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DOCTORAL THESIS DOCTORAL THESIS Sport Injury-Related Growth Theory-to-Practice Roy-Davis, Kylie Award date: 2017 Awarding institution: University of Roehampton General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Download date: 15. avr.. 2025 Sport Injury-Related Growth: Theory-to-Practice Kylie Roy-Davis A thesis submitted in partial fulfillment for the degree of PhD Department of Life Sciences University of Roehampton 2017 i This thesis is dedicated to Adam. ii Declaration This thesis is the author’s own work, and has not been previously submitted for an award of this university or any other institution. Signed:…………………………….. Date:……………………………….. STATEMENT 1 The content of the thesis is legally allowable under copyright legislation. Signed:…………………………….. Date:……………………………….. STATEMENT 2 I hereby give consent for my thesis, if accepted, to be available for photocopying and for interlibrary loan, and for the title and summary to be made available to outside organizations. Signed:…………………………….. Date:……………………………….. iii Summary This thesis explored the concept of sport injury-related growth (SIRG). Specifically, the mechanisms through which growth occurs and how it may be promoted for injured athletes. Study 1 used a grounded theory methodology to develop a context-specific theory. Aligning with a Straussian approach, data was collected using semi-structured interviews and analysed using open, axial, and selected coding. Findings revealed that the mechanisms of (a) meta-cognition, (b) positive reappraisal, (c) positive emotions, and (d) facilitative responses are what enable SIRG. These mechanisms are influenced by a combination of internal (e.g., personality) and external (e.g., received social support) factors. These factors enable injured athletes to alter their perception of their injury into an opportunity for growth, and it is by drawing upon and mobilizing a variety of these resources that athletes are able to experience SIRG. Dimensions of growth were psychosocial, physiological, and behavioral. Although this study produced a theory that explains the SIRG process, it does not propose specific techniques or therapies that encourage the development of growth. To address this issue, Study 2 aimed to investigate and identify evidence-based interventions that promote growth after experiencing adversity. To achieve this aim, a systematic review was conducted on literature pertaining to the promotion of growth for populations who have undergone a stressful experience (e.g., medical illness). In total, 34 studies were located and obtained that met the preplanned inclusion criteria. Within these 37 studies, three types of interventions were identified: emotional processing, cognitive processing, and combined techniques. The authors of the studies who successfully demonstrated the promotion of growth either identified or suggested that growth occurs through the mechanisms of cognitive restructuring and/or reappraisal. Other important considerations that were identified through this review were the duration and timing of the intervention in relation to the adverse event, and the importance of the intervention meeting the needs of the participants. Although this study offers valuable insight into how growth may be more successfully nurtured, the studies included within this review did not specifically focus on promoting growth for injured athletes. Consequently, Study 3 sought to complement this study by examining the practice-based experiential knowledge of sport psychologists who have worked with injured athletes in an applied manner. In total, 10 sport psychologists were purposively sampled and interviewed. Data was collected using a semi-structured interview guide and analysed using content analysis. Findings revealed a fluid development framework that consisted of 5 phases: (a) reactionary phase, (b) preparation phase, (c) reflection phase, (d) application phase, and (e) monitoring phase. Within each phase a set of corresponding strategies, skills, and tools were identified that the sport psychologists would utilize to match the needs of the athletes. The sport psychologists also identified a number of personal and environmental factors that either promoted or hindered the development of SIRG. Altogether, this thesis supports and extends research regarding growth and sport injury, as well as offering applied practitioners useful information for promoting SIRG. iv Table of Contents Page Dedication……………………………………………………………………………….... i Declaration……………………………………………………………………………….. ii Summary………………………………………………………………………………….iii Table of Contents…………………………………………………………………………iv Publications and Presentations……………...……………………….……….…...... ……ix Appendices………………………………………………………………………....……...x Tables……………………………………………………………………………………..xi Figures…………………………………………………………………………………... xii Acknowledgements……………………………………………………………………...xiii Chapter 1: Introduction…………………………………………………………………1 What is this Ph.D. about?.............................................................................................2 Background…………………………………………………………………………..2 Conducting research………………………………………………………………….4 Overview……………………………………………………………………….....….6 Chapter 2: Literature Review.........................................................................................11 Abstract ......................................................................................................................12 Introduction ................................................................................................................13 Responses to Sport Injury.....................................................................................13 Models and Theories of Sport Injury .............................................................14 v Responses to Sport Injury Research.....................................................................22 Emotional Responses .....................................................................................13 Coping Strategies ...........................................................................................25 Growth Research ..................................................................................................27 Models and Theories of Growth.....................................................................29 Growth Research ............................................................................................33 Sport Injury and Growth.......................................................................................35 Summary and Recommendation for Future Research................................................39 Chapter 3: A Grounded Theory of Sport Injury-Related Growth .............................43 Abstract ......................................................................................................................44 Introduction ................................................................................................................45 Methods......................................................................................................................49 Philosophical Orientation and Methodology........................................................49 Participants...........................................................................................................50 Data Collection and Procedure.............................................................................51 Data Analysis .......................................................................................................53 Results........................................................................................................................56 