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Catching a ‘sliding’ athlete in your clinic: helping an athlete adjust to their injury
Catching a ‘sliding’ athlete in your clinic: helping an athlete adjust to their injury
Anyone working in sports therapy will be well aware of how common it is for athletes to injure themselves, irrespective of the level at which they participate. Sports therapists also understand that the severity of physical injury - in terms of extent of damage and impact on physical function - is not the only factor determining recovery. Some athletes adjust well to having an injury, whereas others don’t - even though the injury looks the same. What makes the difference is how the athlete psychologically interprets and processes the fact of the injury. What matters, in other words, is the meaning they attach to it: “What does this injury mean to me, my training, my life…?”
By understanding more about what might be going through an athlete’s mind, the support professional will be better placed to ‘catch’ a sliding athlete earlier, take decisions to help them recover more quickly and reduce the risk of demoralisation setting in, both for the injured athlete and indeed for the therapist, when their client fails to respond to treatment recommendations, or to comply with their rehab exercise assignments.
How injury may affect the athlete
Injury can present a real or potential setback for the athlete, lead to a loss of form, wreck the chance of reaching their goals for the season and ruin longer-term aspirations. If an athlete deems the injury to be significant, in terms of the implications they believe it will have (training, competition plans, an activity they enjoy…), then they will experience one or more of a range of psychological reactions. They may become angry about getting injured and factors around at the time when they became injured (opponents, team mates, coaching decisions, their own bad decisions, the environment and so on). They may worry excessively or become anxious about what will happen now they are injured, how long it will take to recover, whether they will ever fully recover, whether they will miss key competitions or be prevented from achieving their full potential. They may become fearful of making the injury worse and overly vigilant for signs that their condition isn’t improving or that there are other things wrong with their body. They may become despondent and depressed, unable to see any point in following treatment advice, in doing rehab exercises; eating well, drinking in moderation or being healthy any longer. They may interact with fewer sportspeople and non-sportspeople and become withdrawn.
Not all injured athletes are the same
For some athletes, injury will bring with it a series of unanticipated and unfamiliar challenges.
Difficulties in dealing with loss: Training, competition and sport are very important to athletes. This is not only true for the elite athlete but for most sportspeople, from recreational level upwards, who spend a fair amount of time exercising, training or preparing for competitions. An injury that limits an athlete’s training can represent a significant loss. Typically, the sense of loss will include:·
- a loss of routine and structure to the week
- a loss of form, physique or condition
- a loss of meaning to what they do, reinforcement of who they are (especially if they are professional and being a sportsperson is their job), of their identity as an athlete – someone who trains, competes, is fit, strong, active
- a loss of activity that provides stress-relief, energy release or endorphin high
and, a loss of positive interaction with people with whom they have important relationships (respect, fun, camaraderie…)
These losses hit some athletes harder than others and can leave a big hole in their lives. Elisabeth Kübler-Ross1 described five stages that people may go through when diagnosed with a terminal illness or are dealing with bereavement. These stages have been observed in people experiencing a range of other significant losses and can help us understand what an injured athlete may go through. The five stages are:·
Denial: “It can’t be true.” ·
Anger: “Why me? It is not fair.” ·
Bargaining: “Just let me finish this next event, then I’ll back-off my training.” ·
Depression: “This is terrible. I’m so upset. There’s no point doing anything. Nothing will help.” ·
Acceptance: “It’s going to be ok. I can enjoy competing at a lower level if that is my new maximum.”
An injured athlete might pass through some or all of these stages, in this or some other order, and may repeat stages. The most adaptive and least destructive stage is acceptance – though it can take some people a long time to reach this stage naturally. This is where they come to terms with what has happened and their new situation.
Difficulties in dealing with fear: As well as experiencing various losses, an injured athlete can find themselves facing a tremendous amount of fear and uncertainty. Questions can arise, such as:
“How will the rest of my season turn out?”·
“Will I be able to bounce back in time for …?”·
“How long will it take to recover?”·
“Is this getting better?”·
“Will I be dropped from the squad?”·
“Is this twinge a sign that I’m not healing?”·
“Will I only be able to compete at a lower level?”·
“Will I have to retire?”·
“Will this injury happen again – perhaps even worse than before?”
Once an athlete detects an injury, difficulties can arise if they rigidly adhere to their training schedule and competitive plans, failing to make adjustments to reduce the load on their body and thereby increasing the risk that their injury will worsen and lengthen the recovery time.
An injured athlete might then develop more difficulties if they deal with their situation by: failing to accept that they are injured; avoiding thinking about the injury or its consequences; failing to do the things that will help or stop doing the things that aren’t helping; failing to set goals; failing to recognise progress or knowing how to make progress, and worrying without generating solutions or an action plan.
For the sports support professional, there are two good reasons for looking out for a sliding athlete:
1. It is likely that a significant proportion of these athletes will experience despondency, depression and low mood. This is associated with reduced motivation and effort towards (rehabilitation and treatment) goals – thus limiting or undermining the therapist’s efforts to help them bounce back quickly.
2. By taking a more holistic approach, through considering the psychological factors, sports therapists can help reduce the risk of clients suffering more than is necessary.
Detecting a slide
Although the tell-tale signs will vary among athletes, the following can indicate that a client isn’t coping very well. The more signs that apply, and the more they are creating problems, the greater the chance that the athlete is having significant difficulty in adjusting to their injury.
Low motivation: Are they failing to do their rehab exercises (despite understanding and remembering about them)? Have they failed to set, buy into or start making the progress you would expect towards any goals that have been suggested? Have they failed to plan or see the steps that will help them return to fuller functioning?
