Atlas›Domain XV · Nature, philosophy, social & rites of passage›Guide 023
Guide XV-023

Surf therapy

A 37 · L 49 · M 1424 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the International Surf Therapy Organization (ISTO) definition as cited in two peer-reviewed papers; The Wave Project (UK) six-week course and Surf Club as described in its published evaluation and programme-theory study; the Waves for Change (South Africa) surf therapy curriculum overview (undated) and its 2024 published description. Where these differ, both versions are named.

Surf therapy is not a single psychotherapy but a family of programmes. ISTO's 2019 definition, as cited by Benninger et al. (2020), describes it as "a method of intervention that combines surf instruction/surfing and structured individual and/or group activities"; Brennan, Stain and Marshall (2024) cite ISTO's wording as a structured intervention that uses surfing "as a vehicle to achieve therapeutic benefit". Programmes are delivered either by licensed clinicians (psychotherapists, psychologists, occupational and physical therapists) applying their training on the beach, or on a health-promotion model with surf coaches and volunteers, with or without clinicians; it can stand alone or sit alongside psychotherapy or medication [source: Benninger et al. 2020]. ISTO was formed in October 2017 when representatives of eight surf therapy programmes met in South Africa, and describes itself as a global community of practitioners and researchers advocating safe, evidence-based surf therapy [source: AORA Alliance ISTO page].

How change is thought to happen. In The Wave Project programme theory, two core mechanisms are self-selected pacing and progression while surfing, and the creation of an emotional and physical safe space at the beach; these are made possible by waves that offer many challenge levels, by removing perceptions of failure and pressure, and by physical and emotional support from mentors, and they lead to mastery, respite and escape, and social connection with a surfer peer group [source: Marshall, Kelly & Niven 2019]. The Wave Project evaluation names five pathways to wellbeing: playing, being in nature, socialising, taking risks and identifying as a surfer [source: Devine-Wright & Godfrey 2020]. Waves for Change describes a three-part theory of change: a safe space with caring adults, the challenge of surfing, and psychoeducation in emotion-regulation skills [source: Beranbaum et al. 2024]. Evidence status in one line: the authors of a 2024 survey of ISTO-affiliated programmes describe recognisable shared structures but a fragmented evidence base lacking robust comparable trials [source: Brennan, Stain & Marshall 2024].

What the psychotherapist does with it: (a) refers a client to, prepares and debriefs a client attending, a surf therapy programme; (b) collaborates with programme staff with the client's consent; (c) works with the meaning of the experience in therapy (mastery, fear, body, belonging, the sea); and (d) only where trained, insured and permitted, delivers or co-delivers sessions on the beach, which raises competence, dual-role and safety questions covered below [synthesis]. Cross-refer 022 (blue care, wild and open-water swimming) and Domain X 196 (cold-water immersion and its harm account).

2. Framework

There is no single phase model across programmes; no formal phase model was described in the 2020 scoping review [source: Benninger et al. 2020]. Two published programme structures and a therapist-side frame follow.

Programme format across the field. Programme length in the reviewed studies ranged from a single day to six months, most often weekly sessions over several weeks [source: Benninger et al. 2020]. In a 2024 survey of 33 ISTO-affiliated programmes, most ran a closed block with a set start and end, most delivered in groups, and the most common block was 6–9 sessions; programme directors ranked time in the water first, then beach socialising, in-water socialising, group discussion, psychoeducation and water safety. Common pre- and post-programme materials were consent forms, information packs and outcome measures; prerequisites included time of day, weather, season and wave quality, and pre-delivery checks covered unsafe water or weather, participants' psychological safety and staff-to-participant ratios [source: Brennan, Stain & Marshall 2024].

Version A: The Wave Project (UK). For young people aged about 8 to 21, mainly referred by professional services (for example CAMHS, social services, schools, mental health charities). Stages: (1) referral; (2) a free course of six weekly weekend sessions, with transport where needed, in which each young person surfs with one-to-one help from a volunteer surf mentor overseen by a surf coordinator; (3) an opt-in follow-on Surf Club; (4) for some, becoming a young volunteer. The stated ethos is acceptance, support and "non-competitive challenge" [source: Devine-Wright & Godfrey 2020; Marshall, Kelly & Niven 2019]. Moving on: completion of the six-week course opens the Surf Club; criteria beyond completion are not published [uncertain: not verified].

