Scholarly Articles

References

Taylor, J. (1990). The causes and prevention of drug abuse in professional sports in America. Psychotherapy and Private Practice, 8, 23-30.

Taylor, J. (1991). Career direction, development, and opportunities in applied sport psychology. The Sport Psychologist, 5, 266-280.

Taylor, J. (1992). Coaches are people too: An applied model of stress management for sport coaches. Journal of Applied Sport Psychology, 4, 27-50.

Simons, R., & Taylor, J. (1992). A psychosocial model of fan violence. International Journal of Sport Psychology, 23, 207-226.

Taylor, J., & Schneider, B.A. (1992). The Sport-Clinical Intake Protocol: A comprehensive interviewing instrument for sport. Professional Psychology: Research and Practice, 23, 318-325.

Taylor, J., Horevitz, R., & Balague, G. (1993). The use of hypnosis in applied sport psychology. The Sport Psychologist, 7, 58-78.

Chiert, T., Gold, S.N., & Taylor, J. (1994). Substance abuse training in APA-accredited doctoral programs in clinical psychology: A survey. Psychological Bulletin, 25, 80-84.

Taylor, J., & Demick, A. (1994). A multidimensional model of momentum in sports. Journal of Applied Sport Psychology, 6, 51-70.

Taylor, J., & Ogilvie, B.C. (1994). A conceptual model of adaptation to retirement among athletes. Journal of Applied Sport Psychology, 6, 1-20.

Taylor, J., & Cuave, K. (1994). The sophomore slump among professional baseball players: Real or imagined? International Journal of Sport Psychology, 25, 230-238.

Taylor, J. (1994). Examining the boundaries of sport science and psychology trained practitioners in applied sport psychology: Title usage and area of competence. Journal of Applied Sport Psychology, 6, 185-195.

Taylor, J. (1995). A conceptual model of the integration of athletic needs and sport demands in the development of competitive mental preparation strategies. The Sport Psychologist, 9, 339-357.

Andersen, M.B., Williams, J.M., Aldridge, T., & Taylor, J. (1997). Tracking the Training and Careers of Graduates of Advanced Degree Programs in Sport Psychology, 19891994. The Sport Psychologist, 11, 326-344.

Taylor, J., & Taylor, S. (1998). Pain education and management in the rehabilitation from sports injury. The Sport Psychologist, 12, 68-88.

Taylor, J. (2008.). Prepare to succeed: Private consulting in applied sport psychology. Journal of Clinical Sport Psychology, 2, 160-177.

Available upon request (not online)

Taylor, J. (1981). The effects of mental fitness on athletic performance. International Journal of Sport Psychology, 12, 87-95.

Riess, M. & Taylor, J. (1984). Ego-involvement and attributions for success and failure in a field setting. Personality and Social Psychology Bulletin, 10, 536-543.

Taylor, J. (1987). Predicting athletic performance with self-confidence and somatic and cognitive anxiety as a function of motor and physiological requirements in six sports. Journal of Personality, 3, 1-15.

Taylor, J. (1987). A review of validity issues in sport psychological research: Types, problems, solutions. Journal of Sport Behavior, 10, 3-13.

Taylor, J. & Boggiano, A.K. (1987). The effects of task-specific self-schemata on attributions for success and failure. Journal of Research in Personality, 21, 375-388.

Taylor, J. (1988). Slumpbusting: A systematic analysis of slumps in sports. The Sport Psychologist, 2, 39-48.

Taylor, J. (1989). The effects of performance and competitive self-efficacy and differential outcome feedback on subsequent self-efficacy and performance. Cognitive Therapy and Research, 13, 67-79.

Taylor, J. & Riess, M. (1989). A field experiment of "self-serving" attributions to valenced causal factors. Personality and Social Psychology Bulletin, 15, 337-348.

Prepare to Succeed: Private Consulting

in Applied Sport Psychology

This article explores the challenges of building a successful private consulting practice in sport psychology. The author examines the extant literature on the experiences of recent graduates as they enter the field of applied sport psychology and also describes how his own educational and early career experiences have shaped his practice. A four-part approach to consulting with athletes is outlined, along with detailed information regarding practice development, clientele identification, and fee structures. The personal qualities essential for creating a successful consulting practice in sport psychology are also explored. Finally, a five-stage model of career development provides guidelines for maintaining and growing a successful consulting practice.

One of the most significant concerns that confronts the field of applied sport psychology is finding jobs for the many graduates who are emerging from master’s and doctoral programs throughout North America (Weiss, 1998; Williams & Scherzer, 2003. Particularly among current students and recent graduates, this concern borders on a fear of whether they will be able to support themselves in a career for which they have invested considerable time, energy, and money in preparation (Andersen, Williams, Aldridge, & Taylor, 1997; Williams & Scherzer, 2003). A substantial number of graduate students and recent graduates indicate that they want to develop careers in private consulting (e.g., Harmison, Dale, Martin,

Durand-Bush, Kellmann, & McCann, 1998). Yet one study of sports-science-trained consultants in applied sport psychology reported that the median income these professionals derived from private consulting in the first 5 years of their careers was only $500 (Andersen, Williams, Aldridge, & Taylor, 1997). Another study that included both psychology- and sports-science-trained professionals indicated a higher, though hardly adequate, median income ($11,000) from private consulting (Meyers, Coleman, Whelan, & Mehlenbeck, 2001). A follow-up study to Andersen et al., conducted by Williams and Scherzer (2003) over the subsequent 5 years, demonstrated increased, and potentially sustainable, income from private consulting for doctoral graduates (mean = $59,000) but little consulting income for master’s graduates (mean = $7,900). The authors note, however, that their sample was small and did not include females, so this statistic may be unreliable.

Private Consulting

The picture that has been painted so far shows somewhat hopeful trends, but Williams and Scherzer (2003) leave little room for optimism: Although some growth was found in full-time consulting positions for doctoral graduates, the opportunities are still minimal and support Meyers, Coleman, Whelan, and Mehlenbeck’s (2001) recent conclusion that part-time, supplemental involvement in SP consulting is more practical today than full-time employment. (p. 352)

These findings could be interpreted in two ways. Optimistically, it may be that with so few consultants in the field, there must be a large and untapped reservoir of potential clients for those coming out of graduate school. Pessimistically, it may be that the dearth of successful consultants is reflective of few opportunities for consulting in applied sport psychology. What is clear at present is that there are many people entering our field and a substantial number who have aspirations to be full-time consultants upon graduation. The Association for Applied Sport Psychology has attempted to address this issue by organizing workshops aimed at providing graduate students and young professionals with information

about consulting avenues they can pursue and processes by which they can create opportunities for themselves (Davidson, Lerner, Murphy, & Taylor, 1998; Smith & Ciervo, 1998). Yet there has been relatively little written or spoken about practical steps that aspiring professionals can take to prepare themselves for the challenges of private consulting and how they can build a clientele that will enable them to have a successful and sustainable career in applied sport psychology.

This article, using my own career as a model, explores the types of challenges practitioners typically encounter in the process of developing a viable consulting career. It outlines a four-part approach to consulting, including detailed suggestions regarding practice development, clientele identification, and fee structures. In addition, it examines the personal qualities that the sport psychologist needs to create a successful consulting practice in sport psychology. Finally, it offers a five-stage model of career development that includes suggestions for maintaining and growing a successful consulting practice.

Applied Sport Psychology in Practice

Though the field of applied sport psychology is diverse in content, ranging from mental skills training to clinical issues with athletes to exercise to health and social issues, the area of greatest interest to sport psychology graduates and professionals is the performance enhancement of athletes (Andersen et al., 1997). Though what performance enhancement entails is a topic of sometimes-heated debate (usually

between the psychology- and sport-science-trained members of our field), I take a broader, bipartisan position. Any psychological approach, strategy, or technique that enhances athletic performance is applied sport psychology. Such interventions may include typical mental-training techniques such as goal setting, relaxation training, positive thinking, and mental imagery. They also include approaches that

are more commonly thought of as clinical or counseling interventions, for example, hypnosis, individual psychotherapy, and family counseling (all of which can be used without the presence of clinically significant difficulties). The particular course of intervention used depends on the education, training, and experience of the professional, and on his or her theoretical and intervention orientation.

Educational and Professional Background

It has been my observation that many psychologists choose their area of specialization based on previous experiences in their own lives. This is how I came to sport psychology. When I was 18 years old, I held a top-40 national ranking in alpine ski racing, yet I almost had success despite myself. I had no confidence, got very nervous before races, and was very inconsistent. That summer I took a college course entitled, Understanding and Coping with Stress. It introduced me to many of the techniques that I now use in my practice, such as positive thinking, mental imagery, and relaxation training. I applied these strategies to my racing in the months leading up to the next competitive season, and the following year was a breakthrough for me. My ranking rose to the top-20 in the nation and I finished consistently well throughout the year. The most amazing aspect of my leap in performance, however, was the psychological growth I experienced. Whereas the year before, I expected to fail before each race, now I was confident, relaxed, and focused. These psychological changes led to the best year of my athletic career. When I entered college, I read several sport psychology books and conducted two research studies in sport psychology. By the end of college, I knew what my life’s work would be. I thought, “I love sports, I love psychology. Put them together, and what do you get? Hopefully a career!” When I entered graduate school, I knew two things. First, I wanted to be a consultant in applied sport psychology. Second, I did not want to deal with serious pathology. Given these considerations, I chose a

doctoral training curriculum in psychology that offered diverse training in personality, social, clinical, and developmental psychology. Additionally, throughout my training, I emphasized three skills that I believed would be the foundation of my practice: public speaking, writing, and individual consulting. Much of my energy during this career-development process was directed toward gaining a high level of competence in these areas.

Fortunately, my training prepared me for the things I wanted to do most in my career: (a) help athletes enhance their performance, (b) work with athletes on subclinical life and developmental issues, (c) maximize the quality of athletes’ lives both within and outside of sport, and (d) diagnose pathology as needed and refer athletes to appropriately trained clinicians when necessary.

Approach to Applied Sport Psychology Consulting

The athlete cannot be separated from the person; when athletes walk onto the field, they do not leave themselves as people on the sideline. Any difficulties that athletes experience away from their sport will affect their performance in their sport. Moreover, the vast majority of performance difficulties clients present (e.g., low motivation and confidence, anxiety, and poor focus) are caused by issues outside of sport. These nonsport difficulties are generally related to their upbringings and their relationships with their parents. Most of these problems present at a subclinical level, and it is likely that if these individuals were not elite athletes and led fairly normal lives, these issues would not have a substantial impact on them. It is only in the demanding world of high-level sport that these issues emerge to impact them negatively as athletes and people.

I use a depth approach in conceptualizing and intervening with athletes, taking into consideration unconscious issues, upbringing, and family dynamics. Although I do not assume that there are underlying issues with the athlete, if they do exist, I want to know immediately. By using this approach, I am able to identify early in my consultation whether the presenting problem is a performance-enhancement issue

or one that requires intervention at many levels of the client as athlete and person (see Gardner & Moore, 2006). This approach has proven to be both efficient, in terms of quickly and clearly identifying the psychological barriers to performance, and effective, because it addresses all of the relevant issues at once from the start of consultation. It also informs conceptualization of athletes’ difficulties and guides the

intervention planning needed to help them resolve their performance problems. Effective intervention plans typically consist of mental-skills training and personal consulting that address both sport-related and personal issues that influence performance. Additionally, parent and coach consulting may also become part of the plan to address the athletes’ concerns in the most comprehensive manner.

