Psychology and The Athletic Trainer

1. Psychology and The Athletic Trainer Bradley T. Klontz, Psy.D.

2. Dr. Brad Athlete High School Tennis Coach DOE Contracted Mental Health Provider Clinical Psychologist Certified Substance Abuse Counselor Consultant Researcher/Author

3. Agenda Psychological factors in Athletic Injuries Imagery to promote healing and enhance performance Pain Management The Athletic Trainer as Counselor

4. Inured Athletes Score higher on all life stress factors and competitive anxiety, and lower on coping resources than uninjured players (Blackwell & McCullagh, 1990; Journal of Athletic Training) High competitive anxiety and tension/anxiety associated with rate of injury; High tension/anxiety, anger/hostility and total negative mood state associated with severity of injury (Lavallee & Flint, 1996; Journal of Athletic Training)

5. Stress and Athletic Injuries Personality Stressors Coping Resources Stress Response Injury Interventions (Anderson & Williams, 1988)

6. Stress Response ? Heart Rate, ? Breathing, ? Muscle Tension, ? Metabolism, ? Blood Pressure, ? Blood Sugar Improved hearing and narrowed vision ? Digestion, ? Growth, ? Tissue Repair, ? Immune System

7. Stress Response Injury Stress and/or negative mood state? muscle tension and physical and mental fatigue ? reduced flexibility ? injury Stress ? narrowed attentional field ? failure to pick up important environmental cues to avoid injury ? injury

8. Interventions Prevention – Instruct or refer for assistance in psychological preventive interventions Cognitive - Reduce Cognitive Appraisal of Stress by challenging distorted thinking and putting things in perspective Physiological- Interventions for the attentional and physiological aspects of the stress response, such as relaxation training and imagery

9. Suggested Reading “The Relaxation & Stress Reduction Workbook, 5th edition”- (2000); Davis, Eshelman & McKay “Full Catastrophe Living: Using the wisdom of your body and mind to face stress, pain and illness”- (1990); Kabat-Zinn

10. Imagery Imagery research to enhance performance in sports since 1930’s Allows person to focus on particular physical behavior or skill and to mentally practice that task or skill Imagery and actual experience trigger similar neurophysiological functions Research ? ? immune system, ? recovery time, ? blood flow to injured area, cancer, reduces pain-stress, reduced pain and anxiety,

11. Imagery to promote healing and enhance performance while injured Teach athletes to think constructively and not destructively when dealing with injury management Allows athlete to cope better with pain Speeds the recovery process Keeps Physical Skills from deteriorating Used in conjunction with other rehabilitation techniques

12. Therapeutic Imagery and Athletic Injuries Richardson & Latuda (1995); Journal of Athletic Training Introduce to Athlete- will not guarantee full recovery; used by many famous athletes to improve skills and recover from injuries Relaxed before imaging Quiet setting Injury Imagery, Skill Imagery, Injury Rehabilitation

13. Injury Imagery Explain in detail what injury entails. Show picture with muscles, ligaments and bones involved in injury “I want you to close your eyes and picture your knee. Now I want you to bring into focus the area that is injured. Picture the x-ray and the unattached ligaments. Once you have these in focus, concentrate on one ligament at a time.” When athlete has image in mind, explain the rehabilitation process- include exercises to be done, conditioning, and a target date for returning to the sport.

14. Injury Imagery cont. “Now I want you to visualize your knee. See the torn ligaments growing back onto the bone. Feel the ligaments growing and see the knee with all parts completely attached.” Athlete should engage in this process 5 minutes, 3 times a day.

15. Skill Imagery Athlete should attend all team meetings, practices and games. Should observe plays and strategies. After practice exercise: “Imagine yourself physically going through the plays in your mind. Take one play at a time but experience all aspects of the play. Then add to the mind-practice, going through the plays with teammates and/or opponents. Go through each play one at a time, just as you saw it practiced on the field.”

16. Injury Rehabilitation After athlete has practiced injury imagery and skill imagery for 1 week, progress to rehabilitation imagery. “I want you to picture your knew where the ligaments are now mending to the bone. You have done a good job in attaching these ligaments in your mind. Now picture your knee completely healed. Mentally raise your knee a couple of inches: now bring it back down. Move it up again and let it back down slowly. I want you to feel the knee raising comfortably.”

17. Injury Rehabilitation, cont. The athlete should go through this exercise for about 10 minutes 3 times a day. Slowly progress with lifting the knee with each imagery session. After approximately 1 week, alter the imagery exercise so the athlete is walking with little discomfort to the knee.

