Down & Out

An athlete in rehab can easily feel scared and alone. Starting rehab support groups, or one-on-one peer mentoring, can help erase the anxiety.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 14.8, November 2004, http://www.momentummedia.com/articles/tc/tc1408/downout.htm

When Dave Yukelson, PhD, began his tenure at Penn State University 16 years ago, he was faced with what he felt was going to be a tough rehab. Just hired as the school’s Coordinator of Sports Psychology Services, he met with a Penn State female gymnast, who had torn her ACL while dismounting the balance beam.

At the same, a star running back on the Nittany Lion football team had completed a successful ACL rehab and was back in action. To prepare the gymnast for her upcoming rehab, Yukelson decided to introduce the two athletes, starting one of his first informal rehab support efforts at Penn State.

"I took her down to the football training room a couple days after the injury," Yukelson says, "and told her, ‘I think you could really benefit from talking to this running back about what he’s gone through, and listen to some suggestions he might make.’

"When they met, the football player reeled off this whole laundry list—what she could expect, when things would get better, how she was going to have to work through the range of motion, how there would be a period of time when she wasn’t going to see the actual range improving and that she would have to work through that plateau," Yukelson continues. "He gave a good perspective on what the next two months were going to be like for her. It was better than anything I could have told her. And as situations like that have continued to evolve, we’ve continued to use athletics as a small community in which we try to facilitate peer help."

Today, more and more athletic training staffs are using peer mentors in the rehab process, and some have established formal support groups that meet on a regular basis. The idea is simple: While going through rehab, athletes can benefit immensely by talking about the process with others who have gone through or are going through similar situations.

How It Works
The University of Tennessee women’s athletic program has a formalized injury support group, overseen by Kristin Martin, LCSN, a licensed clinical social worker employed by the department. "In our society, athletes are not supposed to show weakness, and they’re not supposed to have to talk about these kinds of things," says Martin. "But the fact is they are only human, and when they have an injury—especially when it’s traumatic or season-ending—they need a place to talk without feeling like they are weak."

For Yukelson, the power of rehab groups is in giving people a chance to share their experiences. "It’s therapeutic to hear that there are other people going through similar types of situations," he says. "The idea is to empower the athletes with skills and help normalize their situation by helping them realize there are other people going through similar things."

At the University of Virginia, Joe Gieck, EdD, PT, ATC, Professor of Kinesiology and Director of Sports Medicine, has set up formal groups and one-on-one mentoring relationships, both with success. With the one-on-one mentoring, he feels it works to pair two athletes who are at different points in their rehabs. "The idea is that the mentor has had the same injury and the recently injured athlete can talk to somebody who’s half-way through or somebody who’s all the way through rehab," Gieck explains. "It allows them to see that there are others who are going through similar stuff successfully."

At Ohio State University, Jennifer Carter, PhD, Sports Psychologist, has found success working within the framework of a team. "One year when I was acting as a consultant for a team here at Ohio State, we had a situation where over half the athletes on the team were injured and unable to practice," says Carter. "So during their practice time, I had the injured athletes go into the locker room with me and we ran our own injury support group within the team. That scenario worked because they were already gathered together in one place."

Assembling a Group
Before setting up a peer counseling program, there are some key logistics to think about. For group settings, it’s important to decide who should lead the discussions, how to get the athletes signed up, how many people should be in a group, how to get coaches on board, and what will be discussed.

Gieck feels the choice of the facilitator is key. "You have to find somebody who has the interest, and is respected by the athletes," he says. "If the school has a sports psychology program, it’s a great resource. Or you can try the school’s counseling center, and look for someone who has an interest in athletics.

"The facilitator has to be someone well-versed in active listening, and they have to know how to interact with the athletes in a way that’s going to encourage them to talk and motivate them to attend," Gieck continues. "It’s almost like a minister who’s starting a new church. They’ve got to have a little charisma to get people in the doors before they lay the message on them."

Tennessee uses co-facilitators to lead their groups, both of whom are graduate students at the university. Martin says the group functions best when one facilitator has an emphasis in counseling and the other in sports psychology.

"The facilitator with the counseling background addresses some of the mental health stressors that accompany injury," says Martin, "and the sports psychology facilitator works more with mental training, goals, and refocusing—things that help the athlete get through the recovery process." Martin notes that the co-facilitators work together and are both in the room whenever the group meets.

How do you get athletes to actually sign up for the groups? The University of Tennessee gets around this problem by making the groups mandatory for athletes who have season-ending injuries. Because athletic department officials are so confident in the benefits of the group setting, attendance is required—unless an athlete has an overriding circumstance that prevents her from going.

"Occasionally, it can be hard to get the athletes there at first," says Martin, "but once they attend it becomes a relief for them because what they’re feeling is surreal and they don’t usually have any other place to talk about it."

The University of Virginia is not currently running rehab support groups, but when it has, athletic trainers have encouraged participation by giving athletes some ownership in the process and making attendance easier for them. Because all rehabbing athletes work out in one central location, usually in the afternoon, Gieck asked them to choose a time that would be most convenient for them.

