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Evidence, training paths, and ethics for adding ocean-based care to your MFT practice.
More than 5,000 people now participate in surf therapy programs worldwide, yet most licensed clinicians have never received formal training in ocean-based interventions, and no unified certification standard exists across U.S. licensing boards. For marriage and family therapists, that gap creates both an opportunity and a real professional challenge: how do you responsibly move clinical work from a controlled office to an unpredictable shoreline?
The tension is practical. MFTs and MFT students exploring surf therapy must weigh a still-emerging evidence base against growing client demand, work within scope-of-practice boundaries that were never written with saltwater in mind, and decide whether to facilitate sessions directly or refer out. Programs like San Diego's Groundswell Community Project, founded by a licensed MFT, show that integration is possible, but only with deliberate structure.
The mental health field is moving steadily toward interventions that engage the body and the natural environment, not just the mind sitting in a chair. Surf therapy sits squarely in that current, and its formal definition helps distinguish it from a casual day at the beach.
The International Surf Therapy Organization (ISTO) provides the most widely cited framework. Under ISTO's model, surf therapy combines three elements: structured surf instruction delivered by trained facilitators, supportive relationships built through group cohesion and mentorship, and a strengths-based curriculum designed to foster resilience, self-regulation, and connection. This is not a therapist chatting with a client between waves. Clinical surf therapy follows a protocol, sets therapeutic goals, tracks outcomes, and integrates the ocean environment as a deliberate tool within a broader treatment plan.
That distinction matters. Recreational surfing can certainly improve mood, but it lacks the intentional clinical scaffolding that separates a therapeutic intervention from a hobby. Informal "surf and talk" sessions fall somewhere in between, and clinicians should understand the difference before marketing any ocean-based activity as therapy.
Several converging forces explain the momentum behind surf therapy as of 2026:
The populations most frequently reached by surf therapy programs include trauma survivors, military veterans managing PTSD and moral injury, at-risk youth, and individuals from marginalized communities who face barriers to conventional mental health services. Over 5,000 people now participate in surf therapy programs worldwide, a number that continues to climb as organizations scale access through free events and scholarship models.
The evidence base for surf therapy consists of a small but growing body of randomized controlled trials, observational studies, and one landmark systematic review. Clinicians need to know both the findings and the gaps before recommending this modality.
The most comprehensive synthesis to date, a 2024 systematic review published in PubMed Central, screened 5,666 records and identified only three randomized controlled trials that met inclusion criteria. The review rated the overall certainty of evidence as "very low," citing high risk of bias, heterogeneous protocols, small sample sizes, and no robust, consistent evidence of mental health improvement compared with wait-list or active comparator conditions. That rating does not mean surf therapy is ineffective. It means the research infrastructure is not yet mature enough to draw firm conclusions.
A pilot RCT examining surf therapy for children and adolescents reported within-group effect sizes of 0.57 for depression, 0.43 for anxiety, and 0.79 for emotional difficulties.2 Those figures reflect pre-to-post changes within the surf therapy group rather than between-group differences, an important distinction. The wait-list control group worsened over the same period, which is suggestive but not the same as demonstrating that surf therapy outperformed an active intervention.
In the most rigorous adult trial, Otis and colleagues (2024) randomized active-duty service members and veterans to either surf therapy or hike therapy. Both groups achieved clinically significant reductions in depression and PTSD symptoms maintained at three months, with a 58 percent PTSD remission rate across conditions.3 Critically, the authors found "little evidence for the enhanced effects of surf therapy relative to hike therapy." The results suggest that nature-based, physically active group interventions may share a common therapeutic mechanism rather than pointing to something unique about surfing.
Several non-randomized studies from 2024 and 2025 report large symptom reductions. One 2025 evaluation found that the proportion of veteran participants reporting high anxiety dropped from 40 percent before the program to 10 percent afterward. Another observed immediate reductions in depression (44 percent), anxiety (59 percent), and PTSD symptoms (38 percent), with depression and PTSD improvements partially maintained at 30 days.5 These findings are encouraging, but they come from uncontrolled designs that cannot rule out placebo effects, regression to the mean, or selection bias.