Mental-Skills Training. Athletes most often visit a sport psychologist because they are struggling in some area of their competitive performances and believe that mental-skills training will help them overcome their difficulties. Not surprisingly, most athletes who present for treatment have undeveloped mental skills, notably in the areas of motivation, confidence, intensity regulation, focusing, and emotional control. Early in my consulting career, I did most of my mental-skills work with athletes in an office setting. I found, however, that athletes were mostly unable to take the information and tools we spoke about in my office and readily apply them in their training and competitive settings. In recent years, most of my mental-skills training has been conducted in the context of actual sport-training sessions. This approach ensures that the athletes understand what the mental skill is, how it can be applied to their sport situation, and the need to use it consistently to gain its benefits. In my experience, the sport-training setting is the only setting in which mental skills can be effectively learned, ingrained, and incorporated into athletes’ training and competitive preparations.

Personal Consulting. Mental-skills training is essential for athletes to perform their best and achieve their goals, but it is usually insufficient alone. For the majority of athletes, using mental-skills training alone is like putting a bandage over an open wound; the bleeding is slowed, but it does not heal the wound. Many of the problems that athletes face can be traced to psychological dysfunction that results from a combination of the attitudes, beliefs, and emotional reactions that they develop in their upbringings and the pressures of high-level competitive sport. Personal issues are much more powerful than sport-related mental skills, and even the best mental-skills training cannot override the personal issues that caused the performance dysfunction in the first place. As a consequence, personal consulting is typically essential for a positive intervention outcome.

Effective personal consulting involves counseling that addresses athletes’ difficulties cognitively, emotionally, and behaviorally. It helps athletes understand who they are, why they are who they are, and who they want to be. This work with athletes begins by having them identify the interfering thoughts, emotions, and behaviors in which they engage and understand their origins. These discussions act as a jumping-off point for more in-depth exploration of the causes of their performance dysfunction. The personal issues that athletes most frequently present include low motivation, perfectionism, poor self-esteem, fear of failure, emotional immaturity, and arrested development, all of which manifest themselves profoundly in athletes’ sport performances. Early experiences that athletes have, most often in their relationships with their parents, are usually the causes of their present performance dysfunction. The goal is to identify the psychological and emotional obstacles to athletes’ goals and, in doing so, uncover the emotional ties that connect athletes’ past experiences to their current performance dysfunction. In this way, counseling can help athletes learn to respond to their world based on a healthy set of beliefs, emotions, and behaviors derived from who they are in the present rather than on an unhealthy set of beliefs, emotions, and behaviors originating from who they were in the past.

Parent Consulting. Because the performance dysfunction that I typically see is rooted in the parent-child relationship, I also work extensively with the parents of young athletes. I should point out that this is not family therapy. Rather, it is what I call “sport family engineering,” which involves helping parents to understand what effects, both positive and negative, they have on their children and what they can do to foster healthy growth for their children as people and as athletes. One effective means of catalyzing change in young athletes is to engineer change in the environments in which they live, including family structure and processes, as well as the messages and feedback they receive from their parents. The willingness of parents to take responsibility for their children’s difficulties and their openness to participate in the change process directly determines the degree of positive change that is seen in the child. When necessary, one or both can be referred to a clinical psychologist for their own psychotherapy.

Coach Consulting. Coaches of the athletes also play an essential role in either contributing to or helping to resolve their athletes’ performance struggles. There is a saying, “If you are not part of the solution, you are part of the problem.” This axiom is particularly appropriate with coaches because, as perhaps the second most important adult in the lives of young athletes (after their parents), coaches have the power to either reinforce past unhealthy psychological and emotional patterns or to facilitate positive changes in the athletes with whom they work. Some of my most successful efforts with athletes have involved close collaboration with open and supportive coaches.

Framework for a Consulting Practice

Clientele

My consulting-practice clientele consists primarily of elite, individual sport athletes (though I have also worked with many team athletes as well), including juniors, collegians, age group, world-class, and professional. All of my work comes by word of mouth, and I have never advertised or solicited work from individuals. Most of my work comes from four sources. First, I am a regular speaker at junior training programs and coaches’ organizations. These speaking engagements provide exposure to hundreds of athletes, coaches, and parents. Second, I write extensively for sport-specific publications and have a series of sport-specific mental training books. Writing allows access to a larger population beyond the personal contact gained from speaking engagements. Third, because of my athletic and coaching experience in ski racing, tennis, running, and triathlon, I have a large network of contacts in these sports. Fourth, though I am legally and ethically bound to maintain the confidentiality of my clients, many of them have openly recommended my services to other athletes and coaches.

Consulting Structure

My practice includes two types of clients: (a) traditional hourly clients with weekly appointments and, more importantly, (b) “retainer” clients with contractual agreements for a specified number of days. A typical retainer agreement involves spending 3 days a month with an athlete in his or her training setting. A retainer agreement provides benefits to both the client and consultant. There are few quick fixes in sport psychology; change of almost any sort takes time. Most elite athletes have full-time coaches and physical trainers because sporadic technical and physical work would provide little benefit. The same holds true for mental preparation. A retainer arrangement ensures that the athletes receive consistent and ongoing contact that allows them time to make the necessary psychological, emotional, and behavioral changes. From the standpoint of the practitioner, retainer-based consulting may be the only way to make a comfortable and sustainable living in applied sport psychology. There are simply not enough athletes to see for five to ten sessions and not enough teams, sports clubs, and athletic organizations to maintain a reasonable livelihood. In addition to hourly and retainer clients, seminars and lectures offer another revenue stream, though one that requires marketing and continual development.

Fees

Consulting fees are a source of curiosity, consternation, and trepidation for many new or soon-to-be professionals. The eternal questions are “What do others in our field charge?” and “How much should I charge my clients?” I remember early in my career being happy to receive $35 per hour for my services (just being paid was a thrill!). To determine what a reasonable fee might be for you, several factors should be considered when deciding how much you can or should charge hourly clients. If you are a licensed psychologist or psychotherapist, you are legally and ethically bound to adhere to what is called the “community standard,” namely, a fee that is close to what is typically charged by other mental-health professionals in your area. For example, because of the cost-of-living differences, fees in New York City and Los Angeles are generally higher than those in, say, Des Moines or Denver. Another factor to consider is what your time is worth. If you are a young professional, you may be willing to keep your fee low to generate business. If you are more experienced, fees that are too low may not be adequate to motivate you to take time away from other potential revenue sources such as writing a book or giving talks.

Though many in our field are uncomfortable thinking this way, it is essential to see yourself as an entrepreneur and small-business owner. You must learn to think like a businessperson—that is what you are, after all—and appreciate the rules of the marketplace. You have to weigh the demand for your services and the size of the supply of others like you with whom you will be competing for business. You also must consider how much you need to generate business (as with most commodities, lower fees tend to produce an increase in business). For some professionals, especially those early in their careers, some income is better than no income.

Let your fees mirror your confidence in your abilities. As you gain experience and have increasing success, both highly correlated with competence, you will feel more confident in what you can offer clients and, just like your clients, you will feel greater value in your capabilities and more comfortable asking for higher fees. In addition, a rather ethereal factor that you should take into account is how your fees “feel” to you. Over the years, I have developed a visceral sense when my fees are too low (I do not feel fully valued) and too high (I get an anxious feeling). I have learned to trust these feelings to guide me in establishing my standard fee throughout my career. At some point, however, you might consider testing your value in the marketplace. Some years ago, I was feeling that my value had increased significantly, so with a new client, I decided to “swing for the fences,” asking for a fee that was substantially higher than my prior fees. He accepted it without hesitation, and I had a new standard on which to base my fees.

There are a few basic principles of fee-setting practice that aspiring consultants will want to follow. First, start low. Early on, it is better to undervalue yourself than price yourself out of potential business. Remember that since you are inexperienced, you are probably not as capable as you would like to think you are, so you may not be worth as much as you would like at that point. Recognize that you need business for both the income and the experience, and you do not want to turn people away because they cannot afford you. Establish a consulting fee that is reflective of your current experience and ability and with which you are comfortable. Once you are established, competent, and confident in your capabilities, you can choose to raise your fees and see how the market treats you. If you ask for too much, the market will let you know and you can then lower fee. As another metric, there is always the “cringe factor,” a rule of thumb I use half seriously and half facetiously: If clients do not cringe when I tell them my fee, it probably was not high enough.

Finally, you may want to create a sliding scale for those potential clients who have insufficient resources. If prospective clients cannot afford it, you can choose to lower your fee to a level with which you are both comfortable.

There are, of course, reasons other than income to accept consulting work. You might take on a case, even for a relatively low fee, simply because you believe it will be interesting, offer a unique learning experience, or look good on your resume. Some work may have value in terms of networking and exposure that may provide lucrative opportunities in the future; as such, accepting lower-paying work is an investment (that may or may not pay off). I also periodically accept work just because I think it will be fun. Opportunities to travel or work with a unique clientele should factor into your decisions. Finally, consider offering your services pro bono to organizations that you value. For example, I am a regular speaker for the Leukemia and Lymphoma Society’s Team in Training, a program that offers endurance athletes the opportunity to train and be coached for a variety of running, cycling, and triathlon events in exchange for fundraising to fight cancer. I can attest to the fact that contributing your expertise to a good cause is good for the soul.

Personal Qualities for Consulting Success

In my 22 years of practice, I have had the opportunity to see many professionals aspire to become successful consultants in applied sport psychology. A few have succeeded, but most have failed. This section will examine some of the personal qualities common among those consultants who have become successful.

Motivation

Unfortunately, the field of applied sport psychology is not one, like law, medicine, or business, in which there is clear path to success or frequent opportunities knocking at the door of graduates. Yet there are always opportunities for people who are truly committed and willing to put in the necessary time and effort to be successful. Successful consultants are those who are almost maniacally driven to succeed. They are driven by a tremendous love for their work. This intrinsic motivation keeps them going in the face of uncertainty, slow progress, and setbacks. They have a clear vision of where they want to go and how they are going to get there and are willing to devote their lives to pursuit of that vision.

Patience

I sometimes ask myself why I chose to pursue a career in applied sport psychology consulting. It would have been so much easier to become successful in another professional field. The rule of thumb in the entrepreneurial business world is that it takes 3–5 years to build a small business. By contrast, it took 10 years, 5 years of which was laying the foundation as a university professor, to reach a level of consulting that I considered successful. (I define career success as being financially secure in the short term, capable of saving money for my retirement, able to own a home in a location of my choosing, and providing for my family.) Though I do not consider myself a financial risk-taker, I have always had a fundamental belief that if I worked hard and was patient, I would succeed. There were few giant steps in this process. In fact, only once has an opportunity arisen that took me a quantum leap above where I had been, and it was in the form of a book advance unrelated to sport. Every development, every gain was a small step upward in my career. I did my writing, I gave my pro bono talks, I progressed ever so slowly in the direction I wanted to go until after 10 years, I finally reached a threshold at which I could comfortably support myself as a full-time consultant.

It is this kind of patience that is required to become successful in sport psychology consulting. This patience comes from a reality-based perspective on what it will take for you to achieve success in our field. The reality is that there are no professional or Olympic teams waiting outside your door when you receive your graduate degree. There are no superstar athletes who will hire you and put you on the map. There is only slow and often unsteady progress. Your ability to stay focused on the vision you have for your career, to be patient, and to keep your professional development in a long-term and realistic perspective will dictate whether you will be successful in sport psychology consulting.

Multiple skills

One of the common characteristics associated with all of the successful consultants I know is that they have diverse skills to provide to their individual and group clients. The three foundation skills that they all possess, as I referred to earlier, are counseling, public speaking, and writing. These areas are the primary means by which sport psychologists become known by prospective clients (writing and speaking) and help the athletes with whom they work (counseling).

