One-to-One Support With a Professional Rugby League Player: A Case for Referral?

in Case Studies in Sport and Exercise Psychology

This article presents a reflective case study of an applied consultancy experience with a 22-year-old professional rugby league player. The primary aim of the intervention was to provide the client a confidential space where he could discuss his experiences in and outside of a sporting context while also exploring and challenging his core values and beliefs. The consultancy process lasted for 12 mo, leading to the development of a strong relationship. During this time, the client experienced multiple critical moments such as deselection from the first-team squad and contract negotiations, which at times led to reductions in his well-being and forced the trainee sport and exercise psychologist to consider his scope of practice in relation to mental health and depression. Reflections are provided that explore the possibility of referral during these moments. The case study also provides insight into the trainee sport and exercise psychologist’s philosophy of practice and how influential this can be when considering referral of a client. The importance of supervisor support during uncertain moments is highlighted, and the case study concludes with reflections from the client, trainee practitioner, and peer supervisor regarding the efficacy of the intervention and the decision not to refer.

At the time of the intervention described in this case study, I (first author) was 10 months into British Psychological Society (BPS) Stage Two supervised training and Ben (second author), who adopted the role of peer supervisor or “critical friend” throughout the consultancy process, was 10 months into British Association of Sport and Exercise Sciences (BASES) supervised practice. The BPS and BASES training pathways require applied practitioners to demonstrate a multitude of competencies across a specific time period. Prior to enrollment on these respective training pathways, Ben and I both had experience of working in professional football together, where we would regularly discuss our philosophy of practice and development as applied practitioners. Ben and I had met while studying for a degree in sport psychology (MSc) and developed a strong personal and professional relationship. I would regularly contact Ben for advice and support with this particular case and many others, as his professional role exposed him to Olympic athletes experiencing a variety of challenges as they prepared for life after sport. This applied experience equipped Ben with the knowledge and practical insight to offer advice and support to me as an applied practitioner.

Our philosophy of practice as applied practitioners is to focus on the holistic development of people, in the belief that performance and well-being are inescapably linked (Brady & Maynard, 2010). This means that when working with a client, performance enhancement is always balanced with the welfare of the individual (Stambulova, Wrisberg, & Ryba, 2006). As applied practitioners, we particularly focus on gaining a better understanding of the client’s lived experiences as a person by adopting an existential approach to practice. Existential psychology allows for the exploration of both the positive and negative experiences that an individual might encounter in sporting and nonsporting contexts, by focusing on concepts such as death, love, courage, isolation, anxiety, and meaning (Nesti, 2004). This approach to applied practice can be particularly useful when individuals are experiencing a crisis or are making a transition. When supporting an individual through these transitions or critical moments, an existential practitioner will not focus on the use of techniques to reduce the symptoms associated with this difficult moment (Corlett, 1996) but will instead accept that the individual has freedom and autonomy in the choices he or she makes, embracing the anxiety that will inevitably accompany this freedom. By being authentic and focusing on the encounter itself, an applied practitioner can provide their clients an opportunity to increase their self-knowledge and grow psychologically.

In addition to adopting a philosophy of practice that focuses on both performance and well-being, prior to my engagement with this particular client I had completed a mental health first aid course through my role as mental health “champion” at the university where I was situated. This had improved my knowledge of mental health and increased by ability to spot the signs and symptoms associated with mental health disorders in both students and athletes. Mental health was also a topic we had discussed extensively in the professional doctorate program in sport and exercise psychology that I was enrolled in, where we were regularly exposed to real-world case studies to critically discuss, alongside clinical psychologists and experienced sport and exercise psychologists.

The client (C.T.) involved in the following case study is a 22-year-old professional rugby league player playing for a team in the English Super League. In the last 2 years, he had progressed from the academy at the club into the first-team squad. At the time the consultancy process began, he was a year into his first (2-year) professional contract at the club and had played over 15 times for the first team. Due to the unique circumstances of the client involved in this particular case study, an array of identifiable information has been omitted to ensure that complete confidentiality is maintained. This case study provides a snapshot into the 12-month consultancy process with C.T.

Consultancy Process

Throughout this consultancy process, the boundaries between the intake, needs analysis, case formulation, and intervention were blurred and overlapped with one another, as they often do in one-to-one sport psychology support (Keegan, 2015).

Intake

Before the official start of the consultancy process, C.T. and I had already met (under circumstances that will not be discussed to ensure complete confidentiality of the client). This informal engagement, over time, naturally led to the development of a strong and professional practitioner–client relationship, providing us with a solid foundation when formally engaging in one-to-one sessions together (Gilbourne & Richardson, 2006). During these informal meetings, C.T. and I would often discuss the importance of ethical practice in applied sport psychology, which provided me the opportunity to highlight my own philosophy of practice as an applied practitioner. I reminded C.T. of this approach to practice at the beginning of our first session, while also discussing the boundaries of confidentiality and highlighting my scope of practice in relation to mental health. C.T. understood and stated that he had approached me based on my philosophy of practice, as it had resonated with his own experiences. As a result of our earlier engagement, C.T. seemed comfortable and eager to progress straight into discussing his personal and professional challenges. During the first session, C.T. disclosed that he thought he had experienced depression in the past but made it clear that he did not feel he was currently depressed. Nonetheless, I needed to gain more information from C.T. to inform a potential referral decision, so I spent the remainder of the session exploring his past experiences of depression. C.T. explained that he had never been formally diagnosed with depression but had experienced symptoms associated with depression, such as low mood, inability to sleep, lack of concentration, fatigue, and withdrawing from family, friends, and teammates. Immediately after the intake session, I contacted my supervisor to explain C.T.’s circumstances and to review whether or not this case was grounds for referral. At the time, I didn’t feel that referral was necessary as C.T. wasn’t a threat to himself or others, but as a trainee sport and exercise psychologist I wanted to be sure that this was the right decision. My supervisor and I agreed that it was something I needed to be mindful of as the consultancy process progressed but currently wasn’t something that fell outside of my scope of practice, and as long as I felt comfortable, I should continue to support C.T.