Sport Injury...........................................................................................................57 Meta-Cognition and Positive Reappraisal............................................................58 Positive Emotions and Facilitative Responses.....................................................59 Internal Resources................................................................................................63 External Resources...............................................................................................65 vi Sport Injury-Related Growth................................................................................69 Discussion ..................................................................................................................71 Chapter 4: Interventions to Promote Growth Following Adversity: A Systematic Review of Evidence-Based Practice (Study 2)...............................................................78 Abstract ......................................................................................................................79 Introduction ................................................................................................................80 Methods......................................................................................................................82 Design...................................................................................................................82 Inclusion Criteria..................................................................................................82 Search Strategy.....................................................................................................83 Shifting of Research Papers .................................................................................84 Results........................................................................................................................86 Emotional Processing Interventions.....................................................................86 Cognitive Techniques Interventions...................................................................103 Combined Techniques Interventions..................................................................107 Qualitative Interventions....................................................................................109 Discussion ................................................................................................................112 Chapter 5: Practice-Based Evidence of Facilitating Sport Injury-Related Growth: Phases and Strategies Recommended by Sport Psychologists...................................123 Abstract ....................................................................................................................124 Introduction ..............................................................................................................125 vii Methods....................................................................................................................128 Design and Assumptions....................................................................................128 Sampling Procedure and Participants.................................................................128 Interview Guide..................................................................................................130 Data Analysis .....................................................................................................132 Results......................................................................................................................133 Reactionary Phase ..............................................................................................133 Preparation Phase ...............................................................................................138 Reflection Phase .................................................................................................141 Application Phase...............................................................................................144 Monitoring Phase ...............................................................................................149 Influential Factors of SIRG ................................................................................151 Athlete’s Personality ....................................................................................152 Team Environment/Culture..........................................................................154 Social Support Network ...............................................................................156 Athlete’s Free Time......................................................................................158 Discussion ................................................................................................................160 Chapter 6: General Discussion and Conclusions……………………………………168 Introduction ..............................................................................................................169 Summary of Studies ...........................................................................................169 Study 1: A Grounded Theory of Sport Injury-Related Growth..........................170 viii Study 2: Evidence Based Interventions to Promote Growth Following Adversity: A Systematic Review......................................................171 Study 3: Practice-Based Evidence of Facilitating Sport InjuryRelated Growth: Phases and Strategies Recommended by Sport Psychologists......................................................................................................172 Synthesis of Results Across Studies……………………………………………….173 Theoretical and Empirical Impact of this Thesis......................................................175 Theoretical Impact..............................................................................................175 Empirical Impact ................................................................................................179 Practical Implications...............................................................................................181 Strengths and Limitations.........................................................................................187 Future Research Recommendations.........................................................................188 Overall Conclusions.................................................................................................190 References.......................................................................................................................192 Appendices......................................................................................................................227 ix Publications and Presentations Journal Publications Roy-Davis, K., Wadey, R., & Evans, L. (2017). A grounded theory of sport injury-related growth. Sport, Exercise, and Performance Psychology, 6(1), 35-52. DOI: 10.1037/spy0000080 Conference Presentations Roy-Davis, K., Wadey, R.m & Evans, L. (2017). Practice-Based Evidence of Facilitating Sport Injury-Related Growth: Phases and Strategies Recommended by Sport Psychologists. Poster session to be presented at the 2017 Association for Applied Sport Psychology (AASP) 32nd Annual Conference, Orlando, USA. x Appendices Page Appendix A. Participant consent form- Study 1..................................................................228 B. Participant debrief form- Study 1 ..................................................................231 C. Participant information sheet- Study 1 ..........................................................214 D. Interview Guide- Study 1...............................................................................236 E. Participant consent form- Study 3..................................................................243 F. Participant debrief form- Study 3 ..................................................................246 G. Interview Guide- Study 3...............................................................................249 xi Tables Table 1. Qualitative Assessment for Quantitative Studies ................................................88 Table 2. Emotional Processing Interventions ....................................................................91 Table 3. Cognitive Interventions....................................................................................... 