Differential Psychological Treatment of Injured Athletes Based on Length of Rehabilitaaion

Transcription

1 Journal of Sport Rehabilitation, 1996, 5, O 1996 Human Kinetics Publishers. lnc. Differential Psychological Treatment of Injured Athletes Based on Length of Rehabilitaaion David A. Striegel, Elizabeth G. Hedgpeth, and Claudia J. Sowa This paper describes the psychological processes of injured athletes and corresponding treatments along a continuum based on time away from sport. The first level involves injuries requiring rehabilitation of 0 to 2 weeks. Athletes' reactions focus on resiliency and coping with the stress associated with injury, and treatment emphasizes stress management and development of coping strategies. The second level involves injuries requiring rehabilitation of more than 2 weeks; in this level, motivation and compliance with rehabilitation protocols are dealt with, and treatment focuses on goal setting and injury support groups. The third level pertains to injuries resulting in the termination of an athlete's sport participation. This level involves the potential loss of identity in sport and transitions to a new lifestyle, with treatment strategies focusing on grief responses and career counseling. By viewing the psychology of athletic injury rehabilitation from a perspective that is sensitive to the severity of the injury as well as longevity of rehabilitation, sport psychologists can provide treatment better suited to the individual athlete. Over 25 years ago, Kubler-Ross (5) presented a grief model that outlined the emotional responses of the terminally ill. This model described five primary stages of death and dying: denial and isolation, anger, bargaining, depression, and acceptance. Kiibler-Ross's stages have been applied to individuals' reactions to loss, and Rotella and Heyman (9) and Rotella (8) extended this model to include the processes of injury rehabilitation. Limitations of this approach include (a) the assumption that the psychological processes of injury are the same for all athletes and (b) the conceptualization of all athletic injuries as comparable to death and dying. To address these limitations, researchers have begun to draw upon the literature on stress to conceptualize athletic injury and have begun to view postinjury reaction as an individual coping mechanism that includes both a psychological and a physical component ( ). This manuscript describes a differential treatment approach, based on length of rehabilitation, that incorporates both the individual nature of the stress response and Kubler-Ross's (5) stages in working with injured athletes (see Table I). The approach is divided into three levels: short-term rehabilitation (0 to 2 weeks), longterm rehabilitation (greater than 2 weeks), and termination of participation in sport. D.A. Striegel is with LGE Sport Science, 9757 Lake Nona Rd., Orlando, FL E.G. Hedgpeth and C.J. Sowa are with the Department of Human Services, 203 Memorial Gym, University of Virginia, Charlottesville, VA

2 Differential Psychological Treatment 331 Table 1 Treatment Concerns and Options Associated With the Three-Level Process for Psychological Treatment Based on Length of Rehabilitation Level Length Concern Treatment options weeks Stress 2 >2 weeks Stress Motivation Compliance 3 Withdrawal from sport Stress Motivation Compliance Career termination Stress management Systematic Rationalization Stress management Systematic Rationalization Goal setting Support groups Stress management Systematic Rationalization Goal setting Support groups Career counseling Level 1 : Short-Term Rehabilitation (0 to 2 Weeks) In the first level, the sport psychologist explores the athlete's cognitive appraisal of his or her injury and the stress associated with that event. According to Lazarus and Follunan's (6) transactional model of stress, there is an interaction among the individual, the environment, and in this case, the rehabilitation process. The sport psychologist begins work with the athlete by examining three aspects related to the stress of the injury: the athlete's perception of his or her environment both within and outside of sport, the amount of disruption that the athlete experiences as a result of the injury, and the coping resources that the athlete possesses within the rehabilitation process. The sport psychologist and the athlete discuss the athlete's perceptions of his or her environment and injury during the first session. The primary emphasis is on listening to the athlete. The sport psychologist listens for evidence of the coping resources that are integral to the development of a hardy personality, as defined by Kobasa (4). Hardy individuals develop coping resources in their perceptions of stressors (i.e., the attributions of challenge, control, and commitment) that buffer the detrimental effects of stress. In this case, the sport psychologist listens for indications of personal hardiness in relation to the athletes' attributions toward their injuries. The attribution of challenge is heard as athletes describe their injuries as problems to overcome rather than threats to their personal security or identity. Attributions of control are found in the athletes' beliefs that they have power within the rehabilitation process, are responsible for their actions, and are capable of avoiding feelings of helplessness. Commitment is heard as a reflection of purpose and involvement in what the injured athletes are doing in the athletic training room. In listening to the athlete and understanding the impact that the injury has on the athlete's life, the sport psychologist can help the athlete develop and reinforce

