Preliminary Evidence for the Treatment of Performance Blocks in Sport: The Efficacy of EMDR With Graded Exposure

Prevalence of Performance Block Symptoms

Consistent with previous research (e.g., Marquardt, 2009; Rotheram et al., 2012), pre- and postintervention prevalence of the yips was assessed using visual inspection (where 0 = no yips and 1 = yips) and kinematic data. Specifically, before and after the intervention, the participant was required to perform 10 putts on a level putting green to each of 2 target holes at 0.91 m (3 ft) and 1.22 m (4 ft) distances. Distances were identified according to the participant’s most anxiety-inducing situation associated with the yips. Conditions were mild, dry, and with a light breeze on both occasions. To assess the degree and nature of movement disturbance in the forearms, three-dimensional kinematic data were captured using an electromagnetic sensor positioned 2.5 cm below the base of the putter grip (Polhemus Liberty, Polhemus Inc, Colchester, VT). Data were sampled at 240 Hz and captured using Golf Biodynamics Ultimate System software (Version 11.0.5, GBD Pty, Australia). As per manufacturer’s instructions, an electromagnetic pointer was used to digitize virtual markers used to define the target line. A local coordinate system for the putter was aligned such that the x-axis was coincident with the target line (positive direction away from the hole); y-axis was perpendicular to the target line (positive direction anterior to the participant); z-axis was vertically upward. The key kinematic variables derived from biomechanical analysis included putter face rotation angle and putter face rotation angular velocity. These data were exported using customized MATLAB script (The Mathworks Inc, Natick) and graphed in Microsoft Excel software.

Subjective Units of Distress (SUD; Wolpe, 1982)

SUD scores were recorded throughout EMDR and exposure treatment processes. This was to identify the participant’s subjective level of anxiety (where SUD 0 = no anxiety experienced and SUD 10 = extreme anxiety). These scores also provided a means of monitoring the success of each EMDR session where the aim was to reduce all SUD scores to less than 3 (Shapiro, 1999).

Validity of Cognition Scale (VOC; Shapiro, 2001)

VOC scores were recorded throughout EMDR treatment to monitor the level of belief the participant held in the positive cognitions associated with the problem (where VOC 1 = cognition is totally false and VOC 7 = cognition is totally true).

Impact of Event Scale (IES; Zilberg, Weiss, & Horowitz, 1982)

Consistent with previous research (e.g., Bennett et al., 2016), the IES was adopted as an additional measure of anxiety response to the EMDR treatment. Specifically, this measure assesses trauma-related symptom responses within the subscales: intrusion (intrusively experienced ideas, images, feelings, and/or dreams), avoidance (conscious avoidance of ideas, feelings, or situations related to the event), and physiological arousal (experience of anxiety-related symptoms manifesting in the body: cf. Sundin & Horowitz, 2002). The participant completed the measure pre- and postintervention, responding to each statement to indicate the level of distress experienced in relation to the problem. Distress level was reported using a scale of 0 (not at all) to 4 (extremely), with a total range of 0–88. Intrusive responses were measured by items such as “I thought about it when I didn’t mean to,” avoidance was measured by items such as, “I stayed away from reminders about it,” and physiological arousal was measured by items such as “My feelings about it were kind of numb.” It is recommended that total scores greater than 19 are high and that total scores between 30 and 60 are typical of PTSD sufferers (Zilberg et al., 1982).

Social Validation

Postintervention interviews were conducted with the participant, sport psychologist, and EMDR therapist to assess effects of the intervention and any behavioral changes that coincided with improved performance and symptom reduction. The interview schedule was constructed using a deductive approach to create a predetermined set of themes and categories (Patton, 2002). Interview questions were designed to provide the following: information relating to the participant’s experience of EMDR and its overall effectiveness for the treatment of performance blocks (e.g., extent of symptom reduction), information from the EMDR therapist outlining the procedure followed, and information from both practitioners regarding overall effectiveness of the intervention. This process was supported by the collection of session-by-session data. Interviews were conducted in the participant’s natural performance environment on completion of treatment. Following data collection, the primary researcher transcribed all interviews verbatim. No formal content analysis was performed on the transcripts; however, the full research team studied each transcript highlighting and discussing common themes relating to the treatment protocol and treatment effects. Where appropriate, extracts from the raw data have been directly included in the results.

