‘Using Performance Psychology to Enhance the Rehabilitation & Recovery from ACL Surgery’
Jessie Barr

Hi everyone I’m Jesse Bar, I’m the performance psychologist within the Aspire Orthopaedics team at the UPMC Sports Surgery Clinic this evening I’m going to give you a little insight into the work that I’m doing within the Aspire team around using performance psychology strategies to enhance recovery from ACL reconstruction.

What is the state of play in ACL recovery according to the research at the moment? So according to the results of two systematic reviews and meta analyses conducted on seven and a half thousand patients it was found that to 85-90% of ACL reconstruction patients returned to a fully normal or an almost fully normal knee function after their operation. However, these studies also found that the rates of return performance among these patients was not reaching those same high levels of 85-90%, what they were finding was that 81% were returning to general physical activity or general low levels of sport participation, 63-65% were returning to their pre-injury levels of sport so only ¾ of those who had an ACL reconstruction were actually returning to their pre-injury and pre-surgery levels and up to half were returning to competitive levels of sport. So, what the surgeons were finding in Aspire is actually reflective of the current state of play within the research, that while many will return successfully to normal knee functioning not many were actually making a full return to competitive sport and that’s where I’ve come in to give some support from that psychological point of view.

How I’m going to illustrate that is through a case study of one of the athletes that I came across quite early on when I started within the team. With this case study we’re going to look at a female GAA player who was in her early 30s. She was presenting with her second ACL reconstruction in three years and it was on the same knee so she was back into Santry to get her knee redone. She was referred to me by her physio at about seven months which would be considered that kind of return to play phase this stage, she should have been running, turning, jumping and being involved with general football related activity. At this stage she was hitting all of her physical targets and key performance indicators in her rehabilitation program so physically she was ticking all the boxes that were indicating she was on track to make a full successful recovery. But her progress had stalled she was stuck at the straight-line running phase which you would typically be in much earlier in a rehab program probably at the four to five months mark, this athlete was seven months in and still hadn’t got past straight line running. Why was this? What were some of the issues that she was presenting with? One of the main issues that I could see from my early work, my initial consultation with this athlete, was that she was experiencing significant reinjury anxiety or fear of reinjury.

Reinjury anxiety and fear of reinjury are consistently cited as the most significant reasons for an unsuccessful return to performance or a lack of return to performance so maybe a longer return a more stunted return or someone who doesn’t return at all to their pre-injury levels of competition. So, these are really important factors that I will see a lot of ACL patients experience. What is reinjury anxiety? Reinjury anxiety is cognitive and emotional reactions so it’s thoughts and emotions in response to the anticipation of negative consequences of reinjury so it’s quite future focused. It’s focused on what may happen if the patient has an injury again so this could be thoughts around having to do a surgery again, having to go back to the start with rehab, or what that might mean in terms of their season in terms of their progress so far and what it might mean for example their place on the team. It can manifest in lots of different ways with negative emotions like frustration, hopelessness, anger even and it can just be just a persistent worry and just general uncertainty that the athletes presenting with and as a result the athlete may want to avoid certain movements or activities. What I was seeing with this athlete, in the initial consultation, was significant reinjury anxiety she was terrified essentially of injuring the knee a third time or even injuring her other knee and requiring surgery on the other knee that hadn’t yet had a surgery.

Fear of reinjury on the other hand is more of a response to a perceived threat of a reinjury in the moment and the challenge of this is it doesn’t always show when an athlete presents to the physio, the surgeon or their clinical specialists on check-up. Fear of reinjury usually only manifests when they are actually in the place where they do sport so, on the pitch, on the track wherever they are. It is that immediate emotional response, that immediate fear and stress response and behavioural responses which could lead to avoidance behaviours as well. The fear of reinjury presents in the moment when a person is presented with the opportunity to do something that they fear could cause a reinjury. Where this athlete was experiencing this was on change of direction, so as I mentioned she was stuck in straight line running the change of direction on the pitch was causing a huge fear of reinjury. She was having a strong emotional reaction on the pitch, she had a strong fear of movement and the fear of the pain which is caused by the movement. This was leading to these fear avoidance beliefs which are the thoughts and emotions that were driving the fear that she was experiencing about this change of direction, these turns, causing further injury.

