Received: 8 June 2023 | Accepted: 1 February 2024

DOI: 10.1002/pan3.10620

RESEARCH ARTICLE

A qualitative exploration of the contribution of blue space to

well-­being in the lives of people with severe mental illness

Kim Wright1 | Samantha Eden2 | Anna Hancox3 | Danielle Windget2 | Lewis Elliott4 |
Zoe Glossop3 | Gordon Johnston5 | Rose I. Johnston3 | Fiona Lobban6 |
Christopher Lodge7 | Jasper Palmier-­Claus6 | Sally Parkin2 | Piran C. L. White8 |
Sarah L. Bell4
1
Washington Singer Labs, Department of Psychology, University of Exeter, Exeter, UK; 2University of Exeter, Exeter, UK; 3University of Bath, Bath, UK;
4
European Centre for Environment and Human Health, Peter Lanyon, University of Exeter, Penryn, UK; 5Independent Peer Researcher, Clackmannan, UK;
6
Lancaster University, Lancaster, UK; 7Lancaster University Health Innovation Campus, Lancaster, UK and 8Department of Environment and Geography and
York Environmental Sustainability Institute, University of York, York, UK

Correspondence
Kim Wright Abstract
Email: [email protected]
1. The majority of research into the mental health benefits of blue space (outdoor
Funding information places where water is a central feature) has focussed on the associations be-
Economic and Social Research Council,
tween neighbourhood exposure to these spaces and population-­level incidence
Grant/Award Number: R20637
of unipolar depression or anxiety disorder. There has been little exploration of the
Handling Editor: Karen Mustin
therapeutic use of blue space by those navigating bipolar, schizophrenia or other
psychotic conditions. Knowledge arising from such an exploration could assist in
the design and optimisation of nature-­based care for people with these condi-
tions, as well as with self-­management.
2. We conducted semi-­structured online and telephone interviews with 19 adults
who self-­reported experience of these conditions. Interviews were conducted in
the United Kingdom from August to December 2021.
3. We describe four of the key interpretive themes identified via an in-­depth induc-
tive thematic analysis of the interview transcripts to highlight how participants
sought out moments of affective sanctuary through their blue encounters. Blue
spaces were described as having the potential to reset the mind, emotions and
body. This was in part due to their socially undemanding nature, and ability to
provide respite from a socially stressful world.
4. Participants described developing a blue identity, whereby a sense of attachment
to and shared history with these places was articulated as well as incorporating
blue spaces into self-­ and emotion-­regulation practices. Finally, participants de-
scribed experiences of and recommendations for a therapeutic blue intervention.
The role of biodiversity in contributing to the benefits of blue spaces was implied
primarily in terms of perceived soundscapes, but also through visual observations.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2024 The Authors. People and Nature published by John Wiley & Sons Ltd on behalf of British Ecological Society.

People and Nature. 2024;6:849–864.  wileyonlinelibrary.com/journal/pan3 | 849

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850 WRIGHT et al.

5. Synthesis and applications. Blue care for people with bipolar, schizophrenia or
other psychotic conditions should consider the need that some individuals have
for solitude and proximity to their home when they visit blue spaces, as well as
individual differences in the features of blue space interactions that provide the
greatest benefit.

KEYWORDS
affective sanctuary, bipolar disorder, blue care, blue space, psychosis, schizophrenia, social
prescribing

Bipolar and psychotic conditions including schizophrenia are often or manmade and is accessible to people either through being on or
recurrent and together have been estimated to affect over 3% of near the water, or able to sense it (Grellier et al., 2017). Commonly
the population across the lifetime (Perälä et al., 2007). Individuals included in its definition is the identifiable potential of the environ-
managing these conditions may experience a great deal of distress ment to promote human well-­being (Foley & Kistemann, 2015). In
and ongoing or intermittent difficulties in functioning, as well as this paper, we extend this work with the novel findings of an in-­
having to navigate society with what can be seen as a stigmatising depth qualitative study exploring how people with SMI, who are
diagnostic label. Across all mental health conditions, rates of suicide often overlooked in this body of research, seek out ‘blue’ encounters
are particularly high amongst those with bipolar or schizophrenia (as defined by them) to manage fluctuating symptoms and promote
(sometimes termed ‘severe mental illness’: SMI), as are rates of hos- a sense of well-­being, and how these experiences vary across differ-
pitalisation to manage times of crisis (Baldessarini & Tondo, 2020; ent settings and environmental and social conditions. In doing so, we
Naser et al., 2022). reflect on the potential for such blue encounters to enable moments
Typical treatment regimens for bipolar, schizophrenia and psy- of ‘affective sanctuary’; supporting empathetic, non-­judgemental
chotic conditions vary across health systems. In many Westernised and undemanding forms of more-­than-­human connection in a reso-
nations pharmacotherapy is the first line of treatment; this can nant sensory environment (Butterfield & Martin, 2016).
involve the person taking ‘maintenance’ medications, such as There is evidence to suggest that time spent in or near blue space
lithium, for many years. Formal psychological therapies such as may enhance mental health and well-­being in the general popula-
Cognitive Behavioural Therapy may also be offered. Nevertheless, tion, for example through providing meaningful opportunities for
neither pharmacotherapy nor psychotherapy are completely ef- physical activity, cognitive and emotional restoration or social inter-
fective for all. In addition, some individuals may be intolerant to action (Gascon et al., 2017; Georgiou et al., 2021; Smith et al., 2021;
certain medications or may have concerns about their risk pro- White et al., 2020). Cross-­sectional population-­level studies have
files, whilst formal psychological interventions tend to be ex- identified significant associations between blue space proximity or
pensive to deliver thus limiting access in a resource-­constrained use and reduced risk of depression (Dempsey et al., 2018), lower
health system. Lifestyle-­b ased interventions, whereby the person perceived stress (Poulsen et al., 2022), lower antidepressant medica-
makes changes to their everyday life to manage their condition, tion prevalence (McDougall et al., 2021), less mental distress (White
are often non-­s tigmatising, relatively low-­cost and accessible. As et al., 2021) and lower likelihood of having a common mental health
well as forming part of many people's self-­management, informa- disorder (Garrett et al., 2019). To try to understand the mechanisms
tion about lifestyle is often included in group-­b ased and online by which blue space might bring about these benefits, in-­depth stud-
psychoeducation programmes for people with severe mental ies have explored experiences in these places that might be contrib-
health difficulties. Alongside physical activity, diet and other life- uting to people's sense of mental health and well-­being (Foley &
style variables, nature exposure appears worthy of further explo- Kistemann, 2015). These range from opportunities to gain a sense
ration in this population, particularly given evidence that it can of perspective, be it spatially through encountering the oceanic hori-
play a role in supporting mental health and well-­b eing amongst zon, for example (Bell et al., 2015; Völker & Kistemann, 2015) or
people experiencing other mental health difficulties (Tester-­J ones temporally through recognising water as always flowing (Coleman &
et al., 2020). Kearns, 2015; Windhorst & Williams, 2015), offering a reminder of
In this study, we focus specifically upon blue rather than green endurance, renewal and transformation (Duff, 2012). Participants in
space. There is much less research on the health benefits of blue qualitative studies have described the pleasure and relief of losing
space compared with green space (White et al., 2020). A focus on blue oneself at the dynamic interchange of sea and sky, listening to the
space also reduces the heterogeneity of the experiences explored in soothing motion of waves and water lapping at the shore and tuning
our interviews, allowing for depth rather than breadth of analysis. into shifting qualities of light and colour (Lengen, 2015; Thompson &
Blue space has been defined in various ways, but often refers to Wilkie, 2021). Sounds perceived as natural also contribute to health
outdoor environments in which water is prominent, is either natural and well-­being, and a number of studies have identified restorative
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WRIGHT et al. 851

