A Mindfulness- and Acceptance-Based Intervention for Injured Athletes

Abstract

The aim of this article is to describe a mindfulness- and acceptance-based intervention as it can be applied to athletes recovering from an acute injury. The intervention consists of two parts: (a) a web-based program where athletes are asked to engage in regular formal mindfulness practices, and (b) four sessions with a practitioner. The content of the intervention is described thoroughly, and I provide recommendations for practitioners who want to intervene with this group of athletes. A central point is to adapt the content of the intervention specifically to the rehabilitation context.

Keywords:

• Acceptance
• acute injury
• life values
• present-moment awareness
• rehabilitation

Injury is a challenging setback that many athletes have to handle during their career. Getting injured often causes a great deal of psychological suffering and is considered one of the sport-specific factors that can increase vulnerability for mental health disorders (e.g., Reardon et al., 2019). It is therefore desirable to provide athletes with evidence-based support to help them cope with the situation. A review investigating psychological interventions in injured athletes showed that such interventions are associated with decreased negative psychological consequences (Schwab Reese et al., 2012). However, most of these interventions were based on psychological skills training (PST; including for example relaxation training, self-talk) with a control-based agenda, which can be problematic for athletes suffering from distress (Gardner & Moore, 2006). Some studies have adopted a mindfulness- and acceptance-based approach when working with injured athletes with promising results (Bennett & Lindsay, 2016, Mahoney & Hanrahan, 2011, Mohammed et al., 2018).

Mindfulness- and Acceptance-Based approaches in sports

Mindfulness- and acceptance-based approaches, such as mindfulness (Kabat-Zinn, 2013) or acceptance and commitment therapy (ACT; Hayes et al., 1999), have become increasingly popular in sport psychology for enhancing performance (e.g., Gardner & Moore, 2020; Henriksen et al., 2019). The central feature of this type of approach is to elaborate a modified relationship with internal experiences (i.e., thoughts, feelings, or bodily sensations), rather than seeking to suppress them or change their form or frequency. By learning to monitor, de-center from and accept one’s inner experiences, the individual develops a healthier relationship to and will be less affected by such experiences, which leaves more room to engage in meaningful behaviors that move the individual toward his/her life values and goals.

In their Monitor and Acceptance Theory, Lindsay and Creswell (2017) proposed attention monitoring and acceptance as the two underlying mechanisms of mindfulness practice and highlight the importance of cultivating both through regular practices. Attention monitoring refers to the ongoing awareness of the present moment, no matter whether this experience is pleasant or not. For the injured athlete, this would mean being able to observe unpleasant thoughts and emotions, as they commonly appear after injuries. Acceptance adds an attitude of openness and non-judgment toward ongoing internal or external events. When there is more acceptance of experiencing unwanted thoughts and emotions and less struggle in avoiding or suppressing them, there is more room to concentrate one’s attention on activities that really matter (Hayes et al., 1999). Exploring one’s life values and breaking them down into committed actions is a central part of ACT and is a recommended intervention for injured athletes (Baranoff & Appaneal, 2020; Moesch & Baltzell, 2020). Connecting to one’s life values and engaging in meaningful actions provides opportunities for positive reinforcement. The removal of positive reinforcement, as may happen through an aversive life event (i.e., an injury that prevents the athlete from engaging in practice, competition and the social aspects connected to sports) is a core component in the development of depression (Martell et al., 2001). As low mood is a common emotional reaction after sport injuries, increasing the possibility to experience positive reinforcement must be an integral part of interventions with injured athletes to prevent depression (Lundqvist & Gustafsson, 2020).

Different interventions are available that practitioners can use to guide mindfulness- and acceptance-based interventions for the athlete population at large. The staple intervention of mindfulness-focused research is Kabat-Zinn (2013) Mindfulness-Based Stress Reduction (MBSR). MBSR, however, is very resource intensive (i.e., weekly meetings, appr. 45 min practice each day and a one-day retreat; see Kabat-Zinn, 2013). Although different mindfulness programs have been developed within the sport context with less-intensive formats, these programs focus mainly on performance enhancement. At the onset of this project, no pre-defined program specifically tailored for injury rehabilitation existed yet. The available information was the description of an ACT-intervention of Shortway et al. (2018), that, though, have not yet been tested in a study, and short descriptions about interventions done in the published articles within this field (e.g., Mohammed et al., 2018).

To fill this gap, the present article describes a mindfulness- and acceptance-based intervention that can be followed when intervening with athletes suffering from an acute injury. The intervention aims to (a) teach athletes mindfulness and acceptance skills to help them handle discomfortable emotions and thoughts that normally arise when injured, and (b) support them identifying their life values and related actions as a guide to a meaningful life. The intervention has been tested with adult team and individual athletes competing at a sub-elite to elite level that suffered from ACL/Achilles tendon ruptures. The results revealed significant increased levels of nonreactivity, acceptance and wellbeing after the onset of the intervention, but no significant changes in awareness and symptoms of anxiety and depression (see Moesch et al., 2020).

