“Put me back in, Coach!” – Psychological responses to sports injury

If you’re a basketball fan like me, you’ll be eagerly awaiting the return of the Chicago Bulls’ explosive point guard, Derrick Rose.  Rose missed the whole of the 2012-13 NBA season after suffering a torn ACL the previous year, and a few months ago, I wrote a piece about him and some of the psychological factors that should be taken into account during an athlete’s return to play following injury. You can read it here if you like. It’s not bad.

But one thing that I glossed over was the psychological impact that injuries can have on athletes, and the ways in which they attempt to cope with these often stressful, sometimes traumatic, events. So in this post, I’m going to try to summarise some of the ways that athletes respond to injury, both in terms of the emotions they might experience and the ways in which they might behave, as well as looking at explanations as to why athletes might respond the way they do.

Psychological response to injury

Anyone who’s ever been injured will be able to tell you about the range of moods and emotions that they experienced, both immediately after the injury, and in the following weeks or months.Anyone who says that they didn’t experience an emotional response following injury is clearly a robot, probably sent from the future to destroy the human race. You should run.

Anyway, researchers have investigated psychological responses to injury from a couple of different perspectives. Some suggest that the response to injury follows a similar pattern to a grief response. Kubler-Ross’ (1969)¹ identified five discrete stages that people go through when faced with impending loss (denial, anger, bargaining, depression, and acceptance), and this model seems intuitively appealing when applied to injury.

In a sense, athletes who are injured have suffered a loss of sorts and might go through denial (“I’ll just put some ice on it, it’ll be fine”), anger (“This is bull$&^t!”), bargaining (“What if I got a second opinion?), depression (“This sucks – I hate my life”), and acceptance (“Right, let’s get on with rehab”).

Now the actual evidence for these stages applying to injury is somewhat mixed. Personally, I recognise all of these stages from my own injuries (especially the “I’ll just put some ice on it, it’ll be fine” stage), and depression, as well as anger and frustration, are all easily observable in many injured athletes.

However, research has also suggested that the denial and bargaining stages don’t really apply to athletic injury².  Moreover, people are very different, so we can’t really say that everyone will go through the same five stages in the same order every time they get injured!

The second perspective addresses these problems, and views the injury response as a cognitive appraisal process.  Essentially, this means that athletes experience injury as a stressful event (I wrote a bit about stress a while ago.  You can read it here if you like.  It’s not bad).  When a potentially stressful situation occurs (in this case, injury) a person evaluates the nature of the stressful event against their ability to cope.

This process is called appraisal and consists of two parts: Primary appraisal is concerned with what’s at stake (is this thing a threat to my goals, my self-esteem, my values?), while secondary appraisal is concerned with whether or not a person has the ability and resources to cope.

The appraisal process therefore influences the way that a person responds emotionally to injury and the ways in which they might behave.  So because different people will have different cognitive appraisals, they will respond differently to athletic injuries.

An integrated perspective

One model that attempted to integrate these two perspectives was developed by Wiese-bjornstal and her colleagues³.  This Integrated Model of Psychological Response to Sport Injury suggests that emotions associated with grief are a result the cognitive appraisal process, and are just some of the emotions that athletes can experience after suffering an injury.

The diagram below is an abridged version of Wiese-bjornstal et al.’s model and shows some of the emotional responses (e.g., fear, anger, depression, frustration, boredom) and some of the behavioural responses (e.g., sticking or not sticking to rehab, using social support, effort and intensity, and using psychological skills) that athletes might exhibit.

The cognitive appraisal process drives the emotional and behavioural responses to injury, which in turn drive further cognitive appraisals (the arrows in the diagram), and the appraisal process itself is influenced by a range of personal and situational factors.

While there are a number of emotional and behavioural responses that are perhaps missing from the model (e.g., fear of re-injury, or withdrawal from the sport environment), having an understanding of the ways in which athletes respond to injury, and the factors that can influence that response, can help us to help athletes through what can be an immensely difficult period.

How can we help?

The other day, I was talking to a colleague of mine, a Strength and Conditioning coach, who’s doing some work with a football team. He was telling me about one of the coaches whose attitude towards injured players was something along the lines of: “Injured players aren’t any use to me.  I don’t even want to see them until they’re ready to play.”

Now first of all, this kind of attitude is going to lead to athletes playing through injury and pain. Most people have played or trained through pain and discomfort before, it’s part of being a mentally tough athlete, but it’s important to recognise the difference between pain and an actual injury. Athletes might make injuries worse, or return too quickly and re-injure themselves because they don’t want to fall out of favour with the coach.

According Wiese-bjornstal et al.’s model, coaches contribute to the situational factors that influence cognitive appraisals, so it’s vital that coaches have an understanding of the psychological impact of injuries, and are able to provide the emotional support that their athletes require. Young athletes in particular have described the need for encouragement from coaches to get through the challenges associated with rehabilitation⁴.

Psychology in the treatment room

To increase the chances of successful recovery outcomes, athletes need to have positive cognitive appraisals of the situation. That is, they need to have realistic goals (i.e., not feel the pressure to return too quickly), and believe that they have the coping resources to handle the situation (support from coaches, teammates, parents, friends is vital here).

In the initial stages of injury, sports medicine professionals can help by making sure that athletes have an understanding of their injury, are clear on the implications of their injury, and have realistic timescales for return (minimising their fear of the unknown).

During the rehabilitation phase, athletes can use strategies such as relaxation and imagery (reducing tension, depression, frustration), as well as goal setting (increasing adherence behaviours), to increase the chances of them responding positively to their situation.

Summary

So we know that athletes experience a range of emotions and exhibit varying behaviours when they get injured. Some of these emotions and behaviours can be negative and harm the recovery process, while others  can be adaptive and lead to more positive outcomes.

Wiese-bjornstal et al.’s integrated model also suggests that athletes’ cognitive appraisals of the situation influence their emotional and behavioural responses (and vice versa) and, importantly, there are a number of personal and situational factors that influence those appraisals.

To help athletes deal with the trauma and stress of injury, and to increase the chances of positive recovery outcomes, coaches and sports medicine professionals need to have an understanding of psychological responses to injury and appreciate how they might be able to influence an athlete’s cognitive appraisals by becoming an effective part of the support network.

Have you suffered an injury as an athlete?  Do you work with injured athletes?  Leave a comment below to share you’re thoughts or experiences…

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References

1. Kubler-Ross, E. (1969).  On death and dying.  London, England: Macmillan.
2. Udry, E.M., Gould, D., Bridges, D., & Beck, L. (1997).  Down but not out: Athlete responses to season-ending injuries.  Journal of Sport & Exercise Psychology, 19, 229-248.
3. Wiese-bjornstal, D., Smith, A., Shaffer, S., & Morrey, M. (1998).  An integrated model of response to sport injury: Psychological and sociological dynamics.  Journal of Applied Sport Psychology, 10, 46-69.
4. Podlog, L., Wadey, R., Stark, A., et al. (2013).  An adolescent perspective on injury recovery and the return to sport.  Psychology of Sport & Exercise, 14, 437-446.