Clinical Sport Psychology Services Based in a Doctoral Training Clinic

Transcription

1 Journal of Clinical Sport Psychology, 2007, 1, Human Kinetics, Inc. Clinical Sport Psychology Services Based in a Doctoral Training Clinic Andrew T. Wolanin La Salle University Sport psychology has become an increasingly popular area of interest for psychologists and psychology students. In addition, it has become an integral part of many collegiate and professional organizations that rely on psychological services for both performance enhancement purposes as well as mental health services. A model for delivering sport psychology services through a doctoral training clinic from a practitioner-scientist perspective will be discussed, as well as the challenges that are faced from an organizational and professional perspective. My interest in sport psychology began when, as a collegiate athlete, I sought out methods of enhancing my personal performance. As an undergraduate psychology major, it seemed that much of what I was learning about the relationship between mind and body could help with my training regimens and analyses of past performances. For example, I would consistently track my statistical performances and match it to my pregame routines and subjective mood states. I would attempt to use this data to design effective pregame routines, but without an advanced understanding of sport psychology, my self-designed interventions led more frequently to superstitious behavior than to actual performance enhancement. My formal training in sport psychology began much later, when I was a doctoral student in La Salle University s PsyD program in clinical psychology. This program offers a concentration in sport and performance psychology, and I was part of the initial cohort of three students to complete the concentration. I soon learned that the relationships between psychology and athletics are far greater than I realized as an undergraduate and that they extend well beyond performance into the day-to-day functioning and quality of life of a student-athlete. My current position as the director of a doctoral training clinic with a specialty program in evidence-based sport psychology has provided the chance to see the substantial contributions clinical psychology can make to college athletics. While not without its challenges, this program has allowed for the implementation of an effective model that integrates performance enhancement with treatment of clinical and subclinical psychological concerns. Andrew Wolanin is with the Department of Psychology at La Salle University in Philadelphia. wolanin@lasalle.edu. 270

2 Clinical Sport Psychology Services 271 Training and Professional Development La Salle s sport psychology concentration involved an effective blend of course work in sport psychology based on the Association of Applied Sport Psychology (AASP) guidelines, a 1-year, 20-hour-per-week advanced practicum with La Salle s Division I Athletic Department, and a dissertation in the domain of sport psychology. The coursework provided a solid foundation in sport psychology theories and interventions, which was enhanced by the practical experience obtained while working on practicum with the Athletic Department. The practicum experience consisted of promoting sport psychology services and forming relationships with administrators and coaches, the provision of direct service, and research with student-athletes. My initial contact person in the Athletic Department was the athletic director, who granted me access to coaches meetings and offered other opportunities to meet with coaches. Additionally, I provided life skills lectures to freshman athletes, which served as the initial contact between student-athletes and a sport psychology practitioner. Although the director of the clinical doctoral program/concentration director had already established a great relationship with the Athletic Department, gaining my own entry into the culture of the Athletic Department was the most difficult aspect of both the practicum and the subsequent development of my future sport psychology services at La Salle. The most viable point of entry into the culture was through coaches of specific athletic teams. Fortunately, I was able to design a dissertation topic that involved direct implementation of sport psychology services (Wolanin, 2005), and my initial opportunity was based on forming relationships with coaches of two programs (volleyball and field hockey) who allowed me to deliver services to their teams as part of my dissertation. Eventually, these services expanded into a full range of sport psychology services, which endured beyond the completion of my dissertation. After gaining an entry point that allowed me to provide services to these specific teams, the majority of the other teams and coaches in the Athletic Department were receptive to my involvement with their athletes. Following the year of practicum with the Division I Athletic Department and completion of my dissertation, I left the university to complete my internship training in clinical psychology. During that time, I did not have the formal opportunity to engage in the delivery of sport psychology services. I did, however, continue to stay abreast of the literature in the field while remaining involved in research and honing my clinical intervention and case conceptualization skills. Following my postdoctoral training, I was hired by La Salle University as the director of the PsyD program s training clinic and community mental health center, which is the direct service arm of the university s clinical psychology doctoral program. The primary purpose of my position as clinic director is to oversee the provision of outpatient psychological services by doctoral students to community members, as well as La Salle students and staff. Within this role, I am also involved in teaching at the graduate and undergraduate levels, supervising doctoral students, and developing a specialty practice and research programs. The specialty practice and research programs in which I have become involved are sport psychology and psychological assessment, which have a large of degree of conceptual and practical overlap. At this point, the sport psychology program has developed and maintained working relationships with many of the coaches within the Athletic Department,

