Content uploaded by Stephen Mellalieu
Author content
All content in this area was uploaded by Stephen Mellalieu on Jul 26, 2015
Content may be subject to copyright.
David A. Shearer is with the Department of Psychology, Education, and Careers at the University of
Glamorgan, UK; Stephen D. Mellalieu is with Sports Science, School of Engineering, Swansea
University, UK; Catherine R. Shearer is with Sport Wales, Welsh Institute of Sport, Cardiff, UK.
Shearer et al. PTSD in an Elite Rifle Shooter
Posttraumatic Stress Disorder in an Elite
Athlete: A Case Study of an Elite Rifle
Shooter
David A. Shearer
University of Glamorgan, UK
Stephen D. Mellalieu
Swansea University, UK
Catherine R. Shearer
Sport Wales, UK
While posttraumatic stress disorder (PTSD) is most commonly associated with
survivors of traumatic events (e.g., combat), PTSD can occur after any situation in
which victims perceive that their life or safety is threatened. In sport, athletes
often place themselves in dangerous situations and are also exposed to the same
lifestyle dangers as the general population. The literature on PTSD among athletes
is sparse, and consequently, it is possible that many (non-clinical) sport
psychologists would fail to recognize the symptoms and may subsequently fail to
refer the athlete to the appropriate professional for clinical assistance. In the
following case study, we present an example of an athlete suffering from PTSD
following a serious bicycle accident in which she sustained head and facial
injuries. We briefly detail the nature of PTSD and discuss how sport psychology
services can be implemented alongside a parallel clinical intervention program.
Finally, we offer recommendations for practice when working with athletes with
PTSD.
Keywords: PTSD, athlete, sport, trauma, case study
Posttraumatic stress disorder (PTSD) has received considerable attention in the
media, due in part to the current military actions in countries like Afghanistan and
Iraq. According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR), PTSD is an anxiety-based disorder that can develop following an
event that meets two specific criteria. First, the individual encounters or witnesses an
incident that involves threatened or actual death, serious injury, or a physical threat
to the self or others (criterion A1). Second, during the event, the individual
experiences feelings of fear, helplessness, and horror (criterion A2). After the
traumatic event, these experiences typically result in symptoms such as flashbacks,
nightmares, psychological distress, and physiological reactivity to certain stimuli
(criterion B). In addition, the traumatic experience often results in numbing reactions
and the avoidance of stimuli that are in some way related to the event (criterion C)
and symptoms of heightened arousal including irritability, hypervigilance, and
concentration and sleep difficulties (criterion D; American Psychiatric Association,
APA, 2000).
It is often wrongly assumed that PTSD is reserved only for those who see and
experience life-threatening events. Given that safety is individually perceived,
however, this means that many negative and/or overwhelming “events” could
potentially lead to PTSD. Incidence rates for PTSD indicate that 20.4% of women
and 8.2% of men are likely to develop PTSD after a traumatic event (Resick &
Calhoun, 2001). In sport, athletes often place themselves in situation where their
safety is threatened, both while competing (e.g., a serious injury) and in their daily
lives (e.g., a car crash). Therefore, there is a strong likelihood that sport
psychologists will encounter an athlete with PTSD at some point during their careers
(Gardner & Moore, 2006).
Under the professional practicing guidelines of the American Psychological
Association (APA) and the British Psychological Society (BPS), licensed/chartered
sport psychologists are required to work within their boundaries of competence
(APA Ethical Principles of Psychologists and Code of Conduct, 2010; BPS Generic
Practicing Guidelines, 2008). That is, unless clinically trained, sport psychologists
should always refer clinical issues encountered to a specialist with the licensure and
experience to deal with such issues (e.g., a clinical or counseling psychologist; see
Gardner & Moore, 2006, p. 206). Along with this sound ethical imperative, the sport
psychologist can, in many cases, continue providing parallel support to that athlete
alongside the clinical specialist. Andersen and Van Raalte (2005) have discussed
some of the benefits (i.e., comprehensive care) and costs (i.e., funding issues) of
parallel support, but the literature goes little beyond this discussion. Parallel support
may be particularly important for clients whose clinical issues are not debilitating
enough to require withdrawal from highly competitive training and competition. For
example, athletes who have mild clinical levels of mood or anxiety disorders may
reasonably continue to train and compete if they so choose; however, when
individuals suffer from PTSD, even if the anxiety centers on a trauma outside the
sport, the symptoms they experience will likely affect all aspects of their lives,
including their sport (cf., Royal College of Psychiatrists, 2010). For this reason, it is
important for the sport psychologist to consult with the clinical practitioner and take
into account the etiology and symptoms of the specific clinical issues. To our
knowledge, there are few full accounts of how sport psychologists have worked in
parallel with clinical psychologists and reflections on how these instances impact
upon practice (see Andersen & Van Raalte, 2005; Gardner & Moore, 2006). For this
reason, the aim of the present case study is to provide an account of sport
psychology support provided to an elite female athlete suffering from PTSD.