Version B: Waves for Change (South Africa). For violence- and trauma-exposed children, referred by school staff, with parental consent and the child's verbal assent; coaches are young adults from the same communities, trained in trauma-informed care and water safety and supervised [source: Beranbaum et al. 2024]. The curriculum overview gives an orientation session (schedule, expectations, graduation) and three phases: Phase 1, building healthy relationships ("mastering trust and empathy"): immersion, water skills, pair floating, pair surfing; Phase 2, developing skills to cope with stress: Take 5, checking in with yourself, building a "Power Hand" and a "Power Anchor"; Phase 3, preparing to be independent: a personal mantra ("I Will") and planning to use skills in daily life; then graduation [source: W4C curriculum overview]. Version difference: the overview states 11 sessions over 17 weeks, while the 2024 paper describes a 10-month curriculum of weekly beach sessions including a meal, surfing, psychoeducation and community-building [source: W4C curriculum overview; Beranbaum et al. 2024]. Each session builds on the last, so full attendance is encouraged [source: W4C curriculum overview].

Typical session (Waves for Change overview). Energiser and Take 5 breathing with a feelings check-in, mentors modelling their own feelings; a main activity, often in the water; a circle debrief; free surfing or swimming with coach praise; a closing ritual [source: W4C curriculum overview].

Therapist-side frame [synthesis]. Before: assess fit, screen medical and water-safety issues qualitatively, evaluate the programme, obtain consent (and assent for minors), prepare the client. During: brief check-ins in ongoing therapy, consent-based contact with the programme lead, monitoring of mood, risk and attendance. After: debrief, consolidate gains into everyday life, plan continuation (Surf Club, volunteering, community surfing) and address barriers. Move from preparation to attendance when the client gives informed agreement, medical questions have been routed to the physician and the programme has accepted the referral; move to consolidation when the block ends or the client stops attending.

3. Guiding principles

  • Emotional and physical safe space. Rated a core structure by most surveyed programmes; in practice, protect predictability, acceptance and physical safety before any challenge [source: Marshall, Kelly & Niven 2019; Brennan, Stain & Marshall 2024]. What counts as safe may differ by population, age and gender, so ask the client [source: Brennan, Stain & Marshall 2024].
  • Self-selected pacing and progression. The client chooses how far and how fast; never push into deeper water or bigger waves [source: Marshall, Kelly & Niven 2019]. A 2024 survey did not confirm this as a component across programmes [uncertain].
  • Remove failure and pressure. No ranking or competition; falling off is part of learning [source: Marshall, Kelly & Niven 2019; Devine-Wright & Godfrey 2020].
  • Non-competitive challenge. Offer a real, chosen challenge rather than comfort only; the waves supply multiple challenge levels [source: Devine-Wright & Godfrey 2020; Marshall, Kelly & Niven 2019].
  • Caring adults and mentors. A consistent mentor or coach provides physical and emotional support and models feelings [source: Marshall, Kelly & Niven 2019; W4C curriculum overview].
  • Social connection. The most endorsed programme goal; plan for belonging beyond the block [source: Brennan, Stain & Marshall 2024].
  • Fun and play. Treat enjoyment as an outcome and a pathway, not a distraction [source: Devine-Wright & Godfrey 2020].
  • Keep all pathways available. Deliver mastery, respite and connection together rather than optimising one [source: Marshall, Kelly & Niven 2019].
  • Respect, protect and communicate. Waves for Change's core value ("Bananas") is respecting, protecting and communicating with each other and yourself; build it into group agreements [source: W4C curriculum overview].
  • Never alone; turn back together. Children are never left alone, the group moves at its pace, and anyone unsure means the group turns back [source: W4C curriculum overview].
  • Water safety follows national lifesaving guidance. Lifeguarded beaches, flags, accredited instruction and emergency routes as the RNLI publishes them; the therapist does not improvise water safety [source: RNLI surfsport guide].
  • Trauma-informed delivery. Coaches trained in trauma-informed care and supervised [source: Beranbaum et al. 2024]; only a minority of surveyed programmes list trauma-informed practice as a structure, so check [source: Brennan, Stain & Marshall 2024].
  • Consent and assent. Parental consent and the child's assent for minors; adult informed consent including what is shared with the programme [source: Beranbaum et al. 2024; synthesis].
  • Cultural and language adaptation. Most programmes do not yet adapt to language and culture; ask about the client's relationship to the sea, swimming access and modesty [source: Brennan, Stain & Marshall 2024; synthesis].
  • Role clarity. Know whether you are referrer, collaborator or in-water staff, and contract accordingly [synthesis].
  • Activity, not prescription. Surfing is valued as meaningful activity; do not set exercise targets, and route physical-activity questions to the client's physician or a qualified exercise professional (behavioural-activation framing, Domain II 040) [synthesis].
  • Access and equity. Cost, transport, equipment and waiting lists shape who benefits; plan for them [source: Devine-Wright & Godfrey 2020; Benninger et al. 2020].