Within these three areas, even more specific skills can further broaden the potential client population. Several types of writing and speaking can enhance competence, credibility, and identity. Scholarly writing (e.g., academic books and refereed articles) and speaking (e.g., conference presentations) demonstrate rigor of thinking and offers peer evaluation and acceptance. Popular writing (e.g., trade books and magazine articles) and speaking (e.g., to athletes, coaches, or parents) provide the means to reach a large audience of prospective clients. Even more diverse skills are needed within popular writing and speaking. For example, sport periodicals where I have published include coaching journals, sport-specific magazines, and broad-market newspapers. Popular groups I have addressed range from an audience of 400 10- to 12-year-olds to 300 of the leading tennis coaches in the country. These two kinds of writing and speaking, academic and popular, are vastly different in purpose, content, and style and require special efforts to gainskills in each area.

Counseling skills can also be highly specialized in terms of the areas in which you are competent to work and the client populations with whom you are able to consult. Being able to do mental training with young athletes does not guarantee your competence in addressing other issues that might arise, such as life skills with professional athletes. This is why it is so important to know what kind of work you want to do in your career as you proceed through graduate school. By knowing what you want to do, you can engage in the education, training, and experiences required to obtain competence in those areas.

Creativity

The field of applied sport psychology has not evolved significantly over the last two decades (Gardner & Moore, 2006). Though the research-knowledge base has grown substantially, there have only been a few breakthroughs that have dramatically changed the consulting landscape. As a consequence, consultants can only take the common information and conceptualize and apply it in a new and different way. As in any field, this creative process is one of the hallmarks of what separates those who succeed from those who fail. Creativity is defined as “the ability to transcend traditional ideas, rules, patterns, and relationships . . . and to create meaningful new ideas . . . ” (Webster’s, 1996). This notion of creativity can apply to the kind of program you build your work around, the manner in which you market yourself, the types of writing and speaking you develop for the diverse audiences to whom you present, or the way in which you work directly with your clients.

This process of looking at the field of applied sport psychology in a creative fashion is an active one that can begin in the early stages of a consulting career. Consultants can examine the widely used approaches and techniques and look for ways to modify them. They can use their own vocabulary and imbue an approach with their own personality and style. At the foundation of this process, you must ask yourself, “Am I saying and doing things in my field in new and different ways?” If the answer is no, you should find another way of saying it or doing it.

Five-Stage Model of Professional Development

The experiences I have had in my own practice and the discussions I have had with other consultants have led me to develop a five-stage model of professional development that describes some of the common steps we have taken and things we have done in establishing successful consulting practice (Taylor, 1996). These stages do not necessarily occur in chronological order. Rather, they may overlap or happen simultaneously. I believe that every consultant must progress through these stages to become successful (Taylor, 1991).

Stage One: Competence (Develop Knowledge and Skills)

The first stage is competence. Before anything else, you must be highly skilled in the techniques you use with the population with which you work. Though it is perhaps slightly cynical, I operate under the assumption that when someone leaves graduate school, they are not yet entirely competent and need considerably more knowledge and skills to be ready to offer something of substance to clients. You might find it helpful to think of physicians who must undergo a minimum of a 4-year residency—surgeons’ residencies can last up to 10 years—to be judged competent enough to practice on their own. The goal in this stage is to achieve a reasonable level of competence from which to build.

Competence derives from three areas that are outlined by the American Psychological Association (2002): education, training, and experience. Before competence can be sought, you must have a vision of what kind of work you wish to pursue in applied sport psychology. The essential decision at this juncture will be whether to pursue graduate training in sports science or a subspecialty of psychology. There is no single correct decision about which path to follow. The choice will depend

on several career-direction questions. What area of sport psychology (e.g., performance enhancement, performance dysfunction) most interests you? Where do you believe your strengths lie as a consultant? How difficult is it to gain admission into different graduate programs (i.e., acceptance into psychology programs tends to be more difficult to obtain than acceptance into sport-science programs)? What time commitment are you willing to make (i.e., a PhD from a sport-science program is typically four years, with no internship, while a PhD from a psychology program is a minimum of five years with an internship and is often longer)? And, finally, can you cover the costs of obtaining an advanced degree?

The first step, education, ensures that you obtain the necessary foundation of coursework, research, and practica experiences that acts as your knowledge base for further skill development. There should be congruence between your education and the competencies that you will need to pursue your career goals. This connection will ensure that you have the knowledge and skill sets necessary to practice legally and ethically in your defined areas of competence and in the areas that are of greatest interest to you professionally.

The second step, training, refers to more skill-specific aspects of your emerging competence as a consultant. Typical training experiences include graduate supervised practica, internships, and postdoctoral fellowships, as well as informal training opportunities such as mentor relationships with established professionals in the field. During the training phase, you integrate your educational knowledge base with the acquisition and use of specific techniques and strategies in actual intervention settings. Fundamental to the value of training is receiving extensive supervision from an experienced professional in the field. The didactic learning process that occurs during supervised training will more fully prepare you to enter the field with the tools that when combined with experience, will result in a high level of competence.

The third step, experience, is perhaps the most frustrating of the stages of competence. The classic Catch-22 scenario (i.e., you cannot get experience until you are competent, but you cannot become competent until you have experience) often makes it difficult to get the experience necessary to become truly competent. Gaining experience takes patience and the willingness to accept and, in fact, seek out consulting opportunities that offer little or no remuneration.

Stage Two: Identity (Design Your “Thing”)

The reality of applied sport psychology consulting is that everyone does more or less the same thing. No one has the market cornered on a particular intervention technique or approach. So what distinguishes consultants is how they use these strategies in their own particular way. This ability to distinguish your “thing,” that is, create a unique system of consulting and a one-of-a-kind identity, is what will enable you to differentiate yourself from other consultants. Your goal in applied sport psychology consulting: when potential clients come to you, they are not looking for a sport psychologist, they are looking for you.

The goals in this stage include developing your diverse competencies to a point where you have products (i.e., individual consulting programs, seminars, and writing) that are substantial and effective. You must also clearly detail and organize your personal consulting system. Lastly, from these two areas, you need to create your unique consulting identity that will enable you to stand out from others in the field.

None of these goals can be achieved by coursework, thinking about them, or reading others’ works; your system and identity cannot be learned, copied, or purchased. The only way to achieve these goals is through direct consulting experience. As a consequence, all of your efforts must be directed toward generating consulting, speaking, and writing opportunities. The focus should be on accumulating as much consulting experience as you can regardless of whether it is income generating. The experiences of working with athletes, speaking to sport groups, and writing

about the psychological aspects of sport act as the creative impetus from which your system and identify evolve. Ultimately, your system and identity emerge from your personality, your creative perspective on the role that psychology plays in the athletic performance, and your experiences.

Every successful consultant I know has what I call, “their thing.” This “thing,” which is comprised of their system and identity, is what separates them from others who are trying to do the same type of work. It enables them to offer their clientele something that is perceived as unique, invaluable, and that which cannot be found anywhere else. This “thing” is usually a combination of several strengths. First, successful consultants possess a certain personality style that enables them to connect with, engage, and inspire people. It might be the force of will of one professional, the quiet trust of another, or the impassioned charisma of a yet another.

Second, they have unique competencies that enable them to do things that few others can do. These skills might include the ability to work effectively with a coaching staff, to keep the attention of young athletes, or to have developed an unmatched assessment tool.

Third, they have created a singular place in the field through the use of branded nomenclature. There is a vocabulary that is widely accepted and used in applied sport psychology that many aspiring consultants accept without consideration (e.g., peak performance, enhanced performance, arousal, concentration). Yet, using the same language as everyone else also makes you appear like everyone else. Creating a vocabulary that is unique to your system and identity in applied sport psychology consulting will enable you to stand out from those consultants who sound like every other consultant. For example, Jim Loehr has trademarked “Mental Toughness” and it has become an integral part of part of the everyday language of sport and achievement. In addition, my “Prime Performance” model is a unique, trademarked approach to enhancing athletic performance that separates me from other consultants.

Fourth, successful consultants provide specialized services that appear to be unique to prospective clients. For example, hypnosis, biofeedback, or family therapy may be areas that you can offer that separate you from other consultants. Fifth, a unique identity can derive from the sports in which you specialize. If you can specialize in a sport in which there are few sport psychologists, you can establish yourself as the “go to” person when a consultant is needed in that sport. You might also create a unique identity with the client populations with whom you work. For instance, you might consult mostly with injured or retiring athletes. Sixth, your experiences as an athlete or coach can offer unique identity. For example, my high-level competitive ski racing experience has provided me with an identity that is unique among sport psychologists. Additionally, having a second degree black belt in karate, being a sub-three-hour marathoner, and an Ironman triathlete all provide me with further uniqueness compared with others in our field. Seventh, working in a particular sport for a long period of time and having exposure to many of its athletes and coaches also helps you stand out among sport psychologists who want to work in that sport. Positions that you have held can also contribute to a unique identity. For example, Dr. Shane Murphy, the former Director of Sport Psychology at the U.S. Olympic Training Center, parlayed his expertise and experience in that position into a successful consulting practice, Gold Medal Consultants, before entering academia.

Finally, once you have established your system and identity, you must develop a set of marketing materials that communicate the value of what you have to offer. Most importantly, in the Internet age, a professional-looking web site is essential for providing prospective clients with detailed information about your background and expertise, the services you offer, articles and books you have written, testimonials, and media exposure.

Stage Three: Credibility (Building Trust)

This stage refers to how much people believe in you and have confidence in your ability to help them. Credibility is essential because you may have tremendous competence, but if you cannot convince potential clients of that competence, they are unlikely to hire you.

Credibility derives from several sources. It comes from tangible evidence of academic accomplishment, such as graduate degrees, conference presentations, and peer-reviewed publications. Credibility can also come from professional achievements including presentations to coaching and sports organizations, as well as the publication of articles in magazines and newspapers and trade books related to sport psychology.

In applied sport psychology, significant credibility can come from prior athletic or coaching experience. Being able to demonstrate first-hand and in-depth knowledge or skill in a sport in which you work adds considerably to your perceived value as a consultant. It shows potential clients that you really understand the sport and what athletes in that sport experience psychologically (as well as physically, technically, and tactically). For example, having competed internationally as a ski racer has given me considerable credibility with ski racers and coaches and provided me with an entry to speaking and consulting opportunities in the sport. This type of credibility can be further enhanced by obtaining some form of coaching certification in that sport.

Credibility also evolves from previous consulting experiences with individuals and organizations. Having worked with notable sports organizations, such as national governing bodies or university athletic departments, can carry significant weight with prospective clients. Additionally, testimonials or endorsements from athletes and coaches are also helpful (though issues of confidentiality must be considered). Word of mouth is the most appropriate and effective use of prior consulting experiences. Recommendations and referrals from clients, colleagues, or coaches can add to your credibility as a consultant. Media exposure bestows significant credibility by virtue of the implicit assumption that if you are interviewed or profiled in the media, you must be competent and credible. Finally, credibility is also gained simply in how you present yourself: by the force of your personality, the confidence you exude in your ability, the passion you express for what you do, and how well you can communicate your ideas about your work.