No published RCT has directly randomized participants to surf therapy versus CBT or EMDR for any mental health condition. Some researchers have noted that the 58 percent PTSD remission rate in the surf-versus-hike trial compares favorably to the roughly 33 to 50 percent remission rates reported in meta-analyses of first-line psychotherapies for military PTSD. This comparison is indirect, drawn across different studies with different populations, and should not be interpreted as evidence that surf therapy matches or exceeds established treatments.
The honest summary: early data is promising, especially for PTSD and depression symptoms, but the field rests on very few controlled trials, small samples, and short follow-up periods. A registered trial in Brazil combining surf therapy with mindfulness had not yet published results as of mid-2026. MFTs considering this modality should treat it as an adjunctive, experiential intervention supported by preliminary evidence rather than a standalone treatment with a proven track record.
Early studies suggest surf therapy may reduce symptoms of PTSD, depression, and anxiety, but the current evidence base remains small, methodologically limited, and low-certainty, meaning it should complement, not replace, established treatments.
Should you get in the water with your clients, or send them to someone who already does? That single question shapes almost every decision that follows once an MFT decides to bring surf therapy into their practice.
Most licensed clinicians start with a referral model. You maintain the therapeutic relationship in your office, while a trained surf therapy provider (often through an organization like Groundswell) runs the water-based sessions. You coordinate goals, review progress, and process the client's experience in subsequent talk-therapy sessions. This keeps scope of practice clean and requires no additional water competency on your part.
A co-facilitation model is more involved: the clinician is physically present in the water alongside a certified instructor, blending clinical observation with adventure-based facilitation in real time. This approach demands specialized training, liability coverage, and a genuine comfort in ocean conditions. It is not a starting point for most MFTs, but a progression for those who pursue formal surf therapy credentials.
Surf sessions should be written into the treatment plan as a complementary intervention, not a substitute for individual or family therapy. Language matters here: frame surf therapy as supporting specific goals (nervous system regulation, exposure to group settings, rebuilding trust in the body) rather than as the primary modality addressing a diagnosis. Standard care, whether that is trauma-focused individual work or systemic family sessions, continues on its own track.
Not every client is a fit. Consider three factors before making a referral or recommendation:
Progress notes should track how surf sessions connect back to clinical goals, not just describe the activity itself. Note observable changes in affect regulation, social engagement, or trauma symptoms following sessions. When a co-facilitator or outside program is involved, establish a release of information and a simple communication protocol so both parties are working from the same treatment goals, not duplicating or contradicting each other's work.
For MFTs weighing surf therapy, the central tradeoff is simple: structured training can build competency, but no number of CEUs makes a therapist a competent water safety instructor. That distinction should guide every training decision.
Groundswell Institute offers three progressive surf therapy training tracks, all co-facilitated by licensed clinicians and providing CAMFT-approved continuing education units (CEUs). Level 1, Surf Therapy for Trauma Recovery, is a 6-CEU course delivered self-paced, live virtual, or in person in San Diego.7 It includes one year of online access and serves as the prerequisite for Level 2. That foundational course is also required before Level 3.
Level 2, Surf Therapy Facilitator Training, carries 12 CEUs and is designed for clinicians who are already facilitating or preparing to launch surf therapy programs.9 Level 3 is the most intensive: Groundswell Surf Therapy Provider Training runs for six months, beginning April 2026, with live virtual sessions on Mondays from 5 to 7 p.m. Pacific.10 It includes small group supervision, a Groundswell Surf Therapy certificate, 48 CAMFT-approved CEUs, and one year of recording access. The 2026 cohort is at capacity, and registration is closed, so interested MFTs should plan for the next cycle or begin with Level 1.10
Licensure as an LMFT authorizes psychotherapy, not surf instruction. Surf competency and clinical competency are separate skill sets, and experienced MFTs typically pair with certified surf instructors, lifeguards, or ocean safety personnel when delivering ocean-based interventions. Groundswell's trainings do not appear to waive that reality; rather, they are co-facilitated by licensed clinicians alongside surf professionals, which models the recommended division of roles. Before leading any water-based session, an MFT should confirm what their state practice act permits and carry professional liability coverage that explicitly includes experiential or outdoor modalities.