4. Intervention inventory

Interventions 4.7–4.16 are programme components as Waves for Change and The Wave Project publish them; the therapist delivers them only when trained and employed as programme staff, and otherwise uses them to prepare, debrief and reinforce. Interventions 4.1–4.6 and 4.17–4.22 are therapist-side procedures; programme sources support them only in part, and the procedural steps are marked [synthesis].

4.1 Assessing fit and goals before referral

  • Purpose / when: Decide whether surf therapy suits this client now and what it is for (connection, mastery, respite, emotion regulation). Use when a client, parent or referrer raises it, or when isolation, low mood or trauma-related avoidance would benefit from a structured group activity [source: Benninger et al. 2020 populations; synthesis].
  • Steps: (1) Ask what draws the client to the sea and what they fear about it. (2) Map current goals onto the published pathways: play, nature, socialising, risk-taking, surfer identity [source: Devine-Wright & Godfrey 2020]. (3) Check practical capacity: transport, weekends, cost, equipment. (4) Note current risk (self-harm, suicidality, substance use, dissociation) and whether a group setting is tolerable. (5) Agree one or two observable hopes, in the client's words [synthesis].
  • Example language (illustrative): "What would be different for you if this went well? Not the surfing itself, but how you'd feel walking off the beach."
  • Watch for: Someone else's agenda (a parent or referrer keen, the young person not); surfing proposed as a substitute for needed treatment; compulsive exercise or eating-disorder features (screen and, if present, route to an eating-disorder service or registered dietitian; US support: National Alliance for Eating Disorders). Working: the client can name a personal reason to go.

4.2 Medical and water-safety screening (qualitative)

  • Purpose / when: Identify conditions that need a physician's view before sea activity. Use before every referral [synthesis].
  • Steps: (1) Ask about heart conditions, epilepsy or seizures, pregnancy, breathing problems, recent injury, and medicines that affect alertness, balance or heart rhythm. (2) Ask about swimming ability and any near-drowning or water trauma. (3) Do not judge medical fitness yourself; ask the client (or parent) to consult their physician and to complete the programme's own health form honestly. (4) Never advise starting, stopping or changing a medicine. (5) Explain that cold water can trigger cold-water shock even in strong swimmers (gasping, panic, loss of muscle control) and that hypothermia and drowning are real risks; point to RNLI and national lifesaving guidance rather than giving your own rules [source: London Fire Brigade survival and rescue; RNLI surfsport guide]. Cross-refer Domain X 196 for cold-water immersion.
  • Example language (illustrative): "The programme will ask about health. Some conditions just need your doctor's go-ahead first. Is there anything there you'd like to check with them?"
  • Watch for: Minimising symptoms to avoid exclusion; shame about not swimming. Working: questions routed, form completed, client not hiding information.

4.3 Evaluating a programme before referral

  • Purpose / when: Training, qualifications and standards vary widely across programmes, and shared delivery guidelines have yet to be agreed [source: Brennan, Stain & Marshall 2024]. Use before first referring to any provider.
  • Steps: Ask the provider, and note the answers: (1) Which beach, and is it lifeguarded? How are flags and conditions checked, and who can cancel? [source: RNLI surfsport guide; Brennan, Stain & Marshall 2024]. (2) Who coaches, with what accredited surf-instruction and water-safety qualifications? (3) Staff-to-participant ratios and in-water supervision. (4) Safeguarding policy, named lead, background checks, and how disclosures are handled. (5) Trauma-informed training and supervision for coaches [source: Beranbaum et al. 2024]. (6) Consent forms, information packs, outcome measures used [source: Brennan, Stain & Marshall 2024]. (7) Insurance cover. (8) Adapted equipment and access for disability. (9) Follow-on options. (10) What the programme will and will not share with you [synthesis for items 2, 4, 7, 8, 10].
  • Example language (illustrative): "Before I refer anyone, could you walk me through what happens if conditions change during a session, and who on the beach is qualified to make that call?"
  • Watch for: Vague answers on lifeguarding, qualifications or safeguarding; a programme claiming to treat conditions; pressure to share clinical notes. Working: clear written answers you can show the family.