It is important to emphasize that credibility takes time to establish, and it must be substantially based to truly enhance your career development. Ultimately, credibility can only come through competence, experience, and a job well done. It is tempting early in a career, with the well-intentioned desire to present yourself in the best possible light, to give the appearance of credibility by embellishing your credentials, through subtle overstatement or plain dishonesty. I encourage you, however, to avoid such temptation, as being caught in a “white lie” can have the lasting effect of reducing rather than enhancing your credibility. It also calls into question your integrity and judgment. You must maintain a long-term perspective on your career development and allow yourself the time to gain the skills and experiences that will give you substantial credibility.

Stage Four: Niche (Finding Your Place)

By the conclusion of stage three, you will have achieved a reasonable level of competence, though it will continue to improve with time and experience. Your consulting, speaking, and writing skills will have reached a point at which you are capable of offering clients a variety of effective products to enhance athletic performance. It is now necessary to find your niche and to climb the ladder within that niche.

The first step in this process is to identify several sports on which you wish to focus. Most successful consultants are best known for their work in just a few sports. A “shotgun” approach to making inroads into sport psychology consulting will probably result in spreading yourself too thin to make a meaningful impact and have a recognizable presence in any one sport.

The selection of which sports you choose can be based on several factors. Perhaps the best means of entry into a sport is previous athletic or coaching experience. Since networking is such a big part of developing a successful consulting practice, already knowing people in a sport is a tremendous advantage. In addition, as mentioned previously, prior experience in a sport lends you considerable credibility as you attempt to make contact with athletes, coaches, and administrators in a sport.

You also need to look at what sports appear to have a need for more consultants. Many sports already have a well-established history of interest in sport psychology and, as a result, athletes, coaches, and parents in those sports will have a stronger interest in sport psychology. At the same time, those sports, such tennis and golf, are already saturated at the highest level with consultants who are recognized and sought after. Sports that have few well-known consultants will be easier to make inroads into. You should also consider what sports hold the greatest interest for you. I chose skiing and endurance sports because I have had a long history of high-level participation. Thus, I have intimate knowledge of these sports, and I have a great love for them. Your passion for a sport can be a great asset because it will be communicated to the people with whom you work in that sport and will enhance your value as a consultant.

Once you have selected the sports in which you wish to consult, you must prepare yourself to work on those sports. If you are unfamiliar with the sports (not every consultant need have been an experienced athlete or coach in a sport to be effective), you should study all of its aspects including history, rules, technique, physical elements, competitions, and participants. If you cannot “talk the talk” in a sport, you are setting yourself up for failure. If you have never participated in the sports, some minimal experience can be helpful as a learning tool, but it is not absolutely necessary or even feasible. As a small aside, if you are not highly skilled in a sport in which you will be working, do not participate in the sport with clients. Physically displaying your lack of skill can hurt your credibility.

Having prepared yourself to work in a sport, your next step is to start at the lowest rung of the ladder of the sport and work your way up. This means working with young, low-level athletes as a means of gaining knowledge, experience, and expertise before you consult with higher-level athletes who are more discriminating and more demanding. Patience is essential in this process. I have a saying, “Fast climbs lead to sudden falls.” I learned this lesson first hand when, six months after receiving my doctorate, I was asked to work with a national team. I was totally unprepared for the experience, I failed miserably, and it set my career back in that sport considerably.

The best way to begin this process is to contact youth clubs and programs in the sports you have chosen and offer pro bono or low-fee talks to their athletes, coaches, and parents. Group presentations are an excellent way to generate business because the audience is filled with prospective individual clients. If you do enough of these and do them well, word will spread outward to other clubs and programs and upward to regional and national organizations in that sport. This is precisely the experience I had with tennis. It took me five years at the local and regional levels before I was invited by the U.S. Tennis Association and the U.S. Professional Tennis Association to speak at the national level and another five years before I became a regular speaker and consultant for them. The greatest value of this approach is that word of mouth will become your most effective marketing tool. Word of mouth is so valuable because what it says is that the people with whom you work believe you are competent enough to encourage others to take advantage of your skills as well.

Stage Five: Grow (Expanding Your Practice)

At this point, your basic niche has been established, and you should be making a sufficient living to support yourself. You are now at a place in your career where you have the opportunity to solidify and expand your consulting practice into new areas (Foster & Hays, 1998).

The first place in which you can look at expanding is in new areas within your niche. For example, if you work with young athletes, additional areas might include coach education and sport-parent training. These avenues would enable you to reach more prospective clients and to have a broader impact on athletes’ sport and personal lives. Another related area of expansion is injury rehabilitation, which will likely be a common occurrence among the athletes with whom you work. My extensive involvement with the psychology of injury rehabilitation began when one of my clients tore the anterior cruciate ligament in his knee and asked for help during his recovery. This initial exposure has led to affiliations with several sports-medicine facilities.

Next, you can look for applications of your knowledge to other performance settings. The areas outside of sport in which sport psychologists most often apply their knowledge are business, medicine, and the performing arts. The concept of performance transcends the specific settings in which it occurs. Many of the psychological issues that athletes deal with are directly applicable to dancers, musicians, surgeons, and business executives. As a result, the knowledge and experiences you have gained in sport may be transferable to another performance setting. Just as you need to prepare yourself to work effectively in a particular sport, you also need to ready yourself for the transition to a new performance area. Each setting has unique challenges that must be explored and understood for you to be effective. It is also likely that you will have to modify your “thing” (i.e., system, programs, presentations) to fit the needs of the new area. From both an ethical and competency perspective, you should not enter a new area until you are fully prepared to work in that arena.

Just as you must find entry into a sport in which you would like to work, you must also find a means of accessing these new areas. The most useful means of entry is through contacts and networking. A practice of networking that began with your sport psychology work can be extended to include people in the new areas that can either benefit from your expertise or who are willing to provide an introduction to others who might be interested in your services. The word-of-mouth process is equally valuable in expanding your practice as it is in developing it. For example, my corporate consulting evolved from an athlete’s parents who were businesspeople and saw the bridge between sport performance and performance in the business world.

The Future of Applied Sport Psychology

When I left graduate school, I made a prediction that within 5 years every professional team and major college team would have a full-time sport psychologist on staff. Every 5 years since I have made the same prediction, and each time my prediction was not realized. Yet I see progress every year. More and more athletes and teams are using sport psychologists, I see increasing numbers of young professionals making a go at full-time consulting (though I cannot attest to their success rate), and the field receives increasingly and positive exposure in the media; however, applied sport psychology is still in its infancy. We have a long way to go in our own development as a professional field before it can be fully accepted by the athletic community as an essential component of sports performance. This development includes a more clearly defined educational path, improved training opportunities, and better quality control in the products that the field offers to sport.

My vision of the future of applied sport psychology is cautiously hopeful. There is a clear need for our services at every level of sport, but as yet not a full appreciation of its worth. At some point in the future, I believe there will be a convergence of (a) a readiness on the part of applied sport psychology to offer a mature and sophisticated product and (b) a recognition on the part of athletes, coaches, and administrators in sport of the essential value of applied sport psychology and the need for its consistent use at all levels of sport. Until that time comes, I believe that there will not be sufficient opportunities to meet the demands of recent and soon-to- be graduates in applied sport psychology. There will always be opportunities for the best and the brightest that our field has offer.

Make an Informed Decision

This article has attempted to present an in-depth view of some of the steps, characteristics, and competencies that go into building a successful consulting practice in applied sport psychology. Hopefully, the picture is neither too bleak nor too rosy, but rather an accurate depiction of what it takes to be a successful consultant. It is easy to be seduced by the stories of the successful consultants who work with professional and world-class athletes and have achieved financial success. But it is not wise to base a career decision on the successes of a small percentage of those individuals working in applied sport psychology. The question that you must ask yourself is “Am I capable of and willing to do what it takes to achieve this goal?” It is important as you consider this question that you make an informed decision based on a careful analysis of what is required to be successful in this area.

There are several practical issues that you should consider in answering this question. First, you should be aware of the time commitment that is required. The time involved includes not only up to 5 years of graduate school, but also many hours beyond the typical 40-hr work week that most careers entail. Do you have the patience to pay your dues and progress through this five-stage model? This time commitment also means making sacrifices and choices in other parts of your

life including your social, cultural, and recreational lives. Second, you must determine how you will support yourself and how comfortable you are with financial insecurity. For example, for 2 years before I landed a university faculty position, I eked out a living by teaching tennis and as an adjunct lecturer at a nearby college. After I left academia to pursue a full-time career in sport psychology consulting, I struggled financially for almost 3 years and used up almost all of my savings before I turned the corner on my practice and it became financially viable. In short, it could be more than a few years before you are able to sustain yourself on your consulting alone.

There are also personal questions you must consider. Do you possess the personal qualities described above, including motivation, multiple skills, patience, and creativity? Do you have the capability to develop the necessary competence, credibility, and identity that are required to be successful? In answering all of these questions, you need to look inside yourself to determine whether you have what it takes to become a successful consultant.

Joys of Consulting

A sport psychology consulting career can provide wonderful benefits including freedom, interaction with interesting people, and travel. Professionally, it can be very stimulating and satisfying work, and provides the ability to positively impact people’s lives. Indeed, as Mark Twain once said, “Find something you love to do and you’ll never work a day in your life.”

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. The American Psychologist, 57, 1060–1073.

Andersen, M.B., Williams, J.M., Aldridge, T., & Taylor, J. (1997). Tracking the training and careers of graduates of advanced degree programs in sport psychology, 1989-1994. The Sport Psychologist, 11, 326–344.

Davidson, K.W., Lerner, B., Murphy, S., & Taylor, J. (1998, September). Successful job strategies: Private sector. Presented at the annual meeting of Association for the Advancement of Applied Sport Psychology, Hyannis, MA.

Foster, S., & Hays, K. (1998, September). Diversifying your practice: Transferring your performance enhancement skills to other populations. Presented at the annual meeting of Association for the Advancement of Applied Sport Psychology, Hyannis, MA.

Gardner, F.L., & Moore, Z.E. (2006). Clinical sport psychology. Champaign, IL: Human Kinetics.

Harmison, R.J., Dale, G.A., Martin, S.B., Durand-Bush, N., Kellmann, M., & McCann, S. (1998, September). Persevering in the face of adversity: Examples of young professionals pursuing their dreams in sport psychology. Paper presented at the annual meeting of Association for the Advancement of Applied Sport Psychology, Hyannis, MA.

Meyers, A.W., Coleman, J.K., Whelan, J.P., & Mehlenbeck, R.S. (2001). Examining careers in sport psychology: Who is working and who is making money? Professional Psychology, Research and Practice, 32, 5–11.

Smith, N.D., & Ciervo, R.L. (1998, September). Expanding your career options in applied sport psychology: Jobs for young professionals. Paper presented at the annual meeting of Association for the Advancement of Applied Sport Psychology, Hyannis, MA.

Taylor, J. (1991). Career direction, development, and opportunities in applied sport psychology. The Sport Psychologist, 5, 266–280.

Taylor, J. (1994). Examining the boundaries of sport science and psychology trained practitioners in applied sport psychology: Title usage and area of competence. Journal of Applied Sport Psychology, 6, 185–195.

Taylor, J. Straight talk about full-time consulting: Reality and fantasy. (1996, October). Paper presented at the annual meeting of the Association for the Advancement of Applied Sport Psychology, Williamsburg, VA.

Webster’s new universal unabridged dictionary. (1996). New York: Barnes & Noble.

Weiss, M.R. (1998, September). “Passionate collaboration”: Reflections on the directions of applied sport psychology in the coming millennium. Paper presented at the annual meeting of Association for the Advancement of Applied Sport Psychology, Hyannis, MA.

Williams, J.M., & Scherzer, C.B. (2003). Tracking the training and careers of graduates of advanced degree programs in sport psychology, 1994 through 1998. Journal of Applied Sport Psychology, 15, 335–353.