Needs Analysis

In line with my philosophy of practice, I continued to adopt a client-led approach throughout the second session, because I wanted to understand C.T.’s lived experiences in more detail and gain a better understanding of the reason(s) he had approached me for support. I reinforced at the start of this session that C.T. could discuss his experiences both in and outside of sport, and as with the intake session, C.T. was clearly comfortable with me and was able to provide me with a detailed insight into his experiences. It quickly became clear that C.T. was experiencing a multitude of challenges simultaneously, which were all having a negative impact on both his performance and his well-being (Nesti, 2007). The two main challenges discussed during this second session centered around C.T.’s transition into the first-team squad and his experiences of prolonged deselection. However, as the consultancy process continued and C.T. came closer to the end of his professional contract, he began to question his future in the sport and had to deal with the anxiety that accompanied the decision regarding his next contract.

Progression Into the First-Team Squad

C.T. had recently made the transition from the academy into the first-team squad. He had been at the club for the vast majority of his career as a rugby player; nonetheless, he found this transition difficult. Individuals such as C.T., experiencing this transition from academy to first team, are often progressing from an environment that was nurturing and caring, in which they received a high level of support, to an environment that is lonely and isolated and may lack the necessary support. C.T. was expected to function in this new challenging environment (Nesti & Littlewood, 2011), when he may not have possessed the required skills, knowledge, or experience (Richardson, Relvas, & Littlewood, 2013). Furthermore, he expressed that he no longer belonged to the academy and still had to prove himself as a first-team player, which left him with a sense of uncertainty and anxiety. Individuals making this transition now have a limited amount of time to prove they can perform in the outcome-oriented environment of first-team sport (Nesti, 2010). C.T. no longer fully belonged to either the academy or the first-team squad (Richardson et al., 2013) and so required support to overcome the unique demands of this phase of his career. In addition to having to adapt to this new environment, C.T. was struggling to develop a relationship with the first-team coach (Røynesdal, Toering, & Gustafsson, 2018; Stambulova, Franck, & Weibull, 2012), whom he felt had lied to him about the selection process and as a result could not trust on a personal or professional basis.

Prolonged Deselection

In addition to this, over the last few months C.T. had experienced prolonged deselection from the first-team squad (Brown & Potrac, 2009), which had begun to reduce his confidence in his own abilities. Prolonged deselection, which is often unexpected and unpredictable in nature, has been described in the literature as a critical moment that athletes face throughout their careers (Nesti, Littlewood, O’Halloran, Eubank, & Richardson, 2012). These critical moments describe moments where individuals must confront anxiety, due to changes in their identity (Ronkainen & Nesti, 2017), providing them the opportunity to increase their self-knowledge (Ronkainen, Tikkanen, Littlewood, & Nesti, 2014) and grow psychologically. However, this growth can only occur if these individuals take personal responsibility (Douglas, 2014) and challenge their own personal values and beliefs to improve their self-knowledge (Ronkainen, Harrison, & Ryba, 2014). While progressing throughout the academy, C.T. had rarely experienced deselection and had flourished in this environment, resulting in his playing at an international level. He had also experienced a good start to his professional career in the first-team squad, making a number of appearances. However, due to the increased demands of playing at a professional level, he was finding it increasingly difficult to break into the starting team at the expense of some of the more senior players.

Contract Negotiations

As the consultancy process progressed, C.T. was slowly coming toward the end of his professional contract. Naturally, this left him questioning his career at the club and his future in the sport altogether. In the months leading up to the end of his contract, the chairman of his current club offered C.T. a contract extension. In the same week, two other Super League clubs approached C.T. and expressed their interest in signing him during the next transfer window. C.T. now faced a decision between signing a new contract at his current club or transferring to a new club, which was currently in a better position in the league. As has been discussed, these critical moments always involve anxiety, otherwise described from an existential perspective as normal anxiety (May, 1977), which occurs because of an individual’s ability to act freely and make decisions in a given situation (Nesti, 2004).

Identity

There was also an underlying discussion of identity throughout the consultancy process, with C.T. consistently questioning who he was as both a person and an athlete. The transitions that athletes navigate throughout their sporting careers can often have a negative impact on their well-being (Schinke, Stambulova, Si, & Moore, 2017) and lead them to question who they are and who they want to be (Wylleman & Reints, 2010). When considering these challenges as a collective, it was becoming apparent that C.T. was demonstrating a strong performance narrative in relation to his role as an athlete (Carless & Douglas, 2013). At times, his identity seemed exclusive to his athletic role and he showed signs of developing identity foreclosure (Petitpas, Van Raalte, & Brewer, 2013). Individuals who subscribe to an exclusive performance narrative can begin to demonstrate culturally saturated athletic identities (Ryba & Wright, 2005) or experience a loss of identity altogether (Brown & Potrac 2009), which can lead to depression (Wood, Harrison, & Kucharska, 2017), distress, helplessness, and isolation when experiencing critical moments (Nesti et al., 2012) or when forced to disengage from elite sport (Lavallee, Nesti, Borkoles, Cockerill, & Edge, 2000). This one-dimensional identity can also intensify the emotions experienced during moments of perceived failure or when receiving critical feedback.