3 272 Wolanin and we receive numerous referrals for athletes seeking psychological services. We have also implemented a concussion management program in collaboration with the athletic training staff, and we provide psychological assessment services (e.g., learning disability evaluation, ADHD evaluations, etc.) to athletes as needed. Finally, we engage in multiple research projects in such topics as adherence to treatment following injuries, psychological predictors of athletic success, and body image disturbances among athletes. We currently house our sport psychology program in our doctoral training clinic. This provides space to implement psychological assessments and services, as well as resources to conduct research and training programs. Our sport psychology program also provides on-site consultation and services to the Athletic Department, though it has no formal space in the Athletic Department. La Salle also has a counseling center that is dedicated to the psychological treatment of undergraduate students, including student-athletes. We have developed a collaborative relationship between our program and the counseling center, which allows us to refer athletes to the counseling center for clinical services while still providing clinical sport psychology services as needed. Theoretical Model of Clinical Sport Psychology The theoretical model of sport psychology that informs both our performance enhancement services and our clinical interventions derives from current conceptualizations of evidence-based practice in clinical psychology. The basic premise of evidence-based practice suggests that assessment, conceptualization, and interventions should have a scientific foundation that has been demonstrated through controlled investigation. In 1993, the American Psychological Association s (APA) Society of Clinical Psychology (Division 12) established a Committee on Science and Practice, which developed standards to help researchers evaluate the existing treatment literatures in their areas of expertise. This was done to provide practitioners with guidelines on selection of the most efficacious interventions (Chambless & Hollon, 1998). In addition, our model of providing sport psychology services acknowledges that collegiate athletes constitute a heterogeneous population requiring a wide range of services in accordance with the specific needs of unique individuals. This premise assumes that athletes will present with a range of functioning, including dysfunctions that hinder their performance or prevent them from reaching an optimal level of performance. To assess the different needs of athletes, we use the Multilevel Classification System for Sport Psychology (MCS-SP) to conceptualize each specific case (Gardner & Moore, 2004, 2006). The MCS-SP classifies athletes into four types of performance needs: performance development, performance dysfunction, performance impairment, and performance terminations. Performance development indicates that an athlete is psychologically healthy and could benefit from sport psychology interventions to improve or maintain his or her performance. Performance dysfunction refers to intrapersonal or interpersonal challenges (e.g., adjustment problems, developmental issues, conflict with coach or teammates, etc.) that have reduced an athlete s performance or prevented the athlete from reaching an optimal performance state. Performance impairment indicates

