Sport psychology has become an academic discipline that is broadly concerned with the relationship between psychological behaviour and sport and exercise (Heil, 1993). It has three related focal areas of study, social issues, health and well-being, and performance enhancement (Taylor & Taylor, 1997). According to Heil (1993) the most focused upon of these three areas is the later, dealing with motivation, leadership, team building, group cohesion, and mental training. Although the initial focus has been on enhancing performance in a healthy athlete, having a growing involvement with the sport psychologist has helped lead to greater understanding of the hazards faced by individuals. Along with eating disorders, over training, and psychological stress, injury is one of the many hazards an athlete may face (Pargman, 2007).
The term sport injury has a number of definitions and probably accounts for some disagreement in reported research findings (Pargman, 2007). Some scholars have emphasised major negative life changes events in their definition (Gould, Udry, Bridges &nBeck, 1997). Lysens, Weerdt, & Nieuwboer, (1991) suggest that in order for an athlete to be termed as injured, there only needs to be a one day limit upon participation. Pargman, (2007)pxviii, defines the term sport injury as “Debilitation resulting in the inability to function as competently as before the occurrence of physical trauma during sport participation”. There is no right or wrong terminology suggested by these scholars however, researchers tend to favour objective and quantifiable guidelines such as the number of days absent from the sport (Pargman, 2007).
Due to rigorous training programs and competitions in which athletes often engage, injuries are a pervasive part of sports participation (Kraus & Conroy, 1984). Regardless of their level of involvement, a vast majority of athletes at some point, will experience an injury that will keep them away from their sport for an unwanted period of time. Fortunately, injured athletes today, as a result of the vast development of surgical and rehabilitative technology, one can expect to reach full physical recovery. However, according to Taylor & Taylor, 1997 despite the potential of full physical recovery and all measurable aspects of the injured area indicate full recovery of stability, strength, flexibility, and stamina, athletes do not often return to their full preinjury level of performance. From reviewing relevant literature, it suggests that psychological factors can have an influence on an athlete’s full overall recovery and prevent them from reaching pre-injury level.
There has been a large amount of research investigating athletes’ psychological responses to and rehabilitation from sports injury over the last ten years (Bianco, 2001). Brewer, 2003 suggested that psychological factors do in fact play an important role in the occurrence of, and the recovery from sports injuries. Podlog & Eklund (2006) state that ‘it has been increasingly recognized that physical and psychological readiness to return to sport after injury are not necessarily synonymous’. An athlete may be physically ready to return to sport but not necessarily psychologically prepared. Clinical reports have indicated that returning athletes tend to have fears about re-injury (Rotella, 1985), and concerns about performing up to pre-injury levels (Crossman, 1997). Taylor & Taylor (1997) have also suggested that athletes feel a sense of alienation from other team mates and coaches. These types of pressures to return back to sport have resulted in the loss of confidence and performance in many athletes. A good example of such pressures are that of Canadian national team skiers that were samples by Bianco (2001). Several members of the team were reported to have prematurely returned back to competition in order to avoid losing their place on the team as a result of the pressure they felt of proving themselves to the coaches. All of these skiers later developed further injuries as a result of their premature return.
According to Evans & Hardy (1999), there have been a number of conceptual models developed that specifically address rehabilitation issues and include both the stress and grief process. These issues have been split into situational and personal factors that may influence an injured athletes thoughts, feelings, behaviours, and rehabilitation outcomes (Wiese-Bjornstal & Smith, 1993). Within these situational factors include injury related variables such as severity and type, treatment-related variables e.g. facilities and time demands, as well as various external influences e.g. life stress and social support (Evans &Hardy (1999). The personal factors include variables such as age along with psychological skills and personality traits. Weiss and Troxel, (1986) suggested the importance of examining personal and situational factors as they are believed to be factors that affect an athlete’s response to injury. They developed a stress process model that was suitable for understanding the sport injury process (Wiese-Bjornstal, Smith, Shaffer, Morrey, 1998). This model of process suggests that sports injury is stress-related and prompts appraisals of the injury situation, which in turn influence emotional responses and have an affect on behavioural responses (Wiese-Bjornstal et.,al, 1998).