Aims of the Intervention

It was clear that in the support I provided C.T. I would need to consider his holistic experiences and provide him an opportunity to explore his values and beliefs so he could face the inevitable anxiety that was accompanying these critical moments. At the end of the second session C.T. and I agreed on two clear goals to the intervention: to create a confidential environment where C.T. could discuss his experiences and to explore and challenge his core self and the impact this was having on his current experiences.

The Intervention

The intervention lasted for 12 months in total, and during this time C.T. and I met on 15 occasions (lasting anywhere from 1 to 2 hours, depending on what C.T. had experienced since our last meeting). In addition to this face-to-face contact, C.T. and I would regularly communicate with each other via text messaging. I would usually send him a message after a game to ask about the result and his own individual performance, and C.T. would often message me to let me know how his week had been and to arrange our next session. This consistent communication enabled me to monitor his progress closely, ensuring that I was aware of any setbacks he was experiencing. Without needing to be prompted, C.T. would tell me about aspects of his life relating to his well-being (sleeping better, losing weight, exercising more regularly, etc.), which gave me further insight into his progress.

From the very beginning of the consultancy process, C.T. clearly stated that he wanted to be able to discuss all of his experiences (personal and professional) with someone he could trust. To meet his needs and to work in alignment with my philosophy of practice, C.T. and I consistently engaged in the encounter. From an existential perspective, engaging in the encounter involves the coming together of two people (and personalities) and requires the practitioner to consistently demonstrate presence, empathy, and spontaneity. Existential psychology rejects the use of techniques to reduce the symptoms associated with an experience (Corlett, 1996) and instead encourages athletes to courageously confront the anxiety that always accompanies critical moments throughout their career (Nesti, 2004). This was particularly important when working with C.T., as at the start of the consultancy process, he would often attempt to avoid this anxiety by questioning his future in the sport. By encouraging C.T. to explore and recognize his responsibility and the freedom he had during these difficult moments, I helped him be able to take more control of his circumstances and deal with the pressure and anxiety constructively. To achieve this, I had to truly listen and understand C.T.’s lived experiences, demonstrating empathy throughout the consultancy process. This approach meant I was meeting the complex needs of C.T. as a client but also ensured I was working congruently as a practitioner (Lindsay, Breckon, Thomas, & Maynard, 2007). By being genuine, spontaneous, and authentic, I was able to engage in what is referred to as the I–Thou relationship (Nesti, 2004), which I believed positively affected the consultancy process. By being genuine and authentic (combining my personal and professional selves) throughout the process, I was able to build a strong relationship with C.T. However, I was also mindful that being someone’s equal, from an existential perspective, was different than being his or her friend. Therefore, while engaging in this process, I had to continually reflect on whether the personal/professional boundary was becoming blurred. Furthermore, engaging in the encounter involves immersing yourself in someone else’s lived experiences, which for practitioners can be emotionally demanding (Nesti, 2004). There were a number of occasions (particularly during the more challenging moments) that I would finish the session exhausted and found myself experiencing a similar emotional response to C.T. Therefore, I also had to be mindful not to let these emotional responses negatively affect the consultancy experience.

Scope of Practice

During our first three sessions together, C.T. had demonstrated a noticeable improvement and had begun to make small life changes (sleeping better, eating well, exercising more, etc.). He was beginning to take responsibility for the aspects of his life that he could control. He was also beginning to explore activities outside of a sporting context that helped him switch off from rugby. Moreover, his professional circumstances had changed. The assistant coach, with whom C.T. had a good relationship, had replaced the head coach at the club. As a result, C.T. had been informed that he would be playing for the first team the following week. However, C.T. performed poorly in his return to the starting team and was left out of the squad in the following game, which had had a detrimental impact on his well-being. During one of our weekly text conversations, when discussing how C.T. was feeling, C.T. stated, “I’m really not in a good place at the minute, mate.” Based on discussions C.T. and I had had during our sessions together and the feedback he had sent me via text up until this point, his well-being had been improving; however, it was clear that performing poorly on his return to the team had caused a further reduction in his well-being and I was concerned that any progression he had made over the past few months had now been undone.

After receiving the text, I immediately contacted my supervisor (Eubank, 2016a), as based on this new information, I needed to decide again whether or not C.T. should be referred for more specialist support. My supervisor again took the time to listen to the circumstances surrounding C.T.’s recent experiences and my reflections on the consultancy process so far. He had extensive knowledge of the BPS guidelines and had also attended a conference on mental health in sport that same week; he described the referral process as a traffic-light system, with C.T.’s case bordering the green/amber category. A client in the amber category might be experiencing symptoms associated with low well-being, such as poor mood or sleep deprivation, but was not experiencing a clinically diagnosable mental health disorder. Further reflections with my supervisor highlighted that, perhaps as a result of my trainee status, I might have been overly anxious about C.T.’s changing circumstances (Eubank, 2016b). Our discussion then progressed onto the concepts of comfort and competence. By comfort, my supervisor was referring to whether or not C.T.’s experiences were aligned to my approach to applied practice, and by competence, he was referring to my “ability to function optimally within the recognized limits of knowledge, skill, training, education, and experience” (British Psychological Society, 2009, p. 15). It was clear that C.T. needed support that primarily focused on improving his well-being, as opposed to his performance, but based on the information I had received from C.T. and discussions I had had with my supervisor, it was clear that C.T.’s case was not clinical. Furthermore, as noted herein, my philosophy of practice centers on the assumption that performance and well-being are inescapably linked, and prior to this consultancy I had 2 years’ experience providing support to professional footballers that predominantly prioritized well-being. Hence, my supervisor and I both concluded that I was competent to support C.T. through his current experiences, and I felt more than comfortable doing this based on my approach to practice.

