Psychological Factors in Long-Distance Runner’s Injury and Sport Counseling

When runners, or athletes in general, experience injury, the primary focus of rehabilitation and recovery is the physical condition of a person. However, it is also important to consider the psychological factors involved in the injury as well as in recovery.

Physical injury is not exclusive to somatic repercussions, but also affects an athlete mentally and emotionally. Cognitive and emotional processes involved in high performance, achievement, and success can be significantly affected by physical athletic injury. 

Professionals involved in the rehabilitation and recovery process of runners and other athletes must have the knowledge and expertise not just in handling the physical recovery of injured athletes but also the mental and emotional recovery of athletes. The role of sport psychologists and counselors are important in determining the different techniques necessary to understand the mental and emotional conditions of injured athletes. Why are the psychological factors involved in athletic injury important? 

A study conducted by Smith and Millner (1994) explored the relationship between athletic injury and suicide. They found that athletes experience extreme depression to the extent of attempting suicide after sustaining an injury.  Other feelings involved in athletic injury include, but are not limited to, fear, frustration, depression, anger, and confusion (Bianco, Malo, & Orlick, 1999; Gordon & Lidgren, 1990; Johnston & Carroll, 1998; Sparkes, 1998; Urdy, Gould, Bridges, & Beck, 1997). In this paper, the psychological factors involved and the effects of the injury incurred by a runner will be discussed as well as the type of rehabilitative counseling appropriate for the runner’s physical and mental condition as well as personality.

Psychological Factors in Runner’s Injury
When determining the causes and predictors of athletic injury among runners, several factors are to be considered such as the personality of the runner, history of stressors, coping resources available to the runner, and type of interventions. Personality factors include hardiness, locus of control, sense of coherence, competitive trait anxiety, and intrinsic motivation. Stressors involve stressful life events, daily stressors, and previous injury. Coping resources available to the runner include general coping behavior, social support, stress management techniques, attentional strategy, and prescribed or self-prescribed medication (Cox, 2011). 

Some of the cognitive strategies utilized by elite and marathon runners is association and dissociation, or attention strategies. Attention strategy is a form of cognitive strategy that is related to association and dissociation. When association is used as a cognitive strategy, an individual is attending to his/her body’s internal related cues  such as breathing and muscle tension (Morgan, 1980) and/or external performance information such as distance completed, time, race position, and pace (Scott, Scott, Bedic, & Dowd, 1999; Schomer, 1987). Association is when the primary focus of the runner is the task at hand only. Dissociation, another cognitive strategy, is when a runner focuses on external cues such as listening to music, focusing on the environment, imagining pleasant situations, talking to others, or ways for a person to ignore internal sensory input that can cause discomfort (Tammen, 1996; Schomer, 1987). In identifying which strategy works, Morgan and Pollock (1977, 1978) noted that elite runners prefer association over dissociation mode of attention because association allowed them to better monitor their bodily sensations and resulted in more optimal task performance by helping runners relax.  However, Morgan (1981) also noted that elite runners may shift between association and dissociation strategies during races. When Tammen (1996) studied elite and long distance runners, he found that when running intensity increased, the use of  associative cognition increased as well. Schomer (1986, 1987) found that faster performance is related to body monitoring, considered a form of associative cognition strategy. A study conducted by Masters and Ogles (1998) suggest that dissociation does not appear to increase the risk of injury, while association may lead to increased risk of injury due to continuation of performance despite painful sensory input. Said findings were supported by a previous study conducted by Brewer, Van Raalte, and Linder (1996) that showed injured runners scoring higher on association scores and dissociation was not related to injury. Masters and Ogles (1998) argued the use of dissociation as a training technique because it may improve adherence and increase the self-reinforcing properties of the run without sacrificing safety. Why does the higher use of association strategy a predictor of injury? Runners who use more associative cognitive strategies are mostly goal-oriented and highly competitive. The opposite can be found in dissociating runners with slower race times, lower competition and lower goal-oriented motivation (Masters & Ogles, 1998).