Around this time, Pederson and Gordon (1986), put forward that a resulting consequence of sport injury was a grief response and identified a five stage grief reaction response. These consisted of denial, anger, bargaining, depression, and acceptance or recognition. After the initial shock is over, many athlete’s tend to play down their injury and are in denial about its severity. Once they have realised the extent of their injury the denial is often replaced by anger which can vary in intensity depending on both personal and situational factors. This stage is usually followed by the athlete trying to bargain with themselves for example promising to train extra hard in order to recover quicker. When they have realised the reality of the situation an athlete can then sometimes become depressed. The final stage is when the athlete has accepted the injury and is ready to focus on rehabilitation and returning to sport. Gordon (1986) also proposed that sport injury response from a cognitive-behavioural approach needed to be examined. A review of stage-based versus process based model’s carried out by Brewer (1994) stated that cognitive appraisal models seem to hold the greatest understanding of the sport injury process. However, cognitive appraisal models and grief process models are not mutually exclusive. According to Evans and Hardy (1992)p48, “the sense of loss prevalent in sport injury is a type of cognitive appraisal that leads to emotions commonly associated with grief”. Therefore, grief process models can be included by a broader stress process model.
A more broader integrated process stress model that has been developed by Wiese-Bjornstal et al., (1998) concerning grief process models in sport injury and is known as the integrated model of response to injury. This model posits that ” pre-injury and post-injury factors influence psychological response, that psychological response can and does change over time in a dynamic way, and that recovery-both physical and psychological- is the process continuously in the background of the dynamic process, and thus continue to exert their effects throughout”(Wiese-Bjornstal et al., 1998, 48). There are situational and psycholgical factors that are incorporated within this model that continue to exert their effects throughout the dynamic process. There is a bi-directional arrow at the core of the model of which illustrates the dynamic nature of the recovery process. Even though the frequent path that usually takes place is that cognitive appraisals affect emotions, which then follow on to affect behaviours, there are however influences in the reverse direction that can take place. This central core should also be envisioned as a three dimensional spiral, if the injury outcome is looking positive then the spiral will head in an upward direction, or if the recovery outcomes are negative then the spiral will fall in the downward direction (Wiese-Bjornstal et al., 1998).
An injury specific model similar to that of Hardy, Jones, and Gould (1996) “integrated model of response” has been adapted to focus on personality traits as mediators of the athletes psychological response to injury, ones rehabilitation behaviours and the eventual rehabilitation outcomes (Evans & Hardy, 1999). This particular model suggests that there are three processes (e.g. injury related appraisals, percieved stress, and coping tendoncies) all of which to some extent are influenced by personality factors. These three processes, as well as having reciprocal effects on each other, also influence rehabilitation behaviours which then cause an influence in the rehabilitation outcomes. Within the integrated model of response, social support is identified as a coping resource that directly affects injury outcome.
For most of these athletes, their motivation to participate in their sports has come from the social support that they receive. Social support can be helpful back to recovery to full health and according to Bianco and Eklund (2001) it is aimed at inducing a positive outcome and experience. There is a growing body of interest in the literature of social support particularly where sports injury is concerned.
‘Social support is a multi construct that comprises three sub-constructs which represent its structural, functional and perceptual features’ (Bianco & Eklund, 2001). The structural, functional and perceptual features of social support are said to be interdependent and in order to reveal the mechanism that underlie social support/health relationship they must be examined comprehensively. Holt and Hoar’s (2006) conceptual model of the social support demonstrates that there are three dimensions of social support. The first of these is the structural dimension consisting of our social network. These includes aspects such as interactions, social ties, and the people we seek support from. The second dimension concerns the physical affect that is caused by injury and the support that the athlete receives to overcome this. It is known as the functional dimension and the type of support includes informational, instrumental, emotional and esteem. The third dimension is perceptual and concerns what the injured athlete perceives available to them.