So, just to understand reinjury fear and anxiety it’s a really important factor for me to understand and to understand the sources of it because these fears and anxieties can create some quite strong long-lasting beliefs so I needed to understand the patient’s story. I must understand what was going on up until now where I’m meeting her at seven months, what has created this fear and anxiety and why is it presenting so strong and why now.

Back to the case study of my female GAA player, her first ACL surgery that she had three years prior was very successful, there was a smooth rehabilitation and recovery and she had a full return to performance within 10 months. However, her second ACL she was already significantly behind on her timelines by the time I met her and according to her physio had been quite behind on her timelines all the way along had experienced more setbacks. She had family members who had ACL reconstructions as well with various levels of success so brother and two cousins all male and some had made full successful returns while one had not returned to sport at all, so her experience of those around her had been quite mixed so it wasn’t instilling her with confidence either.

She was working full-time as a teacher so she was quite conscious of spending a lot of time on her feet, she wasn’t getting to recover and you know rest the injured knee as much as she wanted and didn’t have as much time as others to maybe dedicate to her rehab and her recovery. She was one of the most senior members of her club and her county team which was really important to know because there was maybe an element of pressure, an expectation and whether that was external or that was self-imposed she was quite a senior member and had you know aspirations of returning. Finally, what was another really interesting factor to understand in her story she was nearing the end of her playing career and why is this important. Well when we talk about reinjury anxiety and the anxiety related to the future outcomes of an injury she thought she was too old to have to go through the whole process again so if she was to reinjure the knee or injure the other one she thought that was probably going to be the end of her career she didn’t have that much time left in her in her playing career, so that was something that was really important and probably driving a lot of that anxiety was that she really just felt the that her clock was against her.

So, just to take a step back and understand what some of the potential psychological responses to sports injury can be and what maybe creates those response I’m going to introduce the integrated model of response to sports injury. This model indicates what could create the psychological and emotional responses to a sport injury and also to the rehabilitation process, that response is actually created before the injury even happens. It can be linked to personality factors, history of stressors, coping resources interventions, so what does that person already have access to what type of person are they, are they someone whose tendency to be quite anxious so even before the injury happens there are some factors that can create the response. Then once the injury happens once the ACL has been torn there is a number of factors that will impact and contribute to the emotional and psychological responses that the athlete will present with both at the time of injury and throughout the rehabilitation process. The athlete will take into account their personal factors, things like their injury history, have they experienced injury previously for example their individual differences so their motivation their athletic identity, which I’ll speak about in a little bit more detail in a while, that idea of how much they identify with being an athlete what age and gender, they are all of those personal factors can contribute. Those factors are then combined with things like the situational factors, so the sport, when in the season is it right coming into the start of the season versus the end could change the psychological response, who are the people around them those social support networks, is there a lack of social support or is there good availability of support to the athlete, those are some situational factors that can create positive or negative responses. So, as you can see its quite complex, there is no way to really predict how any athlete is going to react so getting that understanding of the person and understanding their story, understanding the beliefs they’re taking with them as well can give an indication of where I can offer my help and support.

So, what does her player tell me about that, why was she experiencing it? Thinking back over the story that I shared she had a very strong belief that if she was having slower progress, which she was in comparison to her first knee, that it meant there was going to be poorer outcomes. She had this belief that because she was not hitting timelines she was not going to make a success or return and had nearly made that decision just by maybe speaking to other people and coming to her own conclusions. She had less opportunities to build trust and confidence in the knee because, she was avoiding a lot of opportunities to build that trust so she was avoiding drills she was avoiding some activities at training which would be opportunities to build confidence and trust in the knee at that later stage of her rehab. She had what we call perceived susceptibility and a lack of control, so this athlete was presenting with the belief that you know my brother has had an ACL reconstruction two of my cousins I’m on my second maybe we just have bad knees or bad ACLs in the family. Suddenly she was kind of accepting that she didn’t have as much control over this injury as she maybe had once thought and there was a perceived susceptibility she’s just someone who’s going to get ACL   injuries and there’s nothing I can do about that. This almost learned helplessness was starting to kick in that no matter what I do I’m probably going to get injured again because look I’m here again my family has been there too.