93 Table 4. Combined Interventions...................................................................................... 96 Table 5. Qualitative Interventions..................................................................................... 97 Table 6. Measures of Growth used in Interventions: Abbreviations and Full Titles.........98 Table 7. Sport Psychologist’s Overall Strategies and Skills............................................145 Table 8. Sport Psychologist’s Overall Tools ...................................................................147 xii Figures Figure 1. Wiese-Bjornstal, D., Smith, A., Shaffer, S., & Morrey, M. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10, 46-68 .........................16 Figure 2. Brewer, B., Andersen, M, & Van Raalte, J. (2002). Psychological aspects of sport injury rehabilitation: Toward a biopsychosocial approach. In D. Mostofsky & L. Zaichkowsky (Eds.). Medical and psychological aspects of sport and exercise, (pp. 44-54). Morgantown, West Virginia: Fitness Information Technology ....................................................................................................19 Figure 3. Kubler-Ross, E. (2009). On death and dying: What the dying have to teach doctors, nurses, clergy and their own families. London, United Kingdom: Taylor & Francis...............................................................................................21 Figure 4. Tedeschi, R., & Calhoun, L. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage Publications..............30 Figure 5. Roy-Davis, K., Wadey, R., & Evans, L. (2017). A grounded theory of sport injury-related growth. Sport, Exercise, and Performance Psychology, 6(1), 35-52..........................................................................................................................56 Figure 6. Shifting of researcher papers..............................................................................85 Figure 7. Conceptual Model of the Development of Sport Injury-Related Growth .......................................................................................................................................................135 xiii Acknowledgments First and foremost, I want to thank my supervisors, Dr. Ross Wadey and Dr. Lynne Evans, as well as my Director of Studies, Dr. Ceri Diss for their continuous support and encouragement during this thesis. I cannot express enough how much I appreciate your time and attention. Thank you for giving me this wonderful opportunity. Particularly Ross, thank you for your guidance and for being a truly wonderful supervisor. A very special thank you to my family. Mom, you have always been my biggest cheerleader and believed in me when I didn’t believe in myself. Grandma and Grandpa, thank you for your enthusiasm, and I’m sorry that I’ve been away for so long. To the rest of my family, thank you for your love and understanding. Thank you to all my friends, both in the U.K. and U.S.A. You’re all amazing, beautiful people and you’ve helped me so much whether you knew it or not. To my fellow PhD candidates, thank you for the happy memories I’ll take with me. It was great sharing this journey with you. I would also like to thank all my participants. I truly appreciate that you gave me your time and shared your stories. This thesis would not exist without you. Lastly, thank you to Adam. You’re the best friend and husband I could ask for. You’re my rock. 1 Chapter 1: Introduction 2 What is this PhD about? The aim of this Ph.D. was to better understand the sport injury experience, particularly how sport injury may actually provide beneficial aspects, commonly referred to as “growth”, for athletes who have sustained injury. More specifically, this programme of research sought to provide practical information that may further assist individuals who work with injured athletes in an applied manner. Through the use of qualitative research and systematic review, this thesis explored the sport injury experience as well as the promotion of growth for injured athletes. The purpose of the first study, A Grounded Theory of Sport Injury-Related Growth, was to develop a context-specific theory pertaining to the development of growth following a sport injury. The second study, Interventions to Promote Growth Following Adversity: A Systematic Review of EvidenceBased Practice, used a systematic review methodology to explore interventions that have been used to promote growth for traumatized populations. The final study, PracticeBased Evidence of Facilitating Sport Injury-Related Growth: Phases and Strategies Recommended by Sport Psychologists, investigated the experiences and expertise of sport psychologists who have worked with injured athletes in order to further comprehend the issues surrounding growth cultivation in a practical setting. Collectively, these three studies have helped to advance the knowledge of sport injury, in particular the ways in which growth may be developed as a result of a sport-related injury. Background The topic of sport injury has long since been an interest of mine, however, I was always drawn to the field of psychology. Fortunately, despite a lifetime of involvement in 3 sport and physical activity I never experienced a significant sport injury, yet I would constantly see friends and teammates struggle through an injury they had sustained through sport. I knew that I wanted to help them, but I did not know how. Although I would often try to help alleviate the burden of their injury, I could see the toll their injury was having on them, not just physically but mentally and emotionally as well. In the days before I even began this Ph.D., when I was still trying to figure out what a thesis was and what mine may look like I met with Dr. Ross Wadey. During this meeting he told me about his idea for a programme of research that would begin with the development of a theory related to sport injury-related growth. Although I was vaguely familiar with the concept of post-traumatic growth, I had not yet seen this concept related to sport injury. This quickly sparked a change in my perception of sport injury- the idea that athletes may actually return to their sport better than they were before their injury. This idea went beyond exciting me; it felt right to me and I could immediately see the contribution this research could have for the field of sport injury. Suddenly, I was seeing sport injuries differently. While it was, and is still, my opinion that sport injury will never be a good thing- no one wants to be injured- but maybe for those unlucky ones who do get injured, my research could help these athletes be a little less unlucky. Maybe sport injuries did not have to be this terrible, debilitative thing. Maybe sport injuries could become an experience that helps athletes. Rather than muddling through their recovery, injured athletes could potentially be guided to achievements