Having worked 20 years within elite sports, I (author) have been in contact with many injured athletes, most of them struggling with their fate. Many times, however, resources for professional interventions for this population are limited. My overarching aim was therefore to develop and make available a resource-friendly, yet still personalized enough intervention to support injured athletes. My academic background includes a PhD in sport science and a PhD in psychology. My applied background consists of formal training in sport psychology and in CBT, including ACT and mindfulness. Additionally, I went through an education as a mindfulness instructor. Thus, my professional philosophy is very much informed by the third-wave CBT approach, both when counseling athletes for performance enhancement and for mental health challenges.

Development of the intervention

A review of the existing mindfulness- and acceptance-based interventions was done, specifically interventions for non-athletic populations, interventions for athletes, and interventions related to chronic pain. The knowledge emerging from reviewing this literature guided the development of the present intervention. During the process, meetings were held with two experts in mindfulness (one university lecturer with a background in research and the application of mindfulness within sports and one medical doctor and mindfulness expert), and the inputs and feedback given by these experts were used to further adapt the intervention.

The intervention

The intervention takes place during 8 weeks and includes two different parts, namely mindfulness practice done at home and individual sessions. The sessions will be individual since it is unusual in most sporting environments to enable several injured athletes to join group sessions. In the following, I will describe the two parts in detail.

Mindfulness practice

The injured athletes should engage in regular mindfulness practice. To guide them in this process, an existing web-based program from Mindfulness Center AB (“mindfulness basics”, nowadays called “mindfulness for stress”, see https://learn.mindfulnesscenter.se/p/mindfulness-vid-stress) was used to enable the participants to easily access and listen to the exercises through a mobile device or computer. The program consists of guided 10-minute mindfulness exercises that the injured athlete has to perform twice a day for six days per week, resulting in 960 min mindfulness practice during the intervention. In addition to the mindfulness exercises, a different theme is presented every week and daily activities are encouraged (see Table 1). To do so, a short audio file is given at the beginning of each week, where the week’s theme is introduced, and the daily activities are described. In the middle of the week, a second short audio file is provided to introduce another daily activity and to support participants’ practice. Four formal mindfulness exercises are included in the program: breathing anchors, body scans, mindful yoga (very simple exercises that were possible to be performed by injured athletes) and sitting meditation. For the two exercises that are often practiced (breathing anchor and body scan), different variations are supplied to create variety. This part of the intervention aims at ensuring that the injured athlete regularly practice mindfulness and acceptance. However, this practice is completely decoupled from the athlete’s specific situation (i.e., injury rehabilitation). As it is central to tailor interventions to the target population’s needs and psychological condition, the intervention should also include more context-specific and personalized parts to maximize effectiveness. This is achieved through individual sessions.

Table 1. Overview of the web-based home program.

Week	Theme	Recommended daily exercise (first and second part of each week)	Meditation exercise
Week 1	Taking a break and getting started	Take three breaths when waiting Take three breaths when you get stressed, observe what happens	BS 6 (3) BA 6 (2)
Week 2	Feeling your body	Do a quick body scan in any position Do a quick body scan when lying in bed or on a couch	BS 7 (3) BA 5 (2)
Week 3	Enhancing your concentration	Take some minutes and focus on your breathing: count at the end of every breath, up to 10 Take some minutes and focus on your breathing, follow the complete breath from in- to outbreath, and count after every breath from 1 to 10	BS 6 (3) BA 6 (1)
Week 4	Calming your thinking	Whenever you feel that your attention is split, or you are stressed, do a breathing anchor for some few minutes and whenever your mind wanders taking your attention back to the breath Continue to train breathing anchor in different situation, when you are stressed, get irritated on someone/something, etc	BA 12 (4)
Week 5	Stretching your limits	Become aware of your body’s movement, e.g., when you eat, or when you go up and down the stairs Be mindful of your movements in your daily life, e.g., when you move your arms when eating	BS 3 (2) BA 3 (1) MY 6 (1)
Week 6	Accepting things as they are	Be mindful when something positive happens, e.g., when you meet a loved person, when you eat something tasty, etc. Be mindful when something negative happens, e.g., when you get irritated about something or someone, and see how it feels in your body	BS 6 (3) MY 6 (1)
Week 7	Just sitting	Sit quiet for a little moment, and become aware of your thoughts, and label them into past, present or future, depending on their content Sit quiet for a little moment, and become aware of whatever comes up in your mind, and label it (e.g., thoughts, noise, feelings, etc.)	BA 6 (4) SM 6 (1)
Week 8	SOAL (stop, observe, accept, let go or respond)	Implement SOAL in daily situations Implement SOAL in uncomfortable daily situations	BS 6 (3) SM 6 (1)

Note. BS = body scan; BA = breathing anchor; MY = mindful yoga, SM = sitting meditation; the number beside the exercise shows how often that exercise is done during that week; the number in parenthesis shows the number of different versions of the exercise in the program.