EMDR Protocol

Consistent with previous research in studies where fidelity of treatment using EMDR therapy in case studies was high (e.g., Lipke & Botkin, 1993; Russel, 2006), the eight-phase standard EMDR protocol was adopted (Shapiro, 2001). Specifically, two sessions focused on Phases 1 and 2: client evaluation (including full mental health assessment and completion of the IES), case formulation, history taking, and client preparation. Additional focus was placed on educating X on EMDR, performance blocks, and anxiety. Reprocessing of target memories (TM’s) was covered in two separate sessions, each lasting approximately 120 minutes. A final review session took place 5 weeks posttreatment (including postintervention IES completion). To monitor the integration of exposure treatment with EMDR and to ensure that both practitioners were kept fully informed on treatment as it progressed, the EMDR therapist and sport psychologist were in communication before and after all sessions.

Graded Exposure

Exposure therapy was delivered by the sport psychologist and involved weekly sessions of in vivo exposure to harmless but distressing, problem-related stimuli. These sessions were delivered at the participants training venue and were all carried out separately to EMDR. Exercises were hierarchically arranged from least to most anxiety-evoking, as identified by X (Table 1). Specifically, X was guided through the process of identifying a series of situations associated with the performance block, toward which he experienced increasing levels of anxiety (where SUD 0 = no anxiety experienced; SUD 10 = extreme anxiety). These boundaries were more specifically defined by X (as SUD 0 = feeling the speed of my arms, control of my arms, and inner calmness and SUD 10 = electric shock in my arms, not in control of my arms, intense anxiety inside). X identified seven levels, with lowest anxiety associated with putting on the green alone (SUD = 2/10) and highest anxiety associated with playing an individual event with a scorecard (SUD = 10/10). Once each level was identified, the importance of weekly practice sessions was discussed, during which X would target each level progressively, recording relative SUD scores.

Week 1, Session 1

The first session involved an initial formulation of the problem between the sport psychologist, EMDR therapist, and X. In this session, intervention goals were established. X stated that he wanted to be able to “go back out and play a round of golf again, just be able to hit the thing like I used too without this disease in control of me.” Further to this, he identified wanting to compete again in a local proamateur competition. An overarching goal was to recapture the level of enjoyment he used to have for golf. Once goals had been established, a graded exposure plan was constructed (see Table 1) and arrangements were made for two future sessions between the sport psychologist and X, and the EMDR therapist and X.

Week 2, Session 2

Meeting between sport psychologist and X. Following informal discussion, the sport psychologist explored X’s current state of well-being and performance. X discussed completing four practice sessions at the first two levels of exposure, with SUD scores of 8/10 and 9/10, respectively. X recognized a felt urgency to overcome the problem and reported experiencing severe anxiety just thinking about going out to practice.

Weeks 3 Through 4, Session 3

Meeting between EMDR therapist and X. After a brief review, the EMDR therapist began Phase 1 of the EMDR protocol: case formulation and client history taking (Shapiro, 1999). Having already conducted an initial formulation with the sport psychologist and X, the aim of this process was to carry out a clinical assessment and explore in more depth any underlying emotional experiences or significant events that might be associated with the performance block. During this session, X identified several significant events, including the early death of his father when he was 2 years old and adjustment to his mother’s remarriage at the age of 10. When recalling a particular period of his life involving a major career transition, he described how he “completely flipped out and just lost it.” Other life events identified included family disruption following his father’s death, the later death of his mother and sister, substantial work-related stress, and unstable relationships. More important, X highlighted substantial emotional suppression throughout his life, driven by the need to “not to be a burden to others or upset other people.” Sport-specific events identified included several performance blocks in competitive situations. The most notable of these was an experience that occurred during a team event in a professional competition when he was attempting a 3-foot putt on the 18th green, the final shot to secure the game for him and his team. This experience ultimately led to his retirement from competition a year later.