properties in relation to the sounds of nature such as bird song, rus- underpinned by the research question, ‘what are the meanings and
tling leaves and water (Hedblom et al., 2017; Nicolosi et al., 2021; practices of blue care in the lives of people with severe mental ill-
Ratcliffe et al., 2013; Van Hedger et al., 2019). Furthermore, natural ness?’. Here we adopt a broad definition of ‘blue care’ to include
sounds, including geophonic sounds, for example running water and any use of blue space by the individual that has relevance to their
biophonic sounds, for example birdsong, can enhance the restorative well-­being.
properties of visual characteristics of environments (Ratcliffe, 2021;
Zhu et al., 2020). Reflecting specific socio-­cultural metaphors, peo-
ple also describe the cleansing sensation of water ‘washing’ worries 1 | M E TH O D
or concerns away (Bell et al., 2015; Lauwers et al., 2021; McNamara
et al., 2020). These benefits are not, however, universal, with con- A qualitative research approach was used, involving in-­depth semi-­
cerns raised about the risks of immersion in polluted waters (Evers & structured online and telephone interviews, to support people with
Phoenix, 2022), alongside experiences of blue space exclusion aris- SMI to share their experiences of blue space and blue care in their
ing through inequalities pertaining to race, gender, class and disabil- own terms, at their own pace, focusing on people who considered
ity (Olive & Wheaton, 2021). blue spaces to play a role in their well-­being. A qualitative approach
The notion of ‘blue care’ has developed in response to the allows for the development of rich understandings of the contexts
growing interest in the mental health and well-­being benefits of in which blue spaces might benefit this population. It allowed us to
blue space encounters, defined by Britton et al. (2020, p. 51) as draw on but not be limited by existing conceptual frameworks, po-
‘blue space interventions: pre-­designed activities or programmes tentially offering an initial step in the development of interventions
(typically physical) in a natural water setting, targeting individuals in the future. Qualitative research with individuals who experience
to manage illness, promote or restore health and/or wellbeing for mental health difficulties raises ethical issues around power, access
that group’. Such structured interventions include, for example, to research and the communication of individual voices (Carlsson
the growing momentum behind ‘surf therapy’ programmes. Initial et al., 2017). Recognising this, individuals with lived experience of bi-
studies support their potential to facilitate at least short-­term men- polar or psychosis formed part of the study team and were involved
tal health improvements (e.g. relating to self-­esteem, self-­efficacy at all stages of the research. All research was conducted in accord-
and social connectedness) amongst military combat veterans with ance with the declaration of Helsinki (World Medical Association
PTSD (Caddick et al., 2015), and vulnerable youth and young adults Declaration of Helsinki, 1989) and approved by the University of
in Cornwall, UK (Devine-­Wright & Godfrey, 2015, 2018) and New [name removed to preserve anonymity during the peer review pro-
South Wales and Victoria, Australia (Drake et al., 2021; McKenzie cess] research ethics committee (ref: eCLESPsy001492 v2.0).
et al., 2021). Such benefits also seem to extend beyond surf ther- Seeking information-­r ich insights, purposive sampling
apy. For example, in a six-­week intervention that engaged individuals (Patton, 1990) was used to recruit 19 individuals with experiences
with wetland nature for the treatment of anxiety and/or depression, of bipolar, schizophrenia or psychosis who identified blue space
Maund et al. (2019) identified significant improvements in men- as supporting their well-­b eing. Participants were recruited from
tal well-­being, anxiety, perceived stress and emotional well-­being across the United Kingdom via university networks of people in-
amongst the 16 participants. terested in research, national and local charities such as Bipolar
Most research into the benefits of blue space for mental health UK, social and traditional media and organisations connected with
has focussed upon anxiety and depression (Coventry et al., 2021; blue spaces. Participants were required to be aged 18 or over and
Gascon et al., 2017; Hermanski et al., 2022), as well as PTSD to have found blue space helpful in supporting their well-­b eing
(Caddick et al., 2015; Walker & Kampman, 2022). Whilst a small either currently or in the past. In addition, participants were re-
number of studies have examined nature proximity in relation to SMI quired to self-­report a formal diagnosis of either bipolar, schizo-
(Boers et al., 2018; Engemann, Svenning, Arge, Brandt, Erikstrup, phrenia or a psychotic condition, or score above the cut off on
et al., 2020; Engemann, Svenning, Arge, Brandt, Geels, et al., 2020; either the Mood Disorders Screening Questionnaire (MDQ;
Helbich et al., 2018) these have tended to focus upon residential Hirschfeld et al., 2000) indicating a positive screen for bipolar, or
closeness to nature, rather than the impact of specific interactions the Prodrome Questionnaire 16 (PQ-­16: Loewy et al., 2011) indi-
with nature. Furthermore, they have tended not to examine more cating a positive screen for psychosis. The MDQ is a self-­report
subtle indices of well-­being in these populations including symptom bipolar screening questionnaire that asks 13 yes/no questions
levels, quality of life and sense of personal recovery. Finally, no stud- pertaining to manic and hypomanic symptoms, irritability, sleep, li-
ies have explored how blue space might be experienced as helpful by bido, thinking, attention and energy levels. In line with established
those with SMI, nor have they examined considerations for blue care thresholds, endorsement of seven or more items combined with
that might be particularly important for this population. In this paper, a ‘yes’ to symptoms occurring in the same period, with moderate
we share the findings of an in-­depth qualitative study that aimed to to serious problems caused, was taken as indicative of a positive
contribute such insights by examining the meanings and practices screen for bipolar. The PQ-­16 is a self-­report psychosis screen-
of blue care in the lives of people with SMI in the United Kingdom, ing questionnaire composed of a series of 16 true or false state-
specifically bipolar, schizophrenia and psychosis. This study was ments referencing positive and negative symptoms of psychosis.
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852 WRIGHT et al.