4.4 Informed consent, assent and information sharing

  • Purpose / when: Agree in advance what the client is joining and who learns what. Waves for Change uses parental consent and the child's verbal assent [source: Beranbaum et al. 2024]; ISTO-affiliated programmes commonly issue consent forms and information packs [source: Brennan, Stain & Marshall 2024].
  • Steps: (1) Go through the programme's information pack with the client (and family). (2) Separate consent to the activity from consent to information sharing. (3) Agree the minimum shared with the programme (for example, relevant triggers, a contact if distressed) and what the programme may tell you (attendance, incidents). (4) Record the agreement; review it if circumstances change. (5) For a minor, seek the young person's assent as well as parental consent, and take a refusal of assent seriously [synthesis].
  • Example language (illustrative): "You decide what the surf team knows about you. Most people share just enough for them to look out for you. What would you want them to know?"
  • Watch for: Over-sharing by referrers; a young person agreeing only to please. Working: a written, client-owned sharing agreement.

4.5 Preparation session: expectations, fear and the body

  • Purpose / when: Reduce anticipatory anxiety and dropout. Some participants describe surfing as cold, hard work, involving falling, wiping out and fear [source: Devine-Wright & Godfrey 2020]. Use in the session or two before the first beach session.
  • Steps: (1) Describe what the programme says a session looks like (arrival, kit, safety briefing, water, debrief). (2) Elicit the worst-case picture and correct misconceptions using the programme's information. (3) Talk about wetsuits, changing, being seen by others and body image; ask what would help (changing robes, arriving early). (4) Rehearse one regulation skill the programme also uses (for example slow, even breathing as in 4.11, without any breath-holding). (5) Plan what the client will say if they want to stop or come out [synthesis].
  • Example language (illustrative): "Everyone falls off, a lot. The question isn't whether you'll fall, it's what you'll say to yourself when you do."
  • Watch for: Avoidance building as the date nears; body shame; trauma reminders (water, beach crowds, physical contact). Working: the client can describe the first session and has a stop plan.

4.6 Touch, boundaries and confidentiality outdoors

  • Purpose / when: In-water support can include physical help (a mentor steadying a board, holding hands while walking in) [source: Marshall, Kelly & Niven 2019; W4C curriculum overview], and beaches are public. Use during preparation, and before any session you attend in person.
  • Steps: (1) Ask the client's preferences about being touched, and who may help them. (2) Make clear that consent is sought before and during any touch, the client can say stop at any time, and touch is never sexual. (3) Discuss being seen: other beachgoers, people they know, photographs and social media (ask whether the programme photographs participants and how consent is obtained). (4) If you attend, agree in advance how you will greet the client in public and what you will not discuss on the beach. (5) Agree weather and cancellation arrangements and travel boundaries (no lifts in your own car unless your service policy and insurance allow it) [synthesis].
  • Example language (illustrative): "If a coach needs to steady you or your board, they should ask first, and you can say no or stop at any point. Who would you feel OK being helped by?"
  • Watch for: Freeze responses to unexpected contact; distress about being photographed. Working: the client can state their touch and photo preferences to staff.

4.7 Orientation and group agreements

  • Purpose / when: Set expectations and shared values before water work. In the Waves for Change curriculum, an orientation session explains the schedule, expectations and graduation, and the core value ("Bananas") is respecting, protecting and communicating with each other and yourself [source: W4C curriculum overview].
  • Steps: (1) Explain the programme arc and what graduation means. (2) Introduce the shared value in the programme's words and ask participants what respecting, protecting and communicating look like on the beach. (3) Agree safety norms: stay with your partner, check on each other, speak up if unsure [source: W4C curriculum overview; Beranbaum et al. 2024]. (4) Explain how to signal wanting to stop [synthesis].
  • Example language (illustrative): "Here everyone looks out for everyone, and that includes you looking out for yourself. If you're not sure, you say so, and we all turn back."
  • Watch for: Participants unable to state the safety norms; group dynamics imported from school. Working: participants remind each other of the agreements.

4.8 Graded group water entry (immersion)

  • Purpose / when: First contact with the water in Phase 1 of the Waves for Change curriculum, building trust [source: W4C curriculum overview].
  • Steps (as the overview describes them): (1) The group holds hands and walks in together at the group's pace. (2) Mentors are positioned at either end of the line and in the water with children. (3) Staff check "Are you ok?" at regular intervals. (4) If anyone is unsure, the whole group turns back together. (5) Hands are let go before ducking under waves so no one is pulled under. (6) A child who is scared can stay in shallow water and practise standing there. (7) Children are never left alone [source: W4C curriculum overview]. Only lifeguard-supported, qualified staff run this; the therapist does not lead water entry without those qualifications [synthesis].
  • Example language (illustrative, for debrief): "You decided when to step further in. What helped you decide?"
  • Watch for: Panic, gasping, freezing, being swept off feet; a child hiding fear to keep up. Working: participants stay connected and speak up when unsure.