Symptoms reported at the time of these events included extreme fear, confusion, and subsequent avoidance of situations that might cause embarrassment or failure (e.g., public speaking, dancing, learning a new skill, and vomiting in public). Some of these symptoms might have been linked to an avoidance of risk and fear of failure developed in childhood: “I was over-cared for and never ever allowed to take a risk or make a mistake.” X was unable to identify a time he had failed and stated, “No. I would never attempt anything if I thought I might not be able to do it; that would just be embarrassing.”

Following the session, the EMDR therapist shared his formulation with the sport psychologist providing the following summary:

This report was supported by scores revealed on the IES, for which X recorded a total score of 36 (total avoidance = 13, M_avoidance = 1.6; total intrusion = 11, M_intrusion = 1.4; total hyperarousal = 12, M_hyperarousal = 2), indicative of the extreme trauma associated with performance blocks.

Weeks 5 Through 7

During this period, X engaged in daily practice sessions using the exposure hierarchy with continued focus on the first two levels (putting on the green alone and setting individual targets on the green alone). X reported reduced SUD scores of 6/10 for both levels. X also reported that during this time, he had made several positive changes to his lifestyle (e.g., leaving the office every evening to schedule time on the putting green, time with his family, and also increased communication with close friends regarding his golf practices). Furthermore, X identified having discussed some deep felt emotion with his wife, something he had repressed to that date.

Week 8, Session 4

Session 4 comprised a review of exposure treatment between the sport psychologist and X, in which X discussed several practices completed on the first level of the hierarchy in which he experienced lower levels of anxiety (SUD = 2/10). X identified that he continued to experience increased anxiety at the second level (SUD 6/10) and so it was agreed he would continue at this level, setting individual targets for himself on the green.

Weeks 9 Through 10, Session 5

During this period, X engaged in daily practice sessions using the exposure hierarchy, initially at Levels 3 and 4; however, in the subsequent session, he reported that he had taken the opportunity to progress up to the sixth level of the hierarchy on three occasions—playing three informal friendly games. He also discussed having shared with details of the current treatment intervention with other players. X reported SUD of 9/10 and the need to return to Levels 4 and 5 (putting on the green with a professional, informal game scenario with two others) until the anxiety levels decreased.

Week 11, Session 6

Meeting between EMDR therapist and X. In accordance with Phase 2 of the EMDR protocol, the EMDR therapist explored X’s internal felt sense of safety associated with different contexts and identified a suitable internal representation of this place to return to after each reprocessing set. The therapist and X then worked together on developing an appropriate sequencing plan for the identified TMs, present triggers, and future desired outcomes identified in the formulation stage. Three memories were listed on the target-sequencing plan (SUDs respective of current anxiety felt when recalling the event):

Processing then started on the first TM. SUD score was 8/10; negative cognitions were “I have to be perfect (and please everyone)” and “I am not in control of my own body.” Positive cognition was “I can be myself,” and the VOC was 2/7. X identified associated feelings of embarrassment and shock as well as tightness in the chest, shaky legs, and feeling hot in the face (embarrassment).

After approximately 12 sets of BLS, SUD score lowered from 8/10 to 0/10. X reported absence of tightness in the chest and stomach, reduced warmth in the face/“flush,” stillness, and mental clarity. X was unable to reactivate an image of the TM and reported “feeling nothing” when the therapist revisited this memory. The therapist observed relaxed posture and use of humor that he later described as a possible coping mechanism for underlying anxiety. The session was drawn to a close activating X’s safe place (Phase 7), after installing the positive cognition “I can be myself” with VOC of 6/7 (Phase 5), and completing a body scan (Phase 6), through which no remaining sensations were reported.

Weeks 12 Through 15, Session 7

Meeting between sport psychologist and X. Although he had not been able to practice as much as intended (causing additional frustration), X reported having taken his first few days annual leave he had ever taken and that he had played two rounds of golf: one on his own and one with two committee members, consequently progressing up toward Level 6 of the graded exposure hierarchy. X reported SUD scores of 2/10 for Level 4, 4/10 for Level 5, and 5/10 for Level 6. X agreed to continue at Level 6 for the next week, identifying a need to increase practice hours at this level. The sport psychologist explored X’s level of anxiety and experience thus far of the EMDR treatment component. X confirmed that he “felt nothing” when recalling the first TM (SUD = 0/10). However, he said that he was due to play on the same course twice in the next couple of weeks in a practice round and then again in the same event as the first TM took place. He attached a SUD score of 7/10 to this event.

