Applying Evidence-Based Principles From CBT to Sport Psychology

Transcription

1 The Sport Psychologist, 2012, 26, Human Kinetics, Inc. professional practice Applying Evidence-Based Principles From CBT to Sport Psychology Siobhain McArdle Dublin City University Phil Moore Manchester Metropolitan University, and Irish Institute of Sport This article highlights four key principles of cognitive behavior therapy (CBT) and proposes situations where these tenets would be relevant from an applied sport psychology perspective. To achieve this aim, a case study of an athlete with a dysfunctional perfectionist mindset is employed. We conclude with possible research directions in applied sport psychology informed by CBT. These recommendations include the need to further develop an evidence based formulation system and the relevance of building a repertoire of evidence-based behavioral experiments to improve practice. Both theory and applied practice in sport psychology are guided by a number of different psychological orientations and frameworks. One of the most employed and referenced in the sport psychology literature is the cognitive-behavioral approach. Evolving from behavior therapy (Wolpe, 1958) and cognitive therapy (Beck, 1976), modern day cognitive behavioral therapeutic (CBT) approaches are better validated than any other therapeutic method (Roth & Fanagy, 2005; Westbrook & Kirk, 2005). Despite the widespread interest in cognitive behavioral approaches among the sport psychology community, few published works have outlined the relevance of key cognitive behavioral principles for applied practice. To address this gap, the aim of this article is to briefly outline four core tenets of cognitive behavioral therapy, propose situations in which these tenets would be relevant from an applied sport psychology perspective, and outline directions for future research. Based on theories of information processing, the foundation of modern CBT is characterized by four key principles. First, a central premise of CBT is that systematic information-processing biases play a role in the development and maintenance of psychological problems (Beck, 1987). Specifically, CBT proposes that psychological problems stem from the interaction of various aspects of life experience: biased or distorted thinking, emotions, physiology, and behavior (Beck, 1995). The interaction of these four systems is also thought to be influenced by McArdle is with the School of Health and Human Performance, Dublin City University, Dublin, Ireland. Moore is with Manchester Metropolitan University, Crewe, UK, and the Irish Institute of Sport, Dublin, Ireland. 299

2 300 McArdle and Moore environmental factors (e.g., social, family, cultural context; Greenberger & Padesky, 1995). A second core principle of CBT is that cognitive change is critical to a positive therapeutic outcome (Clark & Steer, 1996). Change in behavioral, emotional, and somatic symptoms can only be achieved if the mediating cognitive processes and structures are modified in some way (Clark & Steer, 1996). Interventions work to achieve changes in cognitions either directly through cognitive restructuring/ modification or indirectly through behavioral interventions. A third important principle of CBT is the recognition of three distinct types of cognitions at different levels of cognitive processing (Beck, 1976). At the global level are rigid core beliefs that most of the time are not immediately accessible to consciousness (Beck, 1995). These beliefs are viewed as all encompassing and applicable to all life situations (e.g., I am useless ; Beck, 1995). Core beliefs, in turn, influence two other levels of cognition, conscious and preconscious. At the conscious level are assumptions or rules that generalize across situations and often represent the person s attempts to live with negative core beliefs, for example, I must have a great performance every game otherwise my uselessness will be revealed (Beck, 1995). At the preconscious level are automatic thoughts. Characterized as situation specific, automatic thoughts stem from latent faulty structures (i.e., assumptions and core beliefs), and are the type of thoughts that typically run through people s minds automatically and involuntarily (Beck, 1995). These kinds of thoughts tend to be largely dysfunctional in nature (e.g., I am going to look like an idiot defending against this guy ). Although negative automatic thoughts are usually referred to as verbal constructs, they may also take the form of images (Westbrook, Kennerley, & Kirk, 2007). CBT argues that not all negative automatic thoughts carry equal significance. Hot thoughts are those negative automatic thoughts believed to be most relevant and important with respect to therapeutic gain (Beck, 1995). Hot thoughts are distinguished from other negative automatic thoughts by the degree of emotional valence they evoke. Unfortunately hot automatic thoughts are not always explicit because clients often report interpretations of their thoughts instead of actual thoughts (Beck, 1995). The aim of the practitioner, therefore, is to make implicit hot thoughts explicit through guided discovery and other techniques (Neenan & Dryden, 2004). Related to the idea of different types of cognition is the CBT stance that different problems/disorders can be differentiated on the bases of specific cognitive content (Clark & Steer, 1996). A significant body of research has provided support for the cognitive content-specificity hypothesis and has identified particular cognitive themes linked to a number of disorders and problem areas (Beck, Brown, Eidelson, Steer, & Riskind, 1987; Clark & Steer, 1996; Greenberg & Beck, 1989). For example, research has shown that the automatic thoughts of the depressed patient center on themes of loss and defeat whereas other studies have found that anxiety disorders are characterized by themes of danger and threat (Blackburn, James, & Flitcroft, 2006; Wells, 2006). The implication of specific cognitions for the development and maintenance of specific problem areas and therefore relevance to case formulation is the fourth key principle of CBT (Clark & Steer, 1996). In CBT, case formulation is described as a set of hypotheses about the causes, precipitants, and maintaining influences of a person s psychological, interpersonal and behavioral problems (Eells, 2002, p. 815). In situations where clients present with nonclinical difficulties, generic models of case formulation such as the five aspects

