Psychology and The
Athletic Trainer
Bradley T. Klontz, Psy.D.
Dr. Brad
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Athlete
High School Tennis Coach
DOE Contracted Mental Health Provider
Clinical Psychologist
Certified Substance Abuse Counselor
Consultant
Researcher/Author
Agenda
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Psychological factors in Athletic Injuries
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Imagery to promote healing and enhance
performance
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Pain Management
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The Athletic Trainer as Counselor
Inured Athletes
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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)
Stress and Athletic Injuries
Personality
Stressors
Coping Resources
Stress Response
Injury
Interventions
(Anderson & Williams, 1988)
Stress Response
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 Heart Rate,  Breathing,  Muscle Tension, 
Metabolism,  Blood Pressure,  Blood Sugar
Improved hearing and narrowed vision
 Digestion,  Growth,  Tissue Repair, 
Immune System
Stress Response
Injury
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Stress and/or negative mood state muscle
tension and physical and mental fatigue 
reduced flexibility  injury
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Stress  narrowed attentional field  failure to
pick up important environmental cues to avoid
injury  injury
Interventions
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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
Suggested Reading
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“The Relaxation & Stress Reduction Workbook,
5th edition”- (2000); Davis, Eshelman & McKay
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“Full Catastrophe Living: Using the wisdom of
your body and mind to face stress, pain and
illness”- (1990); Kabat-Zinn
Imagery
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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,
Imagery to promote healing and enhance
performance while injured
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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
Therapeutic Imagery and Athletic
Injuries
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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
Injury Imagery
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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.
Injury Imagery cont.
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“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.”
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Athlete should engage in this process 5 minutes,
3 times a day.
Skill Imagery
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Athlete should attend all team meetings, practices and
games. Should observe plays and strategies.
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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.”
Injury Rehabilitation
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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.”
Injury Rehabilitation, cont.
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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.
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After approximately 1 week, alter the imagery
exercise so the athlete is walking with little
discomfort to the knee.
Pain Management
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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
Study
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“Sensory Information Can Decrease ColdInduced 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
Suggestions for Suggestions
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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.”
Suggestions for Suggestions, cont.
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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…”
The Athletic Trainer as Counselor
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Daily availability
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Role as health care providers
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Relationships build on trust
National Survey- 1996
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Injury Prevention
Injury Rehabilitation
Nutrition.
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Racial Issues
Suicide
Financial Issues
Family Matters
Relationship Issues
Sexual Issues
Alcohol Problems
Journal of Athletic Training
Psychological Reactions to Injury
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Identity Loss
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Fear and Anxiety
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Lack of confidence
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Performance decrements
Suicide
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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
Common Factors in Attempted
Suicides of Injured Athletes
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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
Assessment
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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
Intervention
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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?
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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
Mandated Reporters?
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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)
Mandated Reporters, cont.
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Reason to believe that child abuse or neglect will
occur in the reasonably foreseeable futurereport 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”
Other Issues
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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