Following established thresholds a score of 6 or above using the phone (in line with participant preference) to minimise physical harm
distress weighting calculation was taken as indicative of a positive to participants in the context of the Covid-­19 pandemic. Although
screen for psychosis. a relatively new development for some people, video-­conferencing
The final purposive sample included 11 women and 8 men. The as a means of facilitating qualitative data collection can be highly
youngest participant was 25 and the oldest was 68. In terms of acceptable to participants (Archibald et al., 2019). Guidance has
ethnicity, 15 participants described themselves as White, three as emerged in recent years to support the use of this method, includ-
Asian and one as being of Mixed Heritage. Participant pseudonyms ing the need to attend to technical, ethical and data security issues
and selected information are given in Table 1 (with care taken to (Lobe et al., 2020). Before the interview participants were sent five
preserve the anonymity of the participants). Eighteen participants questions they could reflect on if they wished, in order to help them
lived in England, and one lived in Wales. Nine lived in a major or gather their thoughts in advance and reduce potential anxiety (see
minor urban conurbation, one in a city/town, six in urban areas with Appendix S1).
significant rural elements, and three in a largely rural area. Seven de- While open questioning and active listening were prioritised
scribed themselves as experiencing significant barriers to accessing during each interview, an initial interview guide (see Appendix S2)
blue spaces. Eleven described themselves as competent swimmers. was developed by the study authors in collaboration with individuals
In terms of mental health history, 14 reported having a formal diag- with personal experience of SMI to support discussion. A pluralistic
nosis of bipolar and a further two had not received this diagnosis but approach was taken (Chamberlain et al., 2011), whereby individuals
believed it applies to their experiences and screened positive on the were invited to share an object, photo or memory that reflected a
MDQ, whilst three reported having a formal diagnosis of schizophre- salient dimension of their blue space interactions, to put participants
nia or a psychotic condition. at ease and provide a springboard for enriched accounts of their in-
Individuals who gave informed consent to take part were invited teractions with blue spaces in the first part of the interview. Sixteen
to answer some questions (online or on paper) about demographic participants brought at least one item to the interview, including
characteristics, access to blue space, swimming competency (as this photographs (12 participants), objects (stones, blue glass, shells,
may influence available blue space activities), and their self-­reported coral: 2 participants), a self-­created painting (1 participant) and an
diagnosis, and were invited to complete the MDQ and PQ-­16 as image created by another person (1 participant).
appropriate. Data collection was carried out between August and The second part of the interview built on these discussions, en-
December 2021. Each participant was invited to participate in a abling participants to reflect and discuss in more detail what blue
semi-­structured interview, conducted online using Zoom or over the space is to them personally, the specific blue spaces that feature in
their life, in what ways, and what makes these places particularly
TA B L E 1 Participant pseudonyms and selected demographic pleasurable or meaningful. Particular care was taken to explore par-
information. ticipants' blue space experiences in relation to specific mood states
Self-­reported diagnosis/ and states of mind, as well as more generally in relation to feelings of
Pseudonym Gender screening outcome well-­being. The interview finished with a range of biographical ques-
Bilal Male Bipolar tions exploring how different blue spaces had been particularly help-

Clare Female Bipolar

ful or otherwise at different life stages, any barriers encountered in
relation to accessing blue spaces, along with advice for others expe-
Rob Male Bipolar
riencing similar barriers. The final interview question asked individu-
Zoe Female Bipolar
als to describe their perfect blue space, which helped to understand
Michelle Female Bipolar
some of the most important or desired qualities embodied by the
David Male Bipolar
concept of blue space for that participant.
Sharmin Female Bipolar
Interviews lasted approximately 90 min (with the option for
Yusuf Male Bipolar breaks and to complete over more than one sitting) and were audio-­
Naomi Female Bipolar recorded and transcribed. Each anonymised transcript was subject
Joe Male Schizophrenia/psychosis to in-­depth, thematic analysis (Gale et al., 2013). This approach
Becky Female Bipolar involved initial familiarisation and iterative development of an an-
Brian Male Bipolar alytical coding framework (sensitised by existing literature whilst
Alice Female Schizophrenia/psychosis prioritising the views, perspectives and experiences described by

Tom Male Bipolar participants), charting of the data, and then mapping and interpre-
tation of the data. Initial analysis involved contribution of all mem-
Vicky Female Bipolar
bers of the research team (n = 12) who were each randomly assigned
Laura Female Schizophrenia/psychosis
a transcript to explore, before meeting as a team to discuss initial
Sue Female Bipolar
themes and ideas. Four researchers (KW, SE, DW and AH) used these
Graham Male Bipolar
discussions and reflections to develop an initial thematic framework.
Donna Female Bipolar
In order to agree the final coding of transcripts, researchers KW and
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WRIGHT et al. 853

AH independently coded each, meeting regularly to discuss similari- Table S1 (Appendix S3) displays the overall coding framework
ties and discrepancies in the coding. In addition, the coding pair met developed during the thematic analysis of the interview transcripts.
with additional members of the research team who acted as ‘critical In the section below we focus on a subset of key interpretive themes
friends’, prompting revision of the framework as appropriate. This identified through the analysis. In particular, we consider those
process was adopted to increase the rigour of the analysis (Smith & themes that highlight how varied sensory, social and emotional
McGannon, 2018), and to allow multiple voices within the research qualities of blue encounter helped participants to manage specific
team to inform the interpretation and reflection stages. The pho- challenges associated with bipolar or psychosis through enabling
tos and objects brought to the interviews by participants primarily moments of ‘affective sanctuary’ (Butterfield & Martin, 2016);
aimed to facilitate engagement with the topic and enable partici- providing opportunities for a blue ‘reset’, nurturing undemanding
pants to express and reflect on their emotions and memories relat- forms of more-­than-­human connection and fostering a blue identity.
ing to blue space during the early part of the interview, and as such Recognising the limits to such moments, however, we also reflect
were not part of the analysis in their own right. on whether or how blue space could be included within therapeutic
interventions for people with SMI.