4.9 Pair floating and pair surfing

  • Purpose / when: Phase 1 activities for "mastering trust and empathy"; partners check in, stay together, share boards and celebrate each other's efforts [source: W4C curriculum overview].
  • Steps: (1) Pair participants (a nervous child may be given a mentor or peer as a "special partner"). (2) Partners check in with each other before entering. (3) Partners support each other floating, then share a board. (4) Partners name and celebrate one effort each made. (5) Debrief on what it felt like to trust and be trusted [source: W4C curriculum overview].
  • Example language (illustrative): "What did your partner do that made it easier to trust them?"
  • Watch for: Mismatched pairs; a child who cannot tolerate being relied on; rough play. Working: partners check on each other unprompted.

4.10 One-to-one mentored surfing with self-selected pacing

  • Purpose / when: The core Wave Project format: each young person surfs with one-to-one physical and emotional support from a volunteer surf mentor, overseen by a surf coordinator [source: Devine-Wright & Godfrey 2020; Marshall, Kelly & Niven 2019]. Waves offering multiple challenge levels let the young person choose their pace and progression [source: Marshall, Kelly & Niven 2019].
  • Steps: (1) Mentor and young person agree today's choice (stay in the whitewater, try lying down, try standing, rest on the beach). (2) The mentor offers support and encouragement without pressure. (3) Progress is defined by the young person, not by comparison. (4) Effort and courage are acknowledged, not only success. (5) Mentors receive brief training in which support and the removal of failure and pressure are emphasised [source: Marshall, Kelly & Niven 2019; steps 1, 3 and 4 synthesis].
  • Example language (illustrative): "You're in charge of how far we go today. Want to try another one, or take a breather on the sand?"
  • Watch for: A mentor pushing; a young person over-reaching to impress; exhaustion and cold. Working: the young person makes choices and reports mastery ("I did it myself").

4.11 Take 5 breathing and feelings check-in

  • Purpose / when: Waves for Change's opening routine and core coping skill: a short, slow, evenly counted in-and-out breathing exercise repeated a few times, followed by a feelings check-in in which mentors model naming their own feelings; used to calm down, in and out of the water, and before reacting [source: W4C curriculum overview]. Never combined with breath-holding [synthesis].
  • Steps: (1) Gather in a circle on the sand. (2) Lead the breathing in the programme's structure. (3) Mentors name a feeling of their own first. (4) Each participant names how they feel and whether they want help. (5) Later sessions extend this to "checking in with yourself" and deciding whether to cope alone or ask for help [source: W4C curriculum overview].
  • Example language (illustrative): "Let's Take 5 together. ... I'm feeling a bit nervous about the waves today. How about you?"
  • Watch for: Breathing exercises can raise anxiety or dissociation in some trauma survivors; allow eyes open and opting out. Working: participants use it spontaneously before entering the water or after a fall.

4.12 Wipeouts as coping practice

  • Purpose / when: The curriculum frames wipeouts as a time to use Take 5 [source: W4C curriculum overview]; Wave Project participants name falling and wiping out as part of the challenge [source: Devine-Wright & Godfrey 2020]. Use whenever a participant falls or is knocked over.
  • Steps: (1) After a fall, staff check the participant is safe and orientated. (2) Prompt the coping skill. (3) Normalise falling as part of surfing. (4) Ask whether they want another go or a rest. (5) In therapy, link the sequence (setback, regulate, choose) to setbacks in daily life [steps 3–5 synthesis].
  • Example language (illustrative): "Big one! You came up, you took your breaths, you decided. That's the skill, on a wave or in a classroom."
  • Watch for: Shame, anger, or repeated falls as a sign of exhaustion or cold; any head knock or swallowing water needs first-aid assessment by programme staff. Working: quicker recovery and a calmer choice after falls.

4.13 Beach body-scan meditation

  • Purpose / when: A Phase 2 Waves for Change activity: lying down for a body scan with slow breathing, noticing thoughts and feelings [source: W4C curriculum overview].
  • Steps: (1) Participants lie or sit comfortably on the sand. (2) The facilitator guides attention through the body. (3) Participants notice thoughts and feelings without judging them. (4) Brief sharing afterwards [source: W4C curriculum overview; step 4 synthesis].
  • Example language (illustrative): "Notice where your body feels warm from the sun and where it still feels the sea. Just notice."
  • Watch for: Distress lying down in a group; trauma survivors may prefer sitting with eyes open. Working: participants report feeling calmer and can name a body sensation.

