The psychology of injury

As a player, like many I was unfortunate to experience serious injuries, which ultimately dictated my transition out of sport into academia. My injury experience instigated my research interest into how athletes psychologically respond to injury and cope with a demanding rehabilitation journey. Since my playing days I have had the opportunity to work with many injured athletes (the majority of which have been football players) from the onset of injury to the return to competition phase. During times of consultancy it has been apparent that many injured players face a number of highly stressful demands that have the potential to significantly affect their responses to, and rehabilitation from injury. Take a minute or two to think about the many demands that an injured player will face that characterize the rehabilitation process. You will probably have thought of several that generally fall across areas such as physical, rehabilitation, emotional, cognitive, financial, social and career. These demands have the potential to play a significant role on the player’s responses to injury and impact upon their rehabilitation. Common responses of injured players include the loss of normal functioning, feelings of isolation, the inability to train, slowness of progress, rehabilitation setbacks, weight gain, a loss of confidence, and a fear of re-injury. Indeed players who I have worked with who are incapacitated due to injury have not be able to function physically as normal which has the potential to disrupt a loss of their goal-directed behavior and in turn, exacerbate feelings of frustration and depression.

Fortunately, models of psychological responses to injury that have been developed from the stress literature have influenced my applied work with injured players. The models highlight that a player’s thoughts will be influenced by three main factors that include their personality, history of demands, and coping resources. The thoughts (or appraisals) of players are key to understand how they are likely to respond particularly in relation to the perception of loss that accompanies the injury. So for example, a player who has a strong footballing identity, who trains hard every day and has done so for the last 20 years and whose lifestyle is completely dependent upon the profession, will have a high value system associated with the sport. Once that tie has been detached (temporarily or permanently through injury) then the perception of that loss together with the three (pre-injury) factors mentioned earlier, will influence the way that the player responds to the injury and its related demands. The emotional responses of an injured player can vary and are typically negative such as shock, tension, depression, anger, confusion, frustration, and anxiety. These responses are also temporally defined and will change over time so as an applied practitioner I need to understand that players will experience common (and normal) responses during the initial, middle, and late phases of rehabilitation before returning to the competitive environment and that these will vary in relation to intensity and frequency. The individual profile of the injured player is therefore important to acknowledge and largely dependent upon pre-injury factors that have the ability to change the way a player appraises the situation that they are in.

Soon after a serious injury, the many players that I have worked will often express difficulty in dealing with pain, the concerns about an accurate diagnosis and prognosis, finance, as well as negative images of the occurrence of the injury. Inevitably, players will feel down, lose self-esteem, start to rely upon others, and question their identity as a footballer. The perception of loss, either real or symbolic, will underpin how the player will behave at this early stage in the rehabilitation process. As a player progresses from this phase into a more engaged phase with physiotherapists, a number of challenges will exacerbate feelings of frustration and uncertainty. This is a difficult phase for a player, as they have to deal with their limited mobility and/or loss of full function alongside aspects such as feeling isolated and dis-engagement from the squad together with a perception of a loss of control and autonomy over the rehabilitation process. Adherence at this phase is key for a player and self-motivational aspects need to be recognized by staff particularly as potential setbacks can threaten compliance and progress. In addition to this, staff should understand the importance in the players’ belief in the efficacy of the rehabilitation programme. Finally, the return to competition phase is often seen as a complex one for both the player and support staff. Players at this stage in their rehabilitation constantly talk to me about the fear of re-injury, the decision to return to sport and whether or not they can return to their pre-injury performance level. Psychological readiness to return to full training and a game situation can often lead a player to ask themselves a number of questions and a need to restore confidence is often at the top of the list when preparing a rehabilitating player for competitive training and game transition.

Interventions that have been offered in the research literature are varied and sport psychology consultants will probably have used many that have been suggested. These vary from social support, to reflective practice, to mental skills programmes that tend to differ according to the phase of rehabilitation that the player is currently working within. However, contextual intelligence is something that I have developed as a result of my past playing experience, injury and my experience working within professional football as a coach. By that I mean, my understanding of the landscape in relation to the people and the demands of the environment. For example, there have been many situations where I have worked with clients in a performance capacity where confidentiality is upheld at all costs. However, as social support plays a key role in the way stress is suppressed (or ‘buffered’) it is important for me to not only recognize the support network of my client but also help him mobilize it to enable him to cope with the demands that he is experiencing. So, with the permission of the client I speak to managers, coaches, rehabilitating staff, players, family and agents to maximize the support that is required to deal with the demand(s) and inform intervention. On a number of occasions I have held consultations with an agent and player and worked closely alongside physiotherapists, strength and conditioning coaches and sports scientists to make sure that training is simulated to accommodate process-related and proximal goals aligned to other targets that have been set for the player. An interdisciplinary approach is mainly adopted that taps into the often apt and resourceful player’s network although facilitating relationship quality between all members involved is always a challenge.

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Last season I was fortunate enough to work with Wales International and Premiere League player, Neil Taylor who in the previous season had represented Great Britain at the 2012 Olympics. After meeting him for the first time I could sense that I would be working alongside a bright and mentally tough individual who demonstrated a high level of resilience. What was refreshing was his attitude to learn about the mental side of injury and his willingness to adopt a refined approach to his game throughout the process. In addition to a mental skills approach that initially involved cognitive restructuring, I engaged in dialogue with both rehabilitation and training staff to ensure that the support that was offered and perceived to be available, matched the demands that Neil was experiencing. This approach was key to the success of his return from a serious injury and a programme that provided evidence-based practice through the integration of psychology. Neil was very open and trusting in his approach and was public when acknowledging the support that I provided. This I believe was not only courageous due to the potential consequences of this behavior, but it highlights the importance of psychological knowledge in the modern game with players accepting its importance as opposed to the stigma that has historically accompanied it in professional sport.

My applied work with injured players is based upon models of stress-response and social support that are largely underpinned by change and growth. Although there are many negative aspects of experiencing injury and its associated demands we should not overlook the opportunity for growth and development whilst experiencing injury. This is an emergent area within the psychology of injury and a colleague of mine, Dr Ross Wadey (@rosswadey) is researching stress-related growth with a focus on the factors and mechanisms that transform adversity into an opportunity for growth and development that is a worthy consideration for applied work within a rehabilitation context.

Injury is always an unfortunate experience for any player and it is apparent that a number of demands will characterize the rehabilitation process. As applied consultants and coaches, we are in a very good position to recognize those and appreciate and understand what the player is going through. A fully integrated approach is one that will add value not only to a successful return to competition but one that will embed psychological aspects into the player’s daily routine to optimize performance both in training and game situations.

Ian Mitchell

Twitter: @ianmitch9