3 Applying Evidence-Based Principles From CBT to Sport Psychology 301 model (i.e., situations, cognition, emotion, physiology, behavior: Greenberger & Padesky, 1995) can be used to inform the intervention process. However, for mood disorders and other types of problem areas, evidence based practice argues for the use of problem-specific/validated CBT models of case formulation where and when those exist (Persons, 1989; Persons & Davidson, 2001). The Application of Cognitive Behavior Therapeutic Principles to Applied Sport Psychology A systematic description of a methodology s application can play an important role in providing evidence for best practice (Gucciardi & Gordon, 2009). A case example will be employed to provide examples of situations in which the CBT principles of a) interacting systems, b) the centrality of cognitive mediation to the human change process, c) types and levels of cognitive processing, and d) cognitive specificity and its link to formulation, can be employed. Case studies provide a platform to illustrate the application of theoretical concepts and therefore bridge the gap between theory and practice (Kuntz & Hesslar, 1998). The case study presented is based on the second author s role as an applied sport psychologist. Case Study A member of a National Squad, Liam (pseudonym), a 26 year old lock had been playing rugby at the international level for 8 years and had represented his country on over 30 occasions. At the age of 18, he had been the youngest player ever selected to play for his country. Liam had previous experience of sport science support but had very limited sport psychology input. In his initial consultation session, Liam indicated a growing sense of underachievement with his current performance. As a consequence he was constantly ruminating over his performances and comparative achievement. He also described himself as feeling low, anxious, lacking in motivation and unable to sleep at night. Liam indicated that he was seeking support because he no longer experienced any enjoyment from his involvement in rugby and could see no way out of his rut. Needs Assessment/Case Formulation A needs assessment or case formulation based on the tenets of CBT would involve employing a generic model of case formulation such as the five aspects model (Greenberger & Padesky, 1995) to initially develop an understanding of Liam s difficulties (Grant, Townend, Mills, & Cockx, 2009: Westbrook et al., 2009). The formulation process would also focus on identifying triggers (e.g., factors that increased or decreased the likelihood of the problem) and modifiers (e.g., contextual factors that influenced the severity of the problem when it did occur; Westbrook et al., 2009). Ascertaining the psychological processes and behaviors maintaining Liam s problem would also be critical (Grant et al., 2009). One technique employed to arrive at formulation is the Socratic method. Socratic questioning involves the practitioner asking the client questions that stimulate reflection and learning and