Individual sessions

The intervention comprises four one-hour sessions. The first session is recommended to be held in persona, whereas the upcoming three sessions can be held as online video meetings or in persona. Meetings in persona are recommended to be held in a quiet space (e.g., an office or a closed space in the arena).

All sessions start with an introduction, including a short update on the client’s progress in rehabilitation, a brief review of the previous session (if applicable) and a check of the progress in the web-based program. Likewise, every session finishes with an ending involving a short summary of the session’s content given by the client and additions by the practitioner if needed, a possibility for the client to ask questions and a short discussion about how and when practice with the web-based program can be done until the next meeting. The introduction and ending take about 5–8 min each and will not be further described.

In every session, the main context of application is injury rehabilitation (e.g., how to implement a mindful stance during rehabilitation activities). However, the discussion is also expanded to include how to apply the concepts in focus or the lesson learned from an exercise in a performance as well as a daily life context. The purpose is to broaden the application of the learned skill to other areas of life relevant to the client. The expectation is to enhance the motivation for the intervention, so that clients can see a further benefit beyond injury rehabilitation. Below, the four sessions are explained in greater detail (an overview of the four sessions is available in Appendix 1).

Session 1

Timepoint: At the beginning of the intervention

Content: Mindfulness, attention control and defusion

Psychoeducation/discussion points: Clients are introduced to Kabat-Zinn (2013) definition of mindfulness, and the different parts of this definition are discussed. A picture showing a mindful and a “mindfull” person on a walk (easily found with a search on the internet) is presented to the clients and a discussion is held on these two different states. The mindful person is experiencing what is going on at a given moment; while the mindfull person is occupied with thoughts that are not connected with the present moment. In this context, the concept of the autopilot is introduced (e.g., when individuals perform tasks without purposeful attention). The practitioner inquiries about clients’ experiences of these two kinds of state and about their perception of which of these states might be more beneficial for exercise fidelity in rehabilitation, for performance contexts and for everyday activities. Toward the end of the session, the discussion moves on to the question of how to handle difficult and unwanted thoughts. Three alternatives are introduced and discussed: suppressing thoughts, changing them into more positive thoughts or accepting and seeing them as thoughts but not facts - a technique known as defusion. The practitioner provided possibilities to engage in defusion, such as labeling thoughts or seeing them as clouds in the sky and explained how defusion can be implemented in rehabilitation and competitive situations.

Exercise: The raisin exercise (Kabat-Zinn, 2013) is done after introducing the concept of mindfulness. The practitioner instructs the client to carefully examine the raisin with several senses (seeing, hearing, smelling), before slowly chewing on the raisin and swallowing it. After the completion of the exercise, the client’s experience of the exercise is explored and discussed.

Session 2

Timepoint: Two weeks into the intervention

Content: Body awareness and life values

Psychoeducation/discussion: Clients are introduced to the concept of body awareness. Bodily symptoms are messages from the body telling us how it is doing and what it currently needs. Clients are introduced to attending to such symptoms without judging or interpreting them, a skill that is specifically put into focus in the body scan exercise. A discussion on the importance of mindfully attending to such symptoms is held, and specific focus is laid on how this can increase the quality of injury rehabilitation. Clients are then educated about what values are, and about the difference between goals (which most athletes easily can relate to) and values. After the exercise (see below), a discussion is held on benefits of defining one’s values.

Exercise: An eye-closed exercise is done, where clients are asked to imagine their 80th birthday and what they want to hear from the speeches of three significant others talking about them. The exercise provides answers to the question what kind of persons the clients want to be and what is important to them, which gives insights into their life values (Harris, 2019). Clients are then asked to note down the most important parts of these speeches and to try to formulate these as life values (i.e., with single words, or in very short sentences). To help them with this, a list of common life values is provided where clients could get inspiration to formulate their ideas.