Psychological factors involved in athletic injury were primarily attributed to stress (Williams & Anderson, 1998). Various life events can be considered life stressors, depending on how a person perceives each situation. For example, promotion, getting married, or having a baby seem to be life changes that bring positive thoughts and feelings. However, for some individuals, these events may cause stress and increase anxiety, therefore, may affect focus as well as somatic sensory inputs in athletes. Personality type is also considered a contributing psychological factor to athletic injury. According to Ford (1980), Type A and Type B personalities are most susceptible to the negative effects of various life stressors. The ABC’s of personality defines Type A’s as people who are often seen as aggressive, hard driving, ruled by the clock and obsessed with accomplishing more than time will allow. Type B’s are people who are classified as easygoing, calm, optimistic, and moderate. Type C’s are people who are viewed as dependent, sweet, passive, gentle, and nice. However, internally they are usually resentful, unforgiving, worried, anxious, bored, frustrated, and apathetic. Type C’s often feel helpless, useless, and unworthy, and tend to experience excessive guilt and despair (Ford, 1981). In relation to attention strategy employed by runners, Type A’s are more inclined to associative cognitive strategy while Type B’s use dissociation more often.  Type C’s, on the other hand, may use an injury as an excuse to poor performance. 

Other factors were identified by Stephan et al (2008) that make other runners susceptible to injury. First, runners who have been previously injured from running expressed higher feelings of susceptibility to re-injury. Second, runners who scored high in neuroticism reported a greater number of somatic complaints and displayed an exaggerated interpretation of somatic sensations (Costa & McCrae, 1985), making neuroticism as a positive predictor of susceptibility to running-related injury. Lastly, obsessive passion was positively related to perceived susceptibility to injury. The more individuals are obsessively passionate, the more they engage in risky behaviors (Vallerand et al., 2003). 

Finally, the sociological culture of sport also influences athletes’ response to injury. Sport ethic, in particular, normalizes pain and injury as well as encourages the value of continuing performance regardless of pain and injury. This type of orientation affects athletes’ perception and response to pain and injury and usually to the athlete’s disadvantage (Weinberg & Gould, 2015).  When Messner (1992) interviewed male athletes, he identified external pressure and threats to masculinity as primary reasons for injury. Also, Frey (1991) discussed the “culture of risk” in sport that pain and injuries are “part of the game” and prompts athletes to regard physical risk as a reasonable choice.


Sport Therapy, Rehabilitation and Counseling
When dealing with an injured runner, several factors must be considered when developing a rehabilitation program such as the runner’s response to injury and rehabilitation, cognitive and emotional response to injury, behavioral response to injury, adherence to injury rehabilitation, coping and intervention, and pain management (Cox, 2011). Some of the emotional responses of injured athletes include fear of the unknown; feelings of tension, anger and depression; frustration and boredom; negative attitude; and grief related to injury. In terms of cognitive appraisal, the injured athlete’s perception of his/her self-worth and self-esteem  after an injury, are important areas to recognize. Pain management, on the other hand, is associated with a person’s way of handling physical pain. Pain tolerance, considered a personal characteristic, must be considered during rehabilitation. Experiencing pain, both from performance and injury, can be subjective. One athlete’s experience of pain can be different from another athlete regardless of the similarity of the source or cause of the pain. Managing and handling pain is also different among athletes, as one athlete may use pain as a form of motivation to continue (i.e. Type A personality), while another athlete may see pain as a sign to decrease performance (i.e. Type C personality). Furthermore, recovering from injury also varies among athletes. One athlete may recover quicker compared to another athlete.  Some researchers reported that pain behavior can be associated with a person’s self-efficacy or that person’s confidence in their ability in controlling pain (cf. Keefe, Rumble, Scipio, Giordano, & Perri, 2004, for a review). Other factors must also be considered when determining the time required or needed for an injured runner to recover or why adjustment to injury can be difficult to some athletes. Petitpas and Danish (1995) listed some symptoms and warning signs that determine poor adjustment to injury: feelings of anger or confusion; obsession with the question of when he or she can return to exercise; denial; a pattern of repeatedly coming back too soon and experiencing re-injury; exaggerated bragging about past accomplishments; the habit of dwelling on minor physical complaints; guilt about letting the team down; withdrawal from significant others;  rapid mood swings; negative statements about impossibility of recovery regardless of effort. 