BPS Guidelines

The BPS Code of Ethics and Conduct (British Psychological Society, 2009) states that sport and exercise psychologists are required to “refer clients to alternative sources of assistance as appropriate, facilitating the transfer and continuity of care through reasonable collaboration with other professionals” (p. 19). However, the guidelines remain a gray area for applied practitioners, and after I read them a number of times throughout this consultancy process, they raised more questions than answers in relation to my role and responsibilities during this particular case. What if the sport psychology practitioner doesn’t recognize that the athlete is experiencing a mental health disorder? What if the athlete purposefully hides his or her condition for fear of being referred? If making the decision to refer, how long would it take for the athlete to be seen by a clinical psychologist? During this time, can the sport psychology practitioner continue to support the athlete? If not, what further support will the athlete have access to while waiting for the appointment? What if referral leads to a loss of trust between the athlete and practitioner, leaving the client with no support? Moreover, once the athlete has seen the clinical psychologist, what if he or she doesn’t want to continue to work with the practitioner? Or what if the athlete refuses the referral altogether? Answers to these questions aren’t provided by the current guidelines, so it seems, when presented with borderline cases such as C.T.’s experiences in this case study, that it is down to individual practitioners to judge whether or not they have the qualifications, expertise, and experience to support the athlete through his or her challenges or leave the athlete to navigate the complexity of a referral process.

Furthermore, athletes are most likely to approach the practitioner(s) that they feel most secure with, meaning that support staff such as sport psychology practitioners, sport scientists, and physiotherapists are highly likely to encounter an athlete experiencing symptoms of poor mental health (Morton & Roberts, 2013). In addition, if a referral is made, there are no guarantees that a clinical psychologist will be able to support the athlete through his or her challenges, given clinical psychologists’ lack of understanding of elite sport (Roberts, Faull, & Tod, 2016). It is apparent then that the current guidelines are not clear and need to be reviewed and reformed to provide applied sport psychology practitioners clearer insight and understanding of their roles and responsibilities in relation to referral of athletes experiencing challenges to their mental health.

Evaluating the Intervention

Client Feedback

Twelve months into the intervention, C.T. agreed to take part in an interview designed to gain a better understanding of whether or not the intervention had successfully met the aims stated at the start of the consultancy process. The interview lasted for 67 minutes, was recorded on a dictaphone, and was then transcribed verbatim. Thematic content analysis was used as the method of data analysis, because it allowed me to become aware of patterns that emerged from the interview, which represented C.T.’s experiences (Braun, Clarke, & Terry, 2015). During the data-analysis process, it was essential for me to recognize how my own philosophy and experiences of the consultancy process would contribute toward the emergence of the themes presented in the next sections (Yilmaz, 2013). While it was impossible for me to remove myself completely from the data-collection and -analysis process, the questions were designed to be open-ended to ensure that C.T. had the opportunity to provide direction to the interview. Furthermore, Ben (second author) reviewed the transcript and themes to increase the credibility and trustworthiness of the findings.

Case for Referral?

During the interview, C.T. discussed his circumstances in more detail but, more important, highlighted that seeking support during this period was one of the most challenging things he had ever done:

Honestly, one of the most challenging parts was the first session, because I used to keep a lot of things in, about rugby, and I’d been going on a downward spiral for a couple of years now and I felt like I was losing it, like losing how I was in rugby, how I was as a person and I just really couldn’t speak to many people and so the toughest part was definitely, when I’d hit rock bottom, being able to go and tell someone about it. . . . Because I wouldn’t even say the toughest part was rock bottom; it was more going to have to speak to someone about it—that was the toughest part.

C.T. was aware of my scope of practice and admitted that if I had decided to refer him, he would have respected the decision but would not have accessed support anywhere else:

I would have had to respect your decision, but to be fair, if I went to speak to someone else, I probably wouldn’t have gone back. If I’m being honest, I probably would have just left it. Other people had already tried, and it just didn’t work. I probably would have just left it. I wouldn’t have pushed you probably [to come back], but I should have done back then, because I needed it, but I probably wouldn’t have. I probably would have just respected it and got on with it.

Before seeking my support, C.T. had been referred to see two other individuals: The welfare officer at the rugby club and the mental health advisor at his university. However, he explained that the support he had received from the club had actually made the situation worse and that the mental health advisor was too “textbook” and knew very little about elite sport:

I tried speaking to someone at the club before and it just didn’t work—there was always a conflict of interest, they just want to jump in and do something for you and it ends up just sending your anxiety either further. . . . Like I went to the guy in Uni as well, like the mental health person or whoever he was, and I didn’t see him again, because of the basis that I just, I just didn’t think he was as good, like he was too like to the book, if you get what I mean?

Athletes can often not seek additional support once referred for a number of reasons (Van Raalte & Andersen, 2013). In C.T.’s case, he struggled to develop an effective relationship with other practitioners who he felt were not able to help him, and so a referral in this particular case would have left C.T. with no support, potentially leading to a further reduction in his well-being.

Impact of the Intervention

After our first session together, C.T. described how he valued how much I knew about professional sport and how I made the environment comfortable for him to discuss his challenges:

You knew a lot about team culture and that was the thing that sold me on it, to be honest, and because you’d worked in other sports, you actually understand compared to others, who had no idea about sport and that just didn’t benefit me at all.

From the first session, my first impression of you was that you were a calm person and you knew how to wind me down, because I was quite emotional. . . . I can remember our first session and it was not overwhelming at all and it was easy to speak to you, and you’d expect the first session when someone’s opening up to someone it might be a bit awkward, but it was just dead natural really quickly and you’re just a really open person to come and speak to, like comfortable and easy to come and talk to. From Session 1, I felt like I could trust you, because if I didn’t I wouldn’t have come back and it was just me and you in a room. I just felt like I could say anything and I’d never had that before. There were things I was talking to you about that I wouldn’t even talk to my mum about or my brother, and it was things . . . I just felt like, how you made the environment around me and spoke to me, I’d just tell you everything.