2 | FI N D I N G S A N D D I S CU S S I O N
2.1 | Theme 1: A blue ‘reset’
Prior to discussing our key interpretive themes, we briefly explain
how ‘blue space’ was described by our participants, and the types In describing the experience of being in a blue space, participants
of blue activities they engaged in. At the outset of each interview, referred to various challenges associated with bipolar or psychosis
participants were asked to explain how they would define ‘blue that they tended to bring to these spaces. Negative emotional states
space’ to ensure a shared understanding between the researcher such as feeling low or anxious were mentioned. However, in the
and participant. Across these personal definitions, participants men- sample as a whole, pertinent challenges were often described with
tioned various places and settings including the sea, rivers, ponds, respect to mental activity or a whole-­body sense of energetic imbal-
lakes and canals. Within their definitions, participants debated the ance. Mental activity included a sense of racing thoughts, connected
boundaries of this concept with respect to size, colour, perceived with either mania/hypomania or anxious worrying, and separately,
naturalness and the extent to which other non-­water elements ruminative thinking. There were also descriptions of sensed lack of
could be present. For example, for some, these spaces included the mental clarity (‘brain fog’). In addition, the content of thoughts was
sky, and several participants remarked that these places were often referred to, most commonly with regard to depressive or negative
not blue in colour. Indeed, as noted in Pitt's (2018, p. 162) research themes but also paranoid ideas and the experience of hearing voices.
around urban waterways and well-­being, ‘murky, more brown than In the body, participants described both having too much energy, as
blue watery environments demonstrate a complexity and ambigu- well as feeling depleted. A sense of mental and physical overwhelm
ity of relationships to water, finding it attractive and repellent, risky was also directly mentioned or alluded to by several participants.
and relaxing’. Whilst some participants perceived blue spaces as the In the interviews, we explored participants' sense of how blue
seemingly ‘naturally’ occurring features of the landscape, others in- spaces helped them to manage these challenges. Several partici-
cluded clearly man-­made bodies of water such as canals and even pants directly employed the metaphor of a ‘reboot’ or ‘reset’, whilst
swimming pools, baths/showers and jacuzzis. Participants described many others appeared to describe an experience of this nature. This
how different types of blue space had different effects, and served was often related to the idea that blue spaces could be cleansing,
different functions for them; consequently, their needs at the time helping to absorb stress, mental overwhelm, excess energy or men-
sometimes determined which space they chose to visit. These func- tal clutter. The result of this ‘reset’ was described as a feeling of men-
tions are elaborated upon below when discussing the key interpre- tal space, increased clarity and dispersal of overwhelm or negativity:
tive themes.
Across the sample, a variety of activities were mentioned in re- if you're feeling overwhelmed….emotionally over-
lation to these spaces. Physically active pursuits included walking, whelmed, it's a kind of a, it feels like a refresh button.
running and cycling, as well as activities in or on the water such as You know yeah you release some of the negativity
swimming, rowing and kayaking. Other activities alongside the water and then you feel like you can start again. (Joe)
that were mentioned included picnicking, sitting and looking at the
surroundings, stargazing, reading or listening to music, socialising It makes my head not go in a rat race. It clears my
or playing with children, and camping. Many described interacting thoughts out of my head. It gets me to focus and also
with the water without the full immersion of swimming, for example sometimes makes me kind of see reality as reality, and
by paddling, touching the water or throwing pebbles into it, demon- it kind of gives me a clear mind. (Yusuf)
strating varying intensities of sensory engagement. Finally, creative
activities were mentioned by some, such as writing about or making For many participants, physical contact with, or immersion in, bod-
sketches, paintings or photographs of the space. ies of water (including the sea and lakes) was mentioned in relation
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854 WRIGHT et al.

to the experience of being reset; some participants described hav- It was like somebody kind of boring a hole through
ing reset experiences whilst walking near natural or urban water your head through your body. And, and kind of clear-
bodies. From participants' accounts, certain types of blue spaces ing out all of the psychic detritus you know. (Naomi)
appeared to possess sensory qualities that facilitated this sense of a
reset. The flux of many blue spaces seemed to engage attention and In the quotation below the participant discusses the impact of being
draw thoughts away from their familiar cognitive pattern. This was near a small dam upon their experience of dissociation, this being the
evidenced most often with respect to sights of moving water, but sense that one is disconnected from the body and the world around
geophonic sounds related to moving water were also mentioned: them:

I think partly it is the sound that it generates because I think if I'm struggling with dissociation, and if I'm
I find that very restful and I suppose it gives you starting to verge more towards the psychotic kind
something to occupy your brain as well, by looking, of spectrum, then I think there's something about
it is another thing that helps you switch off. If you the weir and the sort of, the sense of your emotions,
are looking at water that is relatively stagnant there your thoughts and feelings being overwhelmed by the
comes a point where you think well I have looked noise. There's something about that, I think that just
at that water now, whereas water that is constantly helps to kind of reground me again, that I don't get
changing, like the sea, it's always worth looking at from the silence and the quietness. There's something
and being absorbed in because it is always changing. about that that just makes me reconnect to myself
(Michelle) again for some reason. (Joe)

In addition, there was a sense that this changeability sits within pre- Whilst participants often described feeling calmed by their contact
dictable repetitive parameters, meaning that the unpredictability with blue space, and there was a sense of the space absorbing or dis-
tends to feel contained and unthreatening. This aspect may be wel- sipating excess energy, there were also descriptions of blue spaces in-
comed by some individuals with severe mental health difficulties; psy- creasing energy levels in an invigorating uplifting way:
chosis in particular can be characterised by heightened anxiety and
threat-­sensitivity (Underwood et al., 2016). The predictable aspect of There is an energetic exchange between that pow-
the sensory environment provided by such blue space sanctuaries was erful a body of something natural…at that particular
described as contributing to the reset effect: point in time I got nothing left in me, and in order to
kind of top up my internal cup, then I can, I need to
And like you can watch the waves coming in, and take it from somewhere. And I find it useful to take it
then you hear the noise of them breaking and then from those sorts of places and in terms of elementally,
dragging back out. And you can just set your thinking, water's my guy. (Naomi)
in a way, to it. It's sort of like… I mean—it'll probably
be your next question—about like when you're really These accounts highlight the varied ways in which participants found
manic, there's some-­well when I am anyways or when opportunities to ‘reset’ through unthreatening blue space encounters,
I have been in the past, I find this … rhythm, like being across a variety of mental and emotional states. Opportunities for
able to get into some sort of rhythm in my head, or lis- restoration from directed attentional fatigue are widely discussed in
tening to something with a rhythm, like that can really the blue space literature (Bell et al., 2015; Gidlow et al., 2016; White
… set my …thinking by it. It's sort of a calming thing, if et al., 2013), and experiences of aquatic immersion have been de-
you know what I mean. (David) scribed as a ‘daily hard reset’ (Throsby, 2013). More specifically, na-
ture exposure has been found to be associated cross-­sectionally with
Previous studies have discussed the meditative potential of these re- reduced rumination and in turn reduced negative affect in the gen-
petitive rhythmic aquatic qualities; both through having to stay present eral population (Bratman et al., 2021). However, few studies have
while moving rhythmically through the water (McDougall et al., 2022; highlighted the potential for such blue encounters to realign mental
Walker & Kampman, 2022) and in feeling mesmerised by the reflective and physical energy, or counter repetitive ruminative cycles, mania or
dynamic interchange between water and sky, punctuated by moments dissociation amongst people with severe mental illness. Furthermore,
of intensity with shifts in light, weather or other sensory stimuli (Bell amongst our participants, descriptions of a ‘reset’ function were nota-
et al., 2015; Ryan, 2012). Intense sensation was described by some of bly prominent, relative to the importance this concept is given in the
our participants as facilitating the reset process. This tended to be as a blue space literature more generally.
result of loud sounds or the impact of full embodied aquatic immersion: Beyond such realignment, participants also talked about the po-
tential for blue spaces to bring about important shifts in perspective.
it was just amazing to stand under this waterfall and The vastness of the environment in terms of both time and space
just it was like because of the power of the, the thing. appeared to facilitate this, as did the presence of nature and its
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WRIGHT et al. 855