4 Clinical Sport Psychology Services 273 that the athlete experiences symptoms that meet criteria for psychiatric diagnosis and result in impaired functioning across a number of life domains (e.g., athletics, school, interpersonal, etc.). Finally, performance termination considers problems that occur when athletes are faced with termination of their athletic career. This condition may be due to injury, burnout, being cut from a team, or simply coming to the end of the collegiate career with no future athletic options. A final but equally important component of our model for providing clinical and sport psychology interventions is continual assessment of effectiveness through the use of structured outcome measures. During the initial assessment with an athlete, we use a battery of structured assessments that allows us to identify the appropriate MCS-SP classification level, conceptualize and understand potential dysfunction, and obtain a baseline of the individual s preintervention level of functioning. This assessment battery consists of structured self-report measures designed to discover why an athlete is seeking services, as well as measures of symptom distress, measures pertaining to possible mechanisms of change, and measures of an athlete s overall functioning (see Figure 1). A specific self-report measure is used to identify the reasons that an athlete is seeking services based on the MCS-SP criteria. Other clinical self-report measures, including the Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990), the Beck Depression Inventory-Second Edition (BDI-II; Beck, Steer, & Brown, 1996), and the Beck Anxiety Inventory (BAI; Beck & Steer, 1990) are used to help determine if clinical or subclinical psychological symptoms are present. One of the most common subclinical forms of distress that we see among student-athletes is a high level of worry that causes distress but does not meet sufficient criteria for diagnosis of generalized anxiety disorder. In addition to these measures, we also use the Action and Acceptance Questionnaire-Second Edition (AAQ-II; Hayes et al., 2004) and the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R; Hayes & Feldman, 2004) to understand possible mechanisms of change. These measures examine psychological flexibility and the ability to be present-moment-focused, both of which are viewed as key variables in our understanding of optimal athletic performance. Finally, the Sport Performance Questionnaire (SPQ) and Quality of Athletic Life Inventory (QOALI; adapted from the Quality of Life Inventory) are two experimental measures that I developed to understand change in athletes across sports (Wolanin, 2005). The SPQ is a self-report measure indicating overall performance level as well as functioning in regard to specific components of a performance (e.g., concentration, aggressiveness, endurance, etc.). It may be completed by the athlete and/or his or her coach. The QOALI is designed to assess an athlete s level of satisfaction with his or her overall athletic environment, including teammates, coaches, facilities, and so forth. This battery is given during the initial contact with the athlete and repeated after every four meetings, as well as at the completion of any intervention that is done with the athlete. While the clinical sport psychology assessment battery is designed for practical clinical applications, it also facilitates standardized research on interventions, relationships between constructs, and the development of measures. The assessment battery generally serves our needs well, but there are some concerns about its use that should be noted. First, it takes time to administer and complete, which adds time to meetings with athletes and could potentially decrease an athlete s motivation

5 274 Wolanin Figure 1 Sport psychology assessment battery. to seek services. Furthermore, there is an ethical dilemma inherent in discussing whether an athlete desires his or her coach to complete the SPQ. In some cases, the athlete is comfortable having the coach as a participant in the assessment. In many cases, however, the athlete desires confidentiality regarding the services they are seeking, making it impossible to obtain SPQ ratings from the coach. The overall sport psychology model, including conceptualization, assessment, and treatment, provides a straightforward framework for the services that we provide. The framework consists of three steps (see Figure 2): (a) identify the classification level and presenting problem of the athlete; (b) identify the empirically based intervention (i.e., performance enhancement or clinical intervention) appropriate for the identified concern; and (c) implement the intervention and assess the effectiveness of the intervention. This sequence of assessment and intervention should be viewed as an ongoing cycle, which continues to inform selection of the most appropriate intervention and course of action. For athletes who are functioning at the performance development level according to the MCS-SP, our program typically employs the Mindfulness-Acceptance- Commitment (MAC) protocol for performance enhancement (Gardner & Moore,

6 Clinical Sport Psychology Services 275 Figure 2 Clinical sport psychology assessment and intervention cycle. 2006, 2007). This protocol includes five components that are combined into an intervention package. The educational process of MAC involves a discussion of the self-regulatory process, as well as the experiences athletes have had with their personal performances. Clients are encouraged to become aware of the contingencies of their internal processes and educated about the consequences of their efforts to control their internal experiences. Expanding on this educational component, the athletes are introduced to mindfulness as a variable of their athletic performance. They are taught mindfulness techniques to increase their awareness of their internal states and to enhance nonjudging, in-the-moment attention. The concept of psychological acceptance and flexibility is introduced through the use of cognitive defusion, which aims to disconnect the learned connections between thoughts, feelings, and behaviors. Finally, athletes receive instruction about the benefits of basing their behavior on their values rather than on specific achievement-related criteria or the momentary alleviation of uncomfortable internal states. Athletes who are assessed as belonging at the performance dysfunction level (i.e., subclinical dysfunction) receive an evidence-based clinical intervention that is targeted at their identified problem. For example, consider that an athlete reports