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Pain Education and Management in

the Rehabilitation from Sports Injury

This article addresses the essential role that pain plays in the rehabilitation of sports injury. It will describe important information and approaches that applied sport psychologists can use to more effectively manage pain in the injured athletes with whom they are working. A brief discussion of the most accepted theories of pain will be offered. Types of pain that injured athletes may experience and how they can learn to discriminate between them will be discussed. Also, it will consider how pain can be a useful tool as information about injured athletes' current status in recovery and the need to modify their rehabilitation regimens. The value of measuring pain will be examined with an emphasis placed on a simple and easy means of assessing pain. Next, the article will examine why nonpharmacological pain management may be a useful adjunct to pharmacological pain control. Then, a brief description of the most commonly used pain medications and a detailed description of common nonanalgesic pain management strategies will be furnished. A discussion of how nonpharmacological pain management can be incorporated into the traditional rehabilitation process will be offered. Finally, the article will describe the role that sport psychologists can play in the management of sport injury-related pain. The objective of this article is to provide applied practitioners with the knowledge and tools necessary to assist injured athletes in mitigating the pain they will experience during recovery as a means of facilitating their rehabilitation and return to sport.

Pain is, without a doubt, the most pervasive and debilitating obstacle to effective rehabilitation experienced by injured athletes. It has significant physical and psychological effects in almost every aspect of recovery (Heil, 1993; Pargman, 1993). Yet, despite this importance, little time is devoted to educating injured athletes about pain, how it affects them, and how they can best manage it. Because pain is so poorly understood (Feuerstein, Labbe, & Kuczmierczyk, 1986), the simple expectation of its presence can produce a chain of physiological and psychological responses that may increase the experience of pain, thereby inhibiting rehabilitation.

There are other difficulties with pain that further complicate its understanding and management. Pain is a subjective experience, in which people vary greatly in their levels of pain tolerance and where the cliché, "I feel your pain" is clearly inaccurate (Catalano, 1987). Pain is affected by a wide variety of physical, psychological, social, and cultural influences (Heil, 1993). Also, pain can not be directly measured. As a result, it is difficult for others to evaluate the actual severity of the pain and determine what type of pain management, whether pharmacological or nonpharmacological, may be most appropriate.

Effective pain management begins for injured athletes with a clear understanding of what influences their perceptions about pain and how pain affects them. Next, injured athletes can learn to distinguish different types of pain that they will experience during the rehabilitation process. Then, they can learn to "read" pain, that is, recognize the kind of pain they are having and use it as information in their rehabilitation program. Finally, injured athletes can develop skill in the use of nonpharmacological pain management strategies as a complement or replacement for pharmacological pain control.

There has been extensive study of pain management techniques related to pain experienced in a variety of settings including sport and exercise (Berntzen, 1987; Hackett & Horan, 1980; Vallis, 1984; Whitmarsh & Alderman, 1993). For example, outside of sport, Thompson (1981) reported that relaxation techniques that improved patients' perceptions of control over their pain resulted in greater pain tolerance and a reduction in reported pain. Overall, the investigations indicate that pain tolerance can be improved and people can learn to reduce pain with nonpharmacological pain management strategies (Gauron & Bowers, 1986; Turk, Meichenbaum, & Genest, 1983).

The majority of this research has examined the effectiveness of components of stress inoculation training (SIT; Meichenbaum, 1985). SIT is a treatment paradigm comprised of stress-management techniques that typically include relaxation training, attention diversion (imagery, external diversion, internal diversion), and self-talk strategies to manage perception, evaluation, and response to the stressor (Meichenbaum, 1985). The research conducted in clinical and medical settings have provided strong support for the value of the components of SIT as a means of managing pain (Berntzen, 1987; Hackett & Horan, 1980; Vallis, 1984). In an exercise setting, Whitmarsh and Alderman (1993) reported that SIT as a whole and the use of components of SIT alone proved to be effective strategies for increasing pain tolerance and performance on a physical exertion task. Furthermore, in a study of marathon runners, Masters and Lambert (1989) indicated that runners use both associative (i.e., focusing on bodily sensations) and dissociative (i.e., directing focus away from bodily sensations) techniques to manage running pain and discomfort depending upon whether they were in a training run or a marathon race. To date, there has been no research examining the value of nonpharmacological pain management techniques in a rehabilitation setting. Nevertheless, the analog research just described offers strong support for the contention that these strategies can also be effective as a means of managing pain experienced by injured athletes during rehabilitation and return to sport.

Despite these findings, pain tolerance was not seen by athletic trainers as a characteristic that differentiated injured athletes who coped effectively vs. poorly with their injury and the subsequent rehabilitation (Larson, Starkey, & Zaichkowsky, 1996; Wiese, Weiss, & Yukelson, 1991). This perception may reflect an inability on the part of athletic trainers to accurately distinguish pain tolerance among patients. Additionally, the value of identifying pain tolerance may be seen as having little practical value because it may be something that athletic trainers do not believe injured athletes can actively control. Consistent with this view, pain management techniques were not seen by athletic trainers as strategies that can facilitate rehabilitation or that they should learn to enhance their work with injured athletes (Larson et al., 1996; Wiese et al., 1991). This finding may indicate an unfamiliarity with nonpharmacological pain management techniques, inadequate time to deal with psychological issues, or the absence of an appropriate referral mechanism (Larson et al., 1996).

Theoretical Perspectives of Pain

In order to effectively address the issue of pain and its management, it will be useful to provide a brief overview of the two most widely accepted theoretical conceptualizations of pain and the role that psychological factors play in the experience of pain: Gate control theory of pain (Melzack & Wall, 1965) and parallel processing model of pain distress (Leventhal & Everhart, 1979). Though a detailed discussion of the physiological structures and processes that produce pain is beyond the scope of this article, the consideration of the two theories' perspectives on the impact of psychological and emotional issues on the experience and perception of pain is relevant.

Gate control theory posits that pain travels afferently from the point of stimulation through the spinal cord and into the brain (Melzack & Wall, 1965). These researchers suggest that, in some circumstances, the brain activates efferent fibers that influence the afferent transmission of the pain sensations. Thus, this efferent activity acts as a control gate of pain. They further argue that there is a mechanism in the nervous system which they call the central control trigger, that activates these neural processes which, in turn, exercise control over the afferently traveling pain input. They believe that specific psychological processes that act as control gates to influence the perception and response to pain include attention, emotion, and prior experience (Melzack & Wall, 1965).

The parallel processing model of pain distress focuses more on the psychological influences on the experience of pain and offers a more specific consideration of what the particular control gates might be (Leventhal & Everhart, 1979). These researchers suggest that pain can be processed along two pathways that will impact the experience of pain: informational or emotional. The informational pathway deals with properties such as cause, location, and sensory characteristics. The emotional pathway produces a generalized state of arousal and a particular emotional response, for example, fear, distress, or avoidance. With the experience of pain, individuals develop schemata that represent the informational and emotional components of painful experiences. When people feel pain in the future, the experience of the pain will be determined by which aspect of the pain schema is activated. Finally, they assert that the critical function of these schemata in the processing of pain is as selectors of what people attend to as they experience the pain (Leventhal & Everhart, 1979). Their empirical investigation of this view indicates that when people attend to the informational aspects of the pain, they experience significantly less pain that when they pay attention to its emotional elements. This finding has considerable relevance to the use of pain focusing techniques discussed later in this article.

Types of Pain

Pain is a normal and persistent part of participation in most types of sports activities. There is evidence to indicate that athletes have greater pain tolerance as compared to nonathletes (Jaremko, Silbert, & Mann, 1981; Walker 1971). Nevertheless, it is unclear whether pain experienced during sports participation can be deemed similar to that felt during rehabilitation. These two diverse experiences of pain can produce markedly different physical and psychological perceptions and responses. Performance pain is typically perceived as acute, short in duration, produced voluntarily, under the control of the athlete, and capable of being reduced at will. The usual response to performance pain is positive emotions, feelings of satisfaction, improved performance, and an enhanced sense of well-being. Performance pain is thus viewed as a positive and facilitating aspect of sports participation that reinforces athletes' efforts and inspires them to higher levels of training and competition (Heil, 1993).

Conversely, injury pain is commonly experienced as chronic, long-lasting, uncontrollable, a signal of danger to physical well-being, and motivating athletes to protect the injured area. Athletes' responses to injury pain are a loss of confidence and motivation, increased anxiety and/or depression, and feelings of fear and dread. Injury pain is thus seen as a negative and discouraging part of rehabilitation that can have debilitating ramifications on recovery and return to sport (Heil, 1993).

The most common differentiation between types of pain resulting from injury is that of acute vs. chronic pain (National Institutes of Health Consensus Development Conference, 1986). Acute pain is characterized as that due to a trauma and is experienced as intense, short in duration, and inhibitory to rehabilitation. It is a warning to the body that it is at risk of damage and a signal for the need for immediate attention (Catalano, 1987). Chronic pain is viewed as a more complex phenomenon that is long-lasting, constant, persisting long after the initial injury, and has physical, psychological, and social components (Heil, 1993). Factors that can contribute to the experience of chronic pain include family, work history and environment, cultural expectations, and possible compensation (Catalano, 1987).

Though the acute-chronic dimension of pain is most often referred to in the discussion of pain management, we suggest that in assisting athletes better understand and cope with pain, another distinction may be more useful. This demarcation involves clarifying to injured athletes when the pain they are experiencing is simply a benign artifact of the demands they are placing on the injured area or an important signal of danger of further harm.

Benign pain is typically characterized as dull, more generalized, does not last long after exertion, and is not attended by swelling, localized tenderness, or lasting soreness. Harmful pain is considered to be sharp, localized to the injury area, experienced during and persisting after exertion, and usually associated with swelling, localized tenderness, and prolonged soreness (Rians, 1990). Providing injured athletes with these simple distinctions in the types of pain they may experience can assist them in more clearly identifying what kind of pain they are feeling. This differentiation can then have a significant impact on how they evaluate (benign or harmful), perceive (positively or negatively), and respond (continued effort or protection) to the pain. The particular sequelae that injured athletes follow may dictate the effects of the pain on the quality of rehabilitation. This understanding of the different types of pain may also enhance their perceptions of control over pain, which may have substantial physical and psychological benefits (Averill, 1973; Levendusky & Pankratz, 1984; Mandler & Watson, 1966).

Pain as Information

Typically, pain is perceived as an unpleasant experience meant to be avoided. Yet, one of the values of educating injured athletes about pain, specifically, in differentiating benign and harmful pain, and making pain tangible through the use of assessment, is that it becomes seen as important information that can facilitate the rehabilitation process. Having an understanding of the types of pain they can feel and how it can affect them physically and psychologically enhances their sense of control over their pain (Feuerstein, Labbe, & Kuczmierczyk, 1986). Understanding of pain also enables them to use the information to act appropriately to not only manage their pain, but also, in collaboration with their rehabilitation professional, to adjust their rehabilitation program as needed.

Being able to recognize pain accurately can affect injured athletes' perceptions of and attitude toward the pain. For example, prior to understanding the difference between benign and harmful pain, an injured athlete may have become anxious and backed off his rehabilitation program in response to the pain. In contrast, with this knowledge, the identified benign pain is now viewed as a normal and healthy part of healing and becomes a positive and motivating factor that facilitates rehabilitation.