perceived physical power, promoting a sense of being insignificant own situation became less important. The stone had been there
yet connected: long before the first human being had walked past. Countless gen-
erations, each with lives and fates of their own, had passed by’.
because I am so immersed in nature, and because of The physical expanse of blue settings with broad horizons has also
the, the big space, if you like, blue, green, white, grey, been highlighted as promoting an internal feeling of spaciousness
whatever color it actually is, makes me as I say both (Bell et al., 2015; Conradson, 2005), as well as the ongoing flux of
feel insignificant but part of it all and also helps con- waves, rivers and waterfalls in offering a sense of temporal endur-
textualize any of the things that I might be concerned ance and stability (Windhorst & Williams, 2015).
about, actually don't matter in the grand scheme of
things. (Tom, talking about walking in a mountainous
environment) 2.2 | Theme 2: A socially ‘undemanding’ blue

as much as it stays the same, incrementally it's chang- Many people with bipolar or schizophrenia encounter some degree
ing ….it makes us think quite deeply about sort of the of stigma in society, which can exacerbate feelings of loneliness, ex-
future, and the past and, a lot of things really. (David, clusion and the demands that they have to negotiate on a routine
talking about a local beach near built structures) basis (Degnan et al., 2021; Lim et al., 2018; Temesgen et al., 2018).
As such, it is perhaps not surprising that several participants directly
For some of our participants, encounters with certain blue spaces that described or alluded to social pressures as being an important chal-
had the quality of vastness in time or space (such as expansive coastal lenge in managing their condition. This included concern about fail-
areas or large, flowing rivers) brought a sense of connection with ing to meet normative social expectations and demands, the impact
something bigger, and at the same time a sense of being insignificant, of overstimulation from contact with others, and concern about
which was in all cases perceived positively. This seemed to be because upsetting others when unwell due to behaviours deemed ‘unusual’.
it made worries and concerns feel less important. As illustrated below, Almost all participants reflected a sense of blue spaces providing
these concerns may reflect feeling unable to meet the expectations an antidote to this social pressure through not demanding anything
and preoccupations of society: from them; offering opportunities for non-­judgemental forms of
more-­than-­human connection and interaction with the world. Often
part of the difficulty is that we live in a culture this was described in direct contrast to the demands made by, or
where we are supposedly meant to matter…but if anticipated from, other people, whether they be friends and fam-
we're unable to play the game as depression often ily, colleagues or strangers. In the quotation below the geophonic or
is that debilitating affect, it makes things worse, … it biophonic sounds of the environment, and its appearance, are de-
feeds on itself because if you're depressed you can't scribed as an unconditional gift from the natural space, in contrast to
engage with what is deemed normal. And then that the demands she experiences in the presence of people:
becomes a self-­f ulfilling activity. By being in mas-
sive open space you realize that actually this thing It is giving you beauty and the sounds and it is not
that people think you should be part of is effectively asking anything of you. It is not like a person who you
bu*****t and irrelevant to many things, more than know you have to work out how to behave with them
ever, now because I think the planet is telling us that and remember to ask them questions and that kind
you know our trivial concerns are leading us down of thing, it is just being there for you to enjoy and
a path of nowhereness so it's that, it's the sense it doesn't ask anything of you. (Michelle, describing
of putting myself in perspective that I am a micro- walking by a nearby urban stream)
scopic infinitesimally small piece of stardust in this
wonderful thing, called the universe, some relief. Furthermore, some participants commented that when others are en-
(Tom) countered in these spaces, they tend to follow a convention of giving
you no or minimal recognition, thus imposing low social demands.
Although rarely explored in the context of people with SMI, this
sense of perspective is often discussed in the wider literature I mean that's the thing you do tend to find people are
around nature and health. For example, in a photographic essay just there to relax and so some people don't bother
capturing experiences of nature following a traumatic head injury, you. (Becky, talking about being at a beach)
Ottosson (2001, p. 167) describes the sense of perspective and re-
assurance gained through encountering a lichen-­clad stone in the The relative solitude that blue spaces can offer was described as allow-
hospital gardens: ‘the untouched stone with its blanket of lichen ing one to relax without having to hide aspects of the self or monitor
and moss in various shades of green and grey gave him a sense oneself constantly. It also appeared to provide respite and refuge from
of security through its timelessness, its calm and harmony… His the stimulation associated with social interaction:
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856 WRIGHT et al.

…there's a risk that I come across as a complete fool As a result of the social and sensory qualities noted above, for some
or a mad raving lunatic or I'll say something inappro- people blue space had come to offer an emotional, embodied refuge,
priate, none of which I would wish and they're not my leading them to feel safe, held, contained, grounded and protected:
personality, but, I'm very aware that it is a risk. I talked
boom out of my mouth without any filter, yeah I have …depression is very, very isolating and you can just
to work hard every waking hour to keep that filter in feel incredibly lonely and incredibly, incredibly dis-
place. If I go to a big blue space I don't need the filter, connected from the world and that floating just al-
not that it means I'm necessarily ranting like a nutcase lows me to feel—a bit like you know when I was saying
at the sea or something. I just don't have to worry, we go to [rural pond] and it's like protected? It's that
there's no one I'm going to upset. (Tom) feeling, it's that… held. I felt—you feel held. (Becky)