Week 16, Session 8

Session 7 was held between the EMDR therapist and X and started with Phase 8 of the EMDR protocol, reevaluating the previous work. X had recalled several other memories from his past since the previous session and additional details related to events already discussed. On completing Phase 8, the therapist was concerned about remaining anxiety associated with the first TM that was readdressed with further processing. SUD score was 3/10, negative cognition was “I have to be perfect (and please everyone),” and positive cognition was “I can be myself,” with VOC 3/7. After several sets of processing, SUD score lowered to 0/10, VOC increased to 6/7. The session was concluded at this point with Phases 5–7.

Weeks 17 Through 20, Session 9

In Session 8, the sport psychologist met with X on the putting green at his club, where he continued to practice throughout the course of the conversation. X provided an update on his recent practice against the graded exposure plan, with SUD scores of 3/10 for Levels 5 and 6. X also reported that the previous day he had played a friendly round with three others at one of the courses he had experienced the problem several years ago (graded exposure Level 5). He had experienced extreme levels of anxiety from the point of leaving his house (SUD = 9/10) and that these feelings escalated throughout the day (SUD = 10/10). Physical sensations were tingling and shaking in the forearms, jerky movements on the putting green, and an “electric shock feeling” on the 18th, the same green of his initial performance block. These symptoms resulted in an inability to putt, and subsequent avoidance of finishing shots, suggesting his partner took them. This session lasted approximately 2 hours, during which X talked about the emotional, cognitive, and physical sensations associated with this experience in great depth, until he reported having more clarity and perspective toward it.

Week 21, Session 10

The session started with Phase 8 of the EMDR protocol, reviewing treatment progress. Treatment effects identified included increased communication in X’s relationships and a need to understand the context of early family bereavements. Although X wanted to contact his sister, he recognized significant avoidance with negative cognitions of “not wanting to upset her” and “not knowing how she will react.” After much discussion, X appeared to assess the situation more appropriately.

On revisiting the TM’s, three further rounds of processing were done, until X reported no further disturbance or distress, and complete absence of physical sensations including flushness, tightness, and shakiness. It was agreed that no additional processing was required for the three identified TMs but that X would consider addressing some earlier memories (e.g., death of his father and family disruption). A future template was administered at the completion of Phase 5, synthesizing X’s use of the positive cognition “I can be myself.” X agreed to continue focusing on the use of his positive cognition: “I can be myself,” protecting personal time on a daily basis and pursuing activities considered to be risky options. The sport psychologist then joined the session, and when asked to recall his first and most severe performance block experience, X reported no emotional, cognitive, or physical sensations. X identified final SUD scores of 1/10 for Level 5 of the graded exposure plan, 2/10 for Level 6, and 5/10 for Level 7. Several upcoming competitions were identified that X would enter (Level 7 of hierarchy), and he stated that he could see himself recovering fully.

Week 27, Session 11

Session 10 was conducted 5 weeks posttreatment and consisted of a full review with X, the EMDR therapist, and sport psychologist. Prior to this session, X had competed in two competitive team events (final level of graded exposure), during which he experienced mild performance-related anxiety (SUD = 4/10) but complete absence of physical sensations associated with the performance block. X confirmed that levels of anxiety and physical tension had decreased at all levels of graded exposure. The sport psychologist observed signs of physical relaxation, calmness, and improved articulation of emotion. Additional outcomes included absence of ruminative thoughts, memories, and worries associated with the identified TMs. X reported that discussing each TM and performance block openly had helped him to reappraise memories and that since doing EMDR he perceived these experiences as unimportant.

The intervention came to an end when X’s aims had been achieved. That is, he no longer suffered from the physical, emotional, or cognitive symptoms associated with the performance block, and performance had improved both in training and competition. X discussed enjoying playing again and had experienced significant improvement in social functioning.