What Is Clinical Sport Psychology?

What Is Clinical Sport Psychology?

   Clinical sport psychology is an approach to treating athlete performance difficulties and increasing athlete well-being. It was developed by psychologists Frank Gardner and Zella Moore and is presented in their books Psychology of Enhancing Human Performance and Clinical Sport Psychology, as well as numerous articles.

   Clinical sport psychology is a holistic approach to working with athletes which emphasizes client development of: (1) acceptance of internal experiences; (2) attention that is present oriented and non-judgmental; and (3)behavior that integrates short-term athletic performance needs with long-term athletic goals.

   It is holistic because it operates from the perspective that client functioning cannot be neatly categorized as being “clinical” or as “sport” related, but that each athlete-client’s situation is a unique combination of performance, psycho-social, developmental and other other contextual factors. Clinical sport psychology is based on a movement in behavioral psychology known as third wave behaviorism. It also utilizes elements of schema therapy which is an approach that integrates cognitive-behavioral, object-relations, and gestalt ideas and was developed for clinical work with severe and persistent, multi-problem clients.

   Clinical sport psychology is based on a theory of functional and dysfunctional athletic performance which is called the integrated model of athletic performance. This model is based on empirically supported models of human sexual performance and general social performance as well as additional empirical findings in sport psychology, self-regulation, and non-athletic human performance. It is also based on a theoretical model of self-regulation. Self-regulation is the capacity for metacognitve (reflective/mindful) thought processes in the service of increasing the effectiveness of behavior. Metacognition is a psychological state in which internal experiences are conceptualized in broad, distal terms that foster a sense of choice regarding one’s behavioral repertoire. As psychiatrist Viktor Frankl eloquently wrote, “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response is our growth and freedom.” The integrated model of athletic performance proposes that, in order to perform optimally, it is important to direct attention towards task relevant, in the moment, external factors as opposed to self-judgmental, worrisome, and future oriented cognitive content.

   An important aspect of this model is the concept of experiential avoidance. Experiential avoidance is the attempted  avoidance, escape, or decrease of behavioral or cognitive experience, often as a means of regulating affect. Research suggests that most, if not all, psychological or psychiatric disorders can be conceptualized as serving the function of experiential avoidance. Similarly, clinical sport psychology proposes that experiential avoidance functions as a mediator of athlete performance and overall athlete well-being.

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If attempts at experiential avoidance are made, the following cognitive process is believed to occur: The attempt to suppress negative cognitive or affective content triggers a metacognitive form of scanning for negative internal content. This action is ironically intended to bring into awareness any negative content that is simultaneously trying to be avoided – the mind is actually trying to find the same content it is trying to avoid. When this happens, focus is diverted from external stimuli toward internal stimuli and behavioral repertoires (and subsequent athletic performance) decrease in effectiveness.

Clinical sport psychology relies heavily on assessment of athlete difficulties as a means of determining appropriate treatment. Athlete-client difficulties are conceptualized as being either: (1)  the non-clinical need for performance enhancement tools; (2) sub-clinical levels of psycho-social difficulty that may or may not impact performance; (3) clinical problems that severely impact psycho-social functioning and may or may not impact performance or (4) issues of sport termination.

   The theory of clinical sport psychology has been applied in the development of a technical approach called the mindfulness-acceptance-commitment (MAC) approach to performance enhancement. Although the MAC approach is technically a psychological skills training program, it does not focus on controlling internal experiences as do most psychological skills training approaches. The MAC approach is based on acceptance and commitment therapy and mindfulness-based cognitive therapy.  As previously mentioned, the scientific literature suggests that optimal performance is facilitated by a psychological state that includes a specific form of attention: attention that is focused on task-relevant cues, in-the-moment contingencies, and not toward self-judging, threat scanning, and future oriented cognitive activity. However, most traditional psychological skills training approaches contradict this metacognitive approach associated with optimal human performance. From the perspective of an acceptance model of psychological functioning, it is counter-productive to label internal experiences as positive or negative and even more so to try to control them (which is the goal of traditional psychological skills training.) Alternatively, acceptance-based models promote a way of experiencing the world in which internal experiences are considered to be naturally occurring phenomenon that do not have to be labeled, evaluated, or controlled. In fact, attempts to control internal experiences may contribute to the development of hypervigilane to internal processes associated with threat scanning – just the recipe for dysfunctional performance according to the integrated model of athletic performance. From this perspective, traditional psychological skills training techniques may in fact trigger attentional focus that is task-irrelevant and subsequently disrupt the self-regulation process as well as the functionality of performance. Research on psychological skills training in sport suggests that reducing negative internal processes that are assumed  to mediate performance (such as anxiety and negative cognition) and increasing other assumed mediating variables (such as confidence) do not significantly increase athletic performance.