Sometimes it's like I've had enough of interacting with In offering this sense of refuge and uncomplicated experiences of
people, I'm just like ‘I don't want to talk to anyone!’, more-­than-­human relatedness, the blue space experiences sought out
I just want to be out. And especially if you've had a by participants provided moments of affective sanctuary in the con-
lot of people activity, because there's only so much of text of severe mental illness (Butterfield & Martin, 2016). In this way,
that I can cope with. So it's like, I can do it to a certain such encounters offered participants informal opportunities for blue
extent, and then it's like I need timeout and not to do care (Britton et al., 2020) that did not rely on the existence or provision
stuff with people. (Sue) of structured, group-­based interventions that can be challenging to
participate in when navigating the unpredictability of life with bipolar
Existing studies have highlighted the importance of these simple, calm- or psychosis. We return to such therapeutic implications below.
ing relationships with nature (Bell et al., 2018; Severin et al., 2022),
including the potential to externalise emotions freely at the coast with-
out social judgement, for example through ‘screaming, crying, or sing- 2.3 | Theme 3: Developing a blue identity
ing’ (Severin et al., 2022, p. 7), and the value of nature settings deemed
to receive and absorb people's moods (Adevi & Mårtensson, 2013). Many participants expressed a longstanding emotional and cognitive
This aspect of our participants' accounts was striking, however, in that connection to blue spaces, often starting in childhood. Multiple de-
allusions to blue spaces as a refuge from the social world dominated, scriptions were shared of positive early blue memories, sometimes
relative to descriptions of blue spaces as places for social connection. involving special days out or holidays, but more often reflecting a
Psychiatrist Searles (1960, p. 87) argued that non-­human nature en- sense of blue space contact having been woven throughout early
counters can offer people with schizophrenia ‘peace, stability, compan- and later life for some participants:
ionship’ when human encounters are more challenging. He suggested
the simplest relationships exist with seemingly inanimate objects (such I was born near the sea, my family are from near the
as the lichen-­clad stone noted above), the most complex relationships sea, my family in [location] are near the sea, I'm near
occur with people, and in between lie relationships with plants and an- the sea here—it's, yeah that's, the most important
imals. For our participants, this responsive simplicity extended to re- one, and, I have so many memories that are tied up
lationships with water, provided they could control the social element with the sea. (Clare)
of these interactions. For example, by choosing to visit them at quieter
times of the day or the year, or by inviting particular like-­minded or In some cases, this sense of connection extended to being part of
‘safe’ people to share the space with them. blue space communities such as swimming or environmental groups.
Although experienced as socially undemanding, blue spaces Whether as a result of early connections with and memories of seas,
were nevertheless portrayed by participants as having a valued rivers or lakes, or the value of repeatedly accessing them later in
responsive quality rather than being inert or indifferent to their life, for many participants blue space engagement appeared to have
presence. This was sometimes described in terms of the physical become part of their identity, indicating deep emotional place at-
response of the surroundings to the actions of the participant, for tachments. Such experiences reflect both cognitive forms of place
example ripples appearing on a lake after a stone was thrown in. In connection—a sense of ‘place identity’, whereby time spent in
other instances, this more-­than-­human responsiveness manifested blue space allowed people to express and affirm their self-­concept
as personification of the space, such that the space was viewed as alongside feelings of self-­worth, esteem and agency (Twigger-­Ross
having uncomplicated human qualities or described as a friend: & Uzzell, 1996)—and emotional forms of connection, with affective
attachments to settings evoking feelings of belonging, refuge and
…just nature is like, for me it's like someone touch- comfort (Kyle et al., 2004; Stedman, 2002). Place attachment was in
ing you or hugging you, it gives you that grounding of part evidenced by expressions of gratitude: participants articulated
reminding you of where you are, who you are in the thankfulness for the ability to access particular spaces and for the
space. (Sharmin) opportunity to witness their beauty, as well as experience awe in
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WRIGHT et al. 857

the presence of nature (linked to the feelings of perspective noted home, packed all my stuff and disappeared off to
earlier): camp somewhere and that was kind of I think the first
time I realized that it could be a helpful thing. (Sue)
the first thing I saw was the beach itself, it was just in
sight and I just thought ‘wow of all of our time living It has been argued that natural spaces can play a role in self and emo-
on this earth I've never seen something so nice’, and tional regulation (Korpela, 1989; Korpela et al., 2001); this may also be
the first thing that me and this chap did is we went to considered an expression of what has been termed ‘place dependence’
the beach and we just stared out for like for hours. whereby there is a functional reliance upon a place to perform particu-
(Rob) lar activities or attain particular goals. Our participants gave numerous
examples of blue space practices that enabled them to achieve self or
Emotional attachment was also evident in participants' sense of emotional regulation. Many had incorporated helpful blue space expe-
ownership of particular places. In the wider blue space literature, riences into their lives, both by cultivating strategic blue routines and
such ownership has been expressed in the context of anticipated through reactive use of these spaces. We use the term ‘strategic rou-
or experienced changes to cherished coastal areas, for example tine’ to refer to instances where blue space visits were woven into the
with coastal developments which threaten the rich cultural heritage participant's day or week intentionally, in order to maintain or restore
and natural significance of local environments perceived as pristine a sense of well-­being:
(Kearns & Collins, 2012), with the social risks and uncertainties aris-
ing during the COVID-­19 pandemic (Jellard & Bell, 2021) and with And then the other side is when I would need a bottle
the tensions of coastal localism (Olive, 2015). Participants in our of milk or something like that, I would purposely walk
study often connected their sense of ownership with the desire for through the park, go around the pond, and then go
control over social contact described previously, perhaps reflecting to get the bottle of milk and then walked the same
a form of self-­protection or self-­care: back. (Yusuf)

It's very much become my special place. Like I always In contrast, visits to blue space were also commonly described as being
think ‘no don't come up here anybody else, this is my reactive, in other words occurring in response to certain mood states.
patch!’. (Sue) In some instances, this was described as a conscious decision, in order
to regulate mood:
With regard to place identity, participants talked about changes
in their relationship to blue space over time, in some cases artic- … [after] a very stressful day, I'll just go to my part-
ulating the evolution of what was always viewed as an important ner's house and go ‘take me to the beach’, and go for
relationship: a walk. (Laura)

I think it might have done a bit of a curve? If that In others, participants described a sense of being inadvertently drawn
makes sense? To being a very…. I think a very—a space to these places in particular mood states (as discussed further below):
where you go with family and friends and have lots
of laughter and stuff, as a child. Then probably anger. I think sometimes there is an unconscious decision,
And, other emotions, as a young—as a teenager into a I feel there's a lot going on my head there's just too
young adult being unwell. And then now where it is, much and I just need to get away, and I'll go to a
where it's a good place again. And… but nothing—it peaceful space and it happens to be a lake or a pond
never stopped me going, even when I went through or a canal. (Yusuf)
that middle section, there was never, I was never
gonna not go. Because it was still somewhere that For many participants the places selected seemed to vary according to
made me feel better. (Clare) their self-­regulatory needs at the time: one particular blue space may
not be able to provide the full range of cognitive and affective benefits:
For others, realisation of the significance of these spaces arose at times
of ‘heightened need’ in their lives (Butterfield & Martin, 2016, p.700) So like if I was to take the sea, what it feel like to swim
or with respect to specific ‘milestone’ or transformative experiences in the sea, it feels quite exhilarating and it's quite ex-
(Manzo, 2005), often in connection with important moments in the citing, you know it gives you a rush. Whereas going
management of the condition: swimming in a lake, is I'd say more of a calming activ-
ity. (Zoe)
when I first had the psychiatrist intervention, and you
know I got out of control and it was like I just went Overall participants described rich and multifaceted relationships
biking up the coast in the dark and then I came back with blue space, whereby a range of such places had been able to
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858 WRIGHT et al.

fulfil various roles in their lives, often evolving over time. Specific for example, one person expressed concern about the potential for
blue space sanctuaries sought out by participants acted both as vigorous activity (such as walking to the space) to increase hypoma-
repositories of emotional memories, and as a resource to trans- nia. Memories of visiting blue spaces with the intention of taking
form mental, emotional and physiological state. They provided their own life were mentioned by some. At the same time, partici-
participants with links to their personal and family history, as pants described experiences of blue spaces bringing comfort and a
well as to communities brought together by shared interests or change of perspective even when arriving with suicidal intentions:
concerns. These aspects of our participants' accounts are reminis-
cent of existing concepts and findings in the literature that apply I would say that sitting on that little peninsula throw-
to the wider population; nevertheless, it is possible these func- ing pebbles in probably saved my life. Quite easily,
tions of blue space take on added significance in individuals who yeah. Because it was just… Because I went there…
frequently struggle with intense emotional, energetic and social to drown myself. And then I didn't and it was, it was
difficulties. just because I was throwing pebbles and I just was like
‘what am I doing?’. (Becky)