they had never reached before or change in ways that will positively affect them. This created not only a personal revelation, but also became the inspiration and focus for my Ph.D. 4 Conducting Research Although I knew that the general idea driving my thesis was exploring the concept of growth following sport injury, specifically with the aim of creating a contextspecific theory, I needed to decide how this aim would be achieved. Immediately I knew that this first research effort would be a qualitative nature, a methodology I had become familiar with during my undergraduate and graduate studies, but had never personally undertaken. From my time as a student before starting this Ph.D., I knew that research could be of either a qualitative or qualitative nature, or, in some instances, a mixture of the two. I had conducted quantitative research as a Masters student, and can appreciate the satisfaction questionnaires and a numerical value can bring. However, as someone who hesitates around numbers and gravitates towards stories, I knew that my real interest was in qualitative research. While I was confident that I could rise to the personal challenge a numbers-based study, I instinctively knew that I wanted more than that- I wanted the story beyond the statistics. I wanted to discover and explore the feelings and experiences of these athletes, and wholeheartedly embraced the qualitative approach. Despite my tendency to reduce research methodology to its most basic elements (i.e., quantitative research is numbers, qualitative research is words), this does not fully encapsulate the qualitative research approach. Indeed, the term “qualitative research” lacks a clear definition, and is often defined as simply being the counterpoint to quantitative research (Martin, 2011). Qualitative research does, however, hold common characteristics, such as its search for meanings, subjectivity, context, and reflexivity (Sparkes & Smith, 2014). So while quantitative research is focused on measuring facts and explaining the relationship between these facts in a technical manner, the goal of 5 qualitative research is to gain understanding of how people experience and make sense of the world (Smith & Caddick, 2012). I knew that this was the research I wanted to conduct and I began to familiarize myself with different qualitative approaches, namely the grounded theory methodology, as I knew this would be the research methodology of my first study. What I was unaware of at this point, was the importance of determining my own views of ontology and epistemology. A bit bewildered at first- wasn’t I studying psychology, not philosophy? I soon realized the significance of these concepts and the relationship between personal viewpoints and research design. So rather than rustling up an interview guide and diving into date collection as I had initially imagined, I found myself pondering on various philosophical ideals and reflecting on my own interpretations of reality and knowledge. Eventually, and with much deliberation, I decided my personal beliefs were those of a post-positivist with critical realism and modified dualism/objectivism. To elaborate, critical realism refers to the idea that the reality that humans perceive is influenced by unobservable events and it is only through attempting to understand these events that we are able to comprehend the social world. Modified dualism/objectivism refers to my belief that as a researcher, it is my duty to make efforts to minimize any effect my presence may have on the research process. Upon deciding these views, I could begin to plan and conduct my research accordingly. Throughout this programme of study, as I progressed through my research and decided on the ensuing steps to be taken, I would constantly question whether the research I was designing and analyzing aligned with my personal beliefs. These beliefs have important 6 implications, as my personal assumptions influenced how I approached and conducted the research within this thesis. Overview of the Thesis This dissertation consists of six chapters in total, and contains three original studies. This introduction serves as the first chapter and is presented for the purpose of providing clarity and to prime the reader for the forthcoming chapters. Following this Introduction, Chapter II, Literature Review, is presented to provide a critical review and synthesis of the current literature related to the areas of responses to sport injury, growth research, and sport injury and growth. Specifically, the aims of this chapter are to (a) provide information on the existent research pertaining to sport injury as well as the models and theories of sport injury; (b) review the research related to the emotional responses of athletes upon sustaining injury, and the reported coping strategies these athletes subsequently employ; (c) present and explain the concept of growth following a traumatic or stressful event, including descriptions and critical appraisals of models and theories of growth, as well as describing and critically reviewing prominent growth research; (d) draw together the concepts of sport injury and growth by explaining and critically appraising research that has focused on this area; and (e) summarize the information presented in this chapter and provide recommendations for future research, before concluding with the aims and rationale for this programme of research. Chapter III, A Grounded Theory of Sport Injury-Related Growth, reports results from Study 1, which aimed to develop a context-specific theory of growth following a sport injury by exploring the experiences of injured athletes who perceived a degree of 7 growth from their own injury. A grounded theory methodology was conducted, with 37 injured athletes taking part and providing a total of 70 interviews collected through the use of semi-structured interviews. After each interview, the data was transcribed and analyzed using a method of open, axial, and selective coding. Findings reveal that injured athletes are able to experience the development of growth through the mechanisms of metacognition, positive reappraisal, positive emotions, and facilitative responses. These mechanisms are influenced by the presence of a combination of internal and external factors, which if support the development of growth, will positively affect the athlete and result in a perception of injury has holding inherent opportunities. This theory provides greater insight into the injury experience, particularly the role and occurrence of growth related to sport injury, illuminating why some athletes may be able to experience the development of growth while others are not. However, this study did not provide information on how this growth process may be encouraged in an applied setting, and therefore the aim for the following study focused on delving into the topic of specific interventions that may successfully promote growth. Chapter IV, Interventions to Promote Growth Adversity: A Systematic Review of Evidence-Based Practice, gives a description and the results from the second study of this thesis. This study used a systematic review methodology to investigate the use of interventions that have demonstrated success in promoting post-traumatic growth. As the ultimate goal for this thesis is to provide information that will aid applied practitioners working with injured athletes, the desired research question at the commencement of this study was to focus on research conducted regarding post-traumatic growth and sport injury. However, as this is a relatively new area of research and there is insufficient, if 8 any, existent literature that addresses this research question, the goal of this