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psychological training, imagery, mental training, psychology of injury, psychological skills training techniques, mental training, knee injury, recovery, anterior cruciate ligament rehabilitation, football

How a young footballer used imagery and psychological training to overcome anxiety and lack of confidence after a knee injury

The Sports Injury Doctor

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Many of the athletes that I have worked with are hard-driving and goal-oriented individuals who are continually striving for success and higher standards of performance. Unfortunately, when faced with lay-offs due to injury, such individuals do not always cope well with physical restrictions. Training reductions or cessations that are necessary for successful recovery are often a cause of intense frustration. Injuries are seen as barriers or obstacles that threaten goal-achievement and restrict overall progress. Helping these athletes to adjust to periods of forced inactivity can be challenging and demanding.

Psychological interventions can aid recovery
Recent research has shown that psychological interventions can help athletes to recover more quickly from injuries(1), experience more positive mood states during recovery(2) and maintain confidence(3). For example, one study(1) examined the effects of imagery and relaxation on knee strength, levels of anxiety and perceptions of pain during anterior-cruciate-ligament rehabilitation. Thirty injured athletes were equally divided into three experimental groups and exposed to either no intervention; a placebo intervention, involving attention, encouragement and support; or an imagery plus relaxation intervention. Results revealed that participants subjected to the imagery and relaxation intervention reported significantly less re-injury anxiety and lower perceptions of pain. Additionally, greater knee strength was reported, which seems to support both physical and psychological benefits of this intervention strategy.

Furthermore, in my dealings with injured athletes, I have seen many added benefits of applying psychological skills training techniques. Serious athletes channel large amounts of energy into their physical training and when this is not possible because of injury, channelling these energies into something positive is essential. Otherwise, long lay-offs can become the breeding grounds for depression, anxiety and self-doubt. Mental training can provide a positive outlet that the athlete can equate with progress and moving towards his or her goals. It is often not a perfect substitute for physical training – far from it in many cases – but it can help to promote a sense of exerting some control over the situation and act as a new challenge. In essence, the time spent during periods of injury can be destructive if the athlete allows his/her mind to wander; alternatively, it can be seen as an opportunity to develop skills that might ultimately lead to even better performances. Which would you choose?

Case study: a young football striker
The following case study demonstrates how psychological skills training can help athletes during recovery from injury. To protect confidentiality, the athlete depicted here is really an amalgam of a number of real cases, but the example should suffice to highlight some of the potential benefits of psychological interventions.

Client profile
The athlete involved in this case study was a male football striker in his early 20s who had previously represented his county at schoolboy level. At the time, the participant was competing at collegiate level and had begun working with the psychologist during the early part of the season due to problems with very high levels of cognitive anxiety (performance worries, fear of failure and of letting down his team-mates), and low levels of self-confidence (not in his general ability, but in his ability to perform well under-pressure).

The working alliance between client and psychologist became strong with weekly meetings continuing over about four months prior to injury occurrence. An imagery and self-talk intervention programme had led to the participant experiencing significant reductions in anxiety and increases in self-confidence. This was regularly monitored and assessed by subjective performance assessments (including performance profiling) and various psychological inventories. However, just as the participant was beginning to experience greater psychological control and better on-field performances, he sustained a knee-injury that was to keep him sidelined for around three weeks. The individual was somewhat susceptible to worrying and self-doubt, so the major aim over the period of injury was to maintain the confidence which had developed in order to minimise any knock-on performance effects when returning to competitive action.

Justifying the approach
Petitpas and Danish(4) identified a lowering of confidence, worry concerning recovery and performance decrements as potential negative reactions to injury. Getting athletes to lower their performance expectations post-injury can also be a struggle. Since the relationship between confidence and performance is usually strong, and in many ways confidence is the opposite of cognitive anxiety (both relate to beliefs), the intervention in this case focused on maintaining confidence and developing resilience.

Imagery was the main technique used in this study. Much past research has shown imagery to be a flexible and useful tool that is related to the development and maintenance of self-confidence(5,6). In addition, imagery interventions have previously been related to enhanced recovery times(7).

Essentially, imagery is a form of covert practice where the client creates or re-creates scenarios in the mind, in the absence of real environmental stimuli. It should be an all-sensory experience involving visual, auditory, kinaesthetic and mood elements. The brain actually interprets imaged stimuli very literally, and processes the information in much the same way as real stimuli. Although psychologists are not exactly clear how imagery works, it is highly likely that the mind-body connection is facilitated via the development of a mental blueprint of performance.

The client in this case possessed very good imagery ability and enjoyed using the technique. He was able to elicit vivid images and exert a high degree of control over the outcomes of imagined scenarios. Some clients will need to start with simple imagery practices in order to exert greater control and increase vividness.

Matching individual needs
The key element of any psychological skills training programme is matching the intervention to the client's specific needs. Since imagery can be used in many different ways, and the content of imagery training can vary considerably, selecting the correct type of imagery was essential in this case. One particularly useful imagery model(6) based on an interpretation of many past studies suggests that in order to facilitate self-confidence, the content of the imagery sessions should involve the athlete seeing him or herself mastering difficult situations and overcoming obstacles. Imagining a positive outcome is very important as this is what boosts self-confidence in much the same way as achieving real goals. This type of imagery is particularly pertinent in the case of injured athletes who need to see themselves succeeding and eventually returning to competitive action.