C.T. kept returning to the sessions with me as he felt it was benefitting him and he openly admitted that without this benefit, he would not have kept returning:

I felt like I came back because I gained something, that’s why. Like even though, as cutthroat as this is, even if I liked you as a person, but I was gaining anything from the sessions, I’d have to go somewhere else, because selfishly if it isn’t going to benefit me I’m not going to go. So I came back because it actually benefitted me; I felt like I came out better than when I went in, so that’s what I needed at the time. I gained a bit of hope that it could get better, and that was from you.

These benefits, which C.T. describes in the following, give an insight into the holistic client-led support I was able to provide him, focusing on his development as both a person and an athlete:

You help the person like, if you’re struggling, you don’t try and fix it for me. . . . Using external factors . . . you try and do it internally, instead of externally. You sort of tried to strip down the problems I was having through rugby and tried to make me see that there were other things, and I can remember from the first session and you were trying to bring out just me and not just rugby, and I felt like you were the only person at that time I was speaking to that could do that. So I came back more and more because I finally started to see how it was about me instead of just about rugby, so you just stripped it back and made me realize that myself was more important . . . concentrating on the person and just being able to strip it back and find core problems and allowing them internally to fix them. Like you never told me how to fix something—either I had to realize it or we’d realize it together.

Based on this holistic support, C.T. described how he was able to find himself again, gain more confidence in himself, realize he had control over his own life, and increase his self-awareness:

The way I view myself, is definitely the top one. I didn’t feel like I had my own identity, and now like, even when I wasn’t getting picked, by the end of our sessions, even last year, I was me and I feel like I’ve found myself again, which is nice, And as I said, my confidence was . . . that was just something I was portraying to people, when actually I was struggling a fair bit, and I’ve got that back now, where I feel like I’m just being honest with myself and I’m back to being confident and believing in myself and thinking I can actually change stuff. And if things are going wrong, I can actually change it now; back then I didn’t think I could.

The main thing was, [the sessions] like unclouded the process in my head to be fair. It like, it just shone a bit of light through, if that makes sense? Instead of me thinking about all this other stuff, we were stripping it back and stripping it back, and then it made me realize, “Oh yeah, this is the root of the problem.” Like I had all these mini-things, then we’d somehow strip it to a main thing and we managed to find the root cause of problems, which I couldn’t find on my own. So that’s what I learned about myself, what I was actually annoyed at, so you allowed me to realize that and I learned what my problems actually were, rather than what I perceived them to be at the start.

C.T. felt that these changes helped him as a person outside of rugby, which consequently had an indirect impact on his performance. However, he was clear that the support did not have a direct impact on performance:

No I wouldn’t say it had a benefit performance-wise, in the sense that. . . . It did, because it helped me get back to sleep more, which means I could train a bit better, but I’d always say I put 100% in performance every week, so I think one of the problems I used to talk to you about, was what I didn’t understand . . . why I was being dropped. But I mean . . . so I wouldn’t say it impacted on me performance-wise, but it definitely impacted on me away from rugby a lot, which you actually spend most of your day . . . away from rugby. It certainly helped me outside of it, which would have had a knock-on effect and helped me perform, but not directly, no.

Lessons Learned

The environment of professional sport can often cause or exacerbate existing mental health disorders (Roberts et al., 2016), and athletes are generally at higher risk of developing mental health disorders while experiencing performance failure (Rice et al., 2016), as was the case with C.T. However, athletes often decide not to seek support or underplay their symptoms because of the stigma associated with mental health (not wanting to be viewed as “mentally weak”) and the potential impact this could have on their athletic careers (Gorczynski, Coyle, & Gibson, 2017; Gulliver, Griffiths, & Christensen, 2012; Reardon & Factor, 2010). Furthermore, referral can often be met with skepticism by the athlete (Morton & Roberts, 2013), and it is also common for sport psychology practitioners to take different approaches to referral based on their approach to service delivery (performance vs. well-being; Brady & Maynard, 2010).

It was essential for me, throughout the consultancy process, to continuously question whether or not C.T.’s case provided grounds for a referral to a clinical psychologist. Discussions with my supervisor and Ben (a critical friend) reinforced my earlier reflections that C.T. was not experiencing a clinical mental health disorder (was not a harm to himself or others) and did not require referral. Nonetheless, C.T. was going through a difficult stage of his life, and once the decision not to refer had been made (at both points in the consultancy process), I had to ensure that I was capable and confident as a practitioner to support him through these critical moments. My confidence was undoubtedly influenced by my philosophical approach to practice (supporting the whole person), and with time C.T. and I were able to navigate through this difficult moment in his career. However, it is important to highlight that while C.T. was not experiencing a clinical disorder, other practitioners whose philosophy of practice focuses predominantly on performance enhancement might have referred or chosen not to work with C.T. in these circumstances, highlighting a need for practitioners to fully understand their philosophical approach to practice when considering referral of a client.

After the decision not to refer, C.T. continued to engage in the one-to-one sessions and with time was able to regain his place on the starting team. Alongside this increase in his performance, C.T. committed his future to the club by signing a new professional contract. It seemed that after months of instability, C.T. had finally reached a point in his professional career where he could be proud of his achievements. He expressed this to me during one of our sessions together by stating, “I’ve finally reached a point where I’m happy with who I am again.” However, while this particular case ended with a positive outcome (meeting the agreed aims of the intervention), it was challenging and rewarding in equal measure and highlights the need for the guidelines surrounding referral to be revisited and reformed to provide clearer and more practical advice to applied practitioners who might find themselves in a similar position.