Initially, we outline the background of the athlete and the circumstances behind her
clinical diagnosis. Following this, we describe the clinical intervention that was used
by the clinical neuropsychologist, followed by a summary of meetings and
interventions that were carried out by the sport psychologist in parallel with the
clinical treatment. Finally, we offer reflections on working with athletes with clinical
issues such as PTSD and provide suggestions for practice.
Case Study
The Athlete
Jane is a 21-year old female who shoots in an international target sport squad (name
changed to protect client’s anonymity; all other details provided with the athlete’s
consent). The first author (herein referred to as “sport psychologist”) had provided
psychological support to Jane for two years as the national squad sport psychologist,
working mostly on mental skills training, including goal setting, imagery, and
distraction techniques. Jane began suffering from PTSD symptomatology following
an accident on her bicycle, in which she sustained mild brain trauma (see Kennedy et
al., 2007 for a review of PTSD in these circumstances). After a number of CT brain
scans immediately after the accident, it was confirmed that there was no lasting brain
damage; however, some months after the accident, Jane was still experiencing a
number of psychological symptoms, including anxiety, flashbacks, strong
headaches, and feelings of general fatigue. Diagnosis of these symptoms was
complex, as the symptoms Jane experienced are similar to those of both post -
concussion syndrome and PTSD. According to the DSM-IV-TR criteria, however,
the onset of PTSD can be delayed for some time following the trauma (APA, 2000).
Therefore, following referral by a neurosurgeon to a clinical neuropsychologist,
post-concussion syndrome was ruled out, and she was diagnosed with PTSD and
treated by him to resolve the disorder (see description of the treatment below). After
consulting with the clinical neuropsychologist, the sport psychologist agreed to
provide parallel support to Jane in order to maximize her chances of returning to
international competition. Indeed, part of Jane’s anxiety reflected her worries that
she would never be able to return to full international competition as a rifle shooter
as a result of her headaches and faltering concentration levels (see case assessment
below).
Clinical Intervention
The literature concerning the treatment of PTSD is extensive (see Foa, Keane, &
Friedman, 2000; Resick & Calhoun, 2001). Empirically supported therapies include
trauma-focused cognitive behavioral therapy (TF-CBT), group CBT, stress
management therapy, and cognitive processing therapy (CPT). Of these treatments,
TF-CBT and CPT have garnered the most empirical support (Foa et al., 2000;
Gardner & Moore, 2006; Resick & Calhoun, 2001) and are considered first-line
interventions for this challenging clinical phenomenon. Therefore, the clinical
neuropsychologist assigned to work with Jane engaged in trauma-focused cognitive
behavioral therapy (TF-CBT). In TF-CBT (and CPT as well), PTSD is most often
treated with a combination of imaginal exposure, cognitive restructuring, and in vivo
exposure (see, for example Ehlers, Clark, Hackmann, McManus, & Fennell, 2005).
With imaginal exposure, the client is asked to imagine/re-imagine the event in which
the trauma occurred, with the aim of processing the emotional event fully and over
time, lessening the emotional and physiological responses. In its simplest form, the
images, cognitions, and physiological states associated with the traumatic event are
re-experienced (exposure) in a sequential and directed manner over a number of
sessions. The imagery, however, can also be rescripted to provide the client with a
more accurate appraisal of the event (e.g., Arntz, Tiesema, & Kindt, 2007). In this
instance, the emotional processing and rescripting methods were combined
effectively by the clinical neuropsychologist to treat Jane’s PTSD. Once Jane began
making treatment progress, the clinical neuropsychologist suggested that the sport
psychologist begin working with her to help her transition back into competitive
shooting in parallel with the ongoing clinical treatment.
Although Jane’s PTSD was discussed indirectly within the sport psychology
sessions, as per the APA and BPS ethical codes of conduct, the sport psychologist
only provided support for issues within his own areas of competency (i.e., shooting
performance-related issues; see also Andersen & Van Raalte, 2005). He did not
provide interventions related to the treatment of the PTSD directly. In addition,
during the initial stages, all support was provided in close consultation with the
clinical neuropsychologist to ensure no conflicting advice was provided.
Furthermore, as both the clinical neuropsychologist and the sport psychologist
adhered to the cognitive behavioral (CBT) practice philosophy, this allowed parity in
the style of interventions between clinical and performance issues. Jane reported that
she found this parity reassuring, as she never received conflicting advice and could
understand the similarity in the core values (i.e., the ABC model) in both her clinical
treatment and her performance-based sessions with the sport psychologist.
Sport Psychology Intervention
Summary of Meetings and Interventions With the Sport Psychologist.