Because of her full-time job as I mentioned she did have less time to dedicate to her rehab and recovery. As I mentioned earlier the idea of athletic identity is one of those personal factors, so she was a club and county player one of her most one of the most senior members and a really valued member of both teams. She was someone who herself identified very strongly with being a footballer she’d identified first and foremost, as footballer before she identified as teacher or as anything else so it was a big part of her self-concept who she was, in research will say that someone with a very strong athletic identity may struggle with being away from their sport and not being able to I suppose fulfil that identity. There didn’t appear to be as much external pressure from teammates or managers on either team but she was definitely self-imposing pressure on her return to play and returning to the pitch due to her age, she really felt that time was running out and the clock was against her. Understanding those beliefs, so understanding those contributing factors was starting to paint a picture of where these reinjury fears and anxieties were coming from and what I could do next where could we go with this.

My plan and interventions started with confidence building as I just gave a little indication of I needed. I recognised that the athlete was presenting with a high level of anxiety but very little confidence and one way to counteract the anxiety she was feeling was to build that confidence in her knee and in her body and at that time it was very low so we needed to go back and reflect on the work she had done up until this point on the rehabilitation process that she had done until seven months reflect on that think back through it, reflect on training logs go back her training logs from her first ACL and make some comparisons as well. We needed to cog do some cognitive restructuring through self-talk which is that internal dialogue because when we spoke about what it was she was telling herself, where was her head when she was at training what was she telling herself throughout the day where was her attention throughout the day every little niggle or every little you know awareness in her knee was creating or confirming the belief that her knee was weak wasn’t going to be able to take the demands of change of direction and further match play scenarios. We needed to challenge those beliefs through self-talk interventions, identify those negative unhelpful self-talk that she was engaging in at training and throughout the day make note of it and then create a more helpful script to counteract it. This was so that she has something to respond and challenge and let stop those unhelpful thoughts from spiralling and going unchecked. That was something that was a constant theme throughout, one big part of the work we did was actually just going back and doing some goal setting, seems simple but there were some real glaring gaps in the goal setting that she had been doing up until that point. We looked back at doing some smaller goal setting and I’m going to go into a little bit more detail on that in a second.

Then we did an imagery intervention which is also known as visualization, to try and build confidence in the activity she was going to be putting herself forward, that she had been avoiding up until now, so that was change of direction. Some match play scenarios were causing a huge amount of stress and that stress was leading to her avoiding those movements and avoiding those activities altogether, so imagery was a way of practicing doing some mental rehearsal of being in those scenarios of feeling confident in those scenarios or feeling nervous and still doing it without having to put herself in those physical scenarios. It was a way of training her brain to feel comfortable and confident with those activities before she actually put her body in the situation to do them. Finally, I just taught her some relaxation exercises because what was quite clear was when she was at training and when she’d moved past the easy drills that she was confident with straight line running and they were moving into more complex drills, change of direction, and more Matchplay scenarios her stress was shooting up and as a result, she was creating a lot of tension physically and mentally as well so that tension physically was linked then with some unhelpful self-talk so we had some self-talk interventions but we needed to make sure her body wasn’t tensing up and creating unnecessary barriers through just that physical tension. So, just some simple breathing activities when she noticed those little triggers of those unhelpful thoughts or that tension that was maybe in her jaw or in her shoulders, we just did some breathing activities to just relax and centre herself and then be able to maybe attempt the start of what she was hoping to put herself forward for. So, they’re just some examples of the plans and interventions.

In terms of the outcome and I said I will talk about the goal setting in a second but in terms of what the outcome looked like now this athlete I must preface was very engaged from the start really bought in after about 20 minutes of our discussion I could see that she really wanted the help she really wanted to be involved in this process and it made the work I did much easier. The athlete did present with this reinjure anxiety and fear of reinjury, we had three consultations which looked at those four or five interventions after those three consultations she felt confident enough to return to performance and played just 10 minutes and she was delighted with those 10 minutes. Following that we had one or two more consultations throughout the season and after those she felt confident and ready to return to full match participation, so for the first time in her rehab for that second ACL she felt psychologically ready to return to match participation to match play and was able to overcome those barriers, again, a lot was to do with the athlete, how engaged she was and how willing she was to give everything a go.