7 276 Wolanin high levels of worry that are hindering performance and preventing the athlete from engaging in training with the coach. Based on the underlying mechanism of the dysfunction (i.e., worry), we would use an evidence-based intervention for generalized anxiety disorder (GAD). Although the athlete s condition is subclinical, a manualized cognitive-behavioral therapy for GAD, such as Mastery of Your Anxiety and Worry (Craske & Barlow, 2006), could effectively reduce worry behavior and allow the athlete to achieve desired performance levels. In many cases, we will integrate athletics into the treatment as platforms for behavioral activities and self-monitoring, but the targeted goal of the intervention is not solely athletic performance enhancement. When an athlete is identified to be at the performance impairment level, our focus is to provide a clinical intervention that is not tied to performance enhancement in any way. When we identify a clear clinical problem, we inform the athlete that they have the option of either using the PsyD program s psychological service clinic or the University s student counseling center for services (see Figure 3). Student-athletes will in many cases receive clinical services at our training clinic if they are appropriate for a specialty treatment that we offer (e.g., anger dysregulation, anxiety, etc.) or if for various reasons they choose not to receive services at the University s student counseling center. If our sport psychology program does deliver services for a clinical problem, we use evidence-based treatments that are specifically targeted for the identified problem. Athletes who are at the performance termination level (due to injury or retirement, etc.) may be appropriate for a wide range of interventions. When an athlete is struggling with an injury, our first course of action is referral and consultation with the athletic trainers (see Figure 3). Secondly, however, we may provide an intervention to aid the athlete in effectively coping with the injury, or if necessary, adjusting to life without athletics. When possible, we provide proactive life skills sessions to athletes who are ending their college careers in order to reduce maladaptive adjustment to life without structured athletics. Finally, when assisting coaches with a management issue, we generally use behavioral management strategies that are based on traditional learning theory (e.g., reinforcement contingencies, modeling, and so forth) to aid them in achieving a desired outcome with their athletes. Additionally, we serve as consultants to help coaches manage individual athletes and ensure appropriate referrals within the University. Since the sport psychology program is housed in the doctoral training clinic, we have the opportunity to combine our practice, training, and research programs in a manner that allows each program to influence the other two. Since we take a strong empirical stance on assessment and intervention, we are consistently focused on understanding the effectiveness of our interventions and developing research protocols that allow us to advance the empirical understanding of our work. A Good Day s Work My typical day at La Salle includes directing the doctoral training clinic, providing supervision to doctoral students, teaching, conducting assessments, and delivering direct services to athletes and coaches (see Figure 4). I generally conceptualize my day as having two components: scheduled, structured activities and unscheduled

8 Clinical Sport Psychology Services 277 Figure 3 Sport psychology services decision tree. activities. Structured activities that typically occur are teaching sport psychology, supervision, and providing direct sport psychology services. Teaching undergraduate sport psychology courses is an important part of my role as a clinical sport psychologist. It allows me to integrate sport psychology into the University as a whole, and to engage with many student-athletes who enroll in the course. I have found that offering a sport psychology course helps normalize the idea of sport psychology services and increases the receptiveness of student-athletes who may consider seeking assistance or referring a friend. For example, many of the individual sport psychology referrals are facilitated by student-athletes who had previously taken the sport psychology course. Their involvement in the course allowed them to both see the possible benefits of sports psychology services and suggest sport psychology services to teammates and coaches. Regarding supervision, I have set times to meet with doctoral students who are providing clinical or sport psychology services, as well as students who are engaging in research

9 278 Wolanin Figure 4 Typical activities involved in providing clinical sport psychology services. protocols. My structured direct clinical sport psychology services involve weekly meetings with coaches, teams, and individual athletes and providing concussion management assessments. Unstructured activities generally involve impromptu supervision of direct sport psychology services, as well as meeting with coaches, administrative activities, and attending athletic events. Impromptu supervision revolves around the direct services that trainees are providing, as well as ongoing research studies. This type of supervision may consist of watching a video of an intervention session, discussing statistical procedures, or reviewing assessment results. Many of the clinical sport psychology services that I deliver to coaches and athletes occur according to their needs and timing rather than on my schedule. Examples of these types of impromptu situations would be a call from a coach who is managing an athlete with clinical concerns or from an athlete who wants to discuss performance after the team s latest game. In some circumstances, coaches and athletes need on-thespot education about sport psychology services in order to modify unreasonable