Peer Reflection

Note: This final section of the article was written by a peer rather than the first author.

This case study demonstrates how important it can be for applied practitioners to understand their professional philosophy of practice in an applied setting (Poczwardowski, Sherman, & Ravizza, 2004). This philosophically informed approach can have a direct impact on the decision to refer an athlete experiencing symptoms associated with a mental health disorder (Eubank, 2016a). C.T.’s lived experiences highlight the myriad of potential challenges elite athletes face throughout their careers, which can affect both performance and well-being and potentially lead to the development of depression and other mental health disorders. C.T. disclosed his own personal experience of depression before this consultancy experience and at times during engagement with Nick showed signs of depressive symptoms. Given that the lines of referral are blurred (Roberts et al., 2016), it can be difficult to identify when an applied practitioner engages in practice beyond his or her competency or scope of practice. Supervisors and peer support networks can be crucial in supporting applied practitioners when making this decision. However, arguably the most significant factor is the philosophy of the practitioner. Nick’s existential approach to counseling enabled C.T. to explore his holistic challenges, resulting in an increase in self-awareness. Adopting a philosophy of practice that focuses on both performance and well-being enabled Nick to demonstrate confidence and competence in dealing with C.T.’s experiences, ultimately influencing the decision not to refer. Both Nick and C.T. had to demonstrate courage to engage in the process, which can be extremely challenging for both the client and practitioner. However, by making the decision not to refer and avoiding quick-fix solutions, long-term change can and has been achieved. In this particular case, C.T.’s well-being was enhanced, which indirectly improved his performance as an athlete. This specific case highlights the need to review and reform the current guidelines surrounding mental health and referral for applied sport psychology practitioners, perhaps suggesting that applied sport psychology practitioners would benefit from working alongside clinical psychologists (Rotheram, Maynard, & Rogers, 2016) rather than referring and ceasing support altogether.

References

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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Crossref
    • Search Google Scholar
    • Export Citation
  • Carless, D., & Douglas, K. (2013). “In the boat” but “selling myself short”: Stories, narratives, and identity development in elite sport. The Sport Psychologist, 27(1), 2739. doi:10.1123/tsp.27.1.27

    • Crossref
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    • Export Citation
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    • Crossref
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    • Search Google Scholar
    • Export Citation
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    • Crossref
    • Search Google Scholar
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    • Search Google Scholar
    • Export Citation
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    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Nesti, M., Littlewood, M., O’Halloran, L., Eubank, M., & Richardson, D. (2012). Critical moments in elite premiership football: Who do you think you are? Physical Culture and Sport. Studies and Research, 56(1), 2332. doi:10.2478/v10141-012-0027-y

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    • Export Citation
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  • Nesti, M.S. (2007). Persons and players. In J. Parry, M.S. Nesti, S. Robinson, & N. Watson, (Eds.), Sport and spirituality: An introduction (pp. 721). London, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Nesti, M.S. (2010). Psychology in football: Working with elite and professional players. London, UK: Routledge.

  • Petitpas, A.J., Van Raalte, J.L., & Brewer, B.W. (2013). Athletes’ careers in the United States: Developmental programming for athletes in transition. In N.B. Stambulova & T.V. Ryba (Eds.), Athletes’ careers across cultures (pp. 222234). London, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Poczwardowski, A., Sherman, C.P., & Ravizza, K. (2004). Professional philosophy in the sport psychology service delivery: Building on theory and practice. The Sport Psychologist, 18(4), 445463. doi:10.1123/tsp.18.4.445

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry. Sports Medicine, 40(11), 961980. PubMed ID: 20942511 doi:10.2165/11536580-000000000-00000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 13331353. PubMed ID: 26896951 doi:10.1007/s40279-016-0492-2

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Richardson, D., Relvas, H., & Littlewood, M. (2013). Sociological and cultural influence on player development. In A.M. Williams (Ed.), Science and soccer (3rd ed., pp. 139153). Abingdon, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Roberts, C.M., Faull, A.L., & Tod, D. (2016). Blurred lines: Performance enhancement, common mental disorders and referral in the UK athletic population. Frontiers in Psychology, 7(1), 1067. doi:10.3389/fpsyg.2016.01067

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., Harrison, M.E., & Ryba, T.V. (2014). Running, being and Beijing—Existential exploration of a runner identity. Qualitative Research in Psychology, 11(2), 189210. doi:10.1080/14780887.2013.810796

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., & Nesti, M.S. (2017). An existential approach to sport psychology: Theory and applied practice. International Journal of Sport and Exercise Psychology, 15(1), 1224. doi:10.1080/1612197X.2015.1055288

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., Tikkanen, O., Littlewood, M., & Nesti, M.S. (2014). An existential perspective on meaning, spirituality and authenticity in athletic careers. Qualitative Research in Sport, Exercise and Health, 7(2), 253270. doi:10.1080/2159676x.2014.926970

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rotheram, M., Maynard, I., & Rogers, A. (2016). Using an integrated sport/clinical psychology approach to reduce anxiety and facilitate training adherence. Sport and Exercise Psychology Review, 12(1), 7480.