During the 14-week period of sport psychology support outlined here, there were
seven sessions between the sport psychologist and Jane. The sessions occurred every
two weeks and lasted between one and two hours each time. Although there was an
element of continuous assessment throughout these sessions, the first session was
devoted to assessment and the formulation of a problem list. The remaining six
sessions were used to discuss each of the problems, initiate appropriate
interventions, and reflect on homework and progress from previous sessions. During
this period, Jane continued to work with the clinical neuropsychologist, who used
the empirically-supported exposure-based intervention described earlier. To ensure
no conflict between the clinical and sport psychology interventions, the sport
psychologist and the clinical neuropsychologist discussed their plans for treatment
before the first sport psychology session.
Meeting 1: Problem Assessment.
Having previously worked with Jane, the sport psychologist and Jane had already
developed a strong rapport and working alliance. Rapport has long been established
as an important part of the therapeutic relationship (e.g., Andersen, 2000; Pepitas,
Giges, & Danish, 1999), and cognitive behavioral theory suggests that while a
positive relationship is not a prerequisite, it is helpful in the therapeutic alliance
(Dryden, 1995). The first meeting dealt specifically with Jane’s rehabilitation and
return to competition. The aim of this meeting was to assess Jane’s non-clinical
psychological needs and to plan the support structure (including future meetings,
etc.). The assessment of needs was carried out using a CBT framework and included
a detailed description of Jane’s current situation (i.e., the accident and her recovery),
her current concerns, and an ABC (Activating Behavior-Belief-Consequence) cross-
sectional analysis of those concerns (Wells, 1997). In particular, special attention
was given to ensure that the relevant aspects of her PTSD treatment by the clinical
neuropsychologist were considered so as not to interrupt or contraindicate his
interventions (e.g., setting goals for performance that interrupted or affected her
clinical treatment). From the meeting, three main issues/problems arose in relation
to Jane’s return to competition, and these are presented in order of perceived
importance to Jane. These three issues formed the bases of Jane’s “problem-list” (cf.,
Neenan & Dryden, 2001).
The most important problem described by Jane was concern over the
likelihood of returning to international-level competition in time for a major
multisport international tournament. In particular, some of the anxiety associated
with her PTSD was related to the impact of her accident on her likelihood of success
in the future. It is not uncommon to find that significant portions of athletes’
personal identities are tied to their sport, such that answers to questions pertaining to
“Who am I?” are often based on their identities as athletes (i.e., “I am an athlete;”
Crook & Robertson, 1991; Grove, Lavallee, & Gordon, 1997). When injury and/or
retirement threaten this identity, it can be a source of anxiety for the athlete (Green
& Weinberg, 2001). Dealing with this anxiety became Jane’s number one problem to
address.
Linked to the first problem, the second concern Jane expressed was an
uncertainty of the suitable level/intensity of training, balanced against a fear of
burnout. Since the accident, Jane had been having trouble sleeping. Sleep
disturbance is a known symptom of PTSD (part of criterion D, DSM-IV-TR; APA,
2000), and because of this and her training schedule, she found herself in a constant
state of fatigue. Savis (1994) has suggested that delta sleep is an important factor in
recovery from increased metabolic activity and energy expenditure. During delta
sleep, the circadian cycle for growth hormone secretion and cell division peak,
highlighting an important functional component. Consequently, balancing Jane’s
recovery and her training became an important factor in her rehabilitation.
Finally, for the third problem on her list, Jane indicated that her ability to
concentrate for long periods had been diminished as a result of her accident. Once
again, under criterion D (hyperarousal) of the DSM-IV-TR’s criteria for PTSD,
difficulties with concentration can be expected in individuals with PTSD (APA,
2000). This may well have been compounded further by Jane’s lack of sleep. From a
performance perspective, rifle shooting requires a high degree of concentration, with
female shooters firing 60 shots in succession in both subdisciplines (three position
and prone). Consequently, addressing her concentration issues was essential for Jane
to make a successful return to international competition.
As Jane perceived returning to international competition as her priority, it was
decided in collaboration to work on a plan of action to achieve this goal. Some of the
sport psychology literature suggests that goal setting is a basic psychological skill,
making it a potential intervention option to help athletes plan their training and
competitions (see Kingston & Wilson, 2009). Some of the literature indicates that a
combination of process, performance, and outcome goals are most effective at
maintaining performance and motivation (Hardy, Jones, & Gould, 1996; Kingston &
Hardy, 1994, 1997). Jane became quite anxious, however, when discussing anything
to do with outcomes or performance, often stating, “How can I be sure I can do
that?” Therefore, to direct Jane’s attention toward controllable aspects of her
performance and reduce her anxiety (rather than specific performance scores and
outcomes), she was asked to focus on process goals when training (Kingston &
Hardy, 1997; see also the Appendix herein for a commentary on working with
shooters in general AQ-1) and to only use performance and outcome goals for her
long-term goal attainment.