10 Clinical Sport Psychology Services 279 expectations. For example, if a coach has been having difficulty with a player over the course of a season, asking for significant behavioral changes one week before the postseason in not typically a viable request. Educating coaches and players about realistic outcomes from sport psychology interventions is also important to reduce dissatisfaction and facilitate positive working relationships. Additionally, one of the most important unstructured activities is finding time to watch athletic events and spend time in the Athletic Department. I believe that it is critical to involve myself in the culture of the Athletic Department as a whole and to be truly invested in the health and success of the student-athletes and coaches with whom I work. Rewards and Challenges Engaging in the delivery of clinical sport psychology services is one of the most interesting and enjoyable aspects of my position, but it comes with a unique set of challenges. First, I believe it is impossible to separate performance dysfunction from an athlete s overall dysfunction. Consequently, I have found that my training as a clinical psychologist has been more important than my training in sport psychology theory and interventions. If I had been asked 10 years ago what I would be doing as the sport psychologist for a university, I would have assumed I would be providing performance enhancement techniques, such as guided imagery interventions to improve free throw shooting. The reality, however, is that only a minority of student-athletes who seek services are appropriate for performancefocused interventions. The majority require psychological interventions for clinical or subclinical concerns. The personal challenge that I have faced regarding this issue is how to develop an identity as a clinical sport psychologist given the realities and demands of the services that I provide, as opposed to the assumptions with which I began my training. An organizational challenge that influences my work is the separation (both physical and organizational) between the training clinic and the Athletic Department. In order to develop working relationships with coaches and administrators in the Athletic Department, I must find time to make formal and informal meetings to discuss our services. This time requirement forces me to juggle multiple responsibilities and to increase daily structure as much as possible. Furthermore, communication structures make it difficult, from an organizational perspective, to ensure that our services are being utilized effectively. Creating space on the Athletic Department s website has improved the accessibility of our services, but maintaining a presence within the culture of the Athletic Department requires persistent effort. Finally, there is a considerable challenge to providing a high level of service to the Athletic Department with a staff consisting of doctoral trainees. Typically, each trainee will complete a one-year sport psychology advanced practicum during which he or she is available for 20 hours per week. This reliance on practicum students means that the services we provide to the Athletic Department are delivered by students with variable levels of expertise. Often, students complete their practicum just at the same point that they have developed effective working relationships. Because of these constraints, maintaining quality service is a top priority and, depending upon the availability and skill of practicum students, requires different levels of effort and involvement over the course of a typical year.

11 280 Wolanin I firmly believe that the success of this sport psychology program is based on our ability to form positive working relationships with the Athletic Department personnel. I conceptualize our clinical sport psychology services as a means of increasing student-athlete functioning both on and off the field, as well as making the work of the Athletic Department staff more enjoyable, successful, and interesting. Keeping this idea in mind provides ongoing motivation to develop and enhance our clinical sport psychology program and to train future clinical sport psychologists. References Beck, A.T., & Steer, R.A. (1990). Manual for the Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation. Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory (2nd ed.). San Antonio: The Psychological Corporation. Chambless, D.L., & Hollon, S.D. (1998). Defining empirically supported therapies. Journal of Clinical and Consulting Psychology, 66, Craske, M.G., & Barlow, D.H. (2006). Mastery of your anxiety and worry. New York: Oxford University Press. Gardner, F.L., & Moore, Z.E. (2004). The multi-level classification system for sport psychology (MCS-SP). Sport Psychologist, 18, Gardner, F.L., & Moore, Z.E. (2006). Clinical sport psychology. Champaign, IL: Human Kinetics. Gardner, F. L., & Moore, Z.E. (2007). The psychology of enhancing human performance: The Mindfulness-Acceptance-Commitment (MAC) approach. New York: Springer Publishing. Hayes, A.M., & Feldman, G. (2004). Clarifying the construct of mindfulness in the context of emotional regulation and the process of change in therapy. Clinical Psychology: Science and Practice, 11, Hayes, S.C., Strosahl, K., Wilson, K.G., Bissett, R.T., Pistorello, J., Toarmino, D., et al. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, Meyer, T.J., Miller, M.L., Metzger, R.L., & Borkovec, T.D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, Wolanin, A.T. (2005) Mindfulness-acceptance-commitment (MAC) based performance enhancement for Division I collegiate athletes: A preliminary investigation. Dissertation Abstracts International, 65, (7-B), 3735.