4.14 Power Hand (naming strengths)

  • Purpose / when: Phase 2 strengths exercise in which participants trace a hand and name personal strengths on its fingers [source: W4C curriculum overview].
  • Steps: (1) Mentors model by naming their own strengths. (2) Each participant traces their hand. (3) They name a strength for each finger, drawing on what they have done in the water. (4) Partners or mentors add strengths they observed [source: W4C curriculum overview; steps 3–4 synthesis].
  • Example language (illustrative): "I saw you go back out after that wave knocked you over. What would you call that strength?"
  • Watch for: Inability to name any strength (a clinical sign worth exploring in therapy). Working: strengths stated in the young person's own words.

4.15 Power Anchor (memory object)

  • Purpose / when: Phase 2: making an object, such as a shell necklace, linked to positive memories [source: W4C curriculum overview].
  • Steps: (1) Recall a moment on the beach that felt good or brave. (2) Make or choose an object. (3) Link the object to that memory and to a coping skill. (4) Plan where the object will be kept and when it can be used [source: W4C curriculum overview; steps 3–4 synthesis].
  • Example language (illustrative): "When you touch this shell at school, what moment from the beach do you want it to bring back?"
  • Watch for: Collecting natural items where local rules forbid it; object loss causing distress. Working: the client reports using the anchor outside the programme.

4.16 "I Will" mantra and transfer planning

  • Purpose / when: Phase 3 ("prepare to be independent"): children create a personal mantra and plan how to use the skills in daily life [source: W4C curriculum overview].
  • Steps: (1) Review the skills learned. (2) Each participant writes an "I will" statement. (3) Identify two everyday situations where it applies. (4) Share with a partner or mentor [source: W4C curriculum overview; steps 3–4 synthesis].
  • Example language (illustrative): "Finish this sentence for yourself: 'When things get rough, I will...'"
  • Watch for: Statements that are self-critical or unrealistic. Working: specific, achievable statements the client uses after graduation.

4.17 Circle debrief and group processing

  • Purpose / when: Most programmes in the 2020 scoping review included group processing and/or mental health support [source: Benninger et al. 2020]; Waves for Change sessions close the main activity with participants in a circle discussing the experience and linking it to a value such as supporting each other by communicating and listening [source: W4C curriculum overview]. Use after each water activity.
  • Steps: (1) Sit in a circle out of the wind, warm and dry first. (2) Ask what happened and what it felt like. (3) Link it to the session theme (trust, coping, strengths, independence). (4) Invite one thing each person will take away. (5) Close with the programme's ritual [source: W4C curriculum overview; steps 1 and 4 synthesis].
  • Example language (illustrative): "What did you notice about how the group looked after each other out there today?"
  • Watch for: Cold, hungry or tired participants who cannot reflect (warm and feed first); disclosures in front of peers (pause, follow up privately, follow safeguarding procedure). Working: participants link the water to everyday life without prompting.

4.18 Specific praise ("TLC")

  • Purpose / when: The curriculum uses praise and encouragement including "TLC" (tell it, label it, celebrate it) and coaches praising skills during free surf [source: W4C curriculum overview]. Use throughout.
  • Steps: (1) Tell the young person what you saw. (2) Label the skill or value it showed. (3) Celebrate it in a way that suits them (some prefer quiet praise) [source: W4C curriculum overview; step 3 qualifier synthesis].
  • Example language (illustrative): "You waited for your partner before paddling out. That's looking out for each other. Nice one."
  • Watch for: Praise that singles out a shy child uncomfortably; praise only for standing up on the board (praise effort and care too). Working: participants begin praising each other.

4.19 Debriefing in therapy sessions [synthesis]

  • Purpose / when: Turn beach experience into therapeutic material. Use in the therapy session after each surf session and at the end of the block. Mechanisms to look for, as the programme-theory study names them: mastery, respite and escape, social connection [source: Marshall, Kelly & Niven 2019].
  • Steps: (1) Ask for a concrete moment (best, hardest). (2) Explore the body experience and emotions. (3) Name the mechanism in the client's language ("I did it myself", "I forgot my worries", "they waved me over"). (4) Find an equivalent everyday situation and plan one small transfer step, in behavioural-activation terms (Domain II 040), without setting exercise targets. (5) Note any trauma reminders or risk changes.
  • Example language (illustrative): "You said you forgot everything else for a while out there. Where else in your week do you get even a little of that?"
  • Watch for: Idealising the programme while avoiding therapy topics; post-session lows. Working: the client brings beach examples spontaneously and uses them between sessions.