The therapeutic action of the MAC program occurs via: (1) enhanced attentional awarenes; (2) non-judgmental, task-focused attentional focus; and (3) behavioral flexibility.

   This is accomplished by developing effective self-regulation and values-directed behavior. Effective self-regulation can improve practice and training quality, competitive performance, and athletic enjoyment. Values-directed behavior is a concept associated with acceptance and commitment therapy which means engaging in a life that is vital and meaningful according to one’s unique beliefs about what is truly important. Examples of values-directed athletic behaviors are: (1) sport specific behaviors for which the athlete is adequately prepared; (2) working to improve performance; and (3) experiencing enjoyment in a non-attached manner.

   It is important to remember that the MAC program is a performance enhancement tool that is appropriate for use with certain athlete-clients. These clients -- based on a thorough assessment of their clinical and performance needs -- are deemed psycho-socially successful enough such that the work can appropriately deviate from using more clinical interventions. This does not mean that clients have to be free of all problems in living in order to be candidates for the program. It means that clients with moderate to severe pathology would be more appropriately treated with more clinically oriented interventions. In many cases, these clinical interventions then serve as inadvertent performance enhancement tools due to an increase in overall functioning.

The MAC program follows an intervention protocol which consists of five phases. The phases are: education phase, mindfulness phase, values identification and commitment phase, acceptance phase, and integration and practice phase.

The education phase includes: (1) providing the client with a rationale for the intervention; (2) introducing the relationship between self-regulation and athletic performance; (3) discussing the athlete-client’s prior performances; (4) explaining the concept of experiential avoidance and its relationship to traditional forms of self-regulation; and (5) introducing early cue detection which is the capacity to understand which internal and external events are as triggers for specific patterns of behavior.

The mindfulness phase includes: (1) introducing the concept of mindfulness; (2) discussing the utility of mindfulness for facilitating the psychological state associated with increased performance; (3) teaching mindfulness techniques; (4) contrasting mindfulness with habitual, automatic tendencies to attempt to avoid negative internal experiences; and (5) teaching attention/refocusing skills.

The values identification and commitment phase includes (1) introducing the concepts of values; (2) helping clients determine their values; (3) fostering clients’ use of behaviors that reflect their values; (4) connecting these concepts to both athletic and personal domains; and (5) introducing the concept of cognitive defusion which is the distancing of one’s behavioral repertoire from arbitrary rules.

The acceptance phase includes: (1) enhancing the capacity to connect thoughts, feelings, and behaviors; (2) introducing rule-governed behavior in order to promote cognitive defusion; (3) discussing the negative impact language can have on performance; and (4) integrating the ideas from each of the phases into a comprehensive package of theoretical knowledge and practical skills.

The integration and practice phase includes: (1) promoting the use of the previously learned ideas and skills and (2) addressing related problems or concerns.

My practice is influenced by clinical sport psychology and the MAC approach. I have found that each of my athlete-clients differs in his or her need for focus on interpersonal/intrapsychic dynamics or performance issues and that these needs fluctuate throughout treatment. I have also found that interpersonal/intrapsychic and performance issues can influence and symbolize each other. An awareness of these dialectics promotes avenues of communication and influences my treatment conceptualizations and technique to best serve my athlete-clients.