Journal of Sport Rehabilitation, 1996, 5,330-335

O 1996 Human Kinetics Publishers. lnc.

Differential Psychological Treatment of Injured

Athletes Based on Length of Rehabilitaaion

David A. Striegel, Elizabeth G. Hedgpeth, and Claudia J. Sowa

This paper describes the psychological processes of injured athletes and corre-
sponding treatments along a continuum based on time away from sport. The first
level involves injuries requiring rehabilitation of 0 to 2 weeks. Athletes' reac-
tions focus on resiliency and coping with the stress associated with injury, and
treatment emphasizes stress management and development of coping strategies.
The second level involves injuries requiring rehabilitation of more than 2 weeks;
in this level, motivation and compliance with rehabilitation protocols are dealt
with, and treatment focuses on goal setting and injury support groups. The third
level pertains to injuries resulting in the termination of an athlete's sport partici-
pation. This level involves the potential loss of identity in sport and transitions to
a new lifestyle, with treatment strategies focusing on grief responses and career
counseling. By viewing the psychology of athletic injury rehabilitation from a
perspective that is sensitive to the severity of the injury as well as longevity of
rehabilitation, sport psychologists can provide treatment better suited to the indi-
vidual athlete.

Over 25 years ago, Kubler-Ross (5) presented a grief model that outlined
the emotional responses of the terminally ill. This model described five primary
stages of death and dying: denial and isolation, anger, bargaining, depression, and
acceptance. Kiibler-Ross's stages have been applied to individuals' reactions to
loss, and Rotella and Heyman (9) and Rotella (8) extended this model to include
the processes of injury rehabilitation. Limitations of this approach include (a) the
assumption that the psychological processes of injury are the same for all athletes
and (b) the conceptualization of all athletic injuries as comparable to death and
dying. To address these limitations, researchers have begun to draw upon the lit-
erature on stress to conceptualize athletic injury and have begun to view postinjury
reaction as an individual coping mechanism that includes both a psychological
and a physical component (13-1 5).
This manuscript describes a differential treatment approach, based on length
of rehabilitation, that incorporates both the individual nature of the stress response
and Kubler-Ross's (5) stages in working with injured athletes (see Table I). The
approach is divided into three levels: short-term rehabilitation (0 to 2 weeks), long-
term rehabilitation (greater than 2 weeks), and termination of participation in sport.

D.A. Striegel is with LGE Sport Science, 9757 Lake Nona Rd., Orlando, FL 32827-
7017. E.G. Hedgpeth and C.J. Sowa are with the Department of Human Services, 203 Me-
morial Gym, University of Virginia, Charlottesville, VA 22903.
 Differential Psychological Treatment 331

Table 1 Treatment Concerns and Options Associated With the Three-Level Process
for Psychological Treatment Based on Length of Rehabilitation

Level Length Concern Treatment options

1 0-2 weeks Stress Stress management

Systematic Rationalization
2 >2 weeks Stress Stress management
Systematic Rationalization
Motivation Goal setting
Compliance Support groups
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3 Withdrawal from sport Stress Stress management

Systematic Rationalization
Motivation Goal setting
Compliance Support groups
Career termination Career counseling

Level 1: Short-Term Rehabilitation (0 to 2 Weeks)

In the first level, the sport psychologist explores the athlete's cognitive appraisal of
his or her injury and the stress associated with that event. According to Lazarus and
Follunan's (6) transactional model of stress, there is an interaction among the indi-
vidual, the environment, and in this case, the rehabilitation process. The sport psy-
chologist begins work with the athlete by examining three aspects related to the stress
of the injury: the athlete's perception of his or her environment both within and out-
side of sport, the amount of disruption that the athlete experiences as a result of the
injury, and the coping resources that the athlete possesses within the rehabilitation
process.
The sport psychologist and the athlete discuss the athlete's perceptions of
his or her environment and injury during the first session. The primary emphasis is
on listening to the athlete. The sport psychologist listens for evidence of the cop-
ing resources that are integral to the development of a hardy personality, as de-
fined by Kobasa (4). Hardy individuals develop coping resources in their perceptions
of stressors (i.e., the attributionsof challenge, control, and commitment) that buffer
the detrimental effects of stress. In this case, the sport psychologist listens for
indications of personal hardiness in relation to the athletes' attributions toward
their injuries.
The attribution of challenge is heard as athletes describe their injuries as
problems to overcome rather than threats to their personal security or identity.
Attributions of control are found in the athletes' beliefs that they have power within
the rehabilitation process, are responsible for their actions, and are capable of
avoiding feelings of helplessness. Commitment is heard as a reflection of purpose
and involvement in what the injured athletes are doing in the athletic training room.
In listening to the athlete and understanding the impact that the injury has on
the athlete's life, the sport psychologist can help the athlete develop and reinforce
 332 Striegel Hedgpeth, and Sowa

