11 Psychiatric Issues


11


Psychiatric Issues


Christian Conte, PhD and Donald J. Conte, MS, MA


CHAPTER KEY WORDS



  • Conscious education
  • Exploring options
  • Suicidal ideation
  • Yield theory

CHAPTER SCENARIO


Brian, a running back on the football team, moved halfway across the country to be at your university. A standout athlete since he first started playing the game, Brian was an all-conference player as a freshman, then got a season-ending knee injury at the start of his sophomore year. He worked hard in rehab, but when he got back out onto the field in the first game of his junior season, he endured a season-ending shoulder injury. By his senior year, another running back was an all-star for the team, which dropped Brian on the depth chart. This had a tremendous impact on Brian because he went from being an all-conference player as a freshman to being a backup as a senior, all due to injuries. Two weeks into this season, Brian sustained a concussion, which put him out of play for the following week.


His coaches, teammates, your colleagues, and you all noticed drastic changes in Brian’s demeanor. For example, as a freshman, he was probably best described as the life of the party, but now he was significantly quieter, and he seemed to be angry more frequently. You notice that he has become more agitated and irritable recently, and he disclosed that he and his girlfriend of 2 years recently split. When you make a comment validating Brian’s tough situation, he responds by saying, “I don’t care. I don’t even want to be here anymore,” and then shuts down, not wanting to offer anything else.


SCENARIO RESOLUTION


Now that you know him and both his athletic and personal history to some extent, you are, whether or not you want to be, a part of his situation. Your challenge is to identify whether or not Brian has a psychiatric emergency and would benefit from a referral to a mental health service.


INTRODUCTION


The idea of being responsible for someone else’s emotional and psychological well-being can sound intimidating and overwhelming, especially for those with limited training in the field of psychology and counseling. However, the good news is that, as an athletic trainer, you are not responsible for anyone else’s emotional and psychological well-being. In fact, even if you were a psychologist or counselor, that statement would still be true.


However, you are responsible for the part you play in every communication you have, and, as a professional, you are responsible for identifying when to refer an athlete to counseling or mental health support services. In short, as in any profession in which you work with others, you are always responsible for identifying whether something constitutes a psychiatric emergency.


Injuries can leave anyone feeling vulnerable, and athletes are no exception. From a state of vulnerability, athletes often share personal issues with their trainers. When athletes open up, you have 2 primary areas of focus: identifying psychological issues that require referral and navigating your part of the communication with them. In this chapter, we’ll show you how to both identify psychological challenges in others and communicate effectively with people, regardless of any issue they might be facing.


The first message to learn regarding handling athletes’ psychological issues is this: You do not have to fix anyone. You only have to effectively listen to them to clearly identify what they are communicating. Identifying issues as problematic becomes easier when you set aside the need, desire, or pressure to solve what others are experiencing and instead focus on being accurate in your understanding of what they’re conveying. Perhaps the simplest guideline for recognizing whether an issue is worthy of referral is this: any issue that interferes with a person’s daily functioning is problematic.


Psychological distress is not a sign of weakness. All humans experience psychological struggles from time to time, and injuries that disrupt the projected or expected course of athletes’ lives can certainly weigh on them psychologically. The culture of sports has traditionally discouraged signs of weakness, and while equating psychological distress with weakness is unfortunate and inaccurate, the history of sport culture, coupled with popular understanding of mental health, perpetuates the association. Although many of us in the mental health field have been fighting against this stigma and false association for a long time, it can be the cultural context and the perceived reality of any athlete under stress. The more you align your expectations about your role with the reality of this unfortunate stigma, the more prepared you will be to accurately meet athletes where they are psychologically and to help guide them through any barriers that might impede them from seeking mental health support.


One possible approach to normalize the process of athletes following through with counseling services lies in comparing the roles of sports psychologists, who demonstrably help athletes and teams improve their performance, with the roles of mental health practitioners, who can be thought of as psychological or mental coaches who help people navigate difficult emotional situations.