Jane began by setting her long-term goals (competing at the major
international tournament mentioned earlier and achieving the qualifying score
needed to compete) and then worked backwards to identify other important
competitions and training camps at which her process goals could be monitored.
Eventually, she began to focus mostly on process goals for her shooting for the 2
months ahead (e.g., a strong inner position when shooting, and consistent hold), but
also included performance goals for the duration of the extended physiological
training she was doing (e.g., week 1: 1.5 hours of aerobic work). She believed that
performance goals for her aerobic training were less anxiety provoking, as aerobic
fitness was only an adjunct to her shooting training. Many of the goals were based
upon a previous performance profile that Jane had completed prior to her accident
and had now updated. Performance profiles (Butler & Hardy, 1992) are an ideal tool
for guiding athletes to set appropriate goals that match their weaknesses (Butler,
Smith, & Irwin, 1993). As homework is an important aspect of CBT (see Neenan &
Dryden, 200l), the sport psychologist ended the session by asking Jane to e-mail a
typed and update version of her performance profile and goals (see Figure 1).
Writing down goals is often seen as a useful way of embedding goals into the
athlete’s psyche, maximizing their prominence during training and competition
(Gilbourne & Taylor, 1998).
\FIGURE 1 HERE\
Meeting Two.
Session two began by reviewing Jane’s previous homework task (setting her goals).
Jane expressed concern over how she would be able to set goals six months in
advance, when she could not know how she would be feeling and functioning in six
months. She was still experiencing headaches, and this was limiting the amount of
training she was willing to do. The sport psychologist explained how a key element
of goal setting is flexibility, that is, allowing for things sometimes not always going
as planned (Weinberg, 1994). In addition, as she was setting long- and short-term
goals, it would be possible to adjust her goals on a monthly basis if she was
struggling to achieve them. To help her gain confidence in the goal setting process,
Jane was asked to list the benefits of not setting goals and to compare them to the
benefits of setting goals. This technique is a standard motivational interviewing
method used to resolve ambivalence by highlighting the benefits and costs of two
competing courses of action (Rollnick & Miller, 1995). Her overriding argument in
favor of establishing goals was that although she may not achieve all of her goals, by
setting them she would be giving herself the best possible chance of achieving her
overall long-term goal (i.e., shooting at the major international tournament).
As Jane had highlighted concerns over whether she would achieve her long-
term goals, she was asked to clarify what her thoughts were. She stated that she had
thought, “What if I am too ill and have not recovered enough to achieve my goals?”
CBT identifies fortune telling or “what if” thinking as a cognitive distortion (Neenan
& Dryden, 2001). Focusing on the future to the extent that it causes anxiety and
other emotional discomfort is both impractical and emotionally unhelpful. In an
attempt to dispute this cognitive distortion, the sport psychologist explained the
nature of “what if” thinking to Jane, highlighting that life by its very nature is
difficult to predict. This point was illustrated by suggesting other life events that
could feasibly happen between now and the major international tournament (e.g., she
could win the lottery, she might decide to retire) and suggesting that we could only
plan for what we would like to happen and should remain adaptable in relation to the
events that unfold. From an empirical point of view, she was asked how much
progress she felt she had made to date (which was considerable) and the current
opinions of the medical doctors and clinical psychologist supporting her (also very
positive). Using this as evidence, Jane was asked to make an informed judgment
about her chances of a full recovery. She believed that the evidence indicated that
she would be fully recovered by the major tournament she had identified as her
primary goal; however, she agreed that the best response for now was to stay
focused on the present and the elements that she controlled directly. In a follow-up
phone conversation, Jane reported that she was now feeling much less anxious about
the future and her rehabilitation process.
As highlighted in the initial meeting, Jane also indicated that she was
concerned that she was going to burn out as a consequence of overtraining. Although
she used the word “burnout,” she was uncertain what this actually meant. She was
asked to explain why she thought she was going to burn out. She indicated that she
had been feeling tired for the last couple of days and was suffering from headaches.
Consequently, the symptoms of burnout were described and explained, including
exhaustion, depersonalization, feelings of low personal accomplishment and self-
esteem, and low productivity (Cresswell & Eklund, 2004). She believed that
although she was tired, she did not match all of these symptoms. It was also
highlighted that although she might have overtrained for a couple of days, this in
itself was not going to lead to burnout. Only if she continued to over train and
overreach would she become susceptible to burnout. As a precautionary measure,
she was asked to record in her training diary how she was feeling on a day-to-day
basis. This would also allow her to be more aware of how her training affected her
both physically and emotionally. During a phone conversation a few days later, she
reported feeling much less fatigued, having had a succession of good nights’ sleep.
