Injury and Depression: What Every Coach & Sports Medicine Specialist Should Know
Many people look up to and aspire towards the world’s greatest athletes and at times they can be perceived as having the perfect life; getting to play the sport they love for a living, in the public eye earning respect and adoration and for the elite few, earning large amounts of money. However as those people on the inside of sport will know, the reality can often be quite different.
A more realistic picture might look something like this; spending large periods of time away from home, constantly living out of a suitcase; limited time to spend with family and friends; social life taking a back seat, consistently under pressure to perform, trying to prove yourself day in day out, pressure to ensure contracts are renewed, pushing your body to its physical and mental limits, battling with injuries and pressure to return to the field as quickly as possible. That said I’m sure most athletes wouldn’t change it for the world.
We can all think of examples in the past few years of sports people who have battled with the mental side of life including the likes of Serena Williams, Frank Bruno, Dame Kelly Holmes, Marcus Trescothick and most recently Michael Yardy. And in recent times there have also been the absolutely tragic stories of athletes who have taken their own lives, including Denver Bronco’s Kenny McKinley at the age of 23. Yet people still seem to be under the impression that sports stars are immune from mental health battles.
Depression is an area of mental health that has arguably gained the most attention in recent times especially in relation to athletes. There are a variety of reasons why an athlete may battle with depression, but this article will focus on the vulnerability to depression as a result of an injury.
The role of a Sport Psychologist in relation to injury is two-fold. Firstly, working with athletes to help prevent injury and secondly working with injured athletes to help them deal with the psychological affects of injury. The former may surprise some people but the biggest area of psychological research into injury has focused on the antecedents to athletic injury. We now have a comprehensive understanding of the psychological factors and underlying mechanisms which influence the risk of injury. Therefore applied sport psychologists can work with these factors to try and reduce their influence. Whilst it is beyond the scope of this article to develop this line of thinking further, as a top line insight, psychosocial factors include personality, history of stressors and coping resources whilst stress responses mediate the relationship between these factors and injury. In one soccer based study, players who were psychologically screened and consequently identified as being at high risk of incurring injuries were then split into two groups, with one group receiving training around 6 mental skills (including stress management, relaxation skills and confidence training) whilst the other acted as a control group. Over the 19 week competitive season, the intervention significantly lowered the number of injuries.
Getting injured is naturally a cause for concern for any athlete and their club or country they represent and thankfully the physical rehabilitation for athletes is often outstanding. However, is the psychological rehabilitation given the same recognition, credence and respect? You often hear managers, coaches, sports physicians and the like talking about the mental side of injury, especially in relation to athletes’ confidence to return to action. Yet, are they actually doing something about it? Talking and awareness is a start but intervention is imperative.
Athletes can experience a range of emotional responses to injury including anger frustration, fear of the unknown, confusion, depression and tension. One area in particular that influences the potential for emotional disturbance is that of athletic identity, which I discussed in a previous article. This is the degree to which an athlete identifies with the role of an athlete and the stronger the sense of identity the greater the risk for emotional difficulties such as post-injury depression. This is because injury represents a threat to self-esteem and a potential loss of identity.
So moving more specifically onto that area of depression, what exactly is it? Well depression in a clinical sense is an emotional state, characterised by feelings of great sadness and worthlessness. We have all at some time or other experienced a depressive mood and the word ‘depression’ is one that has leaked into everyday language. On the one hand this can be seen as a positive since it is a word that is more accepted now than it ever has been before, however on the other hand, clinical depression is markedly different to a depressed mood. The DSM-IV-TR criteria for clinical depression is a “sad, depressed mood, most of the day, nearly every day for two weeks, or loss of interest and pleasure in usual activities plus at least 4 other symptoms from an extensive list which includes difficulties in sleeping (insomnia); not falling asleep initially; not returning to sleep after awakening in the middle of the night, and early morning awakenings; or in some cases, a desire to sleep a great deal of the time; negative self-concept, self-reproach and self-blame and recurring thoughts of death or suicide.
Over the years there have been many theories of depression, including both psychological theories such as Beck’s theory of depression, which revolves around the central premise that individuals become depressed as a result of their thinking being biased towards negative interpretations (negative schema), and biological theories evolving around two key neurotransmitters (chemical messengers that enable our brain and nervous system to communicate) serotonin and norepinephrine. There is general consensus that it is most likely an interaction between the two with predisposed vulnerabilities due to genetic or schematic factors triggered by stressful life events, of which an athletic injury would be one example. Therefore if we do not take the psychological rehabilitation of our athletes seriously, then we could be allowing them to fall into a very dangerous trap.
Involving a psychologist in the rehabilitation process of an injured athlete is therefore highly recommended and I would argue essential. The key to this is strong working relationships between all science and medicine staff and indeed coaching staff. The role of a physiotherapist (PT in USA) is particularly important because athletes will often emotionally open up to these practitioners due to the tactile and physical nature of their role. Naturally there will be athlete confidentiality issues at play, however if handled sensitively at the start of the rehabilitation process, there should be a case conference with all staff and the athlete where it is agreed upon that information will be shared freely between all appropriate practitioners with the aim of ensuring the athlete the best possible rehabilitation process. That said, the athlete could of course not agree to this in the first place, or indeed at any time decide that they would like certain information not to be shared and that is of course the athlete’s right, unless he or she is deemed to be at risk of harm and then that right is waivered.