I mentioned goal setting, and this was a big part of our intervention and probably bigger than I anticipated it being because it always seems like one of the simplest interventions, but it can be so effective if done right. What I recognise and in my early discussions with athletes, I always want to identify what their goals are for the rehabilitation, the recovery and what they’re hoping to return to and where she was at seven months this was an athlete who could only run in a straight line her overall goal, was the top of that set of stairs, was to play a match and I said, “Okay well we need to bring it back a bit we’re a really long way away from playing a match if you can’t do anything bar running in a straight line.”  So, we discussed what would be the next step from where she is and she said, “Okay well, the big goal then taking it back a number of steps was change of direction and speed with the ball.” So that became our main focus, we parked the match we said, “We’ll come back to that but let’s just make a smaller more achievable target that is not doesn’t seem so daunting.” And what I realised with talking to her and something I’ve recognised with a lot of the athletes that I’ve been working with it with after an ACL reconstruction is there aren’t enough of those kind of smaller incremental goals between those large milestones and this is probably most evident in the latter part of the rehab because obviously early on in the rehab it’s very controlled, its gym based and there’s a lot of small goals to hit but once the athlete moves out onto the pitch or out into the field to play and they’re back in training suddenly the jump becomes much bigger with less small goals to kind of build that confidence up slowly in the way that we’re being done in the gym ,so, really that was where that lack of opportunity to build the confidence and the trust in the knee was presenting because she hadn’t had the opportunities to actually do that she was just trying to jump too far forward.

So, what we did is we revised the patients goal setting so instead of it being match play we parked that completely and we said okay your performance goal one is that change of direction and speed with the ball, we set that at the top of that set of stairs for where she was at now and again, we brought it back. So that’s the performance goal that’s a performance indicator that she can move on to the next once she was able to change direction and speed with the ball. She knew she was ready to move on to the next step, which was one step closer to match play, but she wasn’t there yet she was still at straight line running so I brought her back again and said “Okay we’re at straight line running what do we need to add next what’s the next process what’s the next step?” . The next process was just change of direction, being able to participate in change of direction drills at a steady pace then she was ready to progress to the next step that next process goal which was a change of direction drills at a steady pace adding in a ball.  Adding in another small demand once she was ready to do that move on to change of direction at speed and finally then she could move on to that performance goal, so we broke it right back down it seemed like it was baby steps but that’s what it was in the gym so we needed to apply that thinking to the pitch work as well. That’s what we wanted to do is to add in those extra steps, to build trust and confidence in the knee so rather than going from running in a straight line to fast change of direction with the ball we needed to add in some steps to build that confidence and make her feel that she was able to do it, and we didn’t move on until she was ready.

We’ve come together and recognised the best approach is getting in as soon as possible and offering that support as soon as possible. My approach now looks like again still understanding the backstory. I offer athletes a discovery call so a free 30-minute call to just give me a bit of background of who they are before they ever commit to initial consultation because I know it can be quite daunting and even in that initial consultation there will be a lot of opportunity to understand their story and their background understanding the injury, what happened, what was their experience, what are the potential repercussions of this injury and their season, their timeline, just to kind of get a sense of what their emotional response looks like and how they’re feeling in that immediate in that initial period, in that early stage of rehab. I want to understand their previous experience of injury because that can really shape how they can apply their skills and apply their knowledge to this new injury, if it’s their first it can be very different to someone who’s had an injury before. Someone who’s had an injury before may feel competent and know what’s to come or maybe having had a previous injury feel dread because they are aware of how taxing rehab can be so knowing if there’s a previous experience of injury can be a really valuable understanding of the level of athletic identity. So how much does that athlete identify with their athlete role, is their identity shaped by being an athlete, are all their friends’ athletes, is their social life centred around their sport, are all their friendships centred around their sport and is all their spare time centred around their sport, that’s important to know to kind of direct towards different strategies. So, identifying how an athlete can manage their time depending on their level of athletic identity, they identify quite strongly we want to find ways to maintain that identity in a different way while they’re injured and just understanding what other interests’ pursuits and what else is going on in their life are they working, are they in school, are they in college or are they a full-time athlete.

By just understanding what else is going to be there to distract them during this rehabilitation process understanding their current knowledge so what do they know about ACL reconstructions what they know about the rehabilitation and the recovery do they have any experience with other people, does any of their teammates family members friends and what was their experience and are there any beliefs or fears they hold about the rehab process or that return to play, are they someone coming in saying understanding that only half of people return to full sport and full competitive levels or are they someone coming in believing that the harder I work in my rehab the more likely I am to return so understanding where they are at the moment and what their beliefs and knowledge is identifying those goals that they have of the rehab and recovery and of the psychological support I support I can offer or is there a certain timeline they want to get back for or are they willing to just see it out and return when their knee is ready, just identifying what those goals are is really important early on to help manage expectations. As I said expectation management is a really important one. If we understand their goals we can then start to put in those strategies to manage expectation, helping them understand that setbacks will happen, when they may happen, how they may react if they do kind of nearly pre-empting it.