According to several researchers, psychological skills including goal-setting; positive self-talk; imagery or visualization; and relaxation training, are important for athletes to learn during rehabilitation from injury (Hardy & Crce, 1990; Petitpas & Danish, 1995; Wiese & Weiss, 1987). Other counseling techniques also include pain management; arousal control  and anxiety management; confidence and assertiveness training; focus and attention strategies; cognitive restructuring; and social support (Brewer, Jeffers, Petitpas, & Van Raalte, 1994; Carroll, 1994; Fisher & Landers, 1983; Gordon & Lidgren, 1990; Ievleva & Orlick, 1991; Lamott & Petlichkoff, 1990; Larson & Zaichkowsky, 1996; Wiese, Weiss & Yukelson, 1991). A study conducted by Schwab Reese et al. (2012) explored the effectiveness of psychological intervention following sport injury and found that guided/imagery relaxation was shown to be associated with  improved psychological coping and reduced re-injury anxiety, while goal-setting was not directly associated with reduction of negative psychological consequences. Furthermore, their results suggest that other psychological techniques such as micro-counseling skills, acceptance and commitment therapy, and written disclosure were also effective (Schwab Reese, Pittsinger, & Yang, 2012).

In developing a rehabilitation and recovery program for an injured runner, cognitive behavior therapy (CBT) can be the primary technique to be used since athletic injury may cause depression and anxiety. This is inline with CBT being considered as the “first line treatment” in most stress-, trauma-, fear-, and anxiety-based disorders (Freedman & Duckworth, 2012). First, it is important to recognize the personality type of the athlete (runner). As discussed in this paper, the personality type of the  runner will be identified based on the ABC’s of personality and the  Big 5 personality traits. Personality factors will help determine the appropriate rehabilitation and recovery program for an athlete. For example, if the runner is a Type A, the person may score low on openness to experience; score high on conscientiousness; and score high on neuroticism. When it comes to extraversion, a Type A personality may score high on factors involved in self-presentation. Martin Ginis and Leary (2004), for example, suggested that self-presentational concerns in sport and physical activity may result in health-damaging behaviors. They also suggested that sport culture emphasizes toughness or training and competing while in pain or injured. Other studies reported that running injury are caused by inappropriate volume and intensity in training as well as overuse (Benson, 1994, 2003; Glover & Schuder, 1988; Wilder & Sethi, 2004).

One of the reasons why CBT is an appropriate type of therapy is because of  the need to manage the pain involved in injury, both physical and psychological. Rehabilitation adherence is also influenced by an athlete’s pain perception and tolerance. For runners who have low tolerance to pain may also have low beliefs in the efficacy of any recovery program. This notion can be supported by various research conducted to explore the relation of self-efficacy and pain tolerance to adherence in the field of medicine, particularly recovery from illnesses and surgery (i.e. Stewart et al., 2003; Toshima, Kaplan, & Ries, 1992). Goal setting and progress recording is also an important part of the program. Progress recording may involve video recording and consistent charting of the runner’s physical progress. This provides the runner a concrete evaluation of his/her recovery. This process also enhances the runner’s self-esteem and self-efficacy when it comes to his/her ability to recover. Goals can be set based on the current level of progress of the athlete and the athlete should be actively involved in setting his/her own recovery goals. Knowing and understanding one’s current level of physical progress may also help the runner not to overwork one’s self, therefore, avoiding further injury as well as decline to one’s self-confidence and self-efficacy. 

