The psychology of sports is a complex field and a profession all to itself; we attempt here to present some basic concepts to benefit our athletes as well as their parents, coaches, teammates, etc. For many youth and collegiate athletes, a significant part of their personal identity is based on sports participation. Any removal from participation can have impacts on more than just the “athletic” part of life; when you sustain an injury that removes you from sport, whether for a short or a long period of time, you are likely to encounter psychological sequelae that can range from healthy “coping strategies” to dysfunctional or even dangerous behavior. It may be helpful for you and those closest to you (parents, coaches, friends and teammates) to be aware of the differences between these healthy responses and potentially problematic behaviors – particularly in cases when referral to a sport psychologist or counselor may be recommended.
Normal Response
You may wonder how to qualify a psychological response as normal, or how to know when it verges on unhealthy. Several conceptual models are available to reference for understanding different responses. The “Stage Model” is well known and outlines possible “reactions” to injury; however, the steps (or progressions) of this model do not identify differences between individuals and the circumstances surrounding the injury. The “Cognitive Model” may better identify anticipated responses by highlighting situational and personal factors that will influence your predicted response in each “stage”. The table below is helpful in presenting this:
| STAGE MODEL | COGNITIVE MODEL | |
| Personal Factors | Situational Factors | |
| Denial | Trait Anxiety | Time of Season |
| Anger | Self-Esteem | Pain |
| Bargaining | Motivation | Social Pressure |
| Depression | Coping Skills | Type of Sport |
| Acceptance | Extrovert/Introvert Psychological Investment in Sport Injury History | Degree of Impairment Duration of Injury |
Clinical, or Sub-Optimal Response Signs of poor response are listed below; it is necessary to recognize signs of negative response and to address them early in the rehabilitation phase as continued pessimism can slow the healing process and produce sub-optimal outcomes.
| Normal Response | Clinical or Sub-Optimal Response |
| Isolation | Withdrawal from team, coaches, friends, etc. |
| Frustration/Imitation/Moodiness | Rapid mood swings |
| Mild appetite changes | Rapid weight fluctuation |
| Sadness | Depression, Extreme display of emotion (frequent crying) |
| Temporary alterations in motivation | Apathy to recovery |
| Minor Sleep disturbances | Insomnia |
| Anger | Extreme display of emotion(rage) |
| Initial Denial | Minimizing severity of injury, Obsessed with return to sport on accelerated time line |
| Mild Anxiety | Exaggerated bragging |
Is your athlete having an appropriate response to injury? Questions to ask in the recovery process to determine whether psychological perspective is positive:
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Positive vs Negative Think: The Mental Effect on Recovery Recovery from injury is affected by multiple life variables; personal factors (pain tolerance, self-assurance, goal perspective, assertiveness, motivation), situational factors (faith in rehab environment, support system, scheduling issues), and psychological factors (emotional reaction to loss, coping skills) will all come into play during the healing process. Your mental approach can have a substantial effect on the rate of healing and ultimately the extent to which you recover. Multiple studies have shown that athletes who are motivated and take an active role in their recovery, who look positively toward the future rather than the past, are more likely to progress through the rehabilitation process quickly. When to refer An athlete’s social support system is important in creating a healthy psychological environment; however, even with a proper support system in place, severe injury and/or prolonged recovery can present major emotional obstacles. When any of the above clinical or sub-optimal responses are observed, referral to a sport/adolescent psychologist or counselor may be recommended. In situations where the injured athlete is at risk for extreme depression, withdrawal, insomnia, rage, and eating disorders, sports/adolescent psychologists are best equipped to provide the athlete with tools to help cope efficiently with their perceived obstacles.