review shifted to concentrate on any intervention-based research conducted with the goal of fostering growth for a population that had experienced a stressful or traumatic event. In total, 37 studies were identified that met the pre-determined inclusion criteria. These 37 interventions fell into 4 categories: (a) emotional processing- seeking to provide the participant with a sense of closure, catharsis, or fulfillment; (b) cognitive strategieswhich attempt to bestow participants with the relevant tools to aid the post-traumatic growth process; (c) combined technique- interventions that drew upon both emotional and cognitive processing techniques; and (d) qualitative interventions- studies which used interventions aimed at promoting growth but focused on gaining rich, in-depth information gathered through interviews and observations. Among the studies that successfully demonstrated the encouragement of growth, the researchers either identified or suggested that these interventions were able to foster growth through the mechanisms of cognitive restructuring and/or reappraisal. This review also identified that both the duration of the intervention and the timing of the intervention implementation after the traumatic event are important considerations. These findings illuminate certain methods through which growth may be better encouraged yet these studies did not focus on promoting growth for injured athletes. The need to further understand the process of urging growth for injured athletes provided the rationale for the following study. Chapter V, Practice-Based Evidence of Facilitating Sport Injury-Related Growth: Phases and Strategies Recommended by Sport Psychologists, explains the procedure and results of the final study in this programme of research. The goal of this study was to gather information about the real-world experiences of sport psychologists who work 9 with injured athletes in a practical setting. In particular, this research sought to explore any issues related to the promotion of growth for applied practitioner working with injured athletes and investigate how these practitioners have been able to successfully encourage growth for injured athletes. This study specifically decided to use sport psychologists for participants, as these individuals were more likely to be familiar with the concepts of post-traumatic growth and therefore provide richer, more in-depth data. Ten sport psychologists were purposively selected for their expertise and experiential knowledge and data was gathered through the use of semi-structured interviews. Analysis of the data revealed that the sport psychologists were able to encourage growth by effectively guiding the injured athlete through a fluid developmental framework. This framework consists of five phases: (a) reactionary phase, (b) preparation phase, (c) reflection phase, (d) application phase, and (e) monitoring phase. The sport psychologists also reported using a variety of specific strategies, skills, and tools that would be employed to match the current needs of the athletes. Finally, a number of personal and environmental factors were identified that either promoted or hindered the development of growth. These results offer useful information to applied practitioners and in this way extend the previous research. Chapter VI, General Discussion and Conclusions, is the final chapter and brings this dissertation to a close by summarizing the three studies and discussing their contribution to knowledge. After this review of the three original studies and their results, this chapter concentrates of the theoretical and empirical impact, as well as the practical implication of this research. Thereafter, the strengths and limitations of this thesis are 10 discussed and recommendations for avenues of future research are presented. Finally, the central aspects of this programme of research are drawn together in an overall conclusion. 11 Chapter 2: Literature Review 12 Abstract The purpose of this chapter was to provide a critical review of the psychology of sport injury literature, the concept of growth following adversity, and recent research that has aimed to integrate these two bodies of literature Specifically, this reviews describes a model, theories, and research related to the psychological response to sport injury, namely the integrated model of response to sport injury developed by Wiese-Bjornstal, Smith, Shaffer, and Morrey (1998). It also synthesizes the literature related to models, theories and research on post-traumatic growth. Lastly, it draws these two concepts together in the context of growth following a sport injury. The review considers both conceptual and methodological issues across the bodies of literature. The chapter concludes with a summary and recommendations for areas of future research. 13 Introduction The purpose of this chapter is to provide a critical review of the research related to the concepts of sport injury and growth following adversity as a basis for the rationale for this programme of research. The chapter has been divided into four sections: Responses to Sport Injury, Growth Following Adversity, Sport Injury and Growth, and Summary. The first section, Response to Sport Injury, will synthesize the research into athletes’ psychological responses to sport injury. The second section, Growth Following Adversity, will explore the literature related to benefits associated with undergoing a traumatic or stressful event across a variety of populations and types of stressful events. The third section, Sport Injury and Growth, will examine the research relating to the benefits derived from experiencing a sport-based injury. This review has been separated so as to introduce the reader first to the topic of Responses to Sport Injury, as this is considered the primary concept of this sport psychology-based thesis. However, this thesis is also concerned with the field of post-traumatic growth and therefore the following section, Growth Following Adversity, helps facilitate knowledge translation between other fields of research and sport psychology by contextualizing growth following sport injury and the large body of research exploring growth following adversity. Finally, to draw these two fields together, the third section, Sport Injury and Growth, provides a contextualized understanding of growth within the context of sport injury. The fourth and final section will provide a summary of the chapter and recommendations for future research. Responses to Sport Injury Although research into the psychology of sport injury dates back to the 1960’s, 14 the majority of it has been conducted over the last 20 years. Findings in this field have indicated that athletes who have sustained injury undergo cognitive, emotional, and behavioural changes, the majority of which have been considered unpleasant in nature (Evans, Mitchell, & Jones, 2006). Indeed, injury has been viewed as a largely negative experience characterized by heightened levels of depression, frustration, and helplessness (e.g., Evans & Hardy, 1995; Leddy, Lambert, & Ogles, 1994). Where positive effects of injury were reported they emerged serendipitously (e.g., Bianco, Malo, & Orlick, 1999; Ford & Gordon, 1999; Hurley, Moran, & Guerin, 2007; Podlog & Eklund, 2006; San Jose, 2003; Tracey, 2003). However, in recent years, researchers have begun to investigate positive consequences related to sport injury (e.g., Udry, Gould, Bridges, & Beck, 1997) encouraging a shift to a more inclusive view of the injury experience (Wadey, Evans, Evans, & Mitchell, 2011), wherein both negative and positive experiences are considered. Unfortunately, to date these studies have been somewhat solitary in nature, and not provided a focused, systematic approach to this important line of enquiry. A more inclusive view of the research to date, suggests that injured athletes report both negative (i.e., anxiety) and positive (i.e., increased resilience) responses, suggesting that injury may not be an inherently a negative experience as originally conceived. Indeed, contrary to the prevailing belief that injury is a largely negative experience, in recent years research has highlighted the ways in which athletes are able to benefit from their injury and even experience a degree of growth as a result of it (e.g., Galli & Vealey, 2008; Podlog & Eklund, 2006; Tracey, 2011; Udry et al., 1997; Wadey et al., 2011; Wadey, Evans, Hanton, & Neil, 2012). 