I use the self-determination theory as a framework for initial interventions and I’m going to talk about that what is a self-determination theory and how am I using that to shape those early stages of interventions with new patients. What is the self-determination theory? The self-determination theory encompasses three concepts, the concept of competence which is where a person is motivated to gain mastery to feel capable and effective in their own actions, so an athlete wants to feel competent even when they’re injured or when they’re rehabbing, we want to encourage autonomy with the athlete. We want the athlete to feel in control of their choices and in their day-to-day life one thing a lot of athletes will say is they don’t feel that they’re in control of their decision-making in their life or their day-to-day when they are rehabbing because someone else tells them what they should do, when they should do it, when they can do more, if they have to pull back and do less so there can be a feeling of a lack of autonomy during the rehab process. What we want to do is create opportunities for autonomy and finally the self-determination theory of motivation, the last factor is relatedness so it’s that idea of feeling connected and belonging to others. It’s a way of recognising that they feel cared for and supported. This self-determination theory and the theory of motivation and it’s all three of these factors can combine to create a motivated athlete who will see out their rehab, who will stay engaged in the process and hopefully feel more in control of that throughout.

So, what can that look like, what are some of the strategies that I do to try and create a self-determined athlete. If I want to encourage an athlete to be more competent something very simple at the early stages I suggest athletes keep a recovery journal to record their progress record any signs of improvement or any upskilling that might happen. With an athlete we want them to take back that bit of control, have a bit of more autonomy but also see that competence grow because that competence is what creates that confidence that we see later on and that trust in the knee so if they’re witnessing their recovery they’re recording their progress and they’re not waiting for the physio or the surgeon to give them the green light they’re also seeing it with their own eyes and they’re recording it they’re creating that confidence throughout the rehab process and feeling more competent in the rehab and in their knee. We want an athlete to be more autonomous so while they feel a lot of controls been taken away they can’t engage in their sport we want them to identify opportunities to develop other skills during the rehab period, so while the injury initially could have brought on all of these really negative and unhelpful responses we want them to see that an injury can be a time of opportunity, it can be time to develop a more rounded athlete that you may not have time to do when you’re training full-time. Encouraging the athlete to seek out those opportunities maybe it’s developing other physical skills like fitness on the bike or upper body for example maybe getting involved in the sport in other ways so still staying involved in the sport and taking back the control of maybe their tactical awareness by doing some video analysis or the strategic awareness by doing some stats work for the team or just even offering a little bit of coaching and just feeling they have something to give back and they have control over their choices. Finally, a self-determined athlete is someone who has that relatedness they feel related to others so helping that athlete at that early stage, identifying who the sources of social support are going to be and what the types are at different times, so, how can they use them, who are the people who have been through it before and can they seek guidance from them about their experience of surgery and injury and learn from them and who are the people that they want to be around when they need a break from all things sport and injury. So, at that early stage now that I’m getting athletes much earlier on through the referral processes this is the type of work I’m doing with them and then as we move through the rehab process we go back to things like goal setting, cognitive restructuring, expectation management those kinds of strategies but at the moment that’s where I keep my focus create those self-determined athletes.

I became aware of the struggle these kids have when they get such a significant injury to their knee over time and in my head that’s a psychosomatic injury so we deal with a somatic aspect where we get the patients to have a stable knee and to get fit but the psychological aspect is significant, I realised this through having adolescents of my own who play sport, fortunately, they haven’t had such a big injury but I could see whenever they had a small injury how important it was for them to be part of the team and to go training. Literally in the office the entire team is crying the patients, the kids themselves, the parents, its often those kids are the best in their sport because they play full on they get injured and then I got the feeling that we need to do something about that to work with a psychologist. I was talking to my colleagues for months trying to liaise with a psychologist and my colleague Gavin McHugh at the time worked with Jesse’s husband now and who was an orthopaedic register and Gavin facilitated the connection and I rang Jesse and I explained to her that we are in a position to carve a new field and she took up the challenge and here we are.