18. Pain Management Under conditions of stress, patients become very susceptible to suggestions Statements by persons of authority directly involved in their care are particularly powerful Words can have powerful detrimental or facilitative effects Suggestibility can be used therapeutically to the patient’s benefit

19. Study “Sensory Information Can Decrease Cold-Induced Pain Perception” Streator, et. al. (1995); Journal of Athletic Training ? anxiety ? ? pain Sensory information ? ? pain Without predictions as to what they will feel and experience ? ? apprehension ? ? pain

20. Suggestions for Suggestions Watch your language. “Tell me when you start hurting.” vs. “Let me know how I can make you more comfortable.” Increasing suggestibility = 2-4 verifiable statements followed by suggestion = “Your knee is hurting badly, you are worried about what will happen, you are breathing very quickly, you are now in good hands and now you can begin to slow your breathing down…” Alter meaning of pain ? “The pain you feel is important because it let us know that something is wrong. We know that now and now or in a few minutes the discomfort can begin to become less intense.”

21. Suggestions for Suggestions, cont. Manipulate intensity of pain ? “See in your mind’s eye a dimmer switch and identify where on that scale you pain is– perhaps at a 9 or 10, and the light is very bright. Remember you are in control now and can turn that switch down as far as possible- perhaps to a 5 or 4 or event to a 3 or 1. The light is much dimmer now and the level of discomfort is less and less.” Imagery as Distraction – “We are here to take care of you so put your mind at rest. Now, I want you to picture yourself on your favorite beach. Imagine the wind in your hair, the feel of the sun on you back, the sand between your toes, the sound of the waves…”

22. The Athletic Trainer as Counselor Daily availability Role as health care providers Relationships build on trust

23. National Survey- 1996 Injury Prevention Injury Rehabilitation Nutrition. Racial Issues Suicide Financial Issues Family Matters Relationship Issues Sexual Issues Alcohol Problems Journal of Athletic Training

24. Psychological Reactions to Injury Identity Loss Fear and Anxiety Lack of confidence Performance decrements

25. Suicide Suicide is the 2nd leading cause of death for those aged 15-24 Studies have shown that post injury mood disturbance is common, particularly in more serious injuries Risk factors for suicide = stressful life events, chronic mental illness/psychiatric disorder, family history of suicide

26. Common Factors in Attempted Suicides of Injured Athletes Serious injury that requires surgical intervention Long, arduous rehabilitation that restricted participation in sport for 6 weeks to 1 year Experienced a deterioration in their athletic skills despite adherence to a vigorous rehabilitation program Felt they lacked their pre-injury competence on return to the sport Replaced in their positions by teammates, a devastating blow to self-esteem Smith & Milliner (1994); Journal of Athletic Training

27. Assessment When concerned ? ERAIQ (Emotional Responses of Athletes to Injury Questionnaire) (Smith, Scott & Weiss, 1990- Sports Medicine) Look for signs of Depression ? changes in sleeping or eating patterns, irritability, poor hygiene, trouble concentrating, agitation, fatigue, feelings or worthlessness, social isolation, no pleasure in activities, thoughts of death, pessimistic view of future

28. Intervention Ask about potential risk factors (relationship/family problems) Ask if he or she has ever attempted suicide Ask if they think about suicide now. How frequently? Do they have a plan? Do they have the means to carry it out? What would keep him or her from carrying it out? Encourage youth to seek counseling Make Referral

29. Mandated Reporters? Child abuse or neglect “the acts or omissions of any person who… is in any manner or degree related to the child, is residing with the child, or is otherwise responsible for the child’s care, that have resulted in the physical or psychological health or welfare of the child, who is under the age of eighteen, to be harmed, or to be subject to any reasonable foreseeable, substantial risk of being harmed”… Physical abuse; sexual contact or conduct; injury to the psychological capacity; not provided in a timely manner with adequate food; clothing; shelter; psychological care; physical care; medical care, or supervision; or child is provided with dangerous, harmful or detrimental drugs (non-prescribed)

30. Mandated Reporters, cont. Reason to believe that child abuse or neglect will occur in the reasonably foreseeable future- report immediately If relative or in the home- Child Welfare Services Outside of the home and non-relative- Police Must follow-up in writing If in doubt, call with a “Hypothetical”

31. Other Issues Age of Sexual Consent = 16 Gap provision- If under age 16 & 5 years age difference = criminal. (Age 19 prohibited from 14; Age 20 prohibited from 15) Drugs/Alcohol- Referral to Counselor and/or Hina Mauka