2.4 | Theme 4: A therapeutic blue intervention Any proposed therapeutic intervention would need to recognise and
manage the flux from blue refuge to risk and find ways to overcome
With growing recognition of the potential health benefits of blue barriers to beneficial access.
space engagement, there has been increasing policy interest in ‘blue Second, participants gave multiple examples of deriving benefits
prescribing’; linking people with particular health needs to specific from settings or objects that do not fall under the strict bounded
blue space activities run by the voluntary sector and community definition of ‘blue space’, including as ‘stepping stones’ to more in-
organisations, from surfing to scuba diving, swimming or wetland tensive blue encounters when otherwise unable to access them.
conservation, for example, to support their health and well-­being These included looking at photos or paintings of blue space, watch-
(Juster-­Horsfield & Bell, 2022; Maund et al., 2019). The priorities ing nature documentaries, visiting swimming pools, having a bath or
of people with bipolar or psychosis are yet to be considered in this shower, standing in the rain, visiting garden or urban water features
body of work. Our interviews indicate that if affective blue space such as fountains, listening to wave sounds, dancing and having blue
practices are to be embedded within a formal therapeutic or treat- home décor or blue glass objects.
ment context, be it through blue prescribing or alternative care path- Third, participants expressed views on the role of blue space in
ways, there are key considerations to address. relation to other aspects of their treatment and care. For some, en-
First, participants described a number of barriers to engaging gaging with blue space was seen as an integral part of their ongoing
with blue space in a beneficial way in situ. These included prac- self-­care and self-­management. A number of participants considered
tical constraints such as availability and cost of transport, time blue space in relation to medication: some viewed blue space as
constraints and mobility. Barriers could also be environmental or preferable to medication and, for them, almost like a medication in
seasonal, such as weather conditions, land ownership and pollution. its own right. Others found blue space visits to complement medica-
The importance of having blue space close to home was a recurring tion rather than to represent an alternative:
feature across the interviews. This proximity not only enabled the
incorporation of these spaces within strategic routines (as discussed There might be a point say where if I am feeling that
above) but also facilitated reactive use of these spaces. Participants I am starting to go a bit up in the air, then I'd maybe
observed that, in addition to practical and environmental barriers, go somewhere like that [blue space]. But that would
features of their condition could make it difficult to access these probably include making sure with my meds and
spaces. Low mood, energy and motivation, and heightened anxiety things like that. So it is like, there is kind of more going
meant that the space needed to be as accessible as possible in order on then you know in sort of managing it as a problem
to increase the chance that the journey to the blue space would take rather than you know suddenly going ‘oh wow blue
place: space’ kind of thing. (Graham)

and even if I'm not feeling so good, I can just sort of As noted above, one mechanism by which it may be possible to fa-
do—if I'm well enough to go out, I can do it as a quick cilitate blue space access is that of nature-­based or ‘blue’ social pre-
walk. (Alice) scribing. Indeed, without referencing this initiative explicitly, some
participants evoked the concept of prescribing when talking about
Related to barriers to access, participants referred to the risks than how blue space could fit into their care plan:
can be associated with these spaces, such as drowning, unfenced or
unmarked areas of danger such as train lines, as well as risks from if you say, give me a prescription for a seaside then I'll
other people using the space. Amongst these, some risks were spe- probably do it because I'm so motivated and it calms
cific to the mental health difficulties participants had experienced, me. (Sharmin)
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WRIGHT et al. 859

At the same time, our participants' accounts sound a note of cau- 3 | CO N C LU D I N G R E M A R K S

tion about the potential for social prescribing to offer optimal blue
space engagement for all, including risks of medicalising people's The accounts shared by our participants paint a picture of a mul-
blue ‘lifelines’ in this way. As described previously, the need for re- tifaceted relationship between blue space and their well-­being. In
active (not just pre-­p lanned) visits to these spaces was emphasised this paper, we have focused on the themes that highlight how var-
across many participant accounts. Linked to this, local and often ied sensory, social and emotional qualities of blue encounter helped
humble places such as a nearby stream, seemed as important as participants to manage specific challenges associated with bipolar
expansive, remote awe-­inspiring locations because they could be or psychosis through enabling moments of ‘affective sanctuary’ or
visited with minimal effort and when the person was otherwise refuge; providing opportunities for a blue ‘reset’, a socially unde-
overwhelmed by symptoms. Our participants expressed feeling manding blue and a blue identity. Recognising the limits expressed
burdened by social pressures, norms and expectations and tended by some of our participants in terms of opportunities to engage with
to view blue space as an escape from these. It is possible that for blue space, we have also reflected on whether or how blue space
some people this valuable aspect of blue space visits could be com- could be included within therapeutic interventions for people with
promised by a perceived necessity or pressure to ‘get better’ that SMI.
might be attached to formal prescription of these visits as a treat- Although our participants did not generally mention nature or
ment, or by the need to visit a busy space and interact significantly biodiversity specifically as contributing to their blue space expe-
with others. Indeed, findings from an international study found riences, the sounds of non-­human nature, specifically geophonic
that, in people with common mental health conditions, pressure sounds of water and biophonic sounds of animals, and to a lesser
to visit nature was associated with reduced intrinsic motivation extent visual experiences, underpinned experiences across all four
to visit, reduced happiness during the visit and increased anxiety themes. Biophonically noisy natural environments tend to be those
(Tester-­J ones et al., 2020). with diverse communities of organisms, and bioacoustic monitoring
As an addition, or alternative, to the offer of prescribed nature is increasingly applied for monitoring biodiversity in terrestrial (Sugai
visits, it may be possible to weave opportunities to engage with et al., 2019) and aquatic (Lindseth & Lobel, 2018; Linke et al., 2018)
nature therapeutically throughout the care pathway and explore habitats. These positive perceptions of the sounds of nature in pro-
interactions between formal therapies and nature exposure (Adevi moting mental health suggest that biodiversity may play a role in
et al., 2018). For example, one participant described how they reg- enhancing the quality of blue spaces for promoting well-­being for
ularly met their therapist outdoors and the natural setting was people with SMI.
used to support their work. In the quotation below, the participant For the range of mental health benefits identified by our partici-
refers to Eye Movement Desensitisation and Reprocessing ther- pants, the role of biodiversity may be direct or indirect. Research on
apy (EMDR) whereby the patient is typically invited to attend to the health benefits of green spaces has shown that the perceived
external bilateral visual, auditory or tactile stimuli whilst bringing biodiversity of a green space, considered in terms of species richness,
to mind traumatic or emotionally charged material, to facilitate its correlates with the well-­being benefits from the use of that space,
reprocessing: although perceived species richness may (Southon et al., 2018) or
may not (Dallimer et al., 2012) reflect actual measured species. In
He [therapist] was amazing and he used to meet me in these situations, the biodiversity of a place contributes directly to
[urban] park every session so we never sat in his uh, the nature experience within it through direct sensory or emotional
consultancy room….he explained it to me…as sort of experiences, whether by sight or sound. In some blue spaces, es-
like a natural sort of…EMDR exercise. (Naomi) pecially marine habitats, biodiversity may not be so immediately
experienced as it is in green spaces. In these situations, it may be
Several participants talked about the potential of bringing blue space the indirect role of biodiversity through enhancing the quality of the
into inpatient settings, either in the form of sensory rooms or outdoor ecosystem more generally, in terms of maintaining the integrity of
water features, or through visits to natural rather than urban places the ecosystem and its associated structure and processes (Cardinale
outside of the hospital. et al., 2012) that is of greatest importance. Through ongoing threats
to blue spaces such as pollution (Grellier et al., 2017) and anthropo-
oh yeah it'd have made me feel much better [as an genic noise (Rountree et al., 2020), we may be inadvertently reduc-
inpatient], to have like a little fountain or something ing their capacity for mental health benefits. The direct and indirect
there, you know the noise of the water, just running mechanisms through which biodiversity contributes to the quality of
water. (Laura) blue and green space, the experiences they provide, and their health
and well-­being benefits, and the links to nature conservation, there-
Further work is needed to determine the most fruitful avenues for en- fore have important implications for policy and management, and
hancing care in this way, recognising the need to support people in should be a focus for further research (Marselle et al., 2021).
creating their own affective blue sanctuaries without imposing stan- Many aspects of the participant accounts and our themes mirror
dardised interactions or creating new risks or demands. concepts from the literature on blue space and well-­being in other
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860 WRIGHT et al.

