The Routledge Handbook of Clinical Sport Psychology

Donald R. Marks, Andrew T. Wolanin, Kendahl M. Shortway, Donald R. Marks, Andrew T. Wolanin, Kendahl M. Shortway

• Verlag: Routledge
• Jahr: 2021
• ISBN:
  9781000413526
• Auflage: 1
• Thema: Psychology
• Thema: Sports Psychology

Clinical sport psychology is a rapidly growing field that brings together research and clinical interventions from both clinical psychology and sport and performance psychology. Complementary to sports medicine and clinical sport psychiatry, clinical sport psychology addresses the mental health needs and psychological well-being of athletes, coaches, and other members of the sport community. It offers scientifically informed conceptualizations of psychological distress as it manifests in sport settings, as well as empirically supported clinical interventions tailored to the needs of sport populations.

This volume addresses the latest research findings regarding mental health among athletes and other sport professionals, including epidemiological research concerning depression, anxiety, eating disorders, and conduct and interpersonal problems. In addition, it explores the unique etiology of mental health problems among athletes, including psychological sequelae of injury and trauma, as well as concise practice guidelines for conceptualizing and treating psychological distress in sport populations. Strategies for thorough yet efficient psychological assessment of athletes, coaches, and other sport professionals are also provided.

A compendium of relevant empirical research and clinical best practices for assessment and treatment, this handbook charts the course that clinical sport psychology has taken since its inception as a distinct clinical specialty and highlights future directions for this rapidly growing practice domain. It offers essential reading for psychologists and other mental health professionals who provide clinical services in sport and performance settings.

Section IV

Best Practices in Clinical Sport Psychology

22
Best Practices in Assessment and Treatment of Mood Disorders in Sport and Performance Contexts

Andrew T. Wolanin and Dan Cohn

As discussions around the acknowledgment of mental health within sport contexts have become more prevalent in recent years, it becomes more important to discuss how to assess and treat mental health issues experienced by athletes. Particularly at the elite level, the high-stakes performance demands, constant scrutiny, and perceived negative personal and social consequences of poor performance can precede, accompany, and/or worsen mental health symptoms. In terms of mood disorders, the research on the prevalence rates (see Beable et al., 2017; Li et al., 2017; Wolanin et al., 2016; Yang et al., 2007) appears to be a clear indicator of the presence of mood disorders within the athlete population. However, at this juncture, randomized controlled studies of the treatment of mood disorders within the athlete population do not yet exist. In their narrative review of the existing literature, Stillman and colleagues (2019) conclude that the existing literature on psychological treatment of athletes as a whole is sparse and generally anecdotal. Thus, the following sections will describe the current evidence-based assessments and interventions for mood disorders, with the majority of the focus being on the treatment of depression. Athlete-specific issues that may arise in the treatment of mood disorders will also be discussed.

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) is the standard in the field of mental health for diagnosis of psychological conditions. Related to mood disorders, the DSM-5 defines bipolar I disorder as having both a manic episode, where the mood is abnormally elevated, and a depressive episode, where one of the symptoms is either depressed mood or loss of interest or pleasure. Major depressive disorder is defined as having five or more of the symptoms associated with a depressive episode most of the day and nearly every day during the same two-week period. Also of note is the diagnosis of persistent depressive disorder, sometimes referred to as dysthymia, which consists of a depressed mood that lasts most of the day and nearly every day for a period of two years or greater.

Assessment

A typical approach to the assessment of any individual coming in for psychotherapy is to utilize the biopsychosocial model (Campbell & Rohrbaugh, 2013). For the assessment of a mood disorder, the clinician would gather information related to the current symptoms elicited, with a particular focus on changes in mood. The clinician would gather history related to any biological predispositions that could be influencing the onset or maintenance of mood-related symptoms and also consider any cultural and demographics factors that could be playing an epidemiological role. The clinician would also gather information related to the presence of any psychological vulnerabilities in terms of developmental history and recurrent patterns of difficulty, psychosocial stressors, and cognitive/emotional byproducts related to the changes in mood. Furthermore, an assessment of how the individual has been coping with their changes in mood would be included, with an emphasis on whether the coping strategies are adaptive or maladaptive. Finally, an assessment of the individual’s social functioning would include an assessment of the support available in the domains such as family, friends, employment, finances, housing, and healthcare. A social history profile would also be ascertained by gathering information about family structure, relationships, education, legal issues, use of substances, and other social factors potentially related to current mood status.

Depending on the theoretical perspective of the clinician treating the mood disorder, the information gathered related to specific psychological factors may differ. Though there are many theoretical stances that could be effectively applied to the treatment of a mood disorder, those that have the most evidence-based support for the treatment of mood disorders will be included in this review: cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and acceptance and commitment therapy (ACT) (Picardi & Gaetano; 2014; Twohig & Levin, 2017). For a practitioner operating from a CBT framework, information gathered would be related to dysfunctional automatic thoughts, negative core beliefs, cognitive distortions, the presence of reinforcement of maladaptive behavior, barriers to the desired behavior, and the presence of paired associations between behaviors and internal or external cues (Campbell & Rohrbaugh, 2013). For example, an athlete may present with negative self-statements such as “I am a failure” after losing in a competitive game and report feeling dejected with decreased motivation to continue practicing. The clinician operating from a cognitive-behavioral viewpoint would attempt to help this athlete modify these self-statements in order to improve mood and increase levels of activity.