15 Models and Theories of Sport Injury As the field of sport injury research has grown, researchers have endeavored to provide explanations of the injury experience and the underlying processes through the development and application of various models and theories. These models and theories include the integrated model of response to sport injury (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998), biopsychosocial model of sport injury rehabilitation (Brewer, 2003), stage-based grief response models (Kubler-Ross, 2009), self-determination theory (Deci & Ryan, 2011), cognitive-motivational relational theory of emotion (Lazarus, 2000), selfefficacy theory (Bandura, 1994), reversal theory (Apter, 1989), personal investment theory (Maehr, & Braskamp, 1986), and protection motivation theory (Rogers, & Prentice-Dunn, 1997). The first three of these - the integrated model of response to sport injury, the biopsychosocial model of sport injury rehabilitation, and the stage-based grief response - will now be discussed, as these are typically the most adopted within the sport injury research. Indeed, the factors and processes identified by these models, and theory, have also been identified in research pertaining to post-traumatic growth; in this way, these models and theory show promise for making connections between the fields of sport injury and growth following adversity. Of particular importance to this programme of research, is the integrated model of response to sport injury (Wiese-Bjornstal et al., 1998), as this model has received the most empirical support to date (Wadey & evans, 2011), and has served as the foundation for this thesis. Although each model and theory has specific strengths, the model that has received the most attention in the literature is the integrated model of response to sport injury (Wiese-Bjornstal et al., 1998). According to this model (see Figure 1), a 16 Stress Response Sport Injury History of Stressors Coping Resources Intervention Personal Factors Situational Factors Cognitive Appraisal Goal adjustment Rate of perceived recovery Self-perceptions Beliefs and attributes Sense of loss or relief Cognitive coping Injury History Severity Type Perceived cause Recovery status Individual Differences Psychological Personality Self-perception Self-motivation Motivational orientation Pain tolerance Athletic identity Coping skills Psychological skills History of stressors Mood states Demographic Gender Age Ethnicity Socioeconomic status Prior sport experience Physical Ergogenic aids Physical health status Disordered eating Sport Type Level of competition Time in season Playing status Practice vs. game Scholarship status Social Teammate influences Coach influences Family dynamics Sports medicine team influences Social support provision Sport ethic/philosophy Environmental Rehabilitation environment Accessibility to rehabilitation Behavioural Response Adherence to rehabilitation Use of PST strategies Use/disuse of social support Risk taking behaviours Effort and intensity Malingering Behavioural coping Emotional Response Fear of unknown Tension, anger, depression Frustration, boredom Positive attitude/outlook Grief Emotional coping Recovery Outcomes -Psychosocial -Physical Figure 1. Wiese-Bjornstal Integrated Model of Response to Sport Injury 17 combination of pre-injury and post-injury variables influence an athlete’s responses to injury and their ensuing recovery outcome. Factors such as personality (e.g., perfectionism), history of stressors (e.g., previous injury/injuries), coping resources (e.g., psychological skills), and interventions (e.g., stress management) comprise the pre-injury variables. Post-injury variables include personal factors (e.g., severity of injury) and situational factors (e.g., time of competitive season). These factors influence an athlete’s cognitive appraisal of their injury and rehabilitation, and their emotional and behavioural responses, and recovery outcome. For example, a runner who has incurred his second knee injury three months before the start of the competitive season, experienced this injury previously (i.e., personal factor/history of stressors), but has sufficient time before the season begins (i.e., situational factors), might have a positive attitude about making a full recovery (i.e., cognitive and emotional response). This in turn could affect his adherence to his rehabilitation programme (i.e., behavioural response), resulting in a shorter, more successful recovery process and returning to competition at an equivalent, or even higher level of functioning than previously (i.e., recovery outcome). In this instance, an athlete may exhibit signs of growth resulting the injury. This model, although well-developed and widely used, however, does not provide a detailed explanation of the mechanisms through which athletes may experience the full range of possible recovery outcomes. More recently, Brewer (2003) developed the biopsychosocial model (see Figure 2), which integrates the frameworks of existing models of sport injury rehabilitation (e.g., Wiese-Bjornstal et al., 1998) with more general models of health outcomes (e.g., Cohen & Rodriguez, 1995). The biopsychosocial model is comprised of seven dimensions: 18 injury characteristics, sociodemographic factors, biological factors, social and contextual factors, intermediate biopsychological outcomes, and sport injury rehabilitation outcomes. In this model, injury characteristics refers to the nature of the injury (e.g., type, location, severity, history), which together with the individual’s sociodemographic factors (e.g., age, gender, race/ethnicity, and socioeconomic status) will influence the biological (e.g., immune functioning), psychological (e.g., personality), and social/contextual (e.g., life stress) factors. These three factors will subsequently affect the intermediate biopsychological outcomes, such as range of motion, strength, pain, and recovery rate. Finally, these intermediate outcomes will influence the rehabilitation outcomes, for example, functional performance, quality of life post-injury, treatment satisfaction, and desire and readiness to return to sport. Within this model, psychological factors play a unique, central role, having a direct bidirectional relationship with biological and socio-contextual factors, and the resulting intermediate and final recovery outcomes. While this model provides a holistic framework that helps to explain the process of sport injury rehabilitation, it does not offer an explanation of the relationships between the specific psychological variables. Prior to models that were specifically developed in a sport injury context, sport injury research often drew upon the stage-based grief model developed by Kubler-Ross (2009). This model (see Figure 3), which was derived to explain the emotional experiences of the terminally ill, postulates that grieving individuals will experience five stages: shock and denial, anger, bargaining, depression, and acceptance. Shock and denial, the first stage, is characterised by an individual’s failure to accept their current situation. This denial is reported to function as a buffer, affording the individual time to 19 Psychological Factors - Personality - Affect - Behaviour Injury Characteristics - Type - Location - Antecedents (history) - Cause - Severity Socio-demographic Characteristics - Age - Gender - Race/ethnicity - Socio-economic status Biological Factors - Endocrine - Respiration - Metabolism - Tissue repair - Sleep - Nutrition - Circulation - Immune functioning - Neurochemistry Social/contextual Factors - Social network - Life stress - Situational characteristics - Rehabilitation environment Biopsychological Intermediate Outcomes - Range of motion - Strength - Endurance - Joint elasticity - Rate of recovery - Pain Sport Injury Rehabilitation Outcomes - Functional performance - Quality of life - Satisfaction of treatment - Readiness to return to sport Figure 2. Biopsychosocial Model. 