According to Freeman and Rees (2008) there are two principle models that explain how social support affects outcomes, otherwise known as the stress buffering model and the main affect model. “A key difference between the two models is the conditions under which support is suggested to be beneficial”p52 (Freeman &Rees, 2008). The main affect is a preventative mechanism as it takes place before the injury happens. The stress-buffering model suggests that social support can decrease stressor’s and buffer the stress felt at the time of injury. Bianco and Eklund (2001) argued that the main affect model is associated with perceived support and that received support is associated with the stress-buffering model. They also suggested that individuals who have a high perceived support will believe that they have the resources to cope with situations, and therefore appraise situations as less stressful leading to more favourable outcomes.
Social support is an interactive process that is influenced by a number of characteristics. These being provider and recipient, the character of the relationship they share, and the sociocultural context in which social support takes place (Bianco & Eklund, 2001). Social support is also driven by instrumental and relational goals and there is evidence to suggest that main effect and buffering effect pathways influence health and well-being.
Taylor and Taylor (1997) state that the role of social support varies among each athlete, this also depends on the sources of support that they receive during the rehabilitation process. It is possible that injured athletes experience uncertainty when they are trying to evaluate their performance outcomes along with their rehabilitation progress. As a result of this Maygar and Duda (2000) suggest that athletes therefore may rely on others in order to help evaluate their current abilities. ‘ in other words, the presence of social support may influence self confidence because supportive significant others become important sources of confidence information for injured athletes’p374 (Maygar and Duda, 2000). It has also been suggested by Maygar and Duda (2000) that athlete’s who perceived that they had more social support at the very beginning of their rehabilitation ‘were utilizing performance sources to restore self-confidence. Along with situational factors, a differing individual factor that may have an influence on confidence restoration is an athlete’s goal orientation. ‘Extensive support for using goal setting as a means to enhance performance can be found within industrial and organizational settings and, to a lesser extent, sport settings’ p310 (Evans and Hardy, 2002). With reference to injury rehabilitation, Duda, Smart, & Tappe (1989) have looked at the relationship of perceived efficacy of the treatment along with the goal orientations to adherence. The results of their research indicated that the athlete’s who believed in the efficacy of the treatment and were more concerned with task-involved goals, it was more likely that they would follow and adhere the correct rehabilitation protocol. Lampton, Lambert, and Yost (1993) determined the relationship of self-esteem and goal orientations to the treatment adherence in a sports medicine clinic. They found that the individuals who missed the most amount of treatment appointments were those who were low in self-esteem and high in ego orientation. Finally, it was suggested that ‘goal orientations and confidence beliefs were expected to to relate to the overall restoration of athlete’s confidence over the course of rehabilitation in the current research’ p375 (Maygar & Duda, 2000).
For many athletes recovering from injury, returning back to sport can be a very difficult process (Bianco 2001). According to Podlog and Eklund (2006), there are no qualitative longitudinal studies found that have examined an athlete’s experiences on return-to-sport. The purpose of Podlog and Eklund (2006) study was to in fact examine the experiences of competitive athletes’ when returning back to sport from a serious injury. The findings from this research indicated that Ryan and Deci (2000) self-determination theory, for coaches and practitioners trying to understand and assist athletes with the return to their sport, may offer a valuable framework in doing so. Ryan and Deci’s (2000) self-determination theory specifically focuses on the effects of varying degrees of self-determination on human behaviour, health and well-being. They believe that an individual’s basic needs of autonomy, competence, and relatedness require fulfilment in order for a person to be self-determined. With reference to autonomy, it is characterized by an internal locus of control. Competence can be seen as an effectiveness that a person engages in. Relatedness is described as a sense of belonging in the social world. When these three basic needs have been satisfied, one is more likely to have increased motivation, personal well-being, and social functioning (Ryan and Deci, 2000). When these basic needs have not been satisfied, one will experience a decrease in the above.