RED FLAGS FOR IMMEDIATE REFERRAL INCLUDE:
- depression for an extended period of time
- extreme loss of interest
- complaints of difficulty sleeping
- reported changes in eating patterns
- ANY MENTION OF SUICIDE OR SUICIDAL THOUGHTS
Role of Social Support System Having a strong social support system, which consists of family, coaches, teammates, friends, etc., is integral in providing emotional support throughout the recovery process. Research has shown that the higher the support level, the lower the risk of injury, and in the event that an injury does happen, this support system acts to minimize recovery time and maximize outcomes of rehabilitation by: listening impartially, making the athlete feel cared for and supported, and keeping emotions in check. ATHLETES WHO FEEL THEY ARE SUPPORTED BY THEIR TEAMMATES, FAMILY, AND FRIENDS TEND TO DO MUCH BETTER PSYCHOLOGICALLY AND RETURN FASTER TO THEIR SPORT. Parents/Family/Friends This subgroup of the social support system is most often relied upon for giving emotional support to the athlete, providing a sense of optimism, and, when possible, to celebrate the successes. Parents, especially, often know the athlete better than anyone and are best equipped to identify emotional and behavioral changes following injury. This group should be the first to notice “red flags” suggesting the need for a referral. Coaches/Teammates Athletes tend to look to coaches and teammates for technical support, including affirmation that they are taking the proper actions physically; because of this it is imperative that coaches are realistic about injuries and are cautious about creating any expectations surrounding the athlete’s return. This does not mean that the coach should project pessimism! Coaches can encourage the athletes to attend all practices, games, and team events – assuring them that they are still a member of the team and helping to reduce the feeling of isolation and avoid additional withdrawal. Physical Therapist/Athletic Trainer (PT/ATC) Physical therapists and athletic trainers working with athletes take care of more than just the physical symptoms of injury, they may also be a resource to care for the athlete’s psychological and emotional health. Essential to this is a relationship built on trust and open communication; an athlete must be actively involved and vested in the rehabilitative process for optimal outcomes. A welcome and supportive environment is most conducive to recovery. Through the rehabilitation process, your physical therapists/athletic trainers will seek to incorporate cognitive approaches to keep the mind “healthy” and engaged to ensure you are in an optimal position for healing. Such approaches may include:
- IMAGERY
- GOAL SETTING
- POSITIVE SELF-TALK
- NEGATIVE THOUGHT STOPPING
- THOUGHT REPLACEMENT
What the athlete can do Your lifestyle can greatly impact recovery. Keeping the body as overall healthy as possible creates a healing environment; appropriate diet and sleep are necessary to provide the energy that the body needs for recovery. Your PT/ATC can be a good resource for activity modifications, in some situations allowing you to maintain conditioning levels and/or remain involved in sport activities even if at a modified level. Caloric requirements are going to change with decreases in sport participation and the PT/ATC can advise nutritional adjustments that will create a healthy environment for healing – avoiding unhealthy caloric restriction. The most important approach for an injured athlete to take when facing recovery is for you to be actively engaged in the rehab process. This can be accomplished by keeping the lines of communication open with the social support system and the therapist(s). Talking is associated with improved recovery, as demonstrated in a 2012 research review, “Effectiveness of psychological intervention following sport injury.” To talk through the injury, begin by first identifying the support person(s) with whom you are comfortable talking about the injury and your feelings/outlook toward recovery. This action will help limit feelings of isolation, frustration, and anxiety. You may also utilize therapeutic imagery to aide healing, supplement the rehabilitation process, and eventually affect performance. In studies of mental imagery sessions, in which the athlete visualizes an object, action, or sensation, circulation increased in areas of the body on which the athlete specifically concentrated. Skill imagery, in which the athlete visualizes certain skills, can be integrated by attending as many games and practices as possible and visualizing being on the field performing specific tasks. This can be done by observing skilled players and by making note of others’ mistakes and visualizing “fixes” to those. Dramatic improvement in skill development and performance can be experienced from mental imagery alone. Attitude plays a significant role in both predisposing an athlete to injury (or re-injury) and ability to recover from injury efficiently. Positive attitude is directly correlated to positive performance, just as negativity is associated with poor performance (negativity → anxiety → impaired performance). Your attitude can be affected by past and present experiences as well as your perceived future in sports. Maintaining a positive mental approach and minimizing unhealthy pressure applied by parents, players, and coaches is paramount during the rehabilitation process. Positive Mental Attitude Links Addressing the impact of keeping a positive attitude, this video of Lissa Rankin, MD, highlights the mind’s ability to mobilize our internal mechanisms for healing as demonstrated in the Spontaneous Remission Project. In the following talk by Shawn Anchor, educator, author, and speaker, he speaks to the importance of happiness and how positivity affects performance. Through his research at Harvard University he has identified that intelligence, creativity, and energy levels all rise in an environment of positivity. He describes these results as the Happiness Advantage. Return to Play Decision Making Factors As you physically near the end of your recovery phase and are preparing to return to play, it is essential to also ensure you are psychologically ready to return to play. Signs that you may not be ready to return to play include lack of confidence/doubting skill level, significant anxiety/apprehension/fear of re-injury, and abnormal complaints of pain inconsistent with injury. In preparation for return to play, the keys to mental readiness include:
- Appropriate progression of rehab including high level agility and sport-specific training.
- Positive affirmation/positive attitude regarding injury, recovery, and future sports participation.
- An intrinsic motivation/desire to return to sport.
There are a handful of validated scales and questionnaires that offer objective measurement for determining an athlete’s psychological status as it relates to sport. One specific scale, the Injury-Psychological Readiness to Return to Sport Scale (I-PRRS), consists of 6 questions which you rate on a scale of 0-100. Once completed, the clinician adds all scores together and divides by 10. It is well supported that a grade of at least 50-60 indicates readiness to return, while a score under 50 suggests that you may need more recovery time and additional emphasis on your psychological well-being.
Injury-Psychological Readiness to Return to Sport Scale (I-PRRS)Please rate your confidence to return to your sport on a scale of 0-100.
0 = no confidence at all
50 = moderate confidence
100 = complete confidence
1. My overall confidence to play is ____.
2. My confidence to play without pain is ____.
3. My confidence to give 100% effort is ____.
4. My confidence to not concentrate on the injury is ____.
5. My confidence in the injured body part to handle demands of the situation is ____.
6. My confidence in my skill level/ability is ____.
Total: _____
Total divided by 10: _____
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