Meeting Three.
Jane had a history of concentration problems during training and competition prior
to her accident; however, these disruptions had worsened following her accident. To
exacerbate this existing problem further, concentration disruptions are a common
symptom of PTSD (Yehuda, 2002). During this session, Jane highlighted how since
returning to training, she had been struggling to maintain her concentration. Target
sports require high levels of concentration to ensure consistent performance. For
example, during competitions, Jane’s discipline required her to take 60 shots within
2 hours 15 minutes. Although we had discussed concentration issues before her
accident, little follow-up work had been done since.
Jane had a tendency to view her concentration as either all good or all bad. In
CBT, this pattern of thinking is often referred to as all-or-nothing thinking (Neenan
& Dryden, 2001). All-or-nothing thinking can lead to emotional disturbance, as such
cognitions are inflexible and inconsistent with reality (i.e., the world is not black and
white). After discussing all-or-nothing thinking in relation to Jane’s concentration,
we decided to set progressive process goals. Specifically, she decided to break her
shooting cycle into 10-shot strings. Initially, Jane’s aim was to remain fully focused
for 10 shots and then adopt a more relaxed focus for the next 10 shots, repeating this
process throughout a session. The aim of this was twofold: first to make
concentration more manageable (i.e., less fatiguing) and second, to help Jane
develop the ability to “turn-on” the concentration when needed. Over time, the aim
was to increase the number of fully focused shots, eventually building toward
repetitive 10-shot strings with small breaks in between. Although there is little
empirical support for the use of goal setting for improving concentration, the act of
goal setting is thought to improve attention to specific tasks (Kingston & Hardy,
1997). Jane’s homework assignment was to try this task and report back during the
following session.
Meeting Four.
This session began by reviewing the homework assigned at the end of meeting three.
Jane stated that she had found it hard to “switch-off” for the second 10-shot string
for the exercise. She believed that the very idea of not concentrating was
counterintuitive to her whole ethos of shooting, even though she was often
concentrating poorly. On reflection, it appeared that the explanation of the exercise
provided by the sport psychologist could have been better. Consequently, it was
explained to Jane that the idea was not necessarily to stop concentrating on the
second 10-shot string, but to direct her attention to other aspects of her technique
instead. In other words, given the effort required to concentrate, this second string
was to act as a mental rest. The aim was to increase her concentration endurance,
and this explanation seemed to “hit home” better than the explanation provided in
the previous session.
In the time between the previous meeting, Jane had competed in a number of
low-priority competitions. She reported finding herself distracted by people behind
the firing point. One reason for this was that she trained by herself with no
distractions, and during competitions the range was very busy and noisy. To help
Jane with this issue, it was decided that she would engage in simulation training to
mimic the competition environment in practice. Specifically, as Jane reported that
she found the sounds of voices most distracting, she started playing a radio talk-
show behind her during training. This type of simulation training is a recognized
technique for improving concentration (Hardy et al., 1996; Moran, 2009). In a short
telephone meeting that followed meeting four, Jane reported that she had found this
exercise very useful, and when combined with the previous concentration goal
setting exercise, she believed that she was making strong gains in the area of
concentration.
Subsequent Sessions.
The remaining three sessions with Jane were spent working on the problems covered
in the first four sessions. This entailed reviewing the homework exercises and
discussing any concerns Jane had. For example, Jane remained concerned about
overtraining and experiencing burnout. Consequently, she found it useful to discuss
what training she had done and how this had made her feel. Together, Jane and the
sport psychologist systematically reviewed each aspect of her training and adopted
alternative training strategies if she perceived any negative effect. Where Jane’s
concerns seemed irrational/illogical or inconsistent with reality, we discussed her
thoughts and subsequent feelings, examined any underlying assumptions, and then
challenged her beliefs using CBT disputing techniques, which focused on
empiricism, pragmatism, and logic. For example, Jane often feared burning out if she
was suffering from a headache or felt tired. We would therefore discuss alternative
(possibly more plausible) explanations (e.g., symptoms of PTSD, dehydration) and
the incidence of these types of symptoms prior to the accident during and after
training sessions. While burnout was never discounted as something that could
happen in the future, Jane agreed to remain focused on the present and elements of
her training that she could control (i.e., her training load/recovery balance and
rehydration strategies). Challenging these concerns in this way and combining them
with the behavioral interventions (e.g., goal setting, simulation training) reduced
Jane’s anxiety about burnout. A similar combination of techniques (i.e., cognitive
and behavioral) were used for any remaining anxieties she had regarding returning to
competition and her progress on developing her concentration levels.