For a practitioner of ACT, the information would be elicited surrounding unsuccessful attempts to try to control thoughts and feelings related to mood, inflexible behavior that is dictated by or “fused with” certain thoughts that have an impact on mood, and actions taken that are inconsistent with the values held by the individual that may be influencing mood state (Hayes et al., 2012). For example, an athlete may find it difficult to manage overthinking near the end of games and therefore request to be subbed out even though they also want to help their team win. The fusion with analytical thinking and values-inconsistent actions would be treatment targets for an ACT clinician. For an IPT practitioner, information gathered would largely focus on the individual’s current relationships, the social and interpersonal contexts in which they occur, and how interpersonal processes are contributing to the changes in mood (Picardi & Gaetano, 2014). For example, an athlete who was recently traded to a new team and reports feeling depressed related to having to change roles from their former team and having trouble fitting in with new teammates may be a good candidate for the IPT approach.

Assessment Measures

The use of self-report measures can aid in the assessment and conceptualization of mood disorders. One of the most widely used measures to assess for depression is the Beck Depression Inventory 2 (BDI-II; Beck et al., 1996). The BDI-II is a 21-item self-report scale used to assess the presence and severity of the clinical symptoms of depression. The ranges of possible scores on the BDI-II correspond with different degrees of depression. The range for minimal symptoms is a score of 0–13, 14–19 for mild symptoms, 20–28 for moderate symptoms, and 29–63 for severe symptoms of depression. The BDI-II has been used in several studies with athletes who are also dealing with concussions (Chen et al., 2008; Kontos et al., 2012; Vargas et al., 2015) and injury (Leddy et al., 1994; Tripp et al., 2003) as well as failure-based depression in athletes (Hammond et al., 2013).

The Center for Epidemiologic Studies Depression Scale (CES-D Scale; Radloff, 1977) is designed to measure depressive symptomatology in the general population. Scores of 22 or higher indicate that a diagnosis of depression is warranted. This measure has been used in several studies with collegiate athletes to assess the depressive symptomatology (Armstrong & Oomen-Early, 2009; Roiger et al., 2015; Wolanin et al., 2016).

The Patient Health Questionnaire module for depression (PHQ-9) is a nine-item depression scale that is often used in primary care settings due to its short-form nature. It consists of the nine symptomatic criteria for a diagnosis of depression included in the DSM-IV (Kroenke & Spitzer, 2002). A score of 0–4 indicates minimal or no depression; 5–9 indicates mild; 10–14 indicates moderate; and 15–19 indicates severe. The PHQ-9 has been used with athletes who have suffered concussions (Kerr et al., 2014) as well as with youth athletes to assess the relationship between stress, mental toughness, burnout, and depressive symptoms (Gerber et al., 2018). The PHQ-2 (Löwe et al., 2005) is the two-item brief assessment used to detect depression and its severity and has been used as a way of screening for depression in German youth athletes (Belz et al., 2018).

The Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960) is clinician-administered as part of a clinical interview in the assessment of depression. The scale consists of 17 items, eight of which are rated on a four-point scale ranging from 0 = not present to 4 = severe, and nine of which are scored from 0–2. A score of 0–7 is the non-clinical range, while a score of 20 or higher indicates at least moderately severe depression. The HAM-D has been used to measure postinjury depressive symptoms in athletes (Appaneal et al., 2009) in a semi-structured interview format.

For the spectrum of bipolar disorder, the Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000) can be used to screen for a history of manic or hypomanic symptoms and syndromes and assess the level of functional impairment due to their presence. Dudek et al. (2016) used the MDQ to screen for bipolar disorder symptomatology in extreme and high-risk sport athletes.

In a review of screening practices for depression in athletes, Trojian (2016) endorsed the use of PHQ-9, BDI-II, and CES-D for assessing depression in athletes due to their high sensitivity and reliability. He recommended using one of these screens as part of baseline neurocognitive testing when there is a concussion, as a way of helping to predict post-concussion depressive symptoms. He also advised clinicians to be mindful of other co-occurring life events, such as major injury, and particularly when working with student-athletes, sexual assault. As part of a holistic sports medicine approach, he also recommends being mindful of other medical conditions where depressive symptoms can occur and suggests athletes with depressive symptoms be tested for iron-deficiency, subclinical thyroid, and vitamin D deficiency. Unique considerations when assessing for depression in high-level athletes include being flexible about timing of sessions, involving family members when there are interpersonal issues, and not compromising (given status of athlete, consequences of missed time) on delivering appropriate treatment protocols, such as recommending hospitalization or medication.

Interventions

After identifying depressive symptoms, athlete mental health must be vigilant as one of the first steps in treatment is early appropriate recognition of the athletes at risk. The decision needs to be made as to whether to treat the presenting concerns clinically or from a “performance” perspective. If it’s determined that the athlete has symptoms of clinical depression, the recommendation can be made to the athlete to utilize a multi-disciplinary team approach. If the athlete was willing to consent to this treatment approach, the team could include a mental health provider familiar with athlete, a team physician or primary care provider, an athletic trainer, and if appropriate the family and coach and other professional support staff. The multi-disciplinary approach has the advantage of increasing recovery time from an injury or other illness along with depression, which can exacerbate injuries or other illnesses if left untreated. In addition, this approach can facilitate a faster return to play if this is the goal of the athlete.

While medications are used to treat depression and other mood disorders, oftentimes in combination with therapy, this section will focus exclusively on non-pharmacological treatment approaches. Thus, the following sections will be overviews of the treatment approaches to mood disorder within clinical populations, with suggestions or unique considerations provided about how that work can be applied to athletes. As a general principle, regardless of theoretical approach, the treatment should be tailored to the individual athletes and their particular clinical situation (see Table 22.1 for a summary of treatment processes in evidence-based therapies).

Table 22.1 Mood Disorder Treatment...