4.20 Collaboration with programme staff [synthesis]

  • Purpose / when: Coordinate care while respecting the client's sharing agreement (4.4). Programmes involve surf coaches, volunteers, and sometimes psychologists, occupational therapists, social workers and youth workers [source: Brennan, Stain & Marshall 2024].
  • Steps: (1) Agree a single programme contact. (2) Share only the agreed minimum. (3) Agree how incidents, safeguarding concerns and non-attendance are communicated, and to whom first. (4) Involve family members and supporters where the client wishes, as the scoping review recommends [source: Benninger et al. 2020]. (5) Record all contact.
  • Example language (illustrative, to staff): "With her agreement, the one thing that would help is knowing if she stops coming, so we can pick it up in our sessions."
  • Watch for: Staff seeking clinical advice beyond your role; information flowing without consent. Working: the client experiences one consistent team.

4.21 Endings, graduation and continuation

  • Purpose / when: Waves for Change ends with graduation; The Wave Project offers an opt-in Surf Club and a route to volunteering, and Surf Club membership and young volunteering grew over the evaluation period [source: W4C curriculum overview; Devine-Wright & Godfrey 2020]. The scoping review recommends attending to socioeconomic barriers to continued surfing and considering surf clubs to sustain outcomes [source: Benninger et al. 2020]. Use in the last weeks of a block.
  • Steps: (1) Mark the ending in therapy as well as at the beach. (2) Review what changed against the hopes agreed in 4.1. (3) Plan continuation: Surf Club, community surfing, volunteering, or another group activity. (4) Problem-solve cost, kit and transport. (5) Prepare for loss of the group and mentor [steps 1, 2, 5 synthesis].
  • Example language (illustrative): "The course is ending, but what you built out there doesn't have to. What do you want to keep?"
  • Watch for: Grief or a dip in mood after the block; continuation blocked by cost. Working: a concrete next step the client has chosen.

4.22 Surf therapy with veterans and service members

  • Purpose / when: Ocean Therapy, an occupational-therapy surfing intervention developed by an occupational therapist, was evaluated in a 2014 feasibility study with Operation Enduring Freedom and Operation Iraqi Freedom veterans with PTSD symptoms [source: USC Chan news on Rogers et al. 2014]. Other studies describe surfing's present focus as respite from PTSD symptoms and success in goal-directed activity as building self-efficacy [source: Benninger et al. 2020]. Session structure of Ocean Therapy [uncertain: not verified].
  • Steps [synthesis]: (1) Coordinate with the veteran's PTSD treatment team; surf therapy is an adjunct, not a replacement for trauma-focused treatment. (2) Screen for trauma reminders in water, helicopters or crowds, injuries and pain. (3) Prepare for hypervigilance and startle in surf. (4) Debrief around self-efficacy and respite (4.19). (5) Support peer connection with other veterans if wanted.
  • Example language (illustrative): "Out there you had to focus on the next wave. What was it like to have your attention there instead of on scanning?"
  • Watch for: Thrill-seeking as avoidance, alcohol use around beach events, physical injury. Working: improved engagement in core PTSD treatment and daily routine.

4.23 Autistic and disabled participants

  • Purpose / when: Surfers Healing, describing itself as the original surf camp for children with autism (since 1996), runs free, volunteer-staffed camps in which children paddle out with instructors on tandem boards; costs cover life vests, wetsuits, boards, permits and insurance [source: Surfers Healing]. Studies include autistic youth and disabled adults [source: Benninger et al. 2020]; The Wave Project notes surfing may not be accessible to some clients even with adapted boards [source: Devine-Wright & Godfrey 2020].
  • Steps [synthesis]: (1) Prepare with the family using photos or a visual schedule of the day. (2) Identify sensory needs (wetsuit pressure, noise, sand, cold) and supports. (3) Agree with the programme how the child communicates "stop". (4) Check adapted equipment, accessible changing and beach access. (5) Debrief with the family afterwards.
  • Example language (illustrative, to a parent): "What usually helps your son when a new place is loud or overwhelming? Let's tell the surf team before the day."
  • Watch for: Overwhelm, elopement towards the water, distress at wetsuit removal. Working: the child shows enjoyment cues and the family wants to return.

4.24 The therapist in the water: delivering or co-delivering sessions [synthesis]

  • Purpose / when: Some programmes are delivered by licensed clinicians who apply clinical training in the surf setting [source: Benninger et al. 2020]. Use only where you hold the required surf-instruction and water-safety qualifications or work alongside qualified coaches and lifeguards, your licence and employer permit it, and insurance covers it. ISTO-published competence standards for clinicians [uncertain: not verified].
  • Steps: (1) Contract the role in writing: therapist, coach, or both, and who holds water-safety authority (never you, unless qualified). (2) Address multiple relationships (therapy client and group member, seeing clients in swimwear, shared transport) in line with your code; for psychologists, APA Ethics Code Standard 3.05 on multiple relationships (APA Ethics Code). (3) Plan confidentiality on a public beach. (4) Keep clinical records as usual. (5) Seek supervision from someone experienced in outdoor practice.
  • Example language (illustrative): "On the beach I'm part of the team; the coaches make the water calls. In our sessions I'm your therapist, and what you tell me there stays there."
  • Watch for: Role blur, boundary drift through informality, being drawn into rescue (RNLI guidance: alert a lifeguard or call 999 or 112 and ask for the Coastguard rather than attempting a rescue yourself [source: RNLI surfsport guide]). Working: clear roles that clients can describe.