Reflections on Practice
The current case study has outlined a situation where an elite athlete received sport
psychology support parallel to her treatment for PTSD by a clinical
neuropsychologist. During the process, the athlete made considerable gains in her
recovery from PTSD; however, the symptoms of the PTSD also had an effect on the
athlete’s sport performance. These effects were dealt with successfully by the sport
psychologist, allowing the athlete to return successfully to training and international
competition.
An important aspect of sport psychology consultancy is to reflect on our
experiences as practitioners in order to improve future practice. In this instance, a
systematic process of reflection was followed in order for the sport psychologist to
learn from his consulting experiences (Anderson, Knowles, & Gilbourne, 2004). In
addition, at the end of every session with the client, reflections were undertaken on
what had been discussed, and the client was asked to indicate which aspects were
helpful and not helpful. This type of collaborative reflection is an important aspect of
effective counseling and therapeutic change, as it gives the client the opportunity to
focus on the techniques they found most helpful (Dryden, 1995). Throughout the
process of support, a consistent CBT approach was adopted, reinforcing the same
messages in each session to ensure client understanding (e.g., focusing on the
present, controllable factors and productive/helpful thinking). Jane’s attitude toward
her rehabilitation changed from an anxious “what if” fortune telling, to a more
rational and pragmatic focus on the present. Qualitative reports (case notes, etc.)
taken during and after meetings with the client indicated that the CBT approach and
associated interventions had been helpful in alleviating concerns regarding Jane’s
long-term future, her fears of burnout, and improving her concentration abilities.
This was also indicated by an improvement in her overall goal profile within the first
month (see Figure 1). Throughout each session, Jane was forthcoming both when
she had found things helpful and unhelpful, allowing her support to be tailored to her
specific needs.
The greatest strength of this case study was the parity in practicing
philosophies used by both the clinical neuropsychologist and the sport psychologist.
Specifically, both practitioners used a CBT framework to direct their intervention
strategies and consultations with Jane. This meant that Jane was receiving a
consistent approach to dealing with the issues she encountered, regardless of whether
these issues were directly clinical (i.e., for PTSD) or performance based. At the
beginning of the support process, the clinical neuropsychologist and sport
psychologist discussed their respective approaches and throughout the consultation
process, they were aware of what each other was working on with Jane. On a
number of occasions, Jane commented that both practitioners were providing a
consistent message and that she was using similar techniques in both her clinical
treatment and her sport psychology support. It is not clear what effect disparate
philosophies would have on the overall effectiveness of any intervention; however, it
is likely that Jane would have been left confused about which approaches to use, and
when to use them.
As Jane was attending school 200 miles away from the sport psychologist, a
number of intermediary sessions were completed via phone. This style of
psychological support is becoming more common with ready access to modern
technology and has been shown to be a useful method for consultation in CBT
(Lyneham & Rapee, 2006; Mohr, Hart, & Vella, 2007; Veazey, Cook, Stanley, Lai,
& Kunik, 2009). The purpose of these phone sessions was to allow Jane to ask
questions regarding things she was concerned about or the intervention program.
Although the phone sessions were effective, face-to-face meetings are preferable, as
they allow for the observation of nonverbal communication and the ability to
demonstrate empathy; however, as an adjunct to normal face-to-face meetings, in
this instance the phone consultations were very useful.
Implications for Future Practice
From the experiences outlined in this case study, there are a number of practical
implications that other psychologists may consider when working with athletes with
PTSD or other clinical disorders. First, it is important for the client to understand the
distinction in roles between a sport psychologist and a clinical psychologist (unless
the psychologist is both, e.g., a clinical sport psychologist). In this way, the client
knows what to expect from each meeting and should have few misconceptions.
Second, even though the client is being treated for a clinical condition, once any
performance-impairing clinical symptoms subside, the client can likely return to
training and competition. The sport psychologist can assist with this process by
helping the athlete make training plans and set competition goals. Finally, even
though the sport psychologist will not directly treat the clinical condition (assuming
they are not clinically trained), this does not mean that they can ignore the presence
of the clinical disorder. They should research the disorder (and any other disorder
they encounter with other athletes) so that they understand fully what their client is
experiencing and can recognize when the client is displaying issues/symptoms
associated with the clinical issue. As seen in the present case study, many of the
performance-related issues were a direct result of the PTSD, and consequently, any
interventions for performance had to be considered and discussed in this context. If
at any point the sport psychologist felt that he was moving away from his boundary
of competency, he would explain this to Jane and suggest that she discuss that
particular issue with the clinical neuropsychologist. It is also not uncommon for two
practitioners to directly consult with each other, assuming appropriate client consent
is provided.
Conclusion
The case study presented here is an account of how sport psychologists can work in
parallel with clinical practitioners. Given the reasonably high incidence of clinical
and subclinical issues in sport psychology (e.g., eating disorders, depression,
substance use; Gardner & Moore, 2006; Moore, Clampa, Wilsnack, & Wright, 2007;
Smolak, Murnen, & Ruble, 2000), more accounts of this nature are warranted.