3 332 Striegel Hedgpeth, and Sowa the attributions that foster hardiness. If it is necessary to help the athlete understand his or her perceptions, the sport psychologist employs a framework, called Systematic Rationalization (12). Athletes can use this strategy to classify stressful life events based on their personal beliefs of control and their perceptions of the importance of the events in their lives. The process involves the following three steps: (a) identification of stressors related to the injury and the rehabilitation process, (b) classification of these stressors according to personal beliefs (controllable or uncontrollable and important or unimportant), and (c) review of stressors by their classification. Stressors seen as important are priority issues for the athlete and therefore become the focus of the work between the sport psychologist and the athlete. Strategies for working with important concerns are based on the athlete's classification of the particular stressor as controllable or uncontrollable. If an important stressor is viewed by the athlete as controllable, stress management techniques are employed. The perception of controllability suggests that the athlete already recognizes what to do to reduce the stress associated with the event. The sport psychologist then provides guidance to direct the athlete's beliefs into behaviors. To reduce the stress associated with important stressors perceived by the athlete as uncontrollable, the sport psychologist must work with the athlete to change his or her perception of the event. Strategies associated with Rational-Emotive Therapy, cognitive restructuring, or coping skills training often are employed. Athletes are encouraged to shift their perception of the stressor from important to unimportant or from uncontrollable to controllable. Although the use of Systematic Rationalization (12) is not limited by time, after 2 weeks the paradigm for working with the psychological aspects of injury rehabilitation begins to shift: The focus changes from coping to maintaining motivation and compliance. Level 2: Long-Term Rehabilitation (More Than 2 Weeks) As the length of rehabilitation increases, lack of motivation and lack of social support become primary stressors. These stressors may act as barriers to compliance with rehabilitation protocols as an athlete's time away from competition increases. Wiese and Weiss (14) suggest that sport psychologists use goal setting to enhance motivation. Although goal setting is an optional technique in Level 1, goal setting has a primary role in Level 2. Gould (3) described a three-step goalsetting process. The first step is for the athlete, athletic trainer, and sport psychologist to decide on realistic rehabilitation goals. Short-term and long-term goals are needed to provide direction and motivation for the athlete. The sport psychologist and the athletic trainer then help the athlete both formulate a plan for achieving goals and evaluate whether the goals are met. If appropriate, rehabilitation is ended or new goals are established. If goals are not met, the sport psychologist and the athlete discuss barriers that hinder the athlete's success and strategies for overcoming the obstacles. A vehicle for addressing lack of social support while increasing motivation is the use of peer mentors and injury support groups (14). Peer mentor relationships are formed by matching an injured athlete with an athlete who has successfully rehabilitated a similar injury. The sport psychologist and the athletic trainer can facilitate this mentoring by establishing a rehabilitation mentor list and having

4 Differential Psychological Treatment 333 the athlete choose a mentor at the start of rehabilitation. To encourage an ongoing mentor relationship, the sport psychologist and the athletic trainer meet monthly with the mentors to clarify information about the rehabilitation process and to provide additional support. Injury support groups also are used to enhance motivation and provide social support. The sport psychologist and injured athletes meet to discuss psychological issues surrounding the injury, and groups focus on either education or counseling. Educational groups provide information regarding rehabilitation and always include the athletic trainer. The purpose of counseling groups is to reassure athletes that they are not alone in their struggles with injury and rehabilitation; these groups may or may not include athletic trainers. Athletes frequently are defined by and dependent upon their physical skills. Therefore, an injury that results in termination of sport participation often affects feelings of self-confidence and self-worth (7). Athletes whose sports careers have ended are represented in the third level of differential treatment. Level 3: Termination of Participation According to Rotella and Heyman (9), athletic injury that results in termination of sport participation may elicit a grief response similar to the grief response of the terminally ill. Because of this grief response, Kubler-Ross's (5) model of death and dying is most applicable to this group of injured athletes. Kubler-Ross's (5) first stage is one of both denial and isolation. In this case, denial functions as a buffer after the athlete learns of the termination of his or her participation in sport. This defense mechanism allows the athlete time to begin to process the ramifications of the injury. According to Etzel and Ferrante (2), isolation is a major factor when injury occurs since the athlete can no longer participate in the day-to-day activities of sport (e.g., traveling, competing, practicing, conditioning). The athlete now spends time with the athletic trainer in a rehabilitation program. The sport psychologist should encourage the athlete to participate in the rehabilitation process to avoid further isolation, although withdrawal may be a natural part of denial. Kubler-Ross's (5) second stage is anger. Anger may take many forms including rage against others (coaches, teammates, friends, and family), fate, or life in general (7). The sport psychologist should work with the athlete to manage and cope with his or her anger in socially acceptable ways. The sport psychologist should also monitor the athlete for internalized rage that is manifested in selfdestructive behaviors such as drug or alcohol abuse. Kubler-Ross's (5) third stage is one of bargaining, in which the athlete engages in an agreement with a greater power in order to change and control the outcome of the injury (termination of participation in sport). When the athlete realizes that this self-talk process is unsuccessful, the fourth stage, depression, occurs. Kubler-Ross (5) divided the fourth stage into two kinds of depression: reactive and preparatory. Reactive depression occurs as a response to the actual loss; preparatory depression is a reaction to impending losses. Reactive depression can be treated through cognitive restructuring techniques. Essentially, the athlete learns to view injury through a hardiness framework. Preparatory depression is more difficult to address within the training room but leads to the final stage of acceptance. Kiibler-Ross (5) stated that "acceptance