"We learned that when we picked a time and said, ‘Okay, you’ve got to be here at 4:30,’ that didn’t work very well," he says. "But when we got the athletes involved together and they said to each other, ‘How about 4:30?’ they were committed to being there.

"We didn’t force them to attend the support group. If they wanted to come, fine. If not, that was fine too," continues Gieck. "But once we got two or three people sitting down for it—we had them meet in a room with all glass doors where you could see people sitting down and talking—the others would say, ‘What’s going on in that room?" Once the group started meeting on a regular basis, Gieck says that athletes from the group would walk around the athletic training room recruiting other injured athletes.

While Virginia let the numbers of participants in its groups vary, Tennessee has found eight to be the ideal number. "Once it gets past 10, it’s not as intimate as it needs to be," says Martin. "If we get that many athletes, then we add another group."

Getting coaches on board is another important part of setting up a group healing process. To earn support from coaches, Gieck recommends that athletic trainers pull coaches aside and explain what they are doing. "One of the problems you may have with coaches is that they can be very suspicious. They may think that the sports psychologist is going to take control of the team away from them," says Gieck. "So you have to gain their confidence by sitting down and talking to them about how the group can help.

"I’ll say, ‘Okay coach, here’s one way we can help your injured athletes: getting them to attend the injury support group,’" continues Gieck. "‘If you can encourage those athletes to meet with the support group, I think it will be very beneficial to their physical rehab.’"

What Is Discussed
At Tennessee, groups meet once a week for an hour and a half. The meetings, which are confidential, start by having each athlete update the group on how she is feeling that particular day. "They’ll share how they’re doing in their rehab, what struggles have come up, and any challenges they’re facing," says Martin.

After the athletes update the group on their individual situations, the facilitators steer the group into a direction that has been mapped out in advance. "Depending on which session it is," says Martin, "they’ll talk about stuff like specific coping skills, grief work, or dealing with the loss of their sport."

The topics can vary depending on the type of athletes in the group, their ages, and where they are in their rehabs. The following are some topics to consider:

Athletes’ Rights: Sometimes, athletes can be confused and scared about their roles and rights during the rehab process. "We have an athletic trainer go in for one session and talk about what the athletes’ rights are in terms of the rehab process," Martin says. "We want each athlete to know what is offered to them and how they can access certain things. Our goal is for them to be well educated on how we can help, and to know that our ultimate goal is for them to get back faster."

Medical Fears: Susan Zaro, MA, MFT, who has facilitated injury support groups at the University of San Francisco and Santa Clara University, addresses athletes’ medical fears as part of her eight-week program. "One of the things I find, particularly among college athletes, is that they’re not confident in what the doctor is doing," says Zaro. "So I try to be direct, telling them, ‘This is your future, and if you don’t have confidence in the doctor or in the process, you need to get a second opinion. You don’t want to go through the rest of your life thinking a doctor screwed up your rehab and your career.’

"Having doubts about whether or not things are going quickly enough, or if the doctor messed up the surgery can affect an athlete’s whole mental outlook in terms of rehabilitation," she continues. "But this is often hard for people to articulate."

Talking to Coaches: At Tennessee, the co-facilitators set aside a session to encourage athletes to maintain communication with their coaches. The athletes learn that keeping in constant contact and providing weekly updates on the progress they are making in rehab are good ways to stay in the coaches’ thoughts and to remain in the team’s long-term plans.

"The athlete-coach interaction is pretty important in terms of injury recovery and teaching the athletes to negotiate the rehab process," says Carter. "I encourage athletes to go to the coach and say, ‘This is what I did in rehab today, this is what the doctor says,’ and really keep the coach updated as a way to keep themselves more involved with the team."

Staying Close to the Team: "It’s not unusual for somebody who has a severe or career-threatening injury to withdraw because they don’t feel like they are part of the team," says Yukelson. "Most of the time they’re working four or five hours a day in the athletic trainers’ room, so their schedules don’t coincide with their teammates’. Plus, they may not be traveling with the team, which only adds to the isolation."

The typical reaction of injured athletes, says Carter, is to feel isolated and think they’re not contributing to the team, even though they’re expected to be at practice. "In our group, we discussed how to be supportive to their teammates who were still playing as well as to help themselves," says Carter. "One thing we found is that people on the team didn’t know much about their injured teammates, as far as when they would be back, and what some setbacks or progress had been going on during their rehab. And you can’t really support somebody unless you know what he or she is going through."

To combat feelings of disconnection, Carter encourages injured athletes to keep up with teammates socially. Yukelson suggests that injured athletes go out of their way to attend practices—even if it’s only for the final half-hour. "When they’re at practice, I might have the injured athletes use imagery techniques to put themselves in the shoes of the athletes who have taken their spot," he adds, "which helps keep them alert while they are there."

Identity Issues: Yukelson says sessions should also teach athletes how to communicate with themselves. When injured, athletes sometimes lose what they perceive as their identity.