20 begin mobilising psychological defences. The second stage is characterised by anger, which is directed either externally (e.g., coach) or internally (i.e., self) and is fuelled by a sense of betrayal. Next, a stage of bargaining, is marked by the individual attempting to find a sense of resolution by offering pledges; this part of the process is typically kept secret or only shared with those the individual deems trustworthy. A period of depression follows, marked by symptoms such as social withdrawal, hopelessness, and unproductiveness. This depressive stage appears to be the longest period within the grief process and is considered to serve as a tool to facilitate acceptance of the impending loss. In the final stage of acceptance, they acknowledge their loss and its consequences. While reaching this stage does not denote a sense of happiness, it does signify the completion of the individual’s progression through the grieving process. Although developed for a different population, sport injury researchers have argued the applicability of grief to an athletic population, positing that athletes’ exhibit a comparable grief response upon sustaining injury (Evans & Hardy, 1995). This grief is postulated to be due to the significant personal loss that occurs as the result of the injury and the interruption it causes to an athlete’s investment in their training and sport participation (Brewer, 1999; Van Der Poel, J., & Nel, P., 2011). However, a number of researchers have questioned the relevance of this model to the sports injury process, not least because of the impermanent nature of most injuries (Rose & Jevne, 1993; Udry et al., 1998). The strengths of the integrated model of sport injury response and the biopsychosial model are that they were developed for sport injury and so are contextual to this field of research (e.g., Brewer et al., 2002; Wiese-Bjornstal et al., 1998). Likewise, the Kubler-Ross stage-based model of grief provides insight into the process that injured 21 Figure 3, Kubler-Ross Stages of Grief Model athletes may face, particularly when the potential for loss if great and their identity as an athlete is threatened. Although these models, alongside others not discussed within this literature review, have aided our knowledge and understanding of specific concepts in an injury context, they are limited in describing and explaining certain phenomena. These limitations include firstly, a failure to define, delimit, and describe specific recovery outcomes, which is essential for elucidating the recovery process and associated outcomes. Also, across these models and theories is a failure to explain the mechanisms for attaining certain recovery outcomes. For example, are there different processes for different recovery outcomes? It is important to ascertain these mechanisms to guide future research and theory development. Finally, the models described above were not Time Process Denial Anger Depression Bargaining Acceptance 22 designed to direct interventions. Indeed, models need to bridge the gap between theory and practice. For example, what interventions should practitioners use to help foster desirable, and prevent undesirable, recovery outcomes? Responses to Sport Injury Research Upon sustaining an injury, athletes are likely to experience a range of emotional, cognitive, and behavioural responses (Evan, Mitchell, & Jones, 2006). As discussed in the previous section, a number of models regarding the response to and rehabilitation from sport injury have been proposed in the sport injury literature. The model that has received the most attention in the response to sport injury research is the integrated model of response to sport injury developed by Wiese-Bjornstal et al. (1998). Researchers have focused on various aspects described in the model including: cognitive appraisal (e.g., Albinson & Petrie, 2003; Chung, 2012; Daly, Brewer, Van-Raalte, Petitpas, & Sklar, 1995; Ruddock-Hudson, O’Halloran, & Murphy, 2012; Weiss & Ebbeck, 1996), social support (e.g., Abgarov, Jeffrey-Tosoni, Baker, & Fraser-Thomas, 2012; Mitchell, 2011; Rees, Mitchell, Evans, & Hardy, 2010; Rees, Smith, & Sparkes, 2003), psychological skills (e.g., Hare, Evans, & Carlow, 2008; Nordin-Bates et al., 2011; Wesch et al., 2012), adherence to rehabilitation (e.g., Marshall, Donovan-Hall, & Ryall, 2012), interventions (e.g., Rock & Jones, 2010), recovery outcomes (e.g., Brewer, 2010), and a number of personal (e.g., athletic identity; Brewer, Cornelius, & Van Raalte, 2010) and situational factors (e.g., timing of injury; Gayman & Crossman, 2003). As it is beyond the scope of this review to examine the research pertaining to each of these variables, the following sections will provide a critical discussion of injured athletes’ emotional responses and coping attempts, as these concepts are germane to this thesis and are prominently featured 23 in both the literature regarding sport injury responses as well as the literature regarding post-traumatic growth. Emotional responses. The initial period following injury occurrence is typically characterized by negative feelings, such as frustration, anger, and depression (e.g., Clement, Arvinen-Barrow, & Fetty, 2015). For example, Mainwaring et al.’s (2004) reported a significant spike in depression, confusion, and total mood disturbance in athletes immediately after injury occurrence; emotions that subsided three weeks after injury, as the athletes began to cope with their situation. To better understand the reactions related to sport injury, Udry et al. (1998) interviewed 21 elite skiers about their responses after sustaining season-ending injuries. In total, 136 psychological reactions were identified and categorized into four dimensions: injury-relevant information processing-awareness (e.g., questioning), emotional upheaval/reactive behaviour (e.g., emotional agitation), positive outlook/coping attempts (e.g., good attitude/optimism) and other (e.g., ambivalence). These results further highlight the temporal nature of psychological reactions to injury, as athletes demonstrated a need to first process their injury-relevant information before responding emotionally. However, the aim of this study was not to determine the temporal sequence of psychological reactions, but to investigate the range of responses that occur. This concept supports, and extends, the findings of Quackenbush and Crossman (1994) who surveyed 25 injured athletes and identified 48 emotional reactions related to the injury experience. Of these 48 reported emotions, 36 were positive (e.g., hopeful) and 12 were negative (e.g., frustrated), and likewise displayed a temporal element, with negative emotions decreasing over time and positive emotions increasing. 