In using imagery, positive self-talk and relaxation, changing a runner’s perception and behavior towards re-injury and healing is important. Re-injury causes psychological distress on injured athletes increasing levels of anxiety and negative thinking. With imagery, the sense of control in an injured athlete is being revived. It may be important to employ associative thinking in this situation, allowing the athlete to pay close attention to his/her physical, emotional, and behavioral responses to his/her current condition and factors that can help in his/her recovery. From awareness, an athlete would be able to recognize what he can or cannot do at the moment. Another concept associated with awareness is the focus on the “here and now” or the present. Mindfulness is a good skill to share to an athlete recovering from injury. Instead of focusing on the past — what caused the injury, the athlete must focus on the present — how to recover from the injury. Goals and timelines are important but focusing on what can be done next or in the future may only cause further anxiety over the length of recovery. After an athlete begins to accept his/her current condition, he/she can be guided to envision him/herself recovered from the injury. Positive imagery with an emphasis on mindfulness should be applied.  It may be helpful to remind injured athletes of how they’ve been utilizing mental imagery to enhance their performance and achieve their goals. Recovering from an injury is no different. Their goal is to recover and return to performing and competing like the injury didn’t occur. It is not a process of forgetting and disregarding the experience but a more positive thought process eliminating perceptions of re-injury. Relaxation can help with positive mental imagery among recovering injured athletes. To decrease anxiety caused by perceptions of susceptibility to re-injury, relaxation is an important skill to be learned. After all, anxiety sends somatic sensory inputs causing muscular tension, heavy breathing, increased heart rate and blood pressure that can impair an athlete’s physical state and performance. Relaxation, imagery and mindfulness techniques — can also be considered as parts of stress and anxiety management techniques — can benefit runners recovering from injuries not just during rehabilitation but also in their future performances. Positive self-talk, on the other hand, would help runners intrinsically motivate themselves from recovering. For example, a runner who scored high on neuroticism may subject him/herself more to negative thinking and responds more poorly to stressors than the average. It is important to promote positive self-talk to runners with this type of personality because an injury and being unable to perform or compete can be a source of anxiety, depression, and anger to said types of athletes. When encouraging positive self-talk, it may be helpful to allow the injured athlete to write a journal of how he/she feels during the entire recovery process. The journal can be used as a guide in reprogramming the athlete’s perception of his/her condition and progress. The journal can also be used as a guide in planning coping techniques if faced by situations of similar, less, or increased gravity. Furthermore, journaling is encouraged to CBT participants and patients because it can help monitor thoughts and feelings that can be debilitating to a person’s recovery.

Finally, it is important to inform the recovering athlete of any possible setbacks they may experience as part of the rehabilitation process. It is common and an important part of the healing process, therefore, should not worry or frustrate the athlete. Setbacks are valuable and  may serve as signal and guide to the athlete’s recovery progress. Sport psychologists can partner with physical therapists in informing athletes of their physical recovery. When it comes to working with other individuals in the rehabilitation and recovery of an injured athlete, social support is also a key component. Support and positive feedback from significant individuals (e.g. family members, friends, coaches, teammates, therapist) in an athlete’s life is as important as the intrinsic motivation of the athlete to recover.  Studies have shown that social support facilitates injury recovery, particularly those that provide emotional support (Williams & Andersen, 2007; Kolt, 2000; Magyar & Duda, 2000). Since injury may cause athletes to experience various emotions such as fear, hopelessness, anxiety, decreased self-esteem, guilt, and lack of self-efficacy, some studies explored and found a positive relationship between social support and treatment adherence, restoration of confidence, distress relief, increase in motivation, and an increased recovery rate for injured athletes (Biano, 2001; Duda & Smart, 1989; Fisher & Domm, 1988). According to Hardy, Burke and Crace (2001), emotional support must be provided through active and empathic listening, demonstration of trustworthiness and understanding, and creation of an accepting and open environment. They also categorized social support into subtypes: emotional support (listening support, emotional comfort, emotional challenge); informational support (reality confirmation, task appreciation, task challenge); and tangible support (material assistance through rewards and personal assistance in the form of time, expertise and knowledge to help with accomplishments).



Conclusion
Athletic injury can be very difficult to go through most especially to people whose daily activities involved training and conditioning one’s mental, emotional, and physical strength for competition and performance. After an injury, an athlete may have to decrease most of his activities that has been part of his daily life. This is the part where some athletes may find mostly difficult to deal with. A runner who is used to waking up early in the morning to run and train before proceeding to his/her other daily tasks may experience distress or even depression due to an injury and a sudden change in daily routine. Also, as physical activities can provide some benefits to a person’s overall well-being through an increase in self-esteem and self-efficacy, as well as the biological bases of the psychological effects of physical activity or running (i.e. release of the hormone endorphins), an injury can affect a person emotionally and mentally. However, there are some suggested benefits to a successful recovery from athletic injury such as personal growth; psychologically-based performance enhancement; increase in self-efficacy, mental toughness, and personal, motivation; physical and technical development benefits associated with injury and recovery experience; and general health improvement (Cox, 2011; Lavallec, Kremer, Moran, & Williams, 2004). This goes without saying that a good and appropriate recovery program for injured runners will more likely enhance their future performance as well as their overall well-being both as a person and as an athlete. Lastly, this tells us the importance of a specialist with training, knowledge, and expertise in the psychological factors involved in injury, rehabilitation, recovery and counseling in the field of sport.

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