More intense emotions: Is there evidence of depression (tearful, low-mood), anger (frustration, annoyance), anxiety (fear, hyper-vigilance, worry), or hopelessness (the future is bleak and not going to be better no matter what they do)?
Denial: Do they deny, dismiss or minimise the severity of their injury or its implications? Do they carry on regardless with training and competition, risking greater injury?
Diet and bodyweight: Is there evidence that their diet has become lower quality (more junk) or that they are over- or under-eating? Has their bodyweight increased or decreased noticeably?
Conversation: Are they less talkative than usual or pre-injury, less upbeat or jokey than before, with no topics that excite them?
Social: Have they withdrawn from others (team mates, training partners, friends, family)?
Risk: Are they engaging in more risky activities or behaviour because of their “don’t care” attitude (recreational drugs, alcohol, fights)?
How to arrest the slide
The sports therapist can play an important role in helping the athlete come to terms with their injury. For instance:·
Explain how injuries, like the one they have, can be difficult to absorb and cope with. It is normal to experience a range of emotional reactions. Show understanding and offer a listening ear. Ask a straightforward question, such as: “How are things for you these days?” or “How are you coping with this injury?”·
Help them view their injury as a challenge, phase or project. Help them see that they can use their extra free time positively to work on other aspects of their sport (technique, flexibility, core strength), or fit in non-sporting activities (reading, seeing friends…). They could think of this time as an enforced break (although this might be difficult early on, if an athlete is denying the extent of their injury or is very angry about it).·
Help them to set very achievable short-term goals and give them encouragement for any progress made. Convince them of the benefits of following the rehab recommendations. Find out what their expectations are for improvement, and challenge these sensitively if they are unhelpful or inaccurate.·
Encourage the athlete to accept support from friends, family and team-mates (especially those who may also be injured). Suggest that they speak with other athletes who have had a similar injury and who have coped well.·
Ask if they want to talk to a professional about how they can manage the changes that their injury has brought about (for instance, psychologist or counsellor with experience in sport).
How to spot a possible slider
Are there any warning signs that can help us predict which non-injured athletes may be prone to experiencing difficulties adjusting to a future injury?The best advice is probably that past behaviour predicts future behaviour. Has the athlete previously had an injury that they had difficulties coping with? Have they a history of low mood or depression? Do they have a small social network and few other interests or meaningful activities outside training?We know that in sport, confidence is vital for an athlete to be successful. However, if the individual has a deeply held belief that they are invincible, that they won’t get injured, then it is likely to be significantly more difficult for them to accept and respond appropriately when an injury does happen. Similarly, if they believe that they’ll be able to soldier on, or bounce back quickly without difficulty from any injury, then they are likely to experience problems if this turns out not to be the reality.
Conclusion
By keeping a watchful eye on injured clients’ outlook and broader state of mind, sports therapists will be better placed to pick up early signs of an athlete who is struggling to come to terms with their injury. The therapist can then help to guide them through this, using a combination of education, goal-setting, support and onward referral where appropriate. References:1. Elisabeth Kübler-Ross (1969) On Death and Dying
This article was the first or two articles on the psychology of injury published recently in the Sports Injury Bulletin (www.sportsinjurybulletin.com)
Dr Victor Thompson, London-based Clinical Sports Psychologist
When a sports psychologist with clinical training might be able to help
How can a Clinical Sports Psychologist help?
As one of the few sports psychologists who has also undergone training as a clinical psychologist, I've decided to write a bit about when it might be worthwhile considering a referral to a clinical sports psychologist.
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In brief, clinical psychologists have undergone a 3 year postgraduate doctorate which trains them to:
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- Work across the life-span (from young children to older adults - over 65-years of age)
- Assess and formulate a client's difficulties (what caused them, what maintains them, and what should shift the problems)
- Work with a wide range of client's and presenting problems
- Apply a range of therapeutic approaches (e.g., cognitive-behavioural therapy, systemic therapy and psychodynamic therapy)
A clinical psychologist who works with athletes (sports people) is likely to be valuable:
- - When the issue is a more complex one concerning the athletes relationship with others (e.g. partner, family, coach, teammate)
- - When the issue concerns unhealthy eating patterns (restricting intake, binging, purging or other bulimic tendencies)
- - When the anxiety or performance stress doesn't respond to usual stress management techniques, perhaps because it has more social judgement elements or some other more complex elements
- - When the athlete is in a downward spiral following on from an injury or some other setback (mood drops, anger increases, unhelpful behaviour and attitudes develop etc)
As with other branches of psychology, clinical psychologists aren't all the same, working in the same way, with the same style and interventions. It is important, therefore, that referring professionals, athletes or others seeking help for an sportsperson, ascertain that the clinical sports psychologist has the expertise you seek. This will be based on the problem that help is being sought for, the age of the sportsperson, the type of sport. Then the initial contact and/or first session will help indicate whether there is a good fit between the sportsperson, their needs and the psychologist.
How do you access a clinical sports psychologist?
- In the UK: We are listed either via the British Psychological Society's Chartered Psychologist's Register http://www.bps.org.uk/e-services/find-a-psychologist/directory.cfm then choose Sp&Ex as the Specialist Term and any other narrowing terms like Geographical Area or Postcode or Surname. Unfortunately when you get the list of names, you will still have to click on each name to see if they have 'DClinPsych' (Doctorate in Clinical Psychology) listed as a qualification.
- In the USA: You will need to check with your state licensing board or perhaps you can search on the American Psychological Association site (www.apa.org)
Dr Victor Thompson
London-based Clinical Sports Psychologist