populations. For example, the development of a place-­based iden- one individual across time (c.f. Dobson et al., 2021). Second, be-
tity, and the shift in perspective on one's own situation that can cause mood, energy, self-­confidence and motivation can be a bar-
be experienced through spending time in a vast, seemingly natural rier to travel, capitalising upon blue spaces that are very close to
space. At the same time, themes and subthemes were identified that home should be given particular consideration, as should the po-
seem more particular to this group of individuals, often because they tential to use objects or settings that act as a proxy for blue space
relate specifically to experiences that are unique to, or magnified when travel is not possible; this is particularly relevant to the pos-
within, those with bipolar or psychosis. For example, the ‘blue reset’ sibility of bringing blue space features into inpatient settings as
theme describes the potential of these spaces to compete with or suggested by some of our participants. This might be achieved
even obliterate intense mental activity that can feel overwhelming, through the creative potential of the imagination or sensory mem-
whether in the form of depressive rumination, worry, racing thoughts ories (Andrews, 2004; Bates et al., 2020; Kearns et al., 2015), or
or the experience of hearing voices. It may well be the case that blue the integration of digital nature. For example, ‘natural’ sound-
space can function in this way for individuals without these mental scapes can enhance cognitive restoration, and feelings of calm,
health difficulties, however, the prominence of this theme within our awe and nostalgia inspired by digital nature scenes (Smalley
participants' accounts is striking. Future research could seek to elab- et al., 2023). This reflects growing research interest in the poten-
orate upon this emerging construct and explore who is most prone tial for ‘virtual’ forms of nature to promote aspects of well-­b eing
to experiencing it, perhaps setting aside diagnostic boundaries; for when access adjustments will not otherwise be sufficient to en-
example, whether it is more prevalent amongst those who report able people to experience nature outdoors (Depledge et al., 2011;
having particular emotional difficulties, or who are more suscepti- White et al., 2018), although noting that this technology can itself
ble to rumination or worry generally. Furthermore, future research be associated with access barriers. Third, the dynamic risks posed
could explore whether and how this phenomenon occurs across a by accessing these spaces in particular mental states should be
range of blue space settings with varied forms of sensory input. acknowledged and considered when planning blue care. Fourth,
A second novel aspect of our findings was the characterisation whilst social prescription of blue space visits may have potential,
of blue spaces by participants as providing a socially undemand- researchers and services should explore varied opportunities to
ing space. Again, in the general population nature-­b ased set- weave exposure to blue space through the care pathway. Last, con-
tings can provide an opportunity for peace and pleasant solitude temporary thinking about treatment for people with severe men-
(Cheesbrough et al., 2019), however, in our sample this potential tal health difficulties acknowledges that patients have therapeutic
was described quite distinctively. Blue spaces were character- goals beyond symptom change, such as increased self-­confidence,
ised as providing respite or sanctuary from what is sometimes, or improved relationships with others and increased sense of pur-
often, an almost overwhelmingly demanding social world, exac- pose and belonging, By describing what blue spaces offer them,
erbated by the experience of their condition. Specifically, partici- our participants' accounts highlight therapeutic needs they have
pants spoke of the potential for blue spaces to limit their exposure that may not be entirely met by conventional treatments.
to stimulation, particularly social stimulation. At the same time, Notably, it was not the aim of this paper to distinguish between
these spaces allowed them to suspend concerns about failing to the specific experiences and benefits associated with blue rather than
meet social expectations and therefore being judged negatively green space: future research might seek to understand commonalities
or causing upset to others. This has important implications for and differences in the therapeutic potential of different types of na-
the blue space settings most likely to be of therapeutic benefit. ture exposure for this population. Furthermore, ours was a small and
Interactions that are offered as part of a group visit, whilst po- predominantly white British sample selected because they experience
tentially helpful for some, may alienate others or fail to capitalise blue space as supporting well-­being. Therefore we cannot expect to
on the full potential of these spaces, unless the group is experi- capture here all of the ways in which blue space may interact with
enced as socially undemanding. Some participants described their well-­being; exploration of this relationship should continue, particu-
blue identity partly in terms of connection with blue space com- larly during the development and evaluation of any blue space-­based
munities such as conservation groups. The potential benefits of interventions. In addition, the activities our participants described
being part of a community that ‘gives back’ to these spaces have within blue space were varied, and thus the pathways by which they
been discussed elsewhere (Buser et al., 2020; Maund et al., 2019; impact upon well-­being are also likely to be varied, and unlikely to be
Olive, 2023); future research could explore the acceptability of captured comprehensively within one small study. Finally, interviews
this form of nature-­b ased social contact for those seeking to bal- were conducted around 18 months after the start of the COVID-­19
ance solitude with connection within blue spaces. pandemic restrictions in the United Kingdom and the significant life-
Finally, when designating a role for blue space in formal and style changes experienced by participants over this period may have
informal care, our data speak to some considerations worthy of influenced the accounts they gave us of their relationship with nature.
attention. First, for a given individual different blue spaces may More broadly, our focus was upon the experience of being in blue
serve different self-­regulatory functions. It is therefore unlikely space in relation to well-­being, rather than upon exploration of the
that there will be one particular type of space that is optimal in broader socio-­cultural contexts in which this occurs. Nevertheless,
terms of its therapeutic benefit across individuals, or even within the benefits of blue space described by our participants speak to
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WRIGHT et al. 861

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