    • Search Google Scholar
    • Export Citation
  • Røynesdal, Ø., Toering, T., & Gustafsson, H. (2018). Understanding players’ transition from youth to senior professional football environments: A coach perspective. International Journal of Sports Science & Coaching, 13(1), 2637. doi:10.1177/1747954117746497

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ryba, T.V., & Wright, H.K. (2005). From mental game to cultural praxis: A cultural studies model’s implications for the future of sport psychology. Quest, 57(2), 192212. doi:10.1080/00336297.2005.10491853

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Schinke, R.J., Stambulova, N.B., Si, G., & Moore, Z. (2017). International Society of Sport Psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622639. doi:10.1080/1612197x.2017.1295557

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stambulova, N., Franck, A., & Weibull, F. (2012). Assessment of the transition from junior-to-senior sports in Swedish athletes. International Journal of Sport and Exercise Psychology, 10(2), 7995. doi:10.1080/1612197X.2012.645136

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stambulova, N.B., Wrisberg, C.A., & Ryba, T.V. (2006). A tale of two traditions in applied sport psychology: The heyday of Soviet sport and wake up calls for North America. Journal of Applied Sport Psychology, 18(3), 173184. doi:10.1080/10413200600830182

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van Raalte, J.L., & Andersen, M.B. (2013). Referral processes in sport psychology. In J.L. Van Raalte & B.W. Brewer (Eds.), Exploring sport and exercise psychology (3rd ed., pp. 337350). Washington, DC: American Psychological Association).

    • Search Google Scholar
    • Export Citation
  • Wood, S., Harrison, L.K., & Kucharska, J. (2017). Male professional footballers’ experiences of mental health difficulties and help-seeking. The Physician and Sports Medicine, 45(2), 120128. doi:10.1080/00913847.2017.1283209

    • Search Google Scholar
    • Export Citation
  • Wylleman, P., & Reints, A. (2010). A lifespan perspective on the career of talented and elite athletes: Perspectives on high-intensity sports. Scandinavian Journal Medicine and Science in Sports, 20(2), 8894. doi:10.1111/j.1600-0838.2010.01194.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Yilmaz, K. (2013). Comparison of quantitative and qualitative research traditions: Epistemological, theoretical, and methodological differences. European Journal of Education, 48(2), 311325. doi:10.1111/ejed.12014

    • Crossref
    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Wadsworth is with the School of Sport and Biomedical Sciences, University of Bolton, Bolton, United Kingdom. Paszkowec is with Athlete Career Transitions, Birmingham, United Kingdom. Eubank is with the School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom.

Wadsworth (n.wadsworth@Bolton.ac.uk) is corresponding author.
  • Brady, A., & Maynard, I. (2010). At an elite level the role of a sport psychologist is entirely about performance enhancement. Sport & Exercise Psychology Review, 6(1), 5965.

    • Search Google Scholar
    • Export Citation
  • Braun, V., Clarke, V., & Terry, G. (2015). Thematic analysis. Qualitative Research in Clinical and Health Psychology, 1(1), 95113. doi:10.1007/978-1-137-29105-9_7

    • Crossref
    • Search Google Scholar
    • Export Citation
  • British Psychological Society. (2009). Code of ethics and conduct. Retrieved from http://www.bps.org.uk/what-we-do/ethics-standards/ethics-standards

    • Search Google Scholar
    • Export Citation
  • Brown, G., & Potrac, P. (2009). “You’ve not made the grade, son”: De-selection and identity disruption in elite level youth football. Soccer & Society, 10(2), 143159. doi:10.1080/14660970802601613

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Carless, D., & Douglas, K. (2013). “In the boat” but “selling myself short”: Stories, narratives, and identity development in elite sport. The Sport Psychologist, 27(1), 2739. doi:10.1123/tsp.27.1.27

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Corlett, J. (1996). Virtue lost: Courage in sport. Journal of the Philosophy of Sport, 23(1), 4557. doi:10.1080/00948705.1996.9714530

  • Douglas, K. (2014). Challenging interpretive privilege in elite and professional sport: One [athlete’s] story, revised, reshaped and reclaimed. Qualitative Research in Sport, Exercise and Health, 6(2), 410430. doi:10.1080/2159676X.2013.858369

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Eubank, M. (2016a). Commentary: Blurred lines: Performance enhancement, common mental disorders and referral in the UK athletic population. Frontiers in Psychology, 7(1), 1709.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Eubank, M. (2016b). Trainee learning experiences for the demonstration of practitioner competence: A commentary on the commentary. Sport and Exercise Psychology Review, 12(2), 8487.

    • Search Google Scholar
    • Export Citation
  • Gilbourne, D., & Richardson, D. (2006). Tales from the field: Personal reflections on the provision of psychological support in professional soccer. Psychology of Sport and Exercise, 7(3), 325337. doi:10.1016/j.psychsport.2005.04.004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Gorczynski, P.F., Coyle, M., & Gibson, K. (2017). Depressive symptoms in high-performance athletes and non-athletes: A comparative meta-analysis. British Journal of Sports Medicine, 51(18), 13481354. PubMed ID: 28254747 doi:10.1136/bjsports-2016-096455

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Gulliver, A., Griffiths, K.M., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12(1), 157. doi:10.1186/1471-244x-12-157

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Keegan, R. (2015). Being a sport psychologist. London, UK: Macmillan International Higher Education.

  • Lavallee, D., Nesti, M., Borkoles, E., Cockerill, I., & Edge, A. (2000). Intervention strategies for athletes in transition. In D. Lavallee & P. Wylleman (Eds.), Career transition in sport: International perspectives (pp. 111130) Morgantown, WV: Fitness Information Technology.

    • Search Google Scholar
    • Export Citation
  • Lindsay, P., Breckon, J.D., Thomas, O., & Maynard, I.W. (2007). In pursuit of congruence: A personal reflection on methods and philosophy in applied practice. The Sport Psychologist, 21(3), 335352. doi:10.1123/tsp.21.3.335

    • Crossref
    • Search Google Scholar
    • Export Citation
  • May, R. (1977). The meaning of anxiety. New York, NY: Ronald Press.

  • Morton, J., & Roberts, C.M. (2013). The hurt business: The harsh realities of high-performance sport. The Sport and Exercise Scientist, 38(1), 2829.