4 302 McArdle and Moore in doing so aid to build the case formulation (Westbrook et al., 2009; Wills, 2009). This emphasis on collaborative empiricism stems from the recognition that not all thoughts are explicit and therefore techniques such as guided discovery are necessary to assist the individual in developing self-awareness (Beck, 1995). For example, as part of Liam s needs assessment, the Socratic method was used to explore a recent game situation in which he failed to make an easy catch. Socratic questioning revealed that Liam s response to this situation was a stream of negative thoughts ( useless, coward, World No 1 wouldn t do that ) and increased feelings of anxiety. Through a process of guided discovery, links between these negative thoughts, symptoms of anxiety, loss of concentration and avoidance of ball contact on the pitch were made. Additional questioning and exploration of situations triggering negative self-talk revealed that Liam had very high standards for himself and believed that I should be exceptional every time he was involved in play. In line with the CBT principle that systematic information processing biases play a role in the development and maintenance of psychological problems (Beck, 1987), an important part of the case formulations process is noting the types of thinking biases regularly expressed by the client. In Liam s case, his language contained many should and musts statements, all or nothing thinking, and a tendency to discount the positives. For example, Liam had a tendency to see situations mainly in black and white terms. Either he perceived that he played exceptional (rarely) or that he played poorly (very often). When probed further on his performance, Liam conceded that there were aspects of his performance that were well executed. Liam s default thinking pattern, however, was to pay more attention to perceived or actual errors in his performance, rather than aspects of his performance that were error free. Through a process of guided discovery, links between his dysfunctional negative thoughts, symptoms of anxiety, loss of concentration, and avoidance of ball contact on the pitch were made. In line with the five aspects model (Greenberger & Padesky, 1995), further exploration of Liam s behaviors revealed that in addition to avoidance behavior on the pitch, Liam also engaged in performance checking behavior (see Fairburn, Cooper, Shafran, Bohn, & Hawker, 2008). This behavior typically took the form of comparing his performance to the performances of an aggregate of the world s best players in his position and his performance as a young international. Consequently Liam s assessment of himself was extremely self-critical and he continuously perceived himself as a failure. Liam s belief that being less than the best player in the world wasn t good enough resulted in standards that he could never meet and behaviors that reinforced his perceptions of inadequacy and failure. In this instance, the CBT principle of employing specific cognitions to inform the case formulation process when relevant was employed. The cognitive biases expressed by Liam over the course of the assessment were typical of perfectionism, for example his all or nothing thinking, I must perform exceptionally well at all times and Being less than the best player in the world isn t good enough. Liam s over-evaluation of achievement in rugby and patterns of thinking assisted in maintaining his low mood, sense of worthlessness, and pervasive feelings of anxiety. In addition, avoidance of key performance situations (e.g., avoiding ball contact at all costs), and performance checking, stemmed from, and in turn reinforced, Liam s dysfunctional perfectionistic thinking.

5 Applying Evidence-Based Principles From CBT to Sport Psychology 303 Clients (including athletes) regularly present with a number of difficulties often secondary to another more primary problem. Employing a house of cards analogy (Fairburn, 2008), from a CBT perspective, intervention should target those cards at the base of the house propping-up Liam s overall difficulties. Liam s over evaluation of achievement, beliefs that he had to perform exceptionally well at all times and be the best in the world in his position, were not only causing a number of his problems, but also served to keep them going. In line with the outlined CBT principles of cognitive specificity and the centrality of cognitive change to the therapeutic outcome, it was believed that tackling cognitive biases associated with perfectionism would in turn have beneficial effects for Liam s low mood, lack of enjoyment, negative self evaluation, anxiety, and performance. Consequently, a model for the treatment of perfectionism (see Fairburn et al., 2008; Shafran, Egan, & Wade, 2010) was used to guide both the sport psychologist (SP) and Liam through the intervention process. A diagram outlining Liam s formulation (see Figure 1) was collaboratively agreed to be relevant and satisfactory by both Liam and the SP. The Intervention Process For more than 20 years, the study of perfectionism has focused on distinguishing between those who are adaptive versus those who are maladaptive in their pursuit of high personal standards (Frost, Marten, Lahart, & Rosenblate, 1990; Hamachek, Figure 1 Liam s case formulation.

