Riding the wave: Occupational therapy’s role in surf therapy

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Brooke Tubbs and Rachel Folan

Riding the Wave: Occupational Therapy’s Role in Surf Therapy

Brooke Tubbs and Rachel Folan 

Surfing found me as I (Brooke) was slipping into the grips of depression, living on the other side of the world, facing homesickness, culture shock, and feelings of self-doubt. The first time I caught a wave I felt a rush of joy, adrenaline, and pride. I was caught in the flow and rhythm of surfing: paddling out, seeing a wave on the horizon, pushing myself to catch it, and riding it with my eyes open to the world.  Surfing allows the rider to oscillate between the thrill of gliding upon a ray of sun-lit water and serendipitous lulls of the rolling waves. As I was finishing my OTD degree, I chose to use my capstone to continue learning about surf therapy with a company called Gnome Surf, based out of New England. Now both Rachel and I apply our foundational OT knowledge as titled surf therapists for Gnome Surf. According to the International Surf Therapy Organization (ISTO), Gnome Surf is one of 47 surf therapy organizations globally. Gnome Surf provides daily surf therapy sessions to individuals of abilities.

ITSO defines surf therapy as “A method of intervention combining surf instructing/surfing and structured individual or group activities that promote psychological, physical, and psychosocial well-being” (2019). As a unique alternative to traditional therapy, some surf therapy programs utilize a designated therapeutic component, while others simply use the outdoors as an experiential/educational component where participants engage with nature to achieve therapeutic benefits (Hawkins, Townsend, & Garst, 2016). Both options require a trained individual to facilitate the interaction for the maximal therapeutic result — occupational therapists are primed to be these facilitators. 

Surf therapy is holistic in nature, addressing the biopsychosocial aspects of the person and mirroring the scope of occupational therapy practice. It has the potential to address 6 out of the 9 areas of occupation, contexts, performance patterns and skills, and client factors outlined in the OTPF 4th Edition (see Table 1). A scoping review of sport as a leisure occupation supports this and describes that sensory integration, social interaction, accessing the natural environment, and the therapeutic properties of water all contribute to the unique experience of surf therapy (Costalonga et al., 2020).

Table 1. Surf Therapy and the OTPF

 

Occupations ADLs
  • Dressing (e.g., swimsuit, wetsuit)
  • Functional mobility (e.g., mounting the board, positioning self, kneeling/standing to maneuver the wave)
IADLs
  • Safety & emergency maintenance (e.g., evaluating risk in the ocean)
Health management

 
  • Socioemotional health promotion and maintenance (e.g., managing emotions, developing self-identity, making choices to improve QoL including surfing)
  • Symptom and condition management (e.g., managing physical and mental health needs during surfing, regulating emotions after falling off the board)
  • Physical activity (e.g., cardiovascular exercise, strength and balance training to maintain or improve health via surfing)
Play
  • Play exploration & participation (e.g., identifying and participating in play activities in the water or on the beach with others)
Leisure
  • Leisure exploration & participation (e.g., identifying surfing and ocean activities as leisure interests)
Social participation 
  • Family participation (e.g., siblings on the board first, practicing the skill of taking turns, family cheering on the participant). 
  • Peer group participation (e.g., cheering on other surfers, high fives on the beach)
Contexts Environmental Factors
  • Natural environment (e.g., ocean and waves, sand vs. rocks, access to the beach, seaweed and sea animals, sunlight, noise level)
  • Products and technology (e.g., surf boards, wetsuits, leashes, sunscreens, swimsuits)
  • Support and relationships (e.g., family, other athletes, surf therapists) 
  • Attitudes (e.g., individual and family, surf therapists, and societal attitudes).
Personal Factors  Age, gender identity, race and ethnicity, cultural identification and attitudes, social background, socioeconomic status, habits and behavioral patterns, temperament, character traits, coping styles, health conditions and fitness levels.
Performance Patterns Routines
  • Beach sequence before getting in the water
  • Sequence to catch a wave 
Roles

 
  • Surfer/athlete
  • Student
Performance Skills Motor skills

 

 Holding onto the surfboard, coordinates movements to position self on the surfboard including kneeling/standing, coordinates movement to paddle, sustains performance for the entire session 
Process skills

 