From an self-determination theory perspective, “the success of an athlete’s return to sport from injury may be related to the degree to which the sporting environment meets the psychological needs of that returning athlete” (Podlog & Eklund, 2006, p45). There has been recent research indicating that issues of competence, autonomy and relatedness, for athletes returning from injury are very important. If this is the case, optimal functioning and performance when returning back to sport should be facilitated when the environment meets these needs of competence, autonomy, and relatedness. When athletes make the transition of returning back to sport, this is certainly the type of knowledge that would be useful for coaches and practitioners assisting these athletes (Podlog & Eklund, 2006).
Self-confidence has been widely acclaimed by theorists, practitioners, and researchers as the most critical psychological characteristic that influences sport performance (Vealey, Hayashi, Garner-Holman, & Giacobbi, 1998). The fascination of the above is the influence that the loss of confidence can have on performance. This has also been recognised by Maygar and Duda (2000),who have stated that “an important component related to the psychological recovery of athletic injury is athletes’ cognitive response to injury”p372. There has been research to suggest that one major cognitive response to injury is that the athletes looses confidence/self-efficacy in their beliefs about returning back to full participation of their sport (Shaffer & Morrey, 1998). Athletes must therefore undergo a process that will help to restore their confidence in their abilities prior to returning back to competition. Drawing from the work of Bandura (1990),” efficacy restoration was defined in the current work as the restoration of self-confidence about successfully performing in sport that is to a level where the individual feels confident enough to return to competition following the completion of injury rehabilitation”p373. From looking at the social cognitive theory (Bandura, 1997), it is thought that personal and situational factors have an influence on the sources of confidence that are adopted in the setting of rehabilitation. When looking at the ability in making a successful transition into full participation after the rehabilitation protocol has been terminated, it is suggested that the sources above have an impact on a person’s confidence and impede this transition.
Taylor and Taylor (1997), have stated that confidence is a multidimensional factor and has a significant influence on different aspects of rehabilitation, the impact of rehabilitation right through to the conclusion. In order for confidence to have a positively maximised impact on rehabilitation, each level of confidence needs to be considered, understood, and addressed. These different levels of confidence include, program confidence, adherence confidence, physical confidence, and return to sport confidence.
Program confidence concerns the strong belief in the effectiveness of the rehabilitation program and is the most fundamental level of confidence a patient must develop (Taylor & Taylor, 1997). If patients do not have confidence in their rehabilitation program they will not be able to gain the benefits from the other psychological factors. This will result in them being less motivated, they will experience more anxiety about their injury, and they will also become more focused on the negative aspects of the rehabilitation rather than the positive. Adherence confidence is being able to have the adherence to successfully complete the rehabilitation program. This may be hard for athletes who have never experienced injury before as they as they have no background on which to base this confidence on. Physical confidence is the level of confidence that relates to how the injured athlete believes that their body especially the part that has been injured is able to cope with the stresses of training and competition within their sport (Taylor & Taylor, 1997). Athlete’s physical confidence is constantly being tested throughout the rehabilitation process. In order to be able to see how their bodies can withstand the demands placed on them, athletes are constantly challenging their bodies. Taylor and Taylor, (1997) also state that “if athletes hope to return to sport and surpass their previous levels of performance, they must reinstall their physical confidence” p106. Return to sport confidence is the final type of confidence that athletes need to maintain or re-establish during their rehabilitation. This type of sport confidence in athletes derives from several avenues. The injured athlete must perceive that their rehabilitation process has been successfully completed and that the injury obtained fully healed. They need to believe that there overall level of physical conditioning and that their technical and tactical abilities are to the best they can achieve. Finally, injured athletes must have a positive and patient attitude about their progression from the initial training to right the way through to competition.
From reviewing literature in the area of sport psychology and injury, it is clear to see that there are many different opinions as to what and why affects a persons psychological state as a result of sustaining injury. There is a need for much further research concerning this topic area and sport psychologists continue to work with injured athletes in order to better to understand what they are going through. This will help athletes to obtain a quicker and more successful recovery with their return from injury.