Any time you put the pressure of solving others’ problems on your shoulders, you place an unnecessary and unrealistic burden on yourself. In contrast, when you recognize that your responsibility is simply to approach others with compassion, with a nonjudgmental attitude, authentic humility, and genuine curiosity to learn about them, you allay the pressure to solve their problems. In addition, you create a psychologically safe environment that enables others to express themselves openly and honestly and share their inner, subjective experience. The more honest others are about what they’re experiencing in the unseen world of their minds, the more accurately you can assess their need for help. By approaching others in this way, you also open a path for them to help themselves by working through their emotions, following through with mental health referrals, or initiating whatever other approach may be helpful.


This chapter first looks at the nature of Yield Theory, a pragmatic approach for helping you communicate with athletes and identify potential psychiatric emergencies, and then demonstrates its use in a case such as Brian’s.


Yield Theory


The hands-on, pragmatic method that we present in this chapter for helping you communicate with athletes in the most intentional way possible is called Yield Theory. Yield Theory is a powerful form of connecting with others, rooted in compassion and conscious education. It is an evidenced-based approach that will help you circumvent others’ fight-or-flight responses (ie, their defensiveness and resistance) to help them identify the heart of their challenges in a straightforward, yet nonthreatening way.1 In other words, Yield Theory helps you communicate with others in a way that makes them feel safe enough to let their guard down and tell you what is really going on. By providing you with a simple yet effective methodology for communication, we hope you will learn how to approach every professional discussion with intentionality.


Yield Theory takes the concept of walking a mile in others’ shoes a step further and invites you to take a moment to visualize yourself as the other person talking to you, complete with that person’s cognitive functioning, ability to experience emotions, and life experiences. When you put yourself behind others’ eyes, it wipes away the tendency for you to listen through the filter of what you believe you would do if you were them. You can set aside biases, preconceived notions, and judgment to focus on assessing what is going on. To accomplish seeing the world as others see it, Yield Theory involves genuinely meeting people at their juncture by using 3 core actions that are ultimately rooted in 7 fundamental components. The 3 core actions are:



  1. Listen
  2. Validate
  3. Explore options

The 7 fundamental components are:



  1. Acceptance
  2. Authenticity
  3. Compassion
  4. Conscious education
  5. Creativity
  6. Mindfulness
  7. Nonattachment

The idea of listening, validating, and exploring options is simple to understand and pragmatic to use—but that is not necessarily easy-to-do. As an analogy, think of the greatest martial artists in the history of the world. Ultimately, their 3 core actions are move, block, and hit, but, as you know, there is great skill in the way they move, block, and hit. Similarly, all great communicators listen, validate, and explore options, but it is how they listen, validate, and explore options that makes all the difference.


Just as it takes practice to become a master martial artist, it takes practice to become a great communicator. By focusing on the technique of how to listen, validate, and explore options with proficiency, you will learn how to connect with others in a deep and meaningful way, even if only during a brief interaction. Through being intentional with your approach, you will learn how to quickly assess whether you need to refer an athlete to mental health professionals for additional support.


Listen


Becoming an effective listener takes practice, but there are ways to increase your ability. To listen to others is to hear the entirety of what they are communicating. Barriers, such as ego or pride, often get in the way of listening well. The ego expects others to match its perspective, making us focus on what we believe others should or will say, rather on what they do say. For instance, it is natural for one to assume, but making assumptions about what others are communicating can lead to inaccurate assessments and miscommunication. Moreover, holding fast to assumptions stems from our ego’s desire to know, be right, or be seen as the expert. The challenge effective listeners face is to set aside their ego and listen for what is actually being communicated. It takes a certain level of self-awareness as well as the humility for having the willingness to learn about the person.


A useful analogy for listening effectively is to imagine that you are standing on one side of an enormous building, and the people with whom you are communicating are standing on the other side. There is no way for you to understand what is going on over there, because you cannot see what is happening, so you have to listen intently to what those people describe they are seeing and experiencing. Instead of listening to correct them and tell them what you believe they are seeing, you would listen openly with the singular desire of learning what they see and experience.