5. Handling problems

  • Fear of the water or panic in the water. Programme responses: shallow-water practice, holding hands, a special partner, turning back together, never alone [source: W4C curriculum overview]. Therapist [synthesis]: explore the fear's origin (near-drowning, inability to swim, trauma); treat surf entry as a graded, chosen approach only with explicit consent, never as forced exposure; a client may simply prefer a land-based alternative. Panic in water is a safety event handled by water-safety staff first, and debriefed later.
  • Dropout and non-attendance. In the first evaluation phase, under two-thirds of clients attended every session and girls were significantly less likely to complete, for reasons not identified [source: Devine-Wright & Godfrey 2020]. Therapist [synthesis]: ask early about body image, changing, periods, peers, transport and weekend conflicts; problem-solve with the programme; normalise missed weeks so shame does not end attendance.
  • Cold, discomfort and fatigue. Participants describe surfing as cold and hard work [source: Devine-Wright & Godfrey 2020]. Programme staff manage kit, warmth and when to come out; the therapist plans warm clothes, food and rest and names cold-water shock and hypothermia as reasons staff may end a session [source: London Fire Brigade survival and rescue; synthesis]. Cross-refer Domain X 196.
  • Conditions cancel sessions; waiting lists. Weather, season and wave quality are delivery prerequisites [source: Brennan, Stain & Marshall 2024]; waiting lists of up to a year were reported [source: Devine-Wright & Godfrey 2020]. Therapist [synthesis]: agree a weather plan in advance, keep therapy going during waits, and frame cancellations as safety decisions, not rejections.
  • Risk-taking or over-excitement. Lifestyle sports offer exhilaration and fear [source: Devine-Wright & Godfrey 2020]; Waves for Change evaluation found changes in risk-taking and sensation seeking [source: Beranbaum et al. 2024]. Therapist [synthesis]: distinguish chosen, supported challenge from reckless or self-harming risk; if risk-taking escalates (ignoring flags, going out alone, substance use at the beach), review risk and safety planning.
  • Disclosure or distress on the beach. Follow the programme's safeguarding procedure; for children, the designated safeguarding lead and mandatory reporting duties where they apply [synthesis]. If a client expresses suicidal thoughts, assess risk in the usual way; crisis lines include 988 (US) and Samaritans 116 123 (UK and Ireland).
  • Trauma reminders and dissociation. Water, crowds, touch, shouting or wetsuits can trigger responses [synthesis]. Agree grounding cues with staff (4.11, 4.13), allow exit, debrief in therapy; consider whether trauma-focused treatment should come first.
  • Mentor or group rupture. A mentor who pushes, or peer teasing, undermines the safe-space mechanism [source: Marshall, Kelly & Niven 2019]. Therapist [synthesis]: help the client name what happened, decide what to say or whom to tell, and with consent raise it with the coordinator; repair within the programme where possible.
  • Stuck or flat response. If the client attends but reports no change, revisit the hopes from 4.1, check whether all pathways (play, nature, connection, mastery, identity) are available to them, and consider a different group activity [source: Marshall, Kelly & Niven 2019; Devine-Wright & Godfrey 2020; synthesis].
  • Compulsive exercise or disordered eating emerging. Screen if surfing becomes driven, linked to weight or body change, or continues despite injury [synthesis]. Refer to an eating-disorder service or registered dietitian (US support: National Alliance for Eating Disorders) and to the client's physician; set no activity or weight targets.
  • Cost, kit and access after the block. Socioeconomic barriers limit continued surfing [source: Benninger et al. 2020]. Help the client locate free follow-on clubs, kit loans and volunteering routes [synthesis].
  • Cultural, religious or modesty concerns. Most programmes do not adapt to language and culture [source: Brennan, Stain & Marshall 2024]. Ask about swimwear, mixed-gender groups and family views; advocate for adaptations or alternatives [synthesis].
  • Injury, near-miss or drowning incident. Programme emergency procedures and lifeguards act first; the therapist offers psychological first aid, follows up exposure to the incident for participants and staff, and supports reporting [synthesis]. Bereavement after a water death: assess grief and trauma; safe messaging if suicide is involved.

Sources

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