Some clinicians ask about an International Surf Therapy Organization (ISTO) certification. As of 2026, we could not locate a current, official ISTO clinician certification pathway with clearly defined eligibility, supervision hours, or course structure. MFTs should not present an unverified ISTO credential as equivalent to Groundswell's CAMFT-accredited track or to their state license.
Groundswell's materials emphasize sequential mastery rather than a fixed renewal cycle. Recording access lasts one year, and Level 3 supervision is built into the six-month cohort, which supports continued consultation. For now, treat ongoing development as practice-based: maintain surf skill competency through qualified instructors, pursue CAMFT-approved CEUs as required by your license, and seek supervision from clinicians experienced in adventure-based or trauma-informed interventions.
The Groundswell Institute offers a structured, three-level certification pathway designed for licensed clinicians and aspiring facilitators. Each level builds on the last, so there is no skipping ahead. Here is the sequence most MFTs follow to move from initial curiosity to a recognized surf therapy credential.
Taking clinical work into the water means taking on risks that a licensed office does not carry: physical injury, drowning, cold shock, sun exposure, and the reality that your clinical role can blur with recreation or supervision the moment you're standing on a beach instead of sitting across from a client.
Here's the uncomfortable truth: state MFT boards, including California's Board of Behavioral Sciences, have not written modality-specific rules for surf, wilderness, or adventure therapy. The definitions of psychotherapy in California law and BBS guidance do not distinguish an office from a beach, which implies existing scope-of-practice and informed-consent standards apply regardless of location, but nothing spells out what's permitted in open water. No state licensure comparison chart even lists outdoor therapy as its own category, and the national exam body has not published guidance either.19 Practically, that means clinicians are operating under general ethical codes rather than a modality-specific rulebook.20
Both CAMFT and AAMFT codes require informed consent as early as feasible, in plain language, with documentation, and specifically call for disclosing risks when a treatment lacks an established evidence base.15 For surf therapy, that translates into several concrete disclosures:
Sound practice means partnering with certified instructors and lifeguards rather than acting as the sole safety authority in the water, maintaining appropriate participant-to-facilitator ratios, and screening for medical or psychological contraindications (cardiac conditions, seizure disorders, acute suicidality) before anyone paddles out. CAMFT's competence standard requires activity-specific training or supervised collaboration, not just clinical licensure.15
On the liability side, standard malpractice policies were written for office-based practice, so confirm coverage extends to outdoor and off-site sessions before running one. Because no board has allocated responsibility for accidents in these settings, liability tends to default to general negligence law, making thorough documentation, waivers, and instructor partnerships your strongest protection.
Expanding into ocean-based work broadens your scope of practice, but it does not waive the same informed consent, confidentiality, and liability standards you would uphold in any clinical setting.
Family surf therapy means bringing two or more members of a household into the water together, under clinical guidance, so their relational patterns show up in real time rather than being described secondhand in an office. A parent's instinct to grab a child's hand before a wave, a partner who paddles ahead without checking back, a sibling who freezes and needs coaxing: these are not incidental details. They are the same dynamics that show up at the dinner table, just harder to disguise.
Structural and attachment-based family therapists already have language for what happens in the surf. Co-regulation looks like a couple timing their breathing before paddling out together. Containment looks like a parent staying close enough to a frightened teenager without hovering. Rupture and repair happen constantly: someone gets knocked down, someone else has to decide whether to check in or paddle on. An MFT trained in ocean-based work can name these moments as they happen, turning a wipeout into a live case study on how the family handles setbacks.
