Athletic Trainers’ Perceptions of Implementing Psychological Strategies for Patient Management: A Systematic Review

Types of Studies

To be eligible, studies had to investigate the current clinical practices and perceptions of certified ATs in integrating psychologically informed practice for patient management. Studies with level 4 evidence or higher were included. The level of evidence was determined using the Let Evidence Guide Every New Decision (LEGEND) tools.¹⁸ Evidence is graded from 1 to 5 based on study design: 1 is the highest level of evidence (eg, randomized controlled trials, controlled clinical trials) and 5 is the lowest level of evidence (eg, expert opinion, case reports).¹⁸ Studies were excluded if they were published before 1999, which was the inaugural year for the PS content area in the Educational Competencies requirements.¹⁰ Studies in which the primary language was not English were not included.

Types of Participants

To be eligible, studies had to include ATs as the population of interest. Studies were excluded if they involved athletic training students or other rehabilitation specialists (eg, physiotherapists, physical therapists) or if the studies explored the athlete’s and/or the patient’s perception of psychosocial techniques or strategies.

Operational Definition and Types of Psychological Strategies

Psychological strategies were defined based on previous systematic reviews (Table 2).^13,14Psychological strategies were defined as techniques including, but not limited to, (1) goal setting, (2) imagery, (3) visualization, (4) social support, (5) cognitive behavioral therapy, (6) self-talk, (7) positive reinforcement, (8) relaxation, and/or (9) coping strategies. Studies were excluded if they investigated the efficacy or testing of outcomes when using psychological strategies rather than the perceptions of ATs implementing them.

Table 2. Operational Definitions of Psychological Strategies

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Knowledge and Perceptions

The studies indicated that included ATs had the knowledge to identify when athletes were psychologically affected by injury and believed that athletes experienced numerous psychological responses as a result of injury.^24,30,31 Authors of 1 study in particular reported that greater than 90% of ATs in their sample believed that it was the responsibility of the AT to recognize adaptive and maladaptive psychological responses during rehabilitation after injury.²⁴ The most commonly identified psychological responses among sampled ATs were anxiety, anger, depression, loss of identity, and fear of reinjury.^25,30,31 However, Zakrajsek et al discovered that ATs in their sample consistently used the term fear to describe an athlete’s concern about reinjury, but their descriptions were more closely related to the term reinjury anxiety.³⁰ Reinjury anxiety is generalized worry about the potential consequences of injury (eg, additional surgery, more time in rehabilitation), whereas fear of reinjury is specific to fear of experiencing the injury itself.³² Both reinjury anxiety and fear of reinjury involve negative thoughts but should be considered distinct constructs that may need to be addressed through different interventions. Included ATs held positive attitudes toward the use of psychosocial strategies; however, not all included ATs believed that it was within their scope of practice or their responsibility to implement psychosocial strategies themselves.^24,28 Athletic trainers in the included studies perceived their overall ability to implement some basic psychosocial strategies (eg, goal setting) as competent, yet they felt less competent with implementing more advanced techniques (eg, imagery).^24,26 Sampled ATs felt competent implementing basic motivational techniques, such as goal setting, effective communication, and active listening, and less competent implementing advanced techniques, such as visualization/imagery, cognitive restructuring, and muscular relaxation techniques.^24,26,28,31