In considering this analogy, you allow yourself to recognize that you simply cannot see what you are not able to see—the interior, subjective world of the speaker. To listen in this way is to do so without judgment, with the humility and genuine sense of curiosity that drives your desire to learn. Think of communication with someone as a learning experience in which the other person is the teacher and you are the eager student.


Just as you cannot simultaneously see 2 opposite sides of a large building while standing on one side, seeing into the inner subjective world of others is equally as impossible. In both instances, listening involves accepting others’ perceptions of their experience. People are not wrong or bad for their feelings, and we cannot tell them what they experience in their own minds. However, what we can do is listen openly. From the position of, “Teach me about what you’re experiencing,” we are in a much better place to show others the kind of interest that is likely to lead to their opening up and being honest about what they’re experiencing. The more open and honest others are about what is going on inside them, the more accurately you can assess the situation.


Listening to Content Versus Process


When it comes to communication, there is a difference between content and process. Content comprises the words people say, whereas process comprises the manner of speech. When a there is a discrepancy between people’s emotions and behavior, it is an indicator that something more is going on psychologically than what they are ready to disclose or what they are aware or unaware of personally. For instance, the response, “I’m fine” can have multiple meanings, depending on the tone the speaker uses, as shown in the following examples:



  • “I’m fine,” he said, annoyed.
  • “I’m fine,” he said angrily.
  • “I’m fine,” he said reassuringly.
  • “I’m fine,” he said indifferently.

In each case, when the person says, “I’m fine,” the meaning is different. In all the cases except one, the process is different from the content. When you listen to others, it is important to listen to both content and process. The bigger the discrepancy, the more likely that something more is going on internally.


There are two creative ways to quickly identify process: (1) imagine that you are seeing that person speak, but the sound is on mute, so you are solely watching the person’s body language and facial expressions and/or (2) to imagine that the person could use only one word to share what she or he wanted to express, and that one word likely comprises the person’s process.


When people speak, they are communicating, both with what they tell you and what their body language, tone, and facial expressions show you. To listen to athletes well is to distinguish between their content and process, and then to recognize which of the 2 is more emphatic. An athlete can tell you that she is okay, but her body language and actions can show you that she is more upset than she is willing to reveal. One reason people do not readily reveal what is going on deep in their emotional worlds is that they, like you, want to feel psychologically safe before they allow themselves to be vulnerable enough to open up.


One of the best ways to help others feel safe enough to open up is by conveying interest and nonjudgment. The pragmatic tool of compassion for communicating interest without judgment is validation.


Validate


Once you have listened to what others say and believe you have identified their process, the second step in the process of Yield Theory is to validate. To validate is to acknowledge how others feel. To validate others’ emotions is not to condone their actions; it is simply to fully acknowledge the emotions they report they have. The more authentic you are in expressing interest in others and validating with compassion, the safer others feel, and the more likely they are to be honest about what they’re experiencing in their inner, subjective worlds.


Making a statement of validation in many ways can be thought of as a self-check. Through validation, you are checking to see whether you have accurately heard what others are expressing. Saying something like, “You seem angry” allows the other person to either confirm your hypothesis or correct you. In general, statements of validation might begin with “You seem …” or “It sounds like you feel …” or just a statement that you are identifying the emotion the other person is expressing. The more you listen with humility, the less attached you’ll be to your response derived from your own thoughts and feelings.


Validation is a focus on the perspective others are sharing that can circumvent their defensiveness. The more others feel understood, the more they feel connected. The more connected we feel with others, the safer we feel—remember, safety is the key to circumventing the fight, flight, or freeze response.


Once people feel validated, they are ready to explore options, but a common mistake communicators often make is rushing a person to explore options when he or she might still be in an emotional state that requires listening and validating. Although the brain is a complex of interacting neurons, problem-solving and emoting largely occur in 2 unique areas of the brain. To help people get to the part of the problem-solving center of their brain that will help them make clear decisions, you want to listen and validate them until they feel validated, not just until you feel you have validated them. Although you can begin to explore options while people are in a heightened emotional state, the general rule of thumb is to validate others until you can see a shift in their nonverbal communication, which indicates they have at least released some energy via your validation.