I suppose I used the example of a 30-year-old case study and the reason I chose her was she was someone who I had seen from right through to return to play and I haven’t had as many yet because a lot of my referrals have been more recent. Would I deal with an adolescent differently? yes and no, I suppose the challenge with an adolescent is often they haven’t had an injury before, so a 30-something year old athlete has probably had a lot of experience or has some experience of an injury. A lot of the adolescence that have presented it would probably be their first, some of them this is their very first injury ever, for many it’s their first major injury and that presents its own challenge. There is a lack of knowledge of what to expect, a lack of I suppose understanding of the value of rehab and sometimes my work is not just from the psychological side but also nearly a coaching side, a coaching of what the importance of what this means to do a full rehab cycle and what that’s actually going to look like. Even making suggestions around really simple strategies like suggesting to join a gym, this was something that was completely out of the norm for that age group that a lot of them had never been in a gym before so I suppose the challenge is what their experience level is, where they’re at in their career compared to an older athlete who probably has that range of experience and you’re dealing with an athlete who has a full career ahead of them so you are really bringing home the importance of following the rehab program staying motivated throughout, seeing the positives, looking for the opportunities because they potentially have 10 or 15 years ahead of them so we want them to try and stay as injury free going back so that’s definitely a way of approaching it is understanding the age and what are the different dynamics, how that looks depending on what their experience is in the sport and as Mihai said they usually are the best in their sport and probably haven’t had many setbacks so far so a lot of it is around coping strategies for dealing with what is probably their first major set and maybe even first major injury.

I do unlike Mihai I’m not a specialist in the knee, you know the skills that I use for ACL patients can be applied to the shoulder, to the hip, to muscular skeletal it’s not necessarily just ACL specifically. Obviously, ACL is one of the you know the longer of the rehabs but I have you know I have a skill set in other areas as well none of the strategies I would use would just be moulded to suit the injury and the demands of that recovery process.

Yes, I suppose to refer back to that earlier question the challenge is often to do with the lack of education and understanding, they maybe don’t know what is ahead of them they maybe don’t know many people who’ve had it maybe they don’t really understand the impact this could have on their career so a year seems like such a long time for these athletes they don’t really have an understanding of what that year might look like and I mean this in the best way possible but parents involvement can be a positive because mostly most of the adolescence who have been in front of me are there on the on the basis that their parents see the value in the psychological support but on the flip side if parent and teen aren’t aligned or there’s a feeling of pressure coming from parent it can it can send a teen digging heels in and wanting to do the opposite so that can sometimes be a challenge, its nearly me being a middle ground for the parent who’s giving the good advice and following what you know Mihai and the clinical specialists have suggested but at the same time the teenager doesn’t want to follow the rehab program then the parent is tearing their hair out so that’s actually been quite a challenge as well is finding where that middle ground is and where I sit without being a nag but also trying to help them understand the value of what suggestions everyone around them is making that. Yeah, just a lot of it is around psycho education, just educating what is to come what the benefits of engaging with my services, with the rehab, will look like long term and why maybe people at home are seeming like they’re being quite pushy. That’s definitely been a unique challenge that I haven’t maybe hadn’t thought of how I’d have to encounter that until I had more parents and teenagers sitting in front of me.

When someone refers into me, if a referral hasn’t been made directly through Mihai my best answer is just to emai, l so my email is just [email protected] just send me an email directly and we can set up an appointment from there. I offer a 30-minute free discovery call because I know psychology for a lot of people especially adolescence is quite daunting, there can be a feeling that if you’re being referred to a psychologist it’s a sign there’s something wrong with mentally and it’s just to maybe break down that stigma and just put someone at ease, it’s a Zoom call they don’t have to come in and commit to a full consultation with me it’s just break the barrier so they understand that this is who you’d be talking to and this is what we might speak about. I kind of just introduce what the work is, how I can help them and just put a face to the name because I know it is very daunting to come into UPMC and walk through those lovely marble corridors and see a psychologist for the first time ever. As Mihai mentioned my own background, was as an athlete, I spent a lot of time injured as an athlete so I kind of have nearly a common ground that I can meet with the athlete as well. I’d never say that someone has to commit to an initial full one-hour consultation, have a chat, introduce their teenager if it is a parent setting it up or if it’s a person looking to make the referral themselves, avail of that call and just get an idea of what the expectations are.