Explaining how, why, for whom and when surf therapy improves mental health and wellbeing in adults: a realist synthesis

Background Nature-based therapies and physical activity are suggested to complement existing mental health therapies; surf therapy combines nature exposure and physical activity. Studies investigate the mechanisms underpinning surf therapy, however, no analysis systematically connects intervention contexts, mechanisms and outcomes, and therefore, the ability to design, implement and evaluate surf therapy programmes is limited. To fill this gap, this realist review aimed to synthesise the causal pathways of change to explain for whom, in what circumstances, how, and why surf therapy supports mental health and wellbeing.Methods Ten databases were searched. Included studies were used to develop Context, Intervention, Mechanism, Outcome configurations (CIMOs).Results Forty-four articles were included. Studies included general and clinical populations attending surf therapy. A surf therapy continuum was proposed to recognise the diversity in programme structures. Additionally, seven pathways of change were developed: circumventing stigma, self-efficacy, respite, positive social connection, positive self-narrative change, metaphor and safe space. Safe space was positioned as a moderator of other pathways.Conclusion Surf therapy operates through multiple mechanistic pathways that support mental health and wellbeing. While many mechanisms overlap with other nature-based and physical activity interventions, surf therapy may be particularly appropriate where both restorative and mastery oriented processes are desired.