The ATs from the included studies were split in the perception of their abilities to recognize the need for further evaluation and referral to appropriate mental health providers.^24–26,29 Cormier et al reported that 97.3% (n = 326) of the ATs in their sample believed that facilitating psychological referral was a major responsibility of ATs.²⁴ Sampled ATs felt moderately to extremely confident recognizing and referring for anxiety, panic attacks, major depressive disorder, suicidal ideation, and eating disorders but felt less confident or unconfident in their ability to recognize signs of psychosis and substance use disorder.²⁵ Included ATs felt fairly confident in screening for risk of any mental health condition, implementing preventative education, recognizing and referring for routine mental health conditions, and recognizing emergency mental health conditions.²⁷ These ATs reported feeling very confident in their ability to refer for emergency mental health conditions.²⁷ There were significant differences in sampled ATs’ level of confidence between National Collegiate Athletic Association divisions, with Division I ATs reporting higher levels of confidence for every question compared with Division III ATs.²⁷ Additionally, there was a significant difference in ATs’ confidence in their ability to recognize routine mental health conditions between Division I and Division II, with Division I ATs reporting higher levels of confidence in this sample.²⁷ Further, there was a significant difference in these ATs’ confidence in their ability to recognize emergency mental health conditions between Division II and Division III, with Division II ATs reporting higher levels of confidence.²⁷ Young et al attributed the differences among ATs’ confidence levels within each division to the varying range of mental health policies and procedures at each level.²⁷ In the Stiller-Ostrowski and Ostrowski study using focus groups, the majority of ATs indicated that they were less confident in their ability to handle referral situations.²⁹ Interestingly, in the Ostrowski et al study, ATs with fewer years of experience reported higher confidence in recognizing and referring for signs of anxiety and panic attacks compared with those with more years of experience.²⁵

Current Clinical Practices

The psychosocial strategies and techniques ATs reported using the most in the included studies were goal setting, communication, active listening, positive self-talk, keeping the athlete involved with the team, creating variety in rehabilitation exercises, using sport-specific exercises, and breathing control in acute injury situations.^26,29–31 The strategies and techniques sampled ATs reported implementing less frequently or not at all were muscular relaxation, mental/healing imagery, thought stopping, cognitive restructuring, visualization, and arousal/anxiety management skills training.^26,29–31 Stiller-Ostrowski and Hamson-Utley found that 89.7% (n = 1701) of ATs in their sample reported that they explained to patients how setting and accomplishing goals in rehabilitation will help them return to sport.²⁶ Most ATs in this study reported that they provided feedback on their patients’ progress on a regular basis.²⁶ Although goal setting was most frequently used among sampled ATs, authors of some studies reported that ATs may not be using goal setting effectively.^26,29,30 Athletic trainers in these particular studies independently set goals for the athlete instead of actively involving the athlete in the process.^29,30 Additionally, sampled ATs reported they did not distinguish between short-term and long-term goals or among physical, performance, and psychological goals, which are necessary components of effective goal setting.^26,30

Of ATs who had access to sport psychology services included in the Cormier et al study, 84.09% (n = 215) reported making referrals to such services; however, the majority of ATs in this sample reported that they did not use a written procedure for guidance in this process.²⁴ The respondents of the survey Young et al distributed reported more than 1 emergency mental health situation in the previous 12 months, demonstrating the importance of having written mental health policies and procedures in place before an incident.²⁷ Included ATs recognized and referred for anxiety, depression, and eating disorders most often and recognized and referred for suicide, nonsuicidal self-injury (NSSI), and psychoses the least.²⁵ Although this may reflect which conditions are more common and thus more likely to be recognized, only 51.5% of the ATs included in this study felt satisfied in their educational preparation related to recognition and referral of these less-common conditions.²⁵ Sampled ATs working in various clinical settings differed in the recognition and frequency of referrals for specific mental illnesses.²⁵ The ATs working in a hospital setting included in this study referred individuals more frequently for panic attacks and NSSI.²⁵ Sampled ATs employed in hospitals or physician offices recognized patients with substance use disorder more frequently compared with ATs employed in other settings.²⁵ Substance use disorder was referred less frequently by the sampled ATs in the industrial, military, and professional sports settings.²⁵