the attributions that foster hardiness. If it is necessary to help the athlete under-
stand his or her perceptions, the sport psychologist employs a framework, called
Systematic Rationalization (12). Athletes can use this strategy to classify stressful
life events based on their personal beliefs of control and their perceptions of the
importance of the events in their lives. The process involves the following three
steps: (a) identification of stressors related to the injury and the rehabilitation pro-
cess, (b) classification of these stressors according to personal beliefs (control-
lable or uncontrollable and important or unimportant), and (c) review of stressors
by their classification.
Stressors seen as important are priority issues for the athlete and therefore
become the focus of the work between the sport psychologist and the athlete. Strat-
egies for working with important concerns are based on the athlete's classification
of the particular stressor as controllable or uncontrollable. If an important stressor
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is viewed by the athlete as controllable, stress management techniques are em-

ployed. The perception of controllability suggests that the athlete already recog-
nizes what to do to reduce the stress associated with the event. The sport psychologist
then provides guidance to direct the athlete's beliefs into behaviors. To reduce the
stress associated with important stressors perceived by the athlete as uncontrol-
lable, the sport psychologist must work with the athlete to change his or her per-
ception of the event. Strategies associated with Rational-Emotive Therapy, cognitive
restructuring, or coping skills training often are employed. Athletes are encour-
aged to shift their perception of the stressor from important to unimportant or from
uncontrollable to controllable.
Although the use of Systematic Rationalization (12) is not limited by time,
after 2 weeks the paradigm for working with the psychological aspects of injury
rehabilitation begins to shift: The focus changes from coping to maintaining moti-
vation and compliance.

Level 2: Long-Term Rehabilitation (More Than 2 Weeks)

As the length of rehabilitation increases, lack of motivation and lack of social
support become primary stressors. These stressors may act as barriers to compli-
ance with rehabilitation protocols as an athlete's time away from competition in-
creases. Wiese and Weiss (14) suggest that sport psychologists use goal setting to
enhance motivation. Although goal setting is an optional technique in Level 1,
goal setting has a primary role in Level 2. Gould (3) described a three-step goal-
setting process. The first step is for the athlete, athletic trainer, and sport psycholo-
gist to decide on realistic rehabilitation goals. Short-term and long-term goals are
needed to provide direction and motivation for the athlete. The sport psychologist
and the athletic trainer then help the athlete both formulate a plan for achieving
goals and evaluate whether the goals are met. If appropriate, rehabilitation is ended
or new goals are established. If goals are not met, the sport psychologist and the
athlete discuss barriers that hinder the athlete's success and strategies for over-
coming the obstacles.
A vehicle for addressing lack of social support while increasing motivation
is the use of peer mentors and injury support groups (14). Peer mentor relation-
ships are formed by matching an injured athlete with an athlete who has success-
fully rehabilitated a similar injury. The sport psychologist and the athletic trainer
can facilitate this mentoring by establishing a rehabilitation mentor list and having
 Differential Psychological Treatment 333

the athlete choose a mentor at the start of rehabilitation. To encourage an ongoing

mentor relationship, the sport psychologist and the athletic trainer meet monthly
with the mentors to clarify information about the rehabilitation process and to
provide additional support.
Injury support groups also are used to enhance motivation and provide so-
cial support. The sport psychologist and injured athletes meet to discuss psycho-
logical issues surrounding the injury, and groups focus on either education or
counseling. Educational groups provide information regarding rehabilitation and
always include the athletic trainer. The purpose of counseling groups is to reassure
athletes that they are not alone in their struggles with injury and rehabilitation;
these groups may or may not include athletic trainers.
Athletes frequently are defined by and dependent upon their physical skills.
Therefore, an injury that results in termination of sport participation often affects
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feelings of self-confidence and self-worth (7). Athletes whose sports careers have
ended are represented in the third level of differential treatment.