By the same token, pain that is recognized as harmful by injured athletes can be used as essential information about various aspects of their current rehabilitation regimen. Issues that this realization could influence include speed of rehabilitation, quantity and intensity of physical therapy, and amount of recovery time allowed between physical therapy sessions. Additionally, this information may indicate the need to examine physical, psychological, and social factors that could be contributing to the harmful pain.

Measurement of Pain

There are a number of assessment tools that are available to measure the degree and quality of pain during rehabilitation including pain drawing (Ransford, Cairns, & Mooney, 1976), the pain rating index of the McGill Pain Questionnaire (Chapman, Casey, Dubner, Foley, Gracely, & Reading, 1985), the Visual Analogue Scales (Gift, 1989; Huskisson, 1974), acute injury assessment (Heil, 1988), and others (Karoly & Jensen, 1987). However, difficulties with many of these assessments are that they are not easily administered and they require special expertise and training in their administration and evaluation.

In response to the need for a simple and easily administered instrument to measure pain, Thorn and Williams (1989) developed the Ratings of Perceived Discomfort. This scale consists of numerical ratings of discomfort on a 0-100 scale with descriptive anchors of no discomfort (0), just noticeable discomfort (10), moderate discomfort (50), and excruciating discomfort (100). Numerical rating scales of pain like the Ratings of Perceived Discomfort have been found to be valid measures of experienced pain in a variety of settings (Karoly & Jensen, 1987).

This pain assessment scale can benefit injured athletes in several ways. It can help them to recognize and discriminate between different levels of pain that they experience during rehabilitation. This can clarify for them whether the pain is benign or harmful, and when they may need to use some form of pain management, whether pharmacological or nonpharmacological. The scale can identify in what situations and why pain occurs. It can also provide feedback about the effectiveness of various pain management strategies that they use. Lastly, the scale can contribute to a greater sense of control of pain on the part of injured athletes by making the pain more tangible. In this case, the pain is no longer an ethereal and aversive presence, but rather it is measurable and can, as a result, be adjusted to a more comfortable level.

Another area of concern in the measurement of pain occurs when injured athletes do not admit to experiencing pain. They may be motivated to do this for a variety of reasons including a "tough athlete" mentality or to give the impression of greater progress than actually exists. Injured athletes who do not acknowledge their pain can put themselves at risk for complications, slowed recovery, and reinjury. Sport psychologists and rehabilitation professionals should be alert to indirect signs of pain that may surface despite the best efforts of injured athletes to conceal their pain. Common indirect indications of pain during physical therapy are reluctance, active avoidance, or nervousness in particular rehabilitation exercises or return to sport activities, facial contortions, muscle tension, and negative emotions. Indirect signs that can occur away from rehabilitation include fatigue, sleep difficulties, decline in normal school, work, or social involvement, and emotional reactivity (Heil, 1993).

The assessment of pain should take a multimethod approach that includes direct and indirect measures and that involves the injured athletes themselves, the sports medicine staff, the sport psychologist, and others in the lives of the athletes who can provide useful information. The goal of pain assessment is to help injured athletes become aware of the pain they are experiencing, increase their understanding of its impact on their recoveries, and provide the basis for an effective pain management regimen that is comprised of both pharmacological and nonpharmacological means of minimizing pain during rehabilitation and return to sport.

Pharmacological and Nonpharmacological Pain Management

One of the biggest problems that injured athletes have to deal with in experiencing pain during rehabilitation is the feelings of helplessness and lack of control. These responses can increase the perception of pain, decrease the quality of rehabilitation, and slow the recovery process. Pain can be controlled with medication, but both the physicians who prescribe the drugs and the injured athletes who take them can have reservations with respect to the dosage and duration of medication usage. Physicians are concerned with potential dependency problems, particularly with a serious injury involving significant damage, lengthy rehabilitation, and chronic pain (Hender & Fenton, 1979; Singer & Johnson, 1987), and the dangers of masking pain that may be of informational or protective value.

Injured athletes often prefer to avoid medication for pain control because drugs are viewed as unhealthy, medication keeps pain outside of their immediate control, and they do not like the side effects associated with some pain medication. Also, in some sports, athletes hold the attitude that the ability to handle pain without medication is an indication of toughness (Heil, 1993; Johnston & Mannell, 1980). Thus for many reasons, physicians and injured athletes may wish to minimize the need for and use of pharmacological pain management.

By using nonpharmacological techniques to reduce pain, several benefits are evident. At a physical level, injured athletes can experience less pain and unnecessary medication can be avoided. Additionally, pain will not interfere with the body's natural healing process. The use of drug-free pain management strategies can also provide psychological and emotional advantages. Perceptions of control will be enhanced, thus increasing confidence and motivation. Also, injured athletes will be more positive, relaxed, and focused, which provide practical benefits in the day-to-day quality of rehabilitation.

A word of caution and warning is warranted here. Nonpharmacological pain management is not an absolute substitute for medication. Rather, it can be an effective complement to normal pharmacological treatment of pain during the course of rehabilitation. Additionally, as the recovery progresses and pain diminishes, these nonpharmacological means of pain management can often supplant medication as the primary method of pain control.

Injured athletes can best judge the amount of pain they are experiencing and what they need to do to relieve it. With proper education about pain, as their rehabilitation progresses, they will learn to differentiate types of pain, when they need some form of pain management, and what type of pain management will be most effective for them. In making these determinations, it would be prudent for injured athletes to consult with their physician to assist them in evaluating what form of pain control is most appropriate.

Pharmacological Pain Management

Some form of pharmacological pain management is an integral and necessary part of most injury and rehabilitation regimens (Heil, 1993). Pain relieving drugs provide comfort immediately post-injury, following surgery (if required), and in response to normal discomfort that occurs during rehabilitation. The particular type, dosage, and duration of pain medication depends on the nature of the injury and the quality of the pain. Within a proper pharmacological treatment plan, severe pain typically moderates within several days which then becomes mild shortly thereafter. Thus, the use of pain medication can be reduced commensurately (Acute Pain Management Guideline Panel, 1992).

Pain due to injury and the type of pain medication that is used can be classified as mild, moderate, and severe. Nonsteroidal anti-inflammatory drugs including aspirin (e.g., Bayer), acetaminophen (e.g., Tylenol), and ibuprofen (e.g., Advil) are considered to be in the mild category and are most commonly used with minor injuries such as muscle pulls and first degree sprains. These drugs are all effective analgesics, and aspirin and ibuprofen also offer anti-inflammatory activity for the swelling that is commonly associated with sports injuries. These medications have few indications of danger or side effects except when a preexisting condition is present (Heil, 1993).

Weak opioids such as codeine (e.g., Percodan) or propoxyphene (e.g., Darvon) are part of the moderate class and are usually used for more serious injuries such as bone fractures and severe lacerations. These drugs are strong analgesics that have a significant impact on the perception of pain. Medication for severe pain includes stronger opioids such as morphine (e.g., Demerol) and are typically used in the early stages of treatment for serious injuries such as ligament reconstruction and compound fractures (Heil, 1993). Despite the popular perception of the risk of dependence on opioids in the treatment of acute pain (King, 1996), there is little evidence of a high rate of occurrence when properly administered (Porter & Jick, 1980). It should also be noted that, due to the risk of dependence from long-term use, opioids are rarely used with chronic benign pain.

Chronic pain is a much more difficult issue to address and can not be treated solely with medication. The consistent presence of pain often produces concomitant psychological distress, (e.g., anxiety and/or depression) and decrements in physical functioning. These debilitating conditions then exacerbate the ongoing pain creating a vicious cycle of physical and psychological suffering. Chronic pain then is defined by both the aversiveness of the distress and the significantly negative impact on behavior and functioning (Heil, 1993). Pharmacological treatment of chronic pain using nonaddictive drugs is only one part of what should be a comprehensive, multidisciplinary approach that employs physicians, psychologists, physical therapists, and other specialists aimed at the alleviation of physical suffering, psychological distress, and functional disability.

Nonpharmacological Pain Management

Nonpharmacological pain management strategies can be classified into two general categories: pain reduction and pain focusing (Heil, 1993). Pain reduction techniques act directly on the nociceptive aspects of the pain, thus decreasing the actual amount of pain that is present. These methods function to attenuate physiological activity that often increases pain. Specifically, they work to reduce sympathetic nervous system responses that increase the experience of pain (Cousins & Phillips, 1985). Pain reduction techniques include deep breathing, muscle relaxation training, meditation, and therapeutic massage (Heil, 1993).

Pain focusing techniques involve directing attention onto (association) or away (dissociation) from the pain as a means of reducing the pain (Morgan & Pollock, 1977; Rosensteil & Keefe, 1983). Consistent with the gate control theory (Melzack & Wall, 1965), these methods act to send efferent inhibitors to the afferent transmission of pain. Pain focusing techniques may also direct attention onto informational aspects and away from emotional aspects of the pain schemata (Leventhal & Everhart, 1979). Pain focusing strategies are comprised of external focus, pleasant imagining, neutral imagining, rhythmic cognitive activity, pain acknowledgement, dramatic coping, situational assessment (Fernandez & Turk, 1986; Wack & Turk, 1984), and hypnosis (Barber, 1977; Patterson, Questad, & de Lateur, 1989; Singer & Johnson, 1987).

Though beyond the scope of this article, it should be noted that there are a variety of nonpharmacological physical interventions that can be used to manage pain during rehabilitation. These strategies include heating techniques such as whirlpool, hot packs, moist air, and ultrasound. Cold treatments consist of cold packs, coolant sprays, ice massage, and cold baths. Other modalities that are effective in pain management are electrical stimulation, manual and mechanical exercise, and acupuncture (Singer & Johnson, 1987).

Pain Reduction

The goal of pain reduction is to diminish autonomic changes associated with increased pain including peripheral vasoconstriction, muscle spasm, and muscular bracing (Cousins & Phillips, 1985). These sympathetic alterations produce the release of norepinephrine, which appears to increase the sensitivity of pain receptors, thus causing injured athletes to experience more pain than was initially felt (Heil, 1993). The objective of pain reduction is accomplished with strategies aimed at inducing states of physiological relaxation and the attendant generalized parasympathetic nervous system activity. It should be noted as well that relaxation will have the concurrent effect of shifting focus away from the pain onto the pleasurable aspects of the particular pain reduction technique or causing a reinterpretation of the perception and meaning of the pain, thus potentially further reducing the experience of pain (Melzack & Wall, 1965).

Deep breathing. Perhaps the simplest, most essential, yet most neglected technique to reduce pain is deep breathing (Catalano, 1987). This necessity of life is often overlooked because people do not always understand the relationship between breathing, physiological changes, and the experience of pain. Deep breathing provides a number of fundamental benefits. As Cousins and Phillips (1985) indicated, pain inhibits breathing, which lessens blood flow and causes muscle spasms and bracing. This lack of oxygen in the system leads to more muscle tension and a concomitant increase in pain. Deep breathing diminishes sympathetic nervous system activity by transporting sufficient oxygen throughout the body, relaxing muscles, and increasing generalized parasympathetic nervous system activity. Deep breathing also acts as an internal distraction. If injured athletes are focused on their breathing, they will be paying less attention to their pain (Catalano, 1987).

Deep breathing can be a valuable and nonintrusive addition to several aspects of rehabilitation. Deep breathing can be incorporated into the beginning and end of physical therapy exercises. Particularly for range of motion exercises, deep breathing can facilitate muscle relaxation which will, in turn, result in greater flexibility. Also, as will be demonstrated, deep breathing is a necessary adjunct to every type of pain reduction technique that will be described below.