    • Search Google Scholar
    • Export Citation
  • Nesti, M., & Littlewood, M. (2011). Making your way in the game: Boundary situations in England’s professional football world. In D. Gilbourne & M.B. Anderson (Eds.), Critical essays in applied sport psychology (pp. 233246). Champaign, IL: Human Kinetics.

    • Search Google Scholar
    • Export Citation
  • Nesti, M., Littlewood, M., O’Halloran, L., Eubank, M., & Richardson, D. (2012). Critical moments in elite premiership football: Who do you think you are? Physical Culture and Sport. Studies and Research, 56(1), 2332. doi:10.2478/v10141-012-0027-y

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Nesti, M.S. (2004). Existential psychology and sport: Theory and application. London, UK: Routledge.

  • Nesti, M.S. (2007). Persons and players. In J. Parry, M.S. Nesti, S. Robinson, & N. Watson, (Eds.), Sport and spirituality: An introduction (pp. 721). London, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Nesti, M.S. (2010). Psychology in football: Working with elite and professional players. London, UK: Routledge.

  • Petitpas, A.J., Van Raalte, J.L., & Brewer, B.W. (2013). Athletes’ careers in the United States: Developmental programming for athletes in transition. In N.B. Stambulova & T.V. Ryba (Eds.), Athletes’ careers across cultures (pp. 222234). London, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Poczwardowski, A., Sherman, C.P., & Ravizza, K. (2004). Professional philosophy in the sport psychology service delivery: Building on theory and practice. The Sport Psychologist, 18(4), 445463. doi:10.1123/tsp.18.4.445

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry. Sports Medicine, 40(11), 961980. PubMed ID: 20942511 doi:10.2165/11536580-000000000-00000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 13331353. PubMed ID: 26896951 doi:10.1007/s40279-016-0492-2

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Richardson, D., Relvas, H., & Littlewood, M. (2013). Sociological and cultural influence on player development. In A.M. Williams (Ed.), Science and soccer (3rd ed., pp. 139153). Abingdon, UK: Routledge.

    • Search Google Scholar
    • Export Citation
  • Roberts, C.M., Faull, A.L., & Tod, D. (2016). Blurred lines: Performance enhancement, common mental disorders and referral in the UK athletic population. Frontiers in Psychology, 7(1), 1067. doi:10.3389/fpsyg.2016.01067

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., Harrison, M.E., & Ryba, T.V. (2014). Running, being and Beijing—Existential exploration of a runner identity. Qualitative Research in Psychology, 11(2), 189210. doi:10.1080/14780887.2013.810796

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., & Nesti, M.S. (2017). An existential approach to sport psychology: Theory and applied practice. International Journal of Sport and Exercise Psychology, 15(1), 1224. doi:10.1080/1612197X.2015.1055288

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ronkainen, N.J., Tikkanen, O., Littlewood, M., & Nesti, M.S. (2014). An existential perspective on meaning, spirituality and authenticity in athletic careers. Qualitative Research in Sport, Exercise and Health, 7(2), 253270. doi:10.1080/2159676x.2014.926970

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rotheram, M., Maynard, I., & Rogers, A. (2016). Using an integrated sport/clinical psychology approach to reduce anxiety and facilitate training adherence. Sport and Exercise Psychology Review, 12(1), 7480.

    • Search Google Scholar
    • Export Citation
  • Røynesdal, Ø., Toering, T., & Gustafsson, H. (2018). Understanding players’ transition from youth to senior professional football environments: A coach perspective. International Journal of Sports Science & Coaching, 13(1), 2637. doi:10.1177/1747954117746497

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ryba, T.V., & Wright, H.K. (2005). From mental game to cultural praxis: A cultural studies model’s implications for the future of sport psychology. Quest, 57(2), 192212. doi:10.1080/00336297.2005.10491853

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Schinke, R.J., Stambulova, N.B., Si, G., & Moore, Z. (2017). International Society of Sport Psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622639. doi:10.1080/1612197x.2017.1295557

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stambulova, N., Franck, A., & Weibull, F. (2012). Assessment of the transition from junior-to-senior sports in Swedish athletes. International Journal of Sport and Exercise Psychology, 10(2), 7995. doi:10.1080/1612197X.2012.645136

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stambulova, N.B., Wrisberg, C.A., & Ryba, T.V. (2006). A tale of two traditions in applied sport psychology: The heyday of Soviet sport and wake up calls for North America. Journal of Applied Sport Psychology, 18(3), 173184. doi:10.1080/10413200600830182

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van Raalte, J.L., & Andersen, M.B. (2013). Referral processes in sport psychology. In J.L. Van Raalte & B.W. Brewer (Eds.), Exploring sport and exercise psychology (3rd ed., pp. 337350). Washington, DC: American Psychological Association).

    • Search Google Scholar
    • Export Citation
  • Wood, S., Harrison, L.K., & Kucharska, J. (2017). Male professional footballers’ experiences of mental health difficulties and help-seeking. The Physician and Sports Medicine, 45(2), 120128. doi:10.1080/00913847.2017.1283209

    • Search Google Scholar
    • Export Citation
  • Wylleman, P., & Reints, A. (2010). A lifespan perspective on the career of talented and elite athletes: Perspectives on high-intensity sports. Scandinavian Journal Medicine and Science in Sports, 20(2), 8894. doi:10.1111/j.1600-0838.2010.01194.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Yilmaz, K. (2013). Comparison of quantitative and qualitative research traditions: Epistemological, theoretical, and methodological differences. European Journal of Education, 48(2), 311325. doi:10.1111/ejed.12014

    • Crossref
    • Search Google Scholar
    • Export Citation
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