Educational Preparedness

The studies indicated that included ATs may have felt dissatisfied with their educational preparedness as it relates to sport psychology principles, psychosocial factors and technique implementation, and recognition and referral of mental illnesses.^{24–26,28–30} Sampled ATs who reported having formal sport psychology training or courses held positive attitudes toward implementing psychosocial techniques.²⁸ Exposure to sport psychology education or coursework was a significant predictor of accuracy in diagnosing psychological symptoms exhibited in athletes in 3 specific case vignettes.²⁴ Hamson-Utley et al concluded that either a lack of formal education or perception of not receiving ample education may be connected to ATs’ use of psychosocial strategies.²⁸ Some ATs from the included studies reported feeling underprepared by their education programs in skill development related to communication with coaches, physicians, and parents as well as skills related to mental health recognition and referral.^25,29 In a study evaluating ATs’ educational satisfaction within the PS competency area, the majority of the included ATs reported feeling satisfied with their education related to basic psychosocial techniques such as motivation and goal setting.²⁶ However, despite more advanced psychosocial techniques included within the PS competency area, ATs in the same study reported less frequent use of such skills (eg, healing imagery, muscular relaxation) due to lack of confidence in implementation.²⁶ In the study by Ostrowski et al, a substantial percentage of the sampled ATs in their study (range, 19.1%–26.3%) reported having no formal education related to mental illnesses (eg, anxiety, panic attacks, major depressive disorder, suicidal thoughts, or NSSI), and in the Stiller-Ostrowski and Ostrowski study, 100% of the recently certified ATs included (N = 11) reported having no formal education related to sport psychology theoretical models (eg, stress-response models, cognitive appraisal model) or social support provision, which are all components of the PS competency area.^25,29

Professional Development and Training Needs

The findings of this systematic review suggest that the ATs included in these studies expressed a desire to increase their current knowledge and understanding of psychosocial strategies and techniques.^26,28,31 The studies included in this systematic review exposed a gap between the PS competencies within ATs’ scope of practice and the knowledge and techniques ATs used in their clinical practice.^{24–26,28–31} Some authors suggested increasing the number of continuing education programs to enhance ATs’ current knowledge, as additional education may increase confidence in using psychosocial techniques more frequently.^26,28 Others suggested reframing the educational guidelines for PS competencies to exclude the use of advanced psychosocial techniques that require more extensive training.²⁴ Stiller-Ostrowski and Ostrowski evaluated recently certified ATs’ perception of their undergraduate educational preparation in the PS competency area and found that these ATs developed their use of psychosocial techniques with practical experience once they were certified instead of during their undergraduate education programs.²⁹ Some studies discovered a need to enhance ATs’ understanding of sport psychology and their recognition and referral of mental illnesses.^25,30 Sampled ATs openly discussed their limited sport psychology knowledge due to limited coursework or lack of understanding.³⁰ These ATs also perceived sport psychology as a “mental tool” to help athletes reach their potential and enhance performance and did not include using sport psychology techniques as part of injury rehabilitation.³⁰

Cormier et al used case vignettes of 3 different athletes experiencing psychosocial symptoms ranging from mild to moderate to severe, with 11 strategies to select for possible treatment intervention.²⁴ Athletic trainers in this sample generally selected the appropriate type and number of techniques to use for the mild and moderate cases; however, the majority of ATs identified that all 11 strategies were helpful for the athlete with severe symptoms.²⁴ The expert panel in this study identified only 4 strategies that would benefit this athlete, displaying that there is a need for additional training in the appropriate implementation of psychosocial techniques.²⁴ Sixty-one percent of the ATs in this study overreferred the athlete with moderate symptoms, suggesting that there is a need to provide additional training in appropriate psychosocial referral.²⁴ Additionally, sampled ATs varied in ability to recognize and refer for specific mental illnesses (eg, substance abuse, NSSI), indicating that providing practical education related to referral could benefit ATs at all levels.²⁴ The respondents of the Young et al survey reported varying levels of professional development related to mental health recognition and referral.²⁷ Approximately 17% of the respondents reported never engaging in professional development training related to mental health.²⁷ Based on their findings, Young et al suggested that more work needs to be done in training ATs in preventing, recognizing, and managing behavioral health care concerns in student-athletes.²⁷ Some studies indicated that athletic training education programs may be underpreparing athletic training students and should increase opportunities for applied learning to increase ATs’ confidence in implementing psychosocial techniques within their clinical setting.^26,29