6 304 McArdle and Moore 1978; Hewitt & Flett, 1991; Hollender, 1965; Parker, 1997). Consequently, it is surprising that sport psychology papers specifically addressing the case formulation/intervention process for dysfunctional perfectionism are nonexistent. In this instance therefore, CBT based formulation and interventions targeted at dysfunctional perfectionistic tendencies have the potential to inform the applied sport psychology literature. From a CBT perspective, the main goals in the treatment of perfectionism are to challenge cognitive biases associated with the perfectionist mindset and to develop and test more adaptive cognitions that promote better functioning (Fairburn et al., 2008; Shafran et al., 2010). Beck and colleagues (1979) argued that the therapist s major task is to help the patient think of reasonable responses to his negative cognitions to differentiate between a realistic accounting of events and an accounting of distorted idiosyncratic meaning (p. 164). This task initially entails educating clients about the cognitive model (Wright, Basco & Thase, 2006). Because negative automatic thoughts are viewed as more accessible and amenable to change than either rules or core beliefs (Neenan & Dryden, 2004), socialisation to the cognitive model typically begins by assisting clients with identifying their automatic thoughts (Wright et al., 2006). Identification of thoughts can be done in a number of manners, for example, recognizing mood shifts, guided discovery, thought records, and role-play exercises (Wright et al., 2006). Through these interventions the practitioner aims to guide clients to recognize the link between an external/internal stimulus, an emotional/physiological response, and their thoughts about the stimulus. Socialisation to the cognitive model then ensues with the practitioner explaining or illustrating the cognitive model with examples of the client s own negative automatic thoughts, emotions, physiological responses, or behaviors. (Beck, 1995). As negative automatic thoughts become evident to clients they can begin to recognize themes running through them (i.e., the principle of cognitive specificity) and particular types of cognitive distortions (e.g., in Liam s case all or nothing thinking; Beck, 1995). Thus, negative automatic thoughts are a means for clients to learn more about themselves in general and the relationship between their cognitive biases and emotional distress more specifically (Neenan & Dryden, 2004). In this instance, Liam was given homework and asked to keep a daily thought record (DTR; Westbrook et al., 2007). In CBT the centrality of homework to the therapy process has been supported by research demonstrating a positive association between homework completion and therapeutic outcome (Kazantzis, Deane, & Ronan, 2000). The DTR was used to record situations linked to changes in mood state, and any associated negative automatic thoughts and other cognitive biases that occurred at that time. An examination of Liam s DTR revealed cognitive patterns of catastrophising, I made a mistake; I m going to lose my place on the team, selective attention What a mess I made of that pass, and self reproach What an idiot. In CBT there is rarely a sharp divide between identifying and modifying automatic thoughts (Beck, 1995; Westbrook et al., 2007). Identification and modification occur in tandem as part of a progressive process to develop an adaptive pattern of thinking. One strategy employed to modify automatic negative thoughts is to examine the evidence (Beck, 1995). This technique involves evaluating the evidence for and against the validity of the automatic thought and then changing the thought in accordance with the newly identified evidence (Wright et al., 2006). In line with the principle of different levels and types of cognitions, the process of

