Originally published Oct 1995
Samantha McLeod
Alphington Sports Medicine Centre
Injury and it's rehabilitation can become extremely stressful, both physically and mentally, for the competitive athlete. The injured athlete not only experiences the psychological trauma associated with the pain of injury and subsequent treatments, but is also subjected to the frustration of not being able to compete or even carry out daily activities.
In summary, the athlete's life becomes uncertain: the sense of control over oneself, so necessary for outstanding performance, is gone. The athlete questions the reasons for the injury and how to prevent a recurrence. Being injured threatens not only an athlete's physical well-being, but acts as a threat to the athlete's self-concept, belief system, social and occupational functioning, values, commitments, and emotional equilibrium. Although some athletes are better prepared to recover from injury they may also face greater stress. Their self-esteem is often wrapped up in their physical achievements, thus athletes need encouragement and support to develop other aspects of their personality.
How do Athletes Respond Psychologically to Injury?
Psychological reactions to sport injuries are often characterised by the individual differences in the participants. Many describe the injury as disastrous, another may view it as the opportunity to show courage, and another athlete may welcome the injury as it prevents his or her embarrassment over poor performances and provides an escape from a losing team, or discourages a pushy parent.
At the time of serious injury, the athlete may normally fear the experience of pain or possible disability. There may be a sense of anxiety about suddenly becoming disabled and unable to continue sport participation. There also may be a sense of guilt about being unable to help the team or 'letting down' the coach. Becoming suddenly dependent and somewhat helpless can cause anxiety in the usually independent and aggressive person. The athlete may regress to childlike behaviour, crying or displaying anger toward the trainer who is administering first aid.
Furthermore, after an injury, athletes often develop irrational thinking. Their common sense and judgement are altered. The injured athlete may be illogical, distort perceptions of events or reach unrealistic decisions and conclusions. These irrational beliefs and self-defeating thought patterns can lead to injured athletes experiencing psychological disturbances such as, frustration, anxiety or stress, fear, decreased self-esteem, anger, depression and may interfere with the athlete's recovery.
Although the uniqueness of the psychological response to injury must be recognised, an athlete who has sustained an injury of such an intensity as to be unable to perform for a long period will typically undergo a sequence of predictable psychological reactions similar to those of a person facing death or for an,, one who has experienced a sudden loss. These reactions include:
- Disbelief, denial, isolation.
- Anger
- Bargaining
- Depression
- Acceptance and resignation while continuing to remain hopeful
Briefly, the immediate response to injury is a sudden shock-like state in which athletes commonly deny the seriousness of the injury or that it has happened at all. As the reality of the injury sets in, the athletes becomes angry at themselves for allowing it to happen, at the person directly responsible for the injury, or at the world for its unfairness. As the anger lessens, the athletes begin to have fears and doubts about the injury, which leads to the need to again (ie promising that if the situation could be reversed or ended they would change certain aspects about their life). Inevitably, the athletes become depressed once they are aware of the disabling nature of the injury, the inability to perform in the same capacity as pre-injury. and the length of time required to recover. Gradually, the athletes learn to accept the nature and severity of the injury, and resign to the situation that they must initiate the rehabilitation process.
Thus dealing with the injury alone, without an understanding of how the injury may impact on the athlete's self-concept, future plans, and social roles may have a negative impact on the morale of the athlete and the rehabilitation process.
How can Psychological Rehabilitation be Enhanced?
Emotions can both help and hinder how an athlete adapts to and is rehabilitated from injury. The degree to which an athlete maintains a negative affect such as anger, determines the transition from incapacitation to rehabilitation. It is only when the athlete regains emotional control that he or she can acknowledge the severity and limiting capacities of the injury. This acceptance leads to a task-focused approach to rehabilitation process that allows the athlete to move from self-protective behaviour to active coping behaviour.
Once athletes have adapted to their injury and learned to accept their incapacity, the first step towards rehabilitation must be determined. Adherence to the physical treatment program is necessary; however, in order to facilitate and promote a positive attitude to rehabilitation, certain psychological factors must also be considered.
The most effective sport psychology strategies available for the psychological rehabilitation of injured athletes focus on the relationship between the sports medicine team and the injured athlete. These strategies include effective communication skills and motivational techniques.
Communication
Health professionals facilitate rehabilitation by providing clear and detailed information about all aspects of the injury including: its rehabilitation and the degree of a sport expected. The role of a sports psychologist in this case, is to train the sports medicine personnel in appropriate communication techniques. Communication such as good listening skills, development of good rapport, use of positive reinforcements, as well as honest, open and consistent information are proven to be effective in rehabilitation.
Motivation
The question of how to motivate athletes to adhere to a rehabilitation program is a critical one. Recovery from injury may be prolonged or more painful if the athlete does not fully commit to the prescribed physical treatment. Some athletes are able to channel their competitive drive into their recovery. However, the discomfort of rehabilitation exercises or the anticipation of pain may be enough to discourage adherence.