Indeed, although each incidence of a clinical issue will be unique to the client and
issue involved, some best practices are directly transferable (e.g., collaboration with
the clinical psychologist). In clinical and counseling psychology journals, case
studies are common practice, but the inclusion of case studies in sport psychology
journals is limited. The more sport psychologists share these experiences, the better
equipped they will be to deal with these issues when they are encountered.
References
Adshead, G. (2000). Psychological therapies for post-traumatic stress disorder. British
Journal of Psychiatry, 177, 144-148. AQ-2
American Psychiatric Association [APA]. (2000). Diagnostic and statistical manual of
mental disorders (4th ed., text revision). Washington, DC: Author.
American Psychological Association. (2010). Ethical principles of psychologists and
code of conduct. Retrieved February 7th, 2011, from
http://www.apa.org/ethics/code/index.aspx.
Andersen, M. (2000). Doing sport psychology. Champaign, IL: Human Kinetics.
Anderson, A.G., Knowles, Z., & Gilbourne, D. (2004). Reflective practice for sport
psychologists: Concepts, models, practical implications, and thoughts on
dissemination. The Sport Psychologist, 18, 188-203.
Andersen, M.B., & Van Raalte, J.L. (2005). Over one’s head: Referral processes. In
M.B. Anderson (Ed.), Sport psychology in practice (pp. 159-169). Champaign,
IL: Human Kinetics.
Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of
imaginal exposure with and without imagery rescripting. Journal of Behavior
Therapy and Experimental Psychiatry, 38, 345-370.
British Psychological Society (2008). Generic professional practice guidelines.
Leicester, UK: British Psychological Society.
Butler, R.J., & Hardy, L. (1992). The performance profile: Theory and application. The
Sport Psychologist, 6, 253-264.
Butler, R.J., Smith, M., & Irwin, I. (1993). The performance profile in practice.
Journal of Applied Sport Psychology, 5, 48-63.
Cresswell, S.L., & Eklund, R. (2004). The athlete burnout syndrome: Proposed early
signs. Journal of Science and Medicine in Sport, 7, 481-487.
Crook. J.M., & Robertson, S.E. (1991). Transitions out of elite sport. International
Journal of Sport Psychology, 22, 115-127.
Dryden, W. (1995). Brief rational-emotive behavior therapy. New York: John Wiley &
Sons.
Ehlers, A., Clark, D.M., Hackmann, A., McMannus, F., & Fennel, M. (2005).
Cognitive therapy for post-traumatic stress disorder: Development and
evaluation. Behavioral Research Therapy, 43, 413-431.
Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Guidelines for treatment of PTSD.
Journal of Traumatic Stress, 13, 539-588.
Gardner, F.L., & Moore, Z.E. (2006). Clinical sport psychology. Champaign, IL:
Human Kinetics.
Gilbourne, D., & Taylor, A.H. (1998). From theory to practice: The integration of goal
perspective theory and life development approaches within an injury-specific
goal setting program. Journal of Applied Sport Psychology, 10, 124-139.
Green, S.L., & Weinberg, R.S. (2001). Relationships among athletic identity, coping
skills, social support, and the psychological impact of injury in recreational
participants. Journal of Applied Sport Psychology, 13, 40-59.
Grove, J.R., Lavallee, D., & Gordon, S. (1997). Coping with retirement from sport:
The influence of athletic identity. Journal of Applied Sport Psychology, 9, 191-
203.
Hardy, L., Jones, G., & Gould, D. (1996). Understanding psychological preparation
for sport: Theory and practice of elite performers . Chichester, UK: Wiley.
Kennedy, J.E., Jaffee, M.S., Leskin, G.A., Stokes, J.W., Leal, F.O., & Fitzpatrick, P.J.
(2007). Posttraumatic stress disorder and posttraumatic stress disorder-like
symptoms and mild brain injury. Journal of Rehabilitation Research and
Development, 44, 895-920.
Kingston, K.M., & Hardy, L. (1994). Factors affecting the salience of outcome
performance and process goals in golf. In A.J. Cochan, & M.R. Farally (Eds.),
Science and golf II (pp. 144-149). London: Chapman and Hall.
Kingston, K.M., & Hardy, L. (1997). Effects of different types of goals upon processes
that support performance. The Sport Psychologist, 11, 277-293.
Kingston, K.M., & Wilson, K.M., (2009). The application of goal-setting in sport. In
S.D. Mellalieu, & S. Hanton (Eds.), Advances in applied sport psychology: A
review (pp. 75-123). London: Routledge.
Lyneham, H.J., & Rapee, R.M. (2006). Evaluation of therapist-supported parent
implemented CBT for anxiety disorders in rural children. Behavior Research and
Therapy, 44, 1287-1300.