 Attends to the entire session, applies knowledge, and uses equipment appropriately, initiates paddling or positioning or kneeling/standing on the surfboard, sequences movements appropriately, adapts performance.
Social interaction skills Initiates and produces social interactions including nonverbal movements, shapes and maintains flow of social interactions, acknowledges and encourages other surfers or the surf therapist, adapts social interaction
Client Factors Beliefs

 
  • Hard work pays off
  • Always get back up on the board
  • Celebrate the small victories 
  • I am capable, I can do this. 
Spirituality

 
  • “Soul surfer” 
  • Surfing evokes a flow state
  • Inherent spirituality of nature 
Body functions

 
  • Mental functions (e.g., maintaining attention to catch waves, motor planning to paddle and stand, regulating emotions, experiencing the flow state with the waves)
  • Sensory functions (e.g., sunlight and reflection off of the water, white noise of the waves, vestibular movement of body in and on the water, salty taste of the ocean, cold water, feeling of the board on the feet, proprioceptive input of the water and the wetsuit, moving into position on the board) 
  • Neuromusculoskeletal and movement related functions (e.g., muscle functions for manipulating the board, moving the body onto the board, paddling, endurance to surf) 
  • Cardiovascular and respiratory system functions (e.g., endurance to surf, holding breath underwater)
  • Voice and speech functions (e.g., communicating with the surf therapist) 
Body structures  Structures related to body functions above 

 

The evidence base for the use of surf therapy as an adjunct intervention continues to grow. With surfing, youth have demonstrated improvements in physical fitness, self-confidence, social skills, positive behaviors, quality of life, self-determination, and sleep (Benninger et al, 2020; Parsons, 2018). Anecdotal evidence from parents of youth with Autism Spectrum Disorder also speaks to the regulating nature of the ocean, including the waves and the wetsuit, along with other forms of natural sensory input (Benninger et al., 2020; Moore, Clapham, & Deeney, 2017). Parents also mention the inclusive nature of the physical and social environment, describing it as a normalizing opportunity for their children (Benninger et al., 2020; Moore, Clapham, & Deeney, 2017).

Surfing as therapy has also been utilized with adults, primarily those with PTSD, substance use disorder, and other mental health challenges. Surfing is categorized as a high-risk leisure activity as it elicits a similar physiological response to other risky behaviors and occupations and can consequently be used to replace those behaviors (Rogers, Mallinson, & Peppers, 2014). For these populations, a major benefit from surf therapy is the application of mindfulness due to the intense focus on one’s body and surroundings to navigate the shifting ocean (Otis, et al., 2020). Surfing requires body awareness to maintain balance, feel the wave velocity, and take corrective action. For those that have experienced trauma, this allows a person to recognize the interplay between emotions and physical sensations. Surf therapy can then be categorized as a body-based therapy, allowing for the completion of “action tendencies” or physical impulses associated with trauma, and ultimately supports emotional regulation (Van der Kolk, 2015). In addition, self-regulation strategies can be taught and implemented while riding this intensity of emotion and hyperarousal during a surf therapy session to then translate to daily life. For veterans, surf therapy has been found to decrease stress levels and depressive symptoms, limit the use of narcotics, and increase self-efficacy; veteran’s report being better able to manage their PTSD symptoms after one or multiple surf sessions (Benninger et al., 2020). Finally, because surf therapy is unorthodox, non-traditional, and it addresses both physical and mental health, it is likely less stigmatizing to these populations and as a result, improves their volition to pursue and continue treatment. 

Case examples, obtained through skilled observation, from the children that I have worked with reinforce the benefits of surf therapy. Child #1 is nonverbal, with sensory processing challenges and ASD. They struggle with listening and following instructions, hyper fixating on objects, decreased attention, and frequently perform maladaptive behaviors, but they love the water. During the first surf session, the child bolts directly into the ocean, with no regard for the surfboard or instructor. They struggle to follow directions in the water and hyper-fixate on getting crashed into by the waves. Slowly, over the next two or three sessions, the child’s attention and listening skills improve, now walking with the instructor into the water. The ocean regulates them enough that they are now able to pay attention on the surfboard to listen to instructors’ directions and successfully ride waves. 