An individual surf therapy session might focus on one person's nervous system response to fear or overwhelm. A couples or family session is structured around interaction:
This is deliberately distinct from general outdoor or nature-based couples work already covered elsewhere on marriagefamilytherapist.org. The ocean adds unpredictability, physical risk, and sensory intensity that a quiet trail walk does not, which is precisely why it surfaces defense patterns faster. MFTs considering this approach should treat it as a systemic intervention with its own protocols, not an extension of general nature therapy.
The core tension for MFTs considering surf therapy is straightforward: no dedicated billing codes exist for ocean-based interventions, yet reimbursement remains possible when you document the service correctly within existing frameworks. Whether surf therapy becomes a sustainable part of your practice or an out-of-pocket burden for clients depends on how well you understand this gap.
Surf therapy lacks its own CPT code, so reimbursement depends on billing under standard psychotherapy codes with the ocean setting functioning as the treatment modality rather than the billable service itself. Licensed MFTs typically use time-based psychotherapy codes: 90832 for 16-37 minute sessions, 90834 for 38-52 minutes, or 90837 for 53 minutes or longer. Family and group therapy codes apply when working with multiple participants.
Medicare reimbursement rates for 2026 illustrate a reality MFTs should anticipate: LMFTs receive lower rates than psychologists or clinical social workers for identical codes. For example, 90834 reimburses approximately $85 for LMFTs compared to roughly $114 for psychologists.24 Private insurers typically use Medicare rates as baselines, adjusting upward or downward based on contracts.
Documentation must clearly establish medical necessity and therapeutic rationale. The surf activity supports clinical goals, but the billable service remains psychotherapy. Out-of-network billing using superbills is common, though denials may occur if payers classify the intervention as recreational or experimental.
When insurance falls short, out-of-pocket costs create barriers for the populations who often benefit most from surf therapy: trauma survivors, veterans, and underserved communities. Nonprofit models become essential here.
Groundswell Community Project operates on a free and sliding-scale funding structure, offering training scholarships with discounts ranging from 25 to 75 percent.26 Their community events provide surf therapy at no cost for water activities, removing financial barriers entirely.26 This dual approach, combining clinical practice with community access programming, offers a template for MFTs seeking to make experiential interventions available regardless of insurance status.
What does a licensed MFT-run surf therapy program actually look like once it moves past theory and into practice? San Diego's Groundswell Community Project offers one of the clearest working examples in the field today.
Groundswell was founded by Natalie Small, a licensed marriage and family therapist who began the work with just eight women who had survived traumatic experiences and found measurable healing through surfing together. That small pilot group has since grown into programming that now reaches more than 5,000 participants worldwide, according to reporting from Fox 5 San Diego (https://fox5sandiego.com/san-diego-guide/things-to-do/san-diego-based-nonprofit-to-host-surf-therapy-event-in-mission-bay/amp/).28 The trajectory matters for MFTs weighing whether ocean-based work can scale beyond a passion project: Small's organization suggests it can, when clinical structure is built in from the start.
The organization's Groundswell Institute branch is where that structure lives. It develops accredited trainings and works to formally incorporate clinical practice standards into the broader Groundswell Surf Therapy model, giving other clinicians a credentialed pathway rather than an informal apprenticeship. For MFTs curious about this niche, the Institute represents the kind of accountable, evidence-informed infrastructure that separates a legitimate clinical adjunct from a recreational add-on.
MFTs and students in Southern California have a direct opportunity to observe the model in action. Groundswell Community Day runs Sunday, September 13, at The Point in Mission Bay, San Diego, starting at 8:30 a.m. in the Bay Room before moving to outdoor programming on the lawn. Activities include surfing, swimming, yoga, sound baths, and alternative therapy sessions open to all skill levels.
Events like this give clinicians a low-risk way to experience the model before committing to formal training, and they reflect the broader goal Groundswell has stated: expanding access to surf therapy through free community programming and scholarships for underserved and marginalized populations.
