent years has been said to outpace our knowledge base and policy (Britton et al., 2020). While studies have clearly demonstrated the potential for blue space to reduce mental distress and promote well-being, the evidence is heterogenous, disparate, and difficult to quantify, creating barriers for policy implementation. As the world continues to urbanise, we are likely to continue to experience rising rates of common mental health conditions. While the risks of water environments are well-known, the potential of blue space as a health-enabling resource with potential for promoting wellbeing, preventing and facilitating recovery from illness, and equigenisis await our exploration.

References:

• Barker, S.B., Rasmussen, K.G., Best, A.M. (2003). Effect of aquariums on electroconvulsive therapy patients. Anthrozoös, 16(2): 229-240.

• Barton, J. & Rogerson, M. (2017). The importance of greenspace for mental health. BJPsych International, 14(4): 79-81.

• Bhugra, D., Castaldelli-Maia J., Torales J., et al. (2019). Megacities, migration, and mental health. Lancet Psychiatry, 6(11): 884–885.

• Britton, E., Kindermann, G., Domegan, C., et al. (2020). Blue care: A systematic review of blue space interventions for health and wellbeing. Health Promotion International, 35(1): 50-69.

• Cracknell, D., White, M.P., Pahl, S., et al. (2017). Aquariums as restorative environments and the influence of species diversity. Landscape Research, 42: 18–32.

• Foley, R., & Kistemann, T. (2015). Blue space geographies: Enabling health in place. Health & place, 35, 157-165.

• Gascon, M., Zijlema, W., Vert, C., et al. (2017). Outdoor blue spaces, human health and well-being: A systematic review of quantitative studies. International journal of hygiene and environmental health, 220(8): 1207-1221.

• Gesler, W.M. (1992). Therapeutic landscapes: medical issues in light of the new cultural geography. Social Science & Medicine, 34(7): 735-746.

• Gibert, L., Coulange, M., Reynier, J. C., et al. (2022). Comparing meditative scuba diving versus multisport activities to improve post-traumatic stress disorder symptoms: a pilot, randomized controlled clinical trial. European journal of psychotraumatology: 13(1), 2031590.

• Grellier, J., White, M. P., Albin, M., et al. (2017). BlueHealth: a study programme protocol for mapping and quantifying the potential benefits to public health and well-being from Europe's blue spaces. BMJ open, 7(6): e016188.

• Haeffner, M., Jackson-Smith, D., Buchert, M., et al. (2017). Accessing blue spaces: Social and geographic factors structuring familiarity with, use of, and appreciation of urban waterways. Landscape and Urban Planning, 167: 136-146.

• Mitchell, H. H., Hamilton, T. S., Steggerda, F. R., et al. (1945). The chemical composition of the adult human body and its bearing on the biochemistry of growth. Journal of Biological Chemistry, 158(3): 625-637.

• Neumann, B., Vafeidis, A. T., Zimmermann, J., et al. (2015). Future coastal population growth and exposure to sea-level rise and coastal flooding-a global assessment. PLOS One, 10(3): e0118571.

• Nutsford, D., Pearson, A. L., Kingham, S., et al. (2016). Residential exposure to visible blue space (but not green space) associated with lower psychological distress in a capital city. Health & place, 39: 70-78.

• Tanja-Dijkstra, K., Pahl, S., White, M. P., et al. (2018). The soothing sea: a virtual coastal walk can reduce experienced and recollected pain. Environment and behavior, 50(6): 599-625.

• UN Water, 2021: Summary Progress Update 2021 – SDG 6 – water and sanitation for all. Version: July 2021. Geneva, Switzerland.

• Vance Jr, J. E. (1972). California and the Search for the Ideal. Annals of the Association of American Geographers, 62(2): 185-210.

• Ventriglio, A., Torales, J., Castaldelli-Maia, J. M., et al. (2021). Urbanization and emerging mental health issues. CNS spectrums, 26(1): 43-50.

• ·Wheeler, B.W., Lovell, R., Higgins, S.L., et al. (2015). Beyond Greenspace: an ecological study of population general health and indicators of natural environment type and quality. International Journal of Health Geographics, 14(1): 1-17.

• White, M. P., Elliott, L. R., Gascon, M., et al. (2020). Blue space, health and well-being: A narrative overview and synthesis of potential benefits. Environmental Research, 191: 110169.

• White, M., Smith, A., Humphryes, K., Pahl, S., et al. (2010). Blue space: The importance of water for preference, affect, and restorativeness ratings of natural and built scenes. Journal of environmental psychology, 30(4): 482-493.

• World Health Organisation (2021) Urban health, https://www.who.int/news-room/fact-sheets/detail/urban-health