Muscle relaxation training. Pain elicits various forms of muscle tension that restrict blood flow and increase pain (Cousins & Phillips, 1985). Direct intervention of the muscle tension through muscle relaxation training can result in a contraindicating effect of relieving muscle tension and reducing pain. Two relaxation techniques, passive and progressive relaxation (Taylor, 1996; Jacobson, 1938, respectively), appear to be effective tools in producing a reduction in muscle tension and increasing an overall sense of physical calm and comfort. Research examining the impact of relaxation training on pain supports this contention. For example, Feuerstein and Gainer (1982) found that muscle relaxation training provided significant pain relief from two types of headaches. Similar findings were reported using both physiological and self-report measures in patients suffering from back, temporal mandibular joint (TMJ), and arthritic pain (Linton, 1982). In addition, a study by Linton and Melin (1983) showed the value of incorporating a relaxation component into a traditional rehabilitation regimen. The rehabilitation plus relaxation group, as compared two control groups, demonstrated a reduction in subjective pain, medication usage, physical activity, and higher overall treatment evaluations.

Muscle relaxation training can be used in a variety of settings to manage pain that is experienced by injured athletes. It is a useful strategy during physical therapy when pain may be preventing them from putting full effort into exercises or it is hindering their completion. Taking a brief break and using one of the muscle relaxation techniques can assist injured athletes in gaining control of their pain and reducing it to a level that will allow continuation of their rehabilitation regimen.

Our clinical experience has indicated that muscle relaxation training is also a comforting ameliorative following daily physical therapy when pain is high and resources to manage the pain are low. Allowing time at the conclusion of a session to induce relaxation has both physical and psychological benefits. By using muscle relaxation training at the end of a session, pain can be decreased and a general sense of physical comfort and well-being can be returned. Psychologically, the negative thoughts and emotions associated with a painful rehabilitation experience can be diminished, thus reducing the likelihood of underadherence as a means of avoiding the discomfort experienced in physical therapy (Taylor & Taylor, 1997).

Muscle relaxation training can be valuable as a means of facilitating sleep in the face of night-time pain (Heil, 1993). Physicians typically discourage patients from using pain medication as a sleep inducer. Yet, the inability to get to sleep and disturbed sleep during the night are common reactions to pain. Muscle relaxation training, used upon getting into bed, can reduce pain and produce a physiologically and psychologically relaxed state, thus making sleep more likely.

Meditation. Meditation in many forms has been used for centuries as a means of creating a state of physical relaxation and psychological tranquility (Feuerstein, Labbe, & Kuczmierczyk, 1986). Its modern nonsecular brethren have also been used as a tool to induce relaxation and manage pain (Benson, 1975; Kabat-Zinn, 1982). Specifically, meditation has been documented as an effective strategy within stress inoculation training to reduce pain (Whitmarsh & Alderman, 1993). Though a lengthy discussion of the various forms of meditation (e.g., Transcendental Meditation, mindfulness, Aryuvedic) is beyond the scope of this article, a description of one type of meditation that is easy to learn and use is appropriate.

In response to the growing interest in meditation in the 1970's, Benson (1975) developed the Relaxation Response. The Relaxation Response borrowed some aspects of traditional meditation such as the mantra (a sound that is purported to have a relaxing effect) and incorporated them into a technique that requires no formal training and can be immediately beneficial. This form of meditation uses the word, One, as a mantra on which people can focus. Benson suggests that, like Transcendental Meditation, practitioners engage in the Relaxation Response twice daily for 15-20 minutes. The Relaxation Response is easy to use, involving the following steps. Injured athletes can go into a quiet room and make themselves comfortable. Closing their eyes, they can repeat their mantra to themselves, taking deep breaths with each incantation. Their focus can naturally drift from their mantra to the feelings of relaxation that will envelop them to other thoughts and feelings that emerge and back to their mantra.

The primary value of the Relaxation Response is the state of deep relaxation that it produces, all aspects of which are contraindicative of the sympathetic nervous system activity that can accentuate pain (Wallace, Benson, & Wilson, 1971). The Relaxation Response has the added benefit of acting as a distraction, drawing focus away from the pain and onto pleasant feelings of relaxation. This form of meditation also has psychological advantages including a greater sense of control on the part of injured athletes over their physiologies and their pain, and a reduction in the negative emotions associated with the experience of pain.

Therapeutic massage. Another effective technique for reducing pain during rehabilitation is therapeutic massage (Weinrich & Weinrich, 1990; Wilkinson, 1995). This strategy is compatible with and complementary to traditional physical therapy. Therapeutic massage is primarily concerned with manual manipulation of muscles, a benefit of which is pain reduction. The particular subtechniques that are used with injured athletes by certified sports massage therapists depend upon the prescription of the orthopaedic surgeon and the rehabilitation regimen designed by the physical therapist in response to the specific needs of the patient. Some of the techniques often used for injury rehabilitation include direct pressure, approximation, reciprocal inhibition, myofascial release, and positional release. Though they differ in the details of application, they share one common element, namely, breaking the pain-spasm-pain cycle through relaxation of the involved muscles. These methods can be used separately or in concert, and their benefits can be maximized when combined with deep breathing, mental imagery, ice, heat, and stretching.

Pain Focusing

Attentional control, termed pain focusing here, has been found to be an effective tool in managing pain in a variety of settings (Blitz, & Dinnerstein, 1971; Chaves, & Barber, 1974; Nideffer, 1981). Pain focusing has been broadly classified into dissociative and associative strategies (Morgan & Pollock, 1977). Dissociative focusing involves directing attention away from the pain that is being experienced onto other salient aspects of injured athletes' attentional fields (Nideffer, 1983). The position held in using dissociative focusing is that if injured athletes are not paying attention to their pain, they will perceive the pain as less intensive (Wack & Turk, 1984). Dissociative techniques, either internal or external, are the most frequently used because there are many to choose from and they are easy to learn (Fernandez & Turk, 1977). There also appears to be a natural desire to avoid rather than confront the pain even when facing the aversive sensations may be more effective. Associative focusing entails directing attention onto the pain and interpreting it in a different way. By doing so, the perception and meaning of the pain is altered and it becomes less aversive.

These researchers seem to implicitly suggest that pain focusing techniques simply distract people away from the pain, that is, though the pain is still there, they do not notice it because their attention is directed away from it (Morgan & Pollock, 1977; Wack & Turk, 1984). Thus, they distinguish between the physiological experience of pain and the perception or awareness of pain. This conceptualization of pain, which appears to support a mind/body dualism, is inconsistent with contemporary models of pain. Gate control theory helps address this problem by suggesting that there is really no distinction between physiological pain and the perceptual experience of the pain, and that these techniques actually reduce pain sensations by blocking them early in their afferent transmission (Melzack & Wall, 1965).

A further differentiation of direction that is made is between external and internal focus. An external focus is comprised of paying attention to cues outside of the person including sights and sounds. An internal focus consists of paying attention to cues inside the person such as thoughts, emotions, and physical sensations. There is some evidence that people have dominant focus styles (Nideffer, 1976; 1983) and individuals may be more adept at and more comfortable with using either external or internal pain focusing techniques.

Some important evidence has emerged on the relative effectiveness of dissociative vs. associative focusing strategies for pain management. In a comprehensive meta-analysis examining this issue, the efficacy of each approach in effectively reducing pain, stress, and anxiety depended upon certain boundary conditions of the specific techniques and the situations in which they are used (Suls & Fletcher, 1985). They reported that dissociation (what they called avoidance) was related to better adaptation in the short-run. Association (what they called attention) was preferable to dissociation when the former focused on informational rather than emotional aspects of the distress. It should be noted that this finding is consistent with the theoretical position of Leventhal and Everhart (1979). Additionally, with more chronic distress, avoidance demonstrated more positive outcomes initially, but attention was related to better long-term outcomes (Suls & Fletcher, 1985).

These results have important practical implications in the use of pain management techniques. Based on the conclusions of Suls and Fletcher (1985), we suggest that dissociative strategies are more appropriate for minor injuries that involve acute pain and short rehabilitation times. Conversely, if there is a more serious injury that will produce chronic pain and a lengthy rehabilitation, then associative methods emphasizing informational components of the pain seem more appropriate.

Heil (1993) also points out that in some rehabilitation situations, dissociative techniques can be potentially harmful. Many physical therapy procedures require focus on proper execution and effort, for example, strengthening or coordination exercises. Dissociative techniques shift focus away from the exercises, increasing the likelihood of poor form and less than complete effort. Also, pain can be a useful gauge of the limits of rehabilitation exercises. Dissociation away from the pain during physical therapy may cause injured athletes to surpass their physical limits, resulting in the possibility of reinjury or additional damage. This last assertion is based exclusively on our own clinical observations. It should be noted that research examining the relationship between associative/dissociative strategies and injury occurrence among healthy endurance athletes does not bear this out (Bond, Miller, & Chrisfield, 1988; Master & Lambert, 1989; McKelvie & Valliant, & Asu, 1985; Ungerleider, Golding, Porter, & Foster, 1989). Their findings indicate that dissociation was not predictive of the incidence of an injury sustained in training or competition. Whether this relationship is relevant to injured athletes during rehabilitation is speculative and warrants investigation.

As the extant literature indicates, associative strategies have a significant place in the pain management repertoire. Associative methods may be most appropriate during the execution phases of physical therapy. This approach enables injured athletes to diminish their pain and, at the same time, use the pain as information about how much to exert themselves and how far they can push their physical limits. Heil (1993) considers the paradoxical quality of associative pain management, namely, how can focusing on pain lessen it? He suggests that pain heightens emotional reactivity which, in turn, accentuates the experience of pain. Moreover, it is the emotional component of pain that contributes substantially to its aversiveness (Leventhal & Everhart, 1979). Associative methods heighten bodily awareness, increase perceptions of control over the pain, and also cultivate a sense of emotional detachment on the part of injured athletes which act to separate the sensory aspects of pain from its physical manifestations. As a result, the initial association with the sensory aspects of pain produces an emotional dissociation, thereby diminishing the discomfort of the pain (Heil, 1993; Leventhal & Everhart, 1979). Associative techniques, notably, mindfulness meditation, have been reported to be effective in decreasing pain in a variety of medical settings (Kabat-Zinn, 1982).

External focus. A difficulty with pain is that it is a powerful cue to which focus is directed. In general, the more injured athletes are focused on the pain (without appropriate use of associative strategies), the more pain they will experience. If they can direct their focus away from the pain, that is, dissociate from it, it can be experienced as less aversive. Yet, due to the salience of pain, simply directing one's focus outward on, for example, a car in the driveway, will probably be inadequate to pull attention away from the pain. In order for external focus to be effective, injured athletes must identify and use equally strong visual, auditory, and other sensory cues.

Salient external-dissociative techniques can be divided into two categories: emotionally powerful and intellectually absorbing. Returning to Heil's (1993) notion of emotional separation, of these possible cues, ones that inspire strong affect that is inconsistent with the pain will, in all likelihood, have the greatest impact. Emotionally powerful activities may include moving music, an engrossing movie, television show, or book, a savory meal, or a busy surrounding such as a party or shopping mall. Intellectually absorbing tasks, because they lack a strong emotional component, rely on attentional and cognitive preoccupation in an activity to the exclusion of the perception of pain. Research examining the impact of the complexity of the dissociative task on physical endurance indicates that task complexity was not related to greater ability to overcome fatigue (Rejeski & Kenney, 1987). Whether this analog setting can be generalized to injury-related pain is uncertain. Our experience indicates that, since pain due to injury is more emotionally salient and not readily controllable (i.e., as compared to the above study, injured athletes can not just stop to alleviate the pain), more complex tasks may be required to distract injured athletes from the pain. We have found that the most effective tasks are those that are complex and detailed, for example, a game of chess, constructing a model airplane, reading a book, or an engaging conversation.