Level 3: Termination of Participation

According to Rotella and Heyman (9), athletic injury that results in termination of
sport participation may elicit a grief response similar to the grief response of the
terminally ill. Because of this grief response, Kubler-Ross's (5) model of death
and dying is most applicable to this group of injured athletes.
Kubler-Ross's (5) first stage is one of both denial and isolation. In this case,
denial functions as a buffer after the athlete learns of the termination of his or her
participation in sport. This defense mechanism allows the athlete time to begin to
process the ramifications of the injury. According to Etzel and Ferrante (2), isola-
tion is a major factor when injury occurs since the athlete can no longer participate
in the day-to-day activities of sport (e.g., traveling, competing, practicing, condi-
tioning). The athlete now spends time with the athletic trainer in a rehabilitation
program. The sport psychologist should encourage the athlete to participate in the
rehabilitation process to avoid further isolation, although withdrawal may be a
natural part of denial.
Kubler-Ross's (5) second stage is anger. Anger may take many forms in-
cluding rage against others (coaches, teammates, friends, and family), fate, or life
in general (7). The sport psychologist should work with the athlete to manage and
cope with his or her anger in socially acceptable ways. The sport psychologist
should also monitor the athlete for internalized rage that is manifested in self-
destructive behaviors such as drug or alcohol abuse.
Kubler-Ross's (5) third stage is one of bargaining, in which the athlete en-
gages in an agreement with a greater power in order to change and control the
outcome of the injury (termination of participation in sport). When the athlete
realizes that this self-talk process is unsuccessful, the fourth stage, depression,
occurs. Kubler-Ross (5) divided the fourth stage into two kinds of depression:
reactive and preparatory. Reactive depression occurs as a response to the actual
loss; preparatory depression is a reaction to impending losses. Reactive depression
can be treated through cognitive restructuring techniques. Essentially, the athlete
learns to view injury through a hardiness framework.
Preparatory depression is more difficult to address within the training room
but leads to the final stage of acceptance. Kiibler-Ross (5)stated that "acceptance
 334 Striegel, Hedgpeth, and Sowa

should not be mistaken for a happy stage. It is almost void of feelings" (p. 113). For
athletes, acceptance is a time of transition, a time to change direction and reassess
aspects in their lives other than sport. The athlete works with the sport psychologist
toward moving into new roles. If the athlete's concerns at this level are beyond the
scope of the sport psychologist's training, athletes need to be referred to mental health
counselors (for suicide assessment) or career counselors (for vocational interest as-
sessment).

Discussion
An important aspect of the differential psychological treatment is delineation of the
athlete's psychological responses to injury by length and outcome of rehabilitation
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rather than by application of a particular paradigm (Kiibler-Ross or stress) across all

athletic injuries. Treatment is determined by length of rehabilitation, and this distinc-
tion begins to define the role of the sport psychologist in the athletic training room.
The differential psychological treatment approach allows the sport psychologist to
match techniques to the individual athlete and his or her level of injury to enhance the
athlete's stress management, motivation, and compliance.
The differential treatment approach is consistent with the research of Smith,
Scott, and Wiese (11) and Smith, Scott, O'Fallon, and Young (lo), who stated that
the Kiibler-Ross ( 5 ) model is not applicable to all athletic injuries. Smith, Scott,
O'Fallon, and Young found that denial was "conspicuously absent from the emo-
tional response of athletes" (p. 48) in their study. These authors (10) also found
that the more severe the injury, the more significant the psychological barriers
experienced by the athlete. When the severity of the injury results in termination of
an athlete's sport career, the differential psychological treatment approach draws
upon Kiibler-Ross's stages and integrates the position of Rotella (8) and Rotella
and Heyman (9) with that of Smith, Scott, O'Fallon, and Young (10) and Smith,
Scott, and Wiese (1I).
Athletic injuries are far too complex to assume that all athletes respond to
rehabilitation in similar ways. The differential psychological treatment approach
presents a feasible explanation for contradictory literature surrounding the appli-
cation of the Kiibler-Ross ( 5 ) and stress paradigms (6) to the psychological re-
sponses of injured athletes. This approach also offers a conceptualization of
psychological reactions to injury along with corresponding therapeutic treatment
for injured athletes. Therefore, the differential psychological treatment helps the
sport psychologist address the needs of the injured athlete.

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