The most common motivational strategy used by sports psychologists to assist injured athletes to comply with their rehabilitation, thus enabling complete recovery and a successful return to competition is GOAL SETTING. The process of goal setting should include goals to follow the prescribed physical treatment and goals to incorporate psychological strategies within the rehabilitation program. The general principles are to set realistic, specific and measurable short-term goals which are written down by the athletes and re-evaluated frequently. In addition, athletes must be provided with feedback as to their progress in relation to the goals.
Once the goals for rehabilitation and physical strategies for attaining them have been established, sport psychologists can incorporate psychological strategies for goal achievement. IMAGERY, VISUALISATION and RELAXATION are most often used in combination to deal with stress and anxiety associated with an injury, as well as POSITIVE SELF-TALK, COGNITIVE RESTRUCTURING and SOCIAL SUPPORT GROUPS.
Relaxation training allows athletes to control their feelings of pain, anxiety and lack of confidence through a series of deep breathing, voluntary muscular contractions, and relaxation exercises.
Imagery, in conjunction with relaxation, is used by athletes to help reduce the anxiety about returning to competition. Visual images used in the process include visual rehearsal, mastery rehearsal, emotive rehearsal and body rehearsal.
Visual rehearsal enables athletes to visualise obstacles in the path of a successful return and to rehearse how they will overcome these problems. Mastery rehearsal may be used to 'mentally rehearse' and help maintain the physical and performance skills of the athlete's sport and to visualise his or her successful return to competition.
Emotive rehearsal helps athletes visualise positive emotions, such as confidence, security and enthusiasm that they will experience on return to competition. Body rehearsal assists the healing process by athletes visualising the internal physical healing of their injury.
Sports psychologists can use COGNITIVE RESTRUCTURING to help the athlete recognise faulty thought patterns and anticipate destructive thoughts and can 'inoculate' the athlete with positive coping resources and strategies, such as THOUGHT STOPPING and POSITIVE SELF-TALK.
Injured athletes tend to dwell on negative or irrational thoughts about themselves, their injury, or their return to competition. For instance, it is reasonable and appropriate to think the injury is unfortunate, untimely, and inconvenient and to feel frustrated, irritated and disappointed, however, it is unreasonable, for athletes to convince themselves that the situation is hopeless, the injury is a sign of weakness or should be hidden, that the season or career has ended, and they will never be able to perform well again.
Thought stopping and positive self-talk can be taught to help athletes to re-direct negative, irrational thoughts into positive, realistic, rational and task-oriented thoughts and affirmations that can often shorten the time taken to move from disbelief to acceptance and to a safe and successful return to competition.
A final factor that can be used to enhance the psychological rehabilitation from injury is the INFLUENCE AND SUPPORT OF OTHER INDIVIDUALS.
In general, injured athletes should be encouraged to continue to be involved with team trainings, games, functions or meetings, so that this positive aspect of their lifestyle is less disrupted. Two psychological strategies employed in rehabilitation to enhance social support include peer modelling and injury support groups. Peer modelling involves linking the injured athletes with athletes who have incurred a similar injury in the past, who successfully coped with it and recovered. These models can provide honest empathy 1 of the pain and emotions involved and encouragement of how to overcome them. Injury support groups enable injured athletes to regularly meet and discuss common concerns, thoughts and emotions with other injured athletes, team-mates, coaches, family, friends, etc.
Thus communication and motivation are two important areas within which sport psychologists can provide the skills to injured athletes in order to enhance their psychological rehabilitation.
When are athletes psychologically ready to return to competition?
Traditionally, injury in sport has been simply treated as a physical problem requiring diagnosis, physical rehabilitation, recovery and return to competition. Consequently, athletes who have completed physical therapy treatment were assumed to be fully prepared for safe and successful return to competition.
Health professionals and athletes must realise that it is unnatural to be psychologically ready to return to competition after physical rehabilitation is complete unless the recovery occurs naturally.
The increased use of equipment and machines to shorten the physical recovery time, has increased the need for special strategies to enhance rapid psychological adjustment, as well. With the emergence of sport psychology, more attention is paid to getting the mind ready to return to competition to match the adjustment of the body. It appears that despite physical readiness, some athletes are not psychologically ready to return to competition.
Upon initial return to competition, fears, anxiety and tension can lead to re-injury, injury to another part of the athlete's body, lowered confidence and temporary poor performance, general depression and fear of re-injury which reduces motivation and desire to return to competition. Thus, it is critical that any fears that athletes have about the completeness of their recovery be alleviated before returning to competition. Sport psychologists can monitor the psychological states of athletes at all stages of the rehabilitation process to help determine the psychological readiness of the athlete to return to competition.
In summary, the approach to injury treatment should not only focus on physical rehabilitation but on the emotional and cognitive components of the injured athlete. In other words, the person, not just the injury should be the focus of treatment. Studying the psychological aspects of the rehabilitation process is fundamentally important and necessary to health care professionals in order to develop means of reducing recovery time spent away from competition, training and to ensure the athlete is holistically recovered and ready to return to full competitive sport.