Child #2 is easily distracted with a decreased attention span, lacks confidence and self-esteem, struggles with self-regulation, and has decreased balance. At first, when walking out into the ocean, they get hit by multiple waves and run towards shore because they are afraid. After implementing breathing and self-regulation techniques as instructed by the therapist, the child agrees to try one wave at a time. The child and therapist catch one wave after another, with the therapist constantly reassuring the child that they are safe and capable. The child begins to trust themself more, letting go of the surf board to sit and then kneel on their own. They start cheering for themselves as they wash onto the beach, and start using more “I can do this” verbiage when talking with the therapist. 

Surf therapy is more than just about building the skills needed to surf a wave on your own. It’s building confidence and self-esteem; it’s trusting someone new to help you succeed; it’s learning to pay attention and sustain that attention; it’s developing skills for regulating your emotions of fear and excitement; and it’s discovering how to fall and fail and get right back onto the board. As the evidence for surf therapy evolves, there will be a need for the innovative perspectives and abilities of occupational therapists to contribute to these efforts. As holistic, biopsychosocial practitioners, trained in activity analysis, environmental adaptations, and the promotion of occupational performance, occupational therapists are well equipped to carve out a place within these surf therapy programs. The training and background of occupational therapists allow them to work with different populations and communities as they are not restricted by their scope of practice to address only certain aspects of health and well-being. 

 

References

Benninger, E., Curtis, C., Sarkisian, G. V., Rogers, C. M., Bender, K., & Comer, M. (2020). Surf therapy: A scoping review of the qualitative and quantitative research evidence. Global Journal of Community Psychology Practice, 11(2), 1–26. 

Costalonga, D. A., Crozier, A. J., Stenner, B. J., & Baldock, K. L. (2020). Sport as a leisure occupation in occupational therapy literature: A scoping review. American Journal of Occupational Therapy, 74, 7403205100. https://doi.org/10.5014/ajot.2020.035949 

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

International Surf Therapy Organization (2019). International Surf Therapy Organization. https://intlsurftherapy.org.

Moore, A. M., Clapham, E. D., & Deeney, T. A. (2017). Parents’ perspectives on surf therapy for children with disabilities. International Journal of Disability, Development and Education, https://doi.org/10.1080/1034912X.2017.1400660F

Otis, N. P., Walter, K. H., Glassman, L. H., Ray, T. N., Michalewicz-Kragh, B., & Thomsen, C. J. (2020). Effects of PTSD and MDD comorbidity on psychological changes during surf therapy sessions for active duty service members. Global Journal of Community Psychology Practice, 11(2), 1–23. http://www.gjccp.org/.

Parsons, D. (2018). The effects of surf therapy on self-determination and quality of life in young adults with Autism Spectrum Disorder. https://scholarworks.csun.edu/bitstream/handle/10211.3/203512/Parsons-Daniel-thesis-2018.pdf?sequence=1

Rogers, C. M., Mallinson, T., & Peppers, D. (2014). High-intensity sports for posttraumatic stress disorder and depression: Feasibility study of ocean therapy with veterans of Operation Enduring Freedom and Operation Iraqi Freedom. American Journal of Occupational Therapy, 68, 395–404. http://dx.doi.org/10.5014/ajot.2014.011221

Van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.

Brooke Tubbs, OTD, OTR/L, is an occupational therapist practicing in an acute care setting. She works for Gnome Surf, a non-profit surf therapy organization in New England, exploring the use of surfing as a modality/intervention. She graduated from Alma College with a Bachelor’s degree in Integrative Physiology and Health Science (2018) and from Northern Arizona University with a Doctorate in Occupational Therapy (2022). Brooke is a William J. Fulbright Scholar (2018). She also has a graduate certificate in Translational Research in Adolescent Behavioral Health (2021) from the University of South Florida. 

 

Rachel Folan, MSOT, OTR/L, is an occupational therapist who has practiced occupational therapy in long term care and skilled nursing facility settings for the past 2 years. She has volunteered and worked with Gnome Surf, a non-profit surf therapy organization based in southeastern MA and RI, as a surf therapist providing surf therapy to children and young adults. She has conducted research for the International Surf Therapy Organization (ISTO), in collaboration with Gnome Surf, about the effectiveness and outcomes of surf therapy for the populations she serves. She graduated from Worcester State University with a Bachelor’s degree in Occupational Studies (2018) and a Master’s degree in Occupational Therapy (2019).

 

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