7 Applying Evidence-Based Principles From CBT to Sport Psychology 305 identifying and modifying negative automatic thoughts is often followed by a focus on eliciting and challenging the individual s rules and core beliefs. The distinction between levels of cognitive processing and how these levels are addressed from a therapeutic perspective differs considerably to much of the literature on self talk in applied sport psychology (e.g., Hamilton, Scott & MacDougall, 2007; Hardy, Jones & Gould, 1996; Mamassis & Doganis, 2004; Thelwell, Greenlees & Weston, 2007; Weinberg & Gould, 2011; Zinsser, Bunker, & Williams, 2010). For example, CBT argues that significant changes in emotions and behaviors rarely stem from addressing negative automatic thoughts alone (Beck, 1995). Given that people typically seek help to change how they feel rather than how they think, interventions targeted at automatic thoughts often fail to facilitate emotionally grounded change (Rouf, Fennell, Westbrook, Cooper, & Bennett-Levy, 2008). In support of this contention, research has shown that interventions targeted solely at automatic thoughts have had little effect on clinical outcome (Simons, Garfield, & Murphy, 1984; Stravynski et al., 1994) One of the most effective ways of influencing emotionally grounded cognitive change is through behavioral experiments (Bennett-Levy, 2003). Behavioral experiments are planned tasks or experiences that are undertaken by the client either in or out of the therapy session. The purpose of behavioral experiments is to provide the client with an experience that will test his or her belief, provide the impetus for constructing and or testing more adaptive beliefs and further contribute to the development of the formulation (Bennett-Levy et al., 2004). The effectiveness of behavioral experiments is well documented (Bennett-Levy et al., 2004). For example, research in which practitioners were asked to employ both automatic thought records and behavioral experiments to modify their own cognitions showed that compared with automatic thought records, behavioral experiments were rated by practitioners as producing significantly greater cognitive and behavioral change (Bennett-Levy, 2003). In their qualitative feedback on why behavioral experiments were viewed as more effective, practitioners indicated that the strength of behavioral experiments lay in the quality of evidential experience. Developing alternative cognitions when using an automatic thought record tended to be believed with the head but not always with the heart, but new cognitions derived from experiments (i.e., experiential learning) were more likely to be believed and accepted (i.e., I have experienced it, therefore it is believable; Bennett-Levy, 2003, 2004). Initial steps in behavioral experiments include collaboratively identifying those cognitions that evoke high emotional response (i.e., hot thoughts) and rating the degree of belief in the targeted cognition as a baseline measure preexperiment (Rouf et al., 2008). Using Liam s recorded self-talk, What a mess I made of that pass, the Socratic method was used to identify those beliefs (rules) underpinning this specific automatic thought. Liam responded with the belief I should perform exceptionally well at all times because doing things perfectly means success, to which Liam gave a rating of 7 (on a scale of 1-8). The modification of this rule was initially targeted cognitively, and Liam was asked to list the advantages and disadvantages of this rule. This type of approach is used to create doubt in the individual s convictions and provide an impetus for change (Beck, 1995). In completing this exercise, Liam recognized that the rule I should perform exceptionally well at all times because doing things perfectly means success led to feelings of misery both on and off the pitch, high levels of anxiety before competition, poor performance, and limited enjoyment

8 306 McArdle and Moore in playing rugby. Next, Liam and the SP collaboratively designed an experiment to test the validity of this rule. The skill in designing a behavioral experiment is to create an experience where as far as possible, whatever happens, the client will make some gains (Westbrook et al., 2009). Therefore it is important to consider all the barriers to the execution of the behavioral experiment and problems that might be encountered beforehand (Westbrook et al., 2009). In this case, as an experiment, Liam agreed to play the first 20 min of his next game with the aim of feeling comfortable and enjoying his role rather than trying really hard to be exceptional. Liam predicted that unless he tried really hard, he would feel very anxious, perform poorly, and feel badly about himself. A week after the game the SP met with Liam and followed up on the results of the behavioral experiment. Liam reflected that when he finished the game, he didn t feel he had played any worse than usual and felt less tension and strain over the course of the match because of his approach to the first 20 min. He was surprised to receive positive feedback from his coach on his performance. When asked to rerate his belief I should perform exceptionally well at all times because doing things perfectly means success, Liam indicated that the strength of his belief had weakened to a 5 (on a scale of 1 8) and acknowledged that lowering his standards actually made him more effective. Liam indicated that he wanted to extend this new approach a little longer in the next game because it made him feel more comfortable and he enjoyed the game more. This outcome reflected positive initial steps in addressing Liam s over evaluation of achievement and dysfunctional rules linked to performance standards. Although behavioral interventions are also employed in sport psychology, the link between behavioral experiments and cognitive change is not always explicitly outlined. In contrast, CBT offers a number of theoretical rationales as to why experiential interventions are so powerful in effecting change in cognitive processes. For example, Wells (2000) metacognitive theory draws on the distinction from experimental psychology literature, between declarative and procedural memory. Declarative memory is comprised of knowledge and beliefs viewed as factual in nature, for instance in Liam s case, My ball handling is inadequate. Procedural memory is characterized as more automatic in nature in that it contains knowledge about plans or procedures that are often implicit (e.g., avoid the ball). Wells (2000) argued that to effect change not only must a new declarative belief be developed (e.g., I am competent at ball handling ) but procedural memory must also be changed through the repeated implementation of a new plan or procedure. So for example, influencing procedural memory by seeking rather than avoiding the ball, Liam gives himself the opportunity to disconfirm his old beliefs and consequently effects change to his declarative memory. In short, metacognitive theory argues that verbal strategies that focus on modifying declarative beliefs, for example replacing the thought My ball handling is inadequate with a more positive thought does not necessarily lead to emotional or behavioral change (Wells, 2000). Procedural memory also needs to be targeted and this is best done through a process that involves experiential work, evaluation, and self reflection. Wells metacognitive theory provides a strong rationale for encouraging Liam to act as if he is a confident ball handler. In sum, the enactment process influences both procedural memory and declarative beliefs and therefore is viewed as much more powerful in effecting cognitive change than purely verbal techniques (Bennett-Levy, 2003).