"We talk about how the injuries are impacting the athlete directly at that moment," says Yukelson. "We might talk about the quality of his or her relationships and aspects of day-to-day life such as getting around, and how difficult it might be to get to classes. We also talk about irritability—the things that get them angry or frustrated—like not being around teammates as much, not being able to show off athletic prowess.

"Self-talk is a really important skill," continues Yukelson. "That’s when they are reframing problems into things they can control. Our goal is to get the athletes to try to be positive and optimistic even when they’re at a plateau."

Finding Mentors
When setting up one-on-one mentoring programs, the logistics are a bit easier, and the key is finding the right mentor—the sports medicine equivalent of playing matchmaker. It’s a situation where, as an athletic trainer, you know each party and you hope what they have in common will give the injured athlete a peek into the future.

"At Penn State, we have a very strong student-athlete advisory board to represent each of our teams," says Yukelson. "And one of the things they target is peer helping and social support. If somebody gets injured, there are other people there who have been through it already." While the advisory board creates an awareness of peer helping, it is the sports medicine staff that is responsible for fostering a connection.

"You might have a freshman who has sprained her medial collateral ligament, and you have a junior who tore his ACL a year earlier, and because of the injury, they can relate to one another," says Yukelson. "I’ll put them together after practice or when they are both in the training room and ask the athlete who has been through it to share his or her experiences. The mentor will say things like, ‘You’re going to be on crutches for a couple weeks, but you’ll get through this phase.’"

Assessing Success
How do you know if a peer support group is fulfilling its purpose? Feedback isn’t always to easy to gauge. Zaro hands out a questionnaire at the last session asking the athletes to rate the group.

"I ask them, ‘Where are you now?’ and I submit that to the athletic department," says Zaro. "It’s anonymous, but it shows what the athletes think, what the program did, and what the athletes’ responses were."

Aside from written evaluations, there are some indications that a group is working. A couple obvious signs, says Martin, are if the athletes are opening up during the session and if they are happy, doing well in school, and celebrating their successes.

"If somebody is making strides in their rehab, they celebrate," she explains. "If an athlete is able to go back to their sport, they really celebrate. Our philosophy is that if you have a happy athlete, he or she is going to do better—in rehab and in life."




Sidebar: Side By Side
In 1992, Bonnie Siple, MS, ATC, Coordinator for the Athletic Training Education Program and Assistant Professor at Slippery Rock University, was fresh out of college and working for the HealthSouth Corp. Rehab Center in Loraine, Ohio. The clinic worked with 18 area schools and employed three full-time athletic trainers.

"We had a sudden influx of high school-aged athletes who needed to do ACL rehabs," says Siple. "And we saw that they were forming these informal support groups when they were waiting around at the clinic, comparing injuries and their rehab. So we decided to formalize the interaction and start a rehabilitation group."

Siple says the athletic trainers generally reserved the afternoons—from about 4 p.m. to 6 p.m.—for high school patients who were coming in for rehab. "Because the patients were at similar phases in their rehab, we could work them out side by side, and have them all start with the same exercises," she says. "It became a lot more efficient for the staff, and it gave the rehabs a team approach."

After a couple sessions, Siple and her co-workers found that the athletes actually looked forward to coming in for rehab. The reason, she says, is that by facilitating group therapy, the clinic was providing a social outlet for the teenagers.

"They were able to talk about what they were experiencing," says Siple. "It’s one thing for me to say, ‘You’re going to be fine, you’re going to be able to get past this hurdle.’ But for them to hear it from someone their own age, who has gone through the experience, is a lot more powerful than anything I could tell them."

In addition to looking forward to seeing each other, Siple’s patients also provided one another with motivation. "I had a group there that was really competitive, and one athlete would say to another, ‘I have five more degrees of range of motion than you do,’ or ‘Look at me, I can lift five more pounds than I could the other day,’" says Siple. "And that attitude became contagious and pushed them to get better."

When they started, Siple and the other athletic trainers didn’t intend to address the social and psychological aspects of the athletes’ rehab, but the group evolved to encompass those issues. "The athletes would come in, and they’d all be stretching at the same time, and they would just talk to each other," she says. "Someone would say something like, ‘There’s no way I’m ever going to get back to playing basketball,’ or ‘I don’t know how I’m ever going to walk normally again,’ and somebody else would say, ‘No, no, you’re doing great. I remember what it was like. Believe me, you are going to get much stronger very soon!’

"A positive attitude will help athletes manage their pain and motivate them to do their rehab. That’s going to keep them on track," Siple adds. "And I definitely think that the group rehab process facilitated that positive attitude. It helped head off some of the post-surgical depression that is common with these types of injuries."

Siple says one of things that helped make the group setting work was that it restored the athletes’ missing sense of teamwork. "By surrounding them with a group of peers, we tapped into their competitive nature and natural desire to be part of team," she explains.

"It ended up being a really positive experience—for them, and for us as well," Siple adds. "It’s an experience I’ll always remember. I’ve always thought that it was one of the best things that I had ever done in terms of helping athletes get through rehab."