5 334 Striegel, Hedgpeth, and Sowa should not be mistaken for a happy stage. It is almost void of feelings" (p. 113). For athletes, acceptance is a time of transition, a time to change direction and reassess aspects in their lives other than sport. The athlete works with the sport psychologist toward moving into new roles. If the athlete's concerns at this level are beyond the scope of the sport psychologist's training, athletes need to be referred to mental health counselors (for suicide assessment) or career counselors (for vocational interest assessment). Discussion An important aspect of the differential psychological treatment is delineation of the athlete's psychological responses to injury by length and outcome of rehabilitation rather than by application of a particular paradigm (Kiibler-Ross or stress) across all athletic injuries. Treatment is determined by length of rehabilitation, and this distinction begins to define the role of the sport psychologist in the athletic training room. The differential psychological treatment approach allows the sport psychologist to match techniques to the individual athlete and his or her level of injury to enhance the athlete's stress management, motivation, and compliance. The differential treatment approach is consistent with the research of Smith, Scott, and Wiese (1 1) and Smith, Scott, O'Fallon, and Young (lo), who stated that the Kiibler-Ross (5) model is not applicable to all athletic injuries. Smith, Scott, O'Fallon, and Young found that denial was "conspicuously absent from the emotional response of athletes" (p. 48) in their study. These authors (10) also found that the more severe the injury, the more significant the psychological barriers experienced by the athlete. When the severity of the injury results in termination of an athlete's sport career, the differential psychological treatment approach draws upon Kiibler-Ross's stages and integrates the position of Rotella (8) and Rotella and Heyman (9) with that of Smith, Scott, O'Fallon, and Young (10) and Smith, Scott, and Wiese (1 I). Athletic injuries are far too complex to assume that all athletes respond to rehabilitation in similar ways. The differential psychological treatment approach presents a feasible explanation for contradictory literature surrounding the application of the Kiibler-Ross (5) and stress paradigms (6) to the psychological responses of injured athletes. This approach also offers a conceptualization of psychological reactions to injury along with corresponding therapeutic treatment for injured athletes. Therefore, the differential psychological treatment helps the sport psychologist address the needs of the injured athlete. References 1. Ermler, K.L., and C.E. Thomas. Interventions for the alienating effect of injury. Athl. Train. 25: , Etzel, E.F., and A.P. Ferrante. Providing psychological assistance to injured and disabled college student athletes. In Psychological Bases of Sport Injuries, D. Pargman (Ed.). Morgantown, WV: Fitness Information Technology, 1993, pp Gould, D. Goal setting for peak performance. In Applied Sport Psychology: Personal Growth to Peak Performance, J.M. Williams (Ed.). Palo Alto, CA: Mayfield, 1986, pp

6 Differential Psychological Treatment Kobasa, S.C. Stressful life events, personality, and health: An inquiry into hardiness. J. Pers. Social Psych. 37: 1-1 1, Kiibler-Ross, E. On Death and Dying. London: Macmillan, Lazarus, R.S., and S. Folkrnan. Stress, Appraisal, and Coping. New York: Springer, Ogilvie, B.C., and M.A. Howe. Career crisis in sport. In Mental Training for Coaches and Athletes, T. Orlick, J.T. Partington, and J.H. Salmela (Eds.). Ottawa, ON: Sport in Perspective Inc. and Coaching Association of Canada, 1982, pp Rotella, R.J. Psychological care of the injured athlete. In The InjuredAthlete, D. Kulund (Ed.). New York: Lippincott, 1986, pp Rotella, R.J., and S. Heyman. Stress, injury, and the psychological rehabilitation of athletes. In Applied Sport Psychology: Personal Growth to Peak Per3Formance, J.M. Williams (Ed.). Palo Alto, CA: Mayfield, 1986, pp Smith, A.M., S.G. Scott, W.M. O'Fallon, and M.L. Young. Emotional responses of athletes to injury. Mayo Clin. Proc. 65:38-50, Smith, A.M., S.G. Scott, and D.M. Wiese. The psychological effects of sports injuries: Coping. Sports Med. 9: , Sowa, C.J. Understanding clients' perceptions of stress. J. Counseling Development 71: , Weiss, M.R., and R.K. Troxel. Psychology of the injured athlete. Athl. Train. 21: , Wiese, D.M., and M.R. Weiss. Psychological rehabilitation and physical injury: Implications for the sports medicine team. Sport Psychologist 1: , Wiese-Bjornstal, D.M., and A.M. Smith. Counseling strategies for enhanced recovery of injured athletes within a team approach. In Psychological Bases of Sport Injuries, D. Pargman (Ed.). Morgantown, WV: Fitness Information Technology, 1993, pp