24 Subsequent studies further suggest that athletes’ emotions are likely to shift and become more positive as they progress through their recovery (e.g., Madrigal & Gill, 2014). However, injury onset is generally found to be associated with the experience of numerous negative emotions such as fear, anger, or depression (Faris, 1985). Rehabilitation is typically characterized as a period that includes discouragement, frustration, and isolation, while return to sport is associated with emotions such as impatience, anxiety, anticipation, and increased confidence (e.g., Bianco, 2001; Granito, 2001; Johnston & Carroll, 1998). In Tracey’s (2003) exploration of college athletes’ recovery from moderate to severe injuries, results showed that emotions fluctuated in the time after injury, characterized by feelings of loss, lowered self-esteem, anger, and frustration. Over time, however, athletes’ view of their injury began to evolve and injury was instead perceived as a challenge and was approached with a positive attitude. Ultimately, these athletes acknowledged that their injury and rehabilitation was a process that facilitated greater self-understanding (e.g., inner strength) and appreciation (e.g., not taking health for granted). Ruddock-Hudson et al., (2014) investigated the emotional reactions of Australian League Football players and found that the severity of the injury appears to moderate athletes’ emotional reactions, with minor and severe and/or long-term injuries showing distinct emotional variations. Minor injuries seem to present little concern or limitations for athletes and so are responded to more positively and optimistically. Conversely, longterm injuries, such as knee reconstructions, invoke negative emotional responses and are viewed as more challenging. Social support is another factor that moderates emotional responses to sport injury, however, this effect diminishes with minor injuries. 25 Coping strategies. Sport injury is an experience associated with a high degree of strain, leading researchers to focus on the coping strategies used by injured athletes during injury onset, rehabilitation, and return to sport (e.g., Evans, Wadey, Hanton, & Mitchell, 2012). Coping is defined as the “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). Just as athletes experience a range of emotional responses as a result of a sport injury, they draw upon a variety of coping strategies, specifically, emotion- or problem- focused. Emotionfocused coping strategies aim to manage the negative emotions associated with the stressor (e.g., emotional disclosure). Problem-focused coping strategies concentrate on tackling the stressful situation (e.g., planning). More recently, researchers have explored the use of avoidant coping (e.g, Allen, Greenlees, & Jones, 2011; Carson & Polman, 2010), which refers to strategies used to avoid the situation through distraction (e.g., cognitive distancing) or social diversion (e.g., walking away). In this way, avoidance coping strategies may facilitate control over short-term emotional states and has been observed to be a strategy regularly used by athletes to deal with acute stress during sport participation (Nicholls, Holt, Polman, & Bloomfield, 2006). However, avoidant coping is generally associated with a number of psychological and physiological outcomes and is suggested to be maladaptive long term (e.g., Kim & Duda, 2003). Other research on coping skills related to sports injury reveal that athletes seek to gather information regarding their rehabilitation to gain a better understanding on the route to recovery (Carson & Polman, 2008), a form of problem-focused coping. Instances of emotionfocused coping strategies throughout the sport injury process (e.g., Udry et al., 1998; 26 Wadey et al., 2012b) include venting of emotions, seeking emotional social support, positive self-talk, and reframing negative thoughts and emotions. The possession and employment of coping skills appear to be shaped in part by instances of past adversity (Bejar & Butryn, 2016). Being exposed to stressful events previously may enable athlete to feel better prepared to face stressors, such as sport injury. Athletes exhibit high degrees of perseverance through their participation in sport and it is speculated that this determined approach helps athletes to cope with their injury. In Albinson and Petrie’s (2003) examination in cognitive appraisals, stress, and coping after sports injury, cognitive appraisals were found to be related to the coping strategies used by injured athletes. Specifically, athletes’ primary and secondary appraisals of their injury related to their coping strategies, with athletes who scored higher in mood disturbance during this period demonstrating higher occurrences of avoidance coping techniques. Findings from this study suggest that the first week post-injury may be a crucial time-point for athletes’ appraisals, as this appraisal will influence athletes’ coping strategies throughout the remainder of their recovery. For example, athletes that utilized avoidant coping techniques at the seven-day mark after injury onset also exhibited less cognitive active coping (i.e., attempts to manage appraisal of stressful event) during subsequent assessments. This suggests that helping injured athletes to manage their cognitive appraisals will also influence their engagement in behaviour aimed at dealing with their injury and its affects. Johnston and Caroll (2000) also found a temporal element, as their results showed that coping varied as a function of stage in rehabilitation. It was also revealed that the use of coping strategies declined over the course of rehabilitation, showing that rather than 27 shifting coping strategies, athletes’ use of coping declined overall as they progressed through recovery. Furthermore, coping appeared to be a stable characteristic of individuals, with no clear situational-specific coping strategy emerged from the data. However, results did demonstrate that participants preferred informational and emotional support in the middle and towards the end of their rehabilitation rather than at the beginning. This may be due to the athletes in their study being less receptive and regarding these types of support to be unnecessary during injury onset to deal with the intense emotions that characterize it. Growth Research Historically, both research and anecdotal evidence has postulated how personal gain can be derived from experiences of overcoming adversity (Joseph & Linley, 2004). However, it has not been until recently that growth following adversity has been studied with empirical and theoretical rigor (e.g., Calhoun & Tedeschi, 2006; Carver, 1998; Heffernon, Grealy, & Mutrie, 2009; Joseph & Linley, 2008; Weiss & Berger, 2010). Growth, defined as the perceived positive change that elevates a person to a higher level of functioning after enduring a stressful or distressing event (e.g., Kampman, Heffernon, Wilson, & Beale, 2015), can be personal (e.g., greater appreciation), psychological (e.g., increased confidence), social (e.g., strengthened relationships), and/or behavioural (e.g., improved coping skills) (e.g., Heffernon et al., 2009). Proposed mechanisms that support, or hinder, the development of growth include deliberate rumination, meaning-making, and social support (Tedeschi & Calhoun, 2004). Growth may also be explained through the prism of mindsets (Dweck, 2006; 2007; 2012). According to Dweck, individuals lie on a spectrum between either a fixed 28 mindset or a growth mindset. Those who lie closer to the end of fixed mindsets believe that each person has a finite amount of un-increasable intelli