Mohr, D.C., Hart, S., & Vella, L. (2007). Reduction in disability in a randomized
controlled trial of telephone administered cognitive-behavioral therapy. Health
Psychology, 26, 554-563.
Moore, Z.E., Clampa, R., Wilsnack, J., & Wright, E. (2007). Evidence-based
interventions for the treatment of eating disorders. Journal of Clinical Sport
Psychology, 1, 371-378.
Moran, A.P. (2009). Attention in sport. In S. Mellalieu, & S. Hanton (Eds.), Advances
in applied sport psychology: A review (pp. 195-220). London: Routledge
Neenan, M., & Dryden, W. (2001). Essential cognitive therapy. London: Whurr
Publishers.
Pepitas, A.J., Giges, B., & Danish, S.J. (1999). The sport psychologist-athlete
relationship: Implications for training. The Sport Psychologist, 13, 344-357.
Resick, P.A., & Calhoun, K.S. (2001). Posttraumatic stress disorder. In D.H. Barlow
(Ed.) Clinical handbook of psychological disorders (3rd ed., pp. 60-113). New
York: Guilford Press.
Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioral
and Cognitive Psychotherapy, 23, 325-334.
Royal College of Psychiatrists (2010, March). Post traumatic stress disorder. Retrieved
March 31st, 2010, from The Royal College of Psychiatrists website:
http://www.rcpsych.ac.uk/mentalhealthinfo/problems/ptsd/posttraumaticstressdis
order.aspx.
Savis, J.C. (1994). Sleep and athletic performance: Overview and implications for
sport psychology. The Sport Psychologist, 8, 111-125.
Smolak, L., Murnen, S.K., & Ruble, A.E. (2000). Female athletes and eating disorders:
A meta-analysis. International Journal of Eating Disorders, 27, 371-380.
Veazey, C., Cook, K.F., Stanley, M., Lai, E.C., & Kunik, M.E. (2009). Telephone-
administered cognitive behavioral therapy: A case study of depression in
Parkinson’s disease. Journal of Clinical Psychology in Medical Settings, 16,
243-253.
Weinberg, R.S. (1994). Goal setting and performance in sport and exercise settings: A
synthesis and critique. Medicine and Science in Sports and Exercise, 26, 469-
477.
Wells, A. (1997). Cognitive therapy of anxiety disorders. Chichester: John Wiley &
Sons.
Yehuda, R. (2002). Post-traumatic stress disorder. New England Journal of Medicine,
346, 108-114.
Zizzi, S., & Perna, F. (2002). Integrating web pages and email into sport psychology
consultations. The Sport Psychologist, 16, 416-431. AQ-3
Appendix
Stereotypical Profile of Small-Bore Rifle Shooters
By their nature, shooting/target sports are predominantly performance and outcome
oriented. In small-bore rifle shooting, the shooters shoots at a target 50 meters away
in an outdoor range, open to the elements. The diameter of the 10-ring on the target
is 10.4 mm and during finals, the maximum score for one shot is 10.9 (centre of 10-
ring), and the difference between winning and coming in second can literally be 1
mm. Having worked with international shooters for a number of years, it has become
apparent that the vast majority of shooters were obsessed with hitting the 10-ring.
Furthermore, the coaches, who were ex-shooters with similar values, reinforced this
predisposition. The unshakable focus on the 10-ring was great when each shooter
was hitting them consistently, but inevitably, eventually they would hit a 9 or worse.
When this happened, it was often followed by a string of poor shots, during which
one could clearly see the shooter becoming more frustrated. Post-performance cross-
examination revealed that they considered any score other than a 10 as a poor shot,
even if they had hit a 9.9 (i.e., 1 mm from 10-ring). Consequently, after a bad shot,
most shooters would report thinking that they “must not hit another 9” or they “must
hit a 10.” From a CBT perspective, this type of cognition is reflective of all-or-
nothing thinking (black or white) and negative future thinking (Neenan & Dryden,
2001). In other words, inflexible beliefs about what was an acceptable score lead to
anxiety concerning scores they should or might achieve in the shots that followed.
Generally, these issues are addressed by highlighting how all-or-nothing thinking is
both inflexible and inconsistent with reality and by encouraging them to focus on
rational, flexible, pragmatic, and logical thoughts and to concentrate on factors
within their control (e.g., their shot routine/preparation, the here-and-now).
Figure 1 — Jane’s performance profile showing short- and long-term goals.
Author Queries:
AQ-1 Figure 2 is not a figure. I made it into an Appendix and referred to it as such
in the text of the paper.
AQ-2 Reference Adshead is not used in the text of the paper. Please list only
references you use.
AQ-3 Reference Zizzi & Perna is not used in the text of the paper. Please list only
references you use.