9 Applying Evidence-Based Principles From CBT to Sport Psychology 307 Evaluation Processes A significant step in any athlete intervention is to assess the effectiveness of the intervention against its intended goals. In the event that the evaluation process reveals limited satisfactory progress, the CBT literature encourages the practitioner to question his or her formulation because the formulation provides the rationale for the intervention (Beck, 1995; Grant et al., 2009). In other words, in the event that the goals of the intervention are not being met, CBT does not look to strategies employed but instead looks to the formulation. Compared with CBT, where from a scientist-practitioner perspective, individualized case formulation is thought to be the cornerstone of evidence-based practice (Tarrier & Calam, 2002), the emphasis on assessment/formulation in sport psychology is far more limited (see Gardner & Moore, 2006). The significance of formulation to CBT is also reflected by the fact that the process of assessment, intervention, and evaluation are not viewed as distinct phases (Grant et al., 2009). The dynamic nature of CBT creates a context in which each of the phases overlap with one another so that each is revisited time and time again. In effect, formulation is a continuous process occurring at each session (Grant et al., 2009). Future Directions of Research Little research has systematically explored and compared the effectiveness of different assessment approaches in sport psychology. In contrast, the formulation process in CBT because of its level of detail, specificity, and theoretical coherence has been the focus of evaluation through experimental methods (Kuyken, Fothergill, Musa, & Chadwick, 2005; Kuyken, Padesky, & Dudley, 2008). The limited theoretical coherence underpinning assessment and intervention processes in sport psychology highlights the need for further research and development. Potential avenues of research include using the cognitive content specificity hypothesis as a guide to develop and test cognitive- specific models linked to sport problem areas (e.g., choking, self-confidence, self-esteem, sport based perfectionism) that inform formulation. A second line of research is to develop an evidence-based formulation system to guide sport psychology practitioners who embrace a cognitive behavioral perspective. Bieling and Kuyken (2003) recommended that a case assessment or formulation system must meet a number of criteria to have scientific status 1) Reliability Is the case formulation system reliable? In other words can sport psychologists reliably formulate cases employing the outlined formulation system? 2) Quality Are key constructs in case formulation meaningfully related to the athlete s problem areas? 3) Outcome Does the case formulation system lead to improved intervention outcomes. Future research should also begin to explore the efficacy of sport specific behavioral experiments for producing cognitive change. This line of research would in turn provide applied sport psychologists with evidence-based behavioral experiments. Similar to resources available to the CBT practitioner, texts including evidence-based behavioral experiments for sport specific problem areas would be positively received by the sport psychology community. This line of research also has the potential to influence core curriculum in undergraduate and postgraduate sport psychology programs. Developing young sport psychologists skills in protocol specific formulation and conducting general

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