A three-stage approach to intervention
Stage one involved a detailed discussion concerning the injury, what it meant to the client, how the client was feeling and coping and any particular concerns that were troublesome. These specific concerns were noted and used later during imagery sessions as the client imagined mastering these scenarios. At this stage the extent of the injury was discussed as the athlete affirmed the physiotherapist's conclusions and physical recovery recommendations. The injury was not severe but a three-week layoff from training was likely, so the client and psychologist negotiated the aims of the upcoming psychological training sessions. A unified approach was agreed. Second, the intervention itself initially involved the client recalling positive performance indicators from recent matches and reliving these via vivid repetitive images. This was essentially for confidence maintenance and to promote a positive mind-set where successes were recalled to working memory and acted to restrict access to pessimistic, negative memories such as sustaining the injury.

The specific images used included recalling goals scored, outpacing defenders, good link-up play with team-mates and quick reactions in tight situations. In each example the psychologist guided the client through these images and attempted to focus on the clarity of visual image, the sounds involved such as when striking the football, the feel of the movements and the excitement and exhilaration involved with successful outcomes. The client reported feeling energised, optimistic and eager to return to playing as soon as possible, following this initial session.

Eventually, stage three of the intervention commenced as the client was preparing to return to physical training and then competition. A number of concerns that were highlighted during the initial meeting were used as a means of psychological strengthening. Specifically, the client reported that speed was his biggest asset and he worried about not being able to accelerate away from defenders over uneven ground due to the after-effects of his injury. He also mentioned making sharp, angled turns and 50-50 challenges as situations within a game that might be troublesome.

In response to this, the client was guided to create up-coming scenarios against known opponents (not recall actual experiences) that involved these concerns. These included both training and match scenarios. He saw himself out-pacing defenders and finishing clinically, making quick-angled turns pushing-off with the previously injured knee and making solid contact and winning 50-50 tackles against tough defenders. A scenario was also used where the player imagined waiting to be introduced as a substitute and dealing with the feelings associated with this. The client was encouraged to create vivid, realistic images that included kinaesthetic feelings of the movements and mood states during practice. Much as in real situations, the client reported feeling a little tense when imagining these potentially threatening challenges, but after a short time, this tension dissipated as successful images were produced. This form of simulation training allowed confidence to be gradually enhanced by mastery imagery.

Outcomes
The client made a successful return to competition following a three-game absence. Although he reported a degree of tension while waiting to be introduced as a substitute in his return to action, this quickly decreased as he made some early positive contributions to the game which closely matched his previous imagery experiences. Over the period of injury, interviews and questionnaire responses revealed that confidence was successfully maintained at a level corresponding to that immediately prior to injury.

Over the entire intervention period of six months, a significantly positive change in mental attitude and psychological characteristics was noted. Most importantly, the imbalance initially reported between anxiety and self-confidence was removed and normal levels of each variable achieved. Although the client still had areas for improvement, significant progress had been made and despite missing four games over the season due to injury, he reached his goal-scoring targets set pre-season. The use of mastery-type imagery appears to have positively influenced self-confidence, and supports the mental imagery model and research previously mentioned(5,6).

In regard to the period of injury, the psychological training appeared to help maintain self-confidence, provide a positive training focus that aided motivation and facilitated the adjustment of goals. It appears that channelling one's energies into training that can ultimately lead to higher levels of performance is a most constructive way of approaching injury lay-offs. This can be an especially good time to introduce the athlete to psychological skills training since many athletes neglect these skills in favour of traditional physical practice during regular training periods.

The intervention highlighted in this study was specifically tailored to the individual's needs and many other various techniques and strategies can be employed to aid the recovery process. Psychological training should always be viewed in conjunction with the work of physiotherapists and other relevant professionals, and should be used to develop realistic confidence (not over-confidence). For longer periods of rehabilitation, imagery could involve the athlete imagining regaining full range of motion at a joint, or completing a set of rehabilitation exercises that have yet to be accomplished in reality.

Lee Crust

References
(1) Cupal, D.D., & Brewer, B.W. (2001). 'Effects of relaxation and guided imagery, re-injury anxiety and pain following anterior cruciate ligament reconstruction.' Rehabilitation Psychology, 46 (1), 28-43.
(2) Johnson, U. (2000). 'Short-term psychological interventions: A study of long-term injured athletes.' Journal of Sport Rehabilitation, 9, 207-218.
(3) Magyar, T.M., & Duda, J.L. (2000). 'Confidence restoration following athletic injury.' Sport Psychologist, 14, 372-390.
(4) Petitpas, A., & Danish, S. (1995). 'Caring for injured athletes.' In S. Murphy (Ed.), Sport Psychology Interventions (pp.255-281). Champaign, Ill. Human Kinetics.
(5) Moritz, S.E., Hall, C.R., Martin, K.A., & Vadocz, E. (1996). 'What are confident athletes imagining? An examination of image content.' Sport Psychologist, 10, 171-179.
(6) Martin, K.A., Moritz, S., & Hall, C.R. (1999). 'Imagery use in sport: A literature review and applied model.' Sport Psychologist, 13, 245-268.
(7) Ievleva, L., & Orlick, T. (1991). 'Mental links to enhanced healing.' Sport Psychologist, 5 (1), 25-40.

psychological training, imagery, mental training, psychology of injury, psychological skills training techniques, mental training, knee injury, recovery, anterior cruciate ligament rehabilitation, football

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