It is likely that out of all science and medicine staff, physiotherapists and strength and conditioning/strength and rehabilitation coaches will have the most contact with an injured athlete and therefore, serve as the eyes and ears for the rest of the medical team. Types of information/feedback that a psychologist in particular would be interested in is whether the athlete is adhering to their rehab programme or indeed over/under-adhering, any differences in mood as time goes on, any behaviour that is out of character for the athlete, any information regarding the athlete’s sleep patterns (e.g. reportedly broken sleep, inability to get to sleep), any significant changes in energy levels (elevated or lowered); insight into any changes in appetite or weight (increases or decreases); complaints of difficulty in concentrating and indecisiveness or indeed behavioural observations of this and observations of distinctly negative self talk, self-blame, self-loathing, and negative thoughts towards the future.
It is obviously not the responsibility of these specialized practitioners to make diagnoses of depression, rather a sport psychologist would likely involve a clinical psychologist or psychiatrist to assist in assessing the severity of the symptoms. Just the same, it is their responsibility to share and facilitate the proper channeling of information. Hence, the key proviso is that this team has been set up correctly from the outset.
Indeed, this process works both ways. It is also important for the psychologist to be sharing information back again; ensuring other practitioners are aware of the work that is going on on the psychological side and encouraging these practitioners to reinforce key messages (where appropriate).
Of the greatest importance is the fact that the athlete is of course central to this process. Secret conversations going on behind the athletes back is unacceptable, however, the medical team needs to recognise that some athletes may not be able to recognise for themselves what is happening. Therefore, it is the responsibility of the support team around the athlete to help interpret and provide goals, encouragement, realistic time-lines, motivation, and direct assistance so as to maximize teamwork and the overall efficacy of the rehabilitative process. Strong relationships, open communication and the involvement of not only physical rehabilitation but also psychological rehabilitation will help to ensure our athletes are looked after to the best degree possible…for everyone has the same goal to help that athlete get back on the field – fully fit – both mentally and physically.
Rebecca Symes is a Chartered Sport Psychologist running a successful consultancy Sporting Success. She works with a range of clients including Surrey County Cricket Club Academy, GB Archery (Paralympic Squad), London Athletics Academy, international youth kickboxers and professional mixed martial arts (MMA) athletes. Rebecca is also part of the psychology team working on the England and Wales Cricket Board (ECB) Elite Player Talent Identification Programme, which is a national programme aimed at establishing the best talent at U13, U16 and U19. Previously, Rebecca has worked with individual competitors in international laser sailing and air pistol shooting. In addition she is currently an associate Performance Coach for K2 Performance Systems helping the corporate world to prepare and perform like elite athletes.
Come See Rebecca Do a Live Clinic: http://www.locker27.com/blog/insight-into-sports-psychology/
Brewer, B.W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of applied sport psychology, 6, 87-100
Brewer, B.W. (2001) Psychology of sport injury rehabilitation. In In R.N. Singer, H.A. Hausenblas & C. Janelle (Eds). Handbook of Sport Psychology. (2nd Ed. Ch. 31. pp 787-809). John Wiley & Sons: New York
Cox, R.H. (2007). The psychology of athletic injuries. In Cox, R.H. Sport Psychology: Concepts and Applications (6th Ed. Ch. 18, pp. 443-462). McGraw-Hill
Granito, V.J. (2001). Athletic injury experience: A qualitative focus group approach. Journal of Sport Behaviour, 24(1), 63-82
Horn. T.S. (2008). Athletic Injury and Sport Behaviour. In Horn, T.S. (Ed.). Advances in sport Psychology. (Ch. 17. pp. 402-422).
Johnson, U., Ekengren, J. and Andersen, M.B. (2005) ‘Injury prevention in Sweden: helping soccer players at risk’, Journal of Sport and Exercise Psychology, vol. 27, no. 1, pp. 32–8.
Lavallee, D. & Flint, F. (1996). The relationship of stress, competitive anxiety, mood state and social support to athletic injury. Journal of Athletic Training, 31, 296-299
Nasco, S.A. & Webb, W.M. (2006). Toward an extended measure of athletic identity: The inclusion of public and private dimensions. Journal of Sport and Exercise Psychology, 28, 434-453
Petrie, T.A. & Perna, F. (2004). Psychology of injury: Theory, Research and Practice. In . In Morris, T. & Summers, J. (Eds), Sport Psychology: Theory, Applications and Issues (pp. 547-571). John Wiley & Sons: Australia
Rees, T. & Hardy, L. (2000). An investigation of the social support experiences of high-level sports performers. The Sport Psychologist, 14, 327-347
Smith, A.M. (1996). Psychological impact of injuries in athletes. Sports Medicine, 22(6), 391-405
Wiese-Bjornstal, D., Smith, A., Schaffer, S. & Morrey, M. (1998). An integrated model of response to sport injury. Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10, 46-69
Williams, J.M., Hogan, T.D., & Anderson, M.B. (1993). Positive states of mind and athletic injury risk. Psychosomatic Medicine, 55, 468-472