Explore Options


When people are struggling emotionally and say extreme things, there is a tendency for listeners to get swept up in the content of what others say and react to it. For example, if an athlete says out of frustration, “I should just quit!” then those around her might respond, “No, you don’t want to do that.” A quick, stereotypical response like that is reflective of minimizing and downplaying that athlete’s emotional experience. It also indicates a failure to realize that what people say in intense emotional states might not be what they actually want to do. Getting swept up in the content of what people say can be misleading, just as you have not always meant what you said in high emotional states. However, instead of focusing in on the content of what others disclose, it is more important for you to focus on the process of what they’re communicating.


The way to do that is to not resist any potential choice they express. The options people mention in intense emotional states are often more indicative of their process or emotional state than of their actual desire. Of course, that is not a hard rule, as sometimes people want to do exactly what they say they will do in extreme emotional states. Again, the goal is to ascertain what others are genuinely communicating and to discern what is being emphasized more—content or process.


No matter what an athlete shares with you regarding potential options, yielding entails going with or verbally playing out that option with compassion, rather than resisting or denying it as a choice. In other words, if someone thinks it, then it is an option for him or her. That does not mean you have to agree with all potential options or that you cannot express an opinion about which option you believe is best. What it does mean is that by not resisting the options people give you, you will have a better chance to meet others where they are, not where you or others might believe they should be.


For example, telling the athlete who says she should quit that quitting is not an option would be the opposite of Yield Theory. Quitting is, in fact, an option, and may be the only one she entertains at the moment. However, you can acknowledge that her personal choice does not have to be the end of the conversation; rather, it is only a starting point for exploring the options she has not yet considered. The more emotional people are regarding a topic, the fewer options they tend to see for themselves, which is why, as a neutral observer, you can show the troubled athlete that more options do exist.


The more time you have to explore options with someone, the more you can play out their ideas to conclusion. So, regarding quitting, you could say, “Okay, so let’s say you quit. That’s definitely an option, and if I’m in your shoes, I can see why I might also want to explore that. So, let’s say you do quit, then what do you plan to do?” Without judging the options that others are considering, you take away the need for them to defend that path of action. Through nonresistance, you can create a safe space psychologically for people to share whatever they need to share.


Again, your goal is not to analyze, diagnose, or treat the psychiatric struggle that you recognize, but it is important for you to recognize what is happening as you communicate clearly and compassionately with the athletes you treat physically. Without downplaying or ignoring what the athlete expresses, keep in mind that whatever option others share with you, it is real and viable in their eyes. By acknowledging their stated options and the feelings and attitudes associated with them, you circumvent their innate desire to defend those options. Whatever option people express, assume that it is realistic, and be prepared to earnestly play out what following through with that option might look like.


For another example, let’s say that an athlete expresses his anger to you about another player “disrespecting him” in the locker room earlier that day. The enraged athlete says that he is considering fighting his teammate. Instead of telling him that it is unwise from a Yield Theory perspective of nonresistance, it is more important to imagine that you were in his place and that you were having an identical emotional response. In that way, you can listen openly to what he has to say without resistance and validate how he feels. Nonresistance does not refer to your condoning anything others say they’re going to do, rather, it means that you do not resist or tell others how they feel or what they should or should not be saying or single out the only option you feel is effective. By listening to this athlete’s experience and validating his anger, you make yourself a safe psychological space in which he is significantly more likely to both be honest about what he is genuinely considering doing and more willing to listen to you play out what it would look like if he actually followed through with that option.



YOU: “Okay, so let’s say you fight him, then what happens?”


ATHLETE: “Then he learns his lesson not to mess with me.”


YOU: “It’s hard to feel like people are messing with you.”


ATHLETE: “I’m sick of him messing with me.”


YOU: “I can’t imagine.”

Oct 13, 2020 | Posted by in ORTHOPEDIC | Comments Off on 11 Psychiatric Issues
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