Pleasant imagining. Pleasant imagining, or soothing imagery, an internal-dissociative strategy, has been found to be an effective means of reducing pain in medical and sports settings (Beers & Karoly, 1979; Berntzen, 1987; Brown, 1984; Whitmarsh & Alderman, 1993). Soothing imagery is one technique that acts equally well as both a pain focusing and pain reduction strategy (Singer & Johnson, 1987). It has the dual effect of acting as a distraction to direct focus away from the pain onto pleasant images and inducing generalized relaxation (Achterberg, 1985; Catalano, 1987).

Neutral imagery. This internal-dissociative strategy is an imagined version of intellectually absorbing tasks (Fernandez & Turk, 1986). With neutral imagery, injured athletes imagine rather than actually engage in the captivating activity, thus producing a similar level of the immersion in the process and completion of the task. Appropriate activities may include replaying a game of chess, building a house, or using performance imagery in their sport.

Rhythmic cognitive activity. This internal-dissociative technique involves a repetitive cognitive task in which injured athletes can settle into a comfortable rhythm (Fernandez & Turk, 1986). Though not intellectually absorbing, the repetition of the activity requires consistent focus and a substantial degree of attention to maintain the rhythm, thus drawing attention away from the pain. Relevant tasks involving rhythmic cognitive activity include counting backwards from 100, repeating a mantra as in meditation (Heil, 1993), or singing to oneself.

Pain acknowledgement. An internal-associative technique, pain acknowledgement, is a form of imagery that is aimed at making the pain more tangible and, as a result, more controllable (Fernandez & Turk, 1986). It involves endowing the pain with physical properties such as size, color, sound, and movement (Leventhal & Everhart, 1979). With the pain in a corporeal form, it is easier to manipulate its "physical" qualities as a means of reducing the pain. For example, an athlete with an injured lower back conceives of her pain as being large, prickly, bright red, loud, and swirling. With this image, she can progressively alter her pain to be smaller, smoother, blue in color, quieter, and calmer.

Dramatic coping. All athletes know that aspiring to be their best takes commitment, sacrifice, and discomfort in order for them to push themselves beyond their apparent limits. It is not uncommon for athletes to create fantasies surrounding their efforts to inspire them and to assist them in better managing their discomfort. These inventions are aimed at reinterpreting their difficulties in a more positive and comforting light. A classic example comes from the movie, "Rocky," in which Rocky Balboa is seen training hard for the championship fight with the backdrop of inspiring music, running through the streets of Philadelphia, and ending up on the steps of the Museum of Fine Art being cheered by a large group of children. What was simply a boxer preparing for a fight was made into an epic battle between the titan and the underdog.

Dramatic coping for injury rehabilitation, an internal-associative strategy, uses a similar approach in which injured athletes view themselves as intrepid warriors and place their recovery in the context of an heroic journey to overcome the odds (Fernandez & Turk, 1986). Thus, focusing on the pain that was previously aversive becomes evidence of their valiant efforts and provides confirmation of their progress toward their monumental goal. Whether world-class athletes in pursuit of Olympic gold or recreational competitors, all athletes have what is for them a pinnacle to which they aspire. Dramatic coping can reframe the pain of rehabilitation for injured athletes as a motivational tool to overcome the difficulties that they will experience during their recovery and return to sport.

Situational assessment. Consistent with the Pain as Information section described above, situational assessment is an external-associative technique that has been found to be used extensively by long-distance runners as a means of managing their discomfort more effectively during training and races (Schomer, 1986, 1987). It involves evaluating the causes of pain and using that information to make adjustments to relieve the pain. Rehabilitating athletes can use situational assessment to gain a greater sense of control over their pain. By identifying its causes, it will be easier to specify the means to alleviate the pain. Thus, by focusing on the pain, that is, associating with it, injured athletes gain a better understanding of the pain and, as a result, are better able to take active steps to relieve it. Rather than working alone to reduce pain, situational assessment can be a useful first step in a multifaceted program that uses several pain management techniques to decrease pain.

Hypnosis. Hypnosis has traditionally been considered as an altered state of consciousness that is produced in individuals through the administration of various induction strategies followed by suggestions aimed at producing a desired change (Chaves, 1993). Hypnosis is purported to have both a distracting effect, drawing attention away from the pain, and a reducing effect, by inducing a deep state of relaxation that attenuates the experience of pain. In fact, the most commonly used strategies that are offered as hypnotic suggestions to manage pain include the previously discussed pain focusing techniques of imagery, pain acknowledgement, and external focus. Other methods that have been used are time distortion, transformation of the pain sensation, numbness, physical relaxation, and age regression-progression (Chaves, 1993).

Hypnosis has been advocated and used in the field of sport psychology as a means of enhancing various contributors to athletic performance (for a review, see Taylor, Horevitz, & Balague, 1993). It has also been demonstrated to be an effective means of controlling pain in a variety of experimental and clinical settings (Ficton, & Roth, 1985; Hammond, Keye, & Grant, 1983; Lenox, 1970; Mayer, Price, Barber, & Rafii, 1976; McGlashan, Evans, & Orne, 1969).

Though there has been no empirical research examining the use of hypnosis in the management of pain due to sports injuries, its use has been widely recommended (Morgan, 1993; Ryde, 1964; Singer & Johnson, 1987; Taylor, Horevitz, & Balague, 1993). Additionally, evidence indicating that hypnosis can affect heart rate, blood pressure, blood flow, respiration, and oxygen uptake suggests that it can influence the healing process. Thus, the use of hypnosis by a trained professional can be another tool that can benefit injured athletes in their management of pain during rehabilitation.

Sport Psychologist's Roles in Pain Management

Sport psychologists can assume several key roles in their work in the injury rehabilitation setting. Initially, consultants can serve an educational role in this process by offering rehabilitation professionals information and skills related to the management of pain that they can use with their patients. Additionally, it is an opportunity for sport psychologists to establish a relationship with them and clarify how consultants can be a useful part of the rehabilitation support staff. This involvement also acts to sensitize rehabilitation professionals as to when an injured athlete might benefit from a referral to a sport psychologist.

Many of the techniques described in this article can be administered by the rehabilitation professionals themselves. With some education and training, rehabilitation professionals can become competent in the use of deep breathing, muscle relaxation training, and other basic pain management strategies. Additionally, a part of the education process with them should include identification of situations related to athletes' experiences of pain that are beyond their skills. Though there are no defined guidelines for when a referral is appropriate, we can offer several parameters. First, rehabilitation professionals should be encouraged to share information about the assessment of pain and the types of pain with their patients. In addition, they should teach simple pain management strategies such as breathing and muscle relaxation training to injured athletes. Second, when these techniques are not effective and the pain is interfering with injured athletes' rehabilitations, a referral is appropriate. We advocate that more sophisticated pain management strategies such as hypnosis, mental imagery, biofeedback, and pain focusing be only administered by qualified professionals (Singer & Johnson, 1987).

The type of pain that injured athletes experience should also be considered in who provides the pain management intervention. We suggest that rehabilitation professionals are most qualified to manage acute, benign pain that arises from exertion in rehabilitation. These strategies can be incorporated into physical therapy exercises to allow injured athletes to put their fullest effort, intensity, and focus into their rehabilitation sessions. Conversely, we believe that trained sport psychologists are best suited to provide pain management to injured athletes when their pain is ongoing, potentially harmful, significantly interfering with the quality of their rehabilitations, and also negatively impacting their daily functioning. For this type of pain, more advanced intervention techniques may be necessary to control the pain and alleviate its negative effect on rehabilitation.

At the same time, rehabilitation professionals need to understand the potential risks of using pain management techniques with injured athletes. These dangers can include blocking pain information, premature participation in rehabilitation and return to sport activities, and risk of reinjury (Singer & Johnson, 1987). A clear appreciation of the benefits and risks of pain management techniques as well as the situations in which they can be used safely will help rehabilitation professionals and injured athletes use these approaches to their greatest advantage.

Sport psychologists also have a responsibility to ensure that they have the necessary qualifications to provide these services. Because of the risks involved in using pain management with injured athletes, we believe that it goes beyond traditional performance enhancement approaches. As such, additional training and experience is needed to safely and effectively provide intervention for injured athletes. Consultants should possess appropriate experience in the form of education and supervised training with these techniques in a rehabilitation setting. They should also have suitable credentials such as relevant advanced degrees, state licensure, or certification from appropriate organizations related to their training and skills. In addition, sport psychologists should consider the special liability issues that are present in the rehabilitation setting. The risks and consequences of intervention are significantly greater than in typical performance enhancement situations and, though not likely, protection against litigation in reaction to a problem that arises during consultation would be prudent.

Using Pain Management

A variety of practical nonpharmacological pain management strategies have been presented that injured athletes can use to gain control over and directly reduce the pain they experience during rehabilitation. It is now necessary to present them with a structure in which they can learn about the methods and apply them to their pain needs. This process of putting pain management into action involves several steps that will lead injured athletes to a clear understanding of the pain management techniques and how to use them to reduce their injury-related pain.

The first step in this process is to introduce injured athletes to the concept of nonpharmacological pain management and educate them as to its value. It is likely that most of them have little or no exposure to such approaches. Particularly in this day and age where medication has become so prevalent, injured athletes may have the tendency to look to medication as a panacea for their pain without consideration of its effects or alternatives for pain control. A detailed discussion of the ramifications of medication for pain management in terms of benefits (e.g., ease of use, immediate pain relief) and potential costs (e.g., loss of control, side effects) can assist injured athletes in making the best decisions to meet their rehabilitation needs. Particular emphasis should be placed on how the use of each type of pain management will positively or negatively impact their rehabilitation and return to sport.

With a level of awareness now created, injured athletes may be receptive to learn more about the value and use of nonpharmacological pain management. Describing in more detail the use of these strategies will help clarify and demystify them, and show injured athletes that their use can not only be effective, but also pleasant. Educating them about the distinctions between pain management techniques based on the associative vs. dissociative and internal vs. external dimensions may further pique their interest and desire to learn more. Following this clarification, injured athletes can be taught how and when to use the methods that are most appealing to them. Allocating time and attention to pain management during physical therapy sessions communicates its importance to injured athletes as a tool integral to the rehabilitation process.

The final step of this process is to allow injured athletes the opportunity to use the pain management techniques when they are experiencing pain. This approach enables them to experiment with different strategies to find out which ones are most effective for them. Following this experimentation, injured athletes can choose several methods that they most prefer and make them a regular part of their rehabilitation program. This allows them to practice the techniques, become more familiar and comfortable with them, and adapt them to fit their particular needs in response to rehabilitation pain.

Conclusion

The debilitating impact of pain on recovery from sports injury is well-documented. Pain can interfere with an effective and timely rehabilitation both physically and psychologically. The purpose of this article was to provide applied sport psychologists who work with injured athletes with the information and strategies to accomplish several important goals. First, the information described here can be used to educate injured athletes on how pain affects them, thereby providing them with a greater sense of control over the discomfort they will experience during rehabilitation. Second, they can have a complete understanding of the ramifications of pharmacological and nonpharmacological pain management on their rehabilitation, enabling them to make an informed decision about what methods they choose to reduce their pain. Third, injured athletes can have the nonpharmacological means to more effectively manage the pain that they experience during their recovery. Finally, the use of this knowledge and the many pain management techniques can assist injured athletes in have a more comfort and manageable rehabilitation that will result in a complete and successful return to sport.

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