Session 3

Timepoint: Five weeks into the intervention

Content: Committed action and acceptance

Psychoeducation/discussion: Clients are educated about the importance of breaking down values into more concrete behaviors to activate values in daily life. A discussion is held about the impact of having clearly defined actions for the rehabilitation period. After the exercise (see below), the practitioner explains that we can choose the values-driven path (engaging in meaningful actions, such as the ones defined by the athlete in the exercise, and doing so whilst experiencing possible discomfort) or the avoidance-driven path (engaging in activities that help to avoid discomfort in the short run but also lead away from values; see Reinebo et al., 2019). Clients are asked to give examples from situations in their rehabilitation and past competitions when following either the avoidance-driven or the values-driven path. Acceptance is then introduced to the clients as a key concept, and a discussion is held on the importance of accepting unpleasant internal and external experience and simultaneously engage in meaningful action.

Exercise: On a worksheet, clients are asked to describe their life values and then note down concrete actions (=committed actions) related to their different values. To make the step toward concrete actions as easy as possible, clients are instructed to answer the question “What’s the smallest, simplest, easiest step you can take in the next 24 h that will take you a bit further toward that valued direction?”. The practitioner can assist those who have difficulties defining concrete actions or if the proposed actions are too vague or difficult to implement in daily life.

Session 4

Timepoint: At the end of the intervention

Content: Open awareness and handling difficult situations

Psychoeducation/discussion: The concept of open awareness is introduced to the clients. As it is a difficult concept to grasp, a comparison is made between the initial meditation practices where focus was laid on a specific stimulus (e.g., the breath) and open awareness, which includes being aware of whatever unfolds in a given situation. A discussion is held on how this concept can be applied to injury rehabilitation. Based on the exercise (see below), the client and practitioner discuss the possibility of responding optimally in a stressful situation, drawing on example situations that the client has experienced in rehabilitation. Toward the end of the session, the athlete is asked to summarize all aspects touched upon during the intervention, and the practitioner adds whatever might have been missed. Lastly, a discussion is held on how the athlete can maintain working with mindfulness and acceptance in the future.

Exercise: The SOAL exercise (Stop, Observe, Accept, Let go or react; introduced in the web-based program) is presented during this session. Going through the four steps makes athletes better prepared to respond wisely in stressful situations instead of reacting mindlessly.

Personal reflections

The intervention was well received by the athletes, as stated both in the anonymous evaluation (Moesch et al., 2020) and in the fact that there was no attrition among the participants. Different reflections emerged that I want to share: The concepts of life values and committed action were highly meaningful for the athletes, as shown in their strong engagement in these activities and in the long mutual discussions. This is a relatively concrete intervention whose benefit is immediately apparent to the athletes. Identifying one’s life values and committed actions increases athletes’ chances of engaging in meaningful behaviors, a way of behavior activation which is considered an important intervention to prevent depression (Lundqvist & Gustafsson, 2020).

The concept of acceptance also seems very meaningful for this specific population. As this part of the intervention was mainly theoretical (involving psychoeducation and discussion) it might be beneficial to include experiential exercises. There are many exercises that can be done together with the client (see Harris, 2019), which I believe would be a fruitful addition to session 3.

On the other side, I experienced that more diffuse concepts, such as body awareness and open awareness, were more difficult for the athletes to grasp, as revealed in their lower degree of engagement. As these concepts are covered in the mindfulness exercises, they may not need to be explicitly stated in the intervention.

A challenge for this (and similar) intervention is to create motivation to ensure that athletes adhere to the mindfulness training. Many athletes did an excellent job following the script recommended in the web-based program (some of them reaching the total amount of 960 min; see Moesch et al., 2020), while for some it seemed difficult to adhere to two mindfulness sessions per day. Even though the dose-response issue is still unclear, Creswell (2017) assumed that larger doses are likely to produce larger effects up to a (still unknown) upper limit dose. Having the athletes engage in vigorous mindfulness practice still seems meaningful to this population for developing a sound mindful stance within the timeframe of the intervention. Therefore, I believe that it is crucial that the practitioner puts effort in targeting adherence (e.g., by helping athletes schedule their practice, discussing possible barriers to practicing and helping them to find solutions) and motivation (e.g., by emphasizing that they can benefit from the intervention also for performance enhancement).

Recommendations

Based on my experience with the intervention, and with regard to the results presented in Moesch et al. (2020), I want to conclude with some recommendations for practitioners who want to implement the intervention. Regarding the timing of the intervention, I recommend starting with the intervention as early as possible in the injury process. As the strongest emotional reactions are shown for athletes right after the injury occurs, athletes need, specifically in this initial phase, to learn ways of relating to difficult experiences (e.g., pain, sadness, negative thinking).

When it comes to the target population, the presented intervention has been specifically developed for and implemented with athletes suffering from acute injuries. Athletes suffering from overuse injury face different challenges (e.g., insecurity about timeframe, no clear diagnosis), which are not targeted in this intervention. However, I see no counter indication in testing this intervention with athletes suffering from overuse injury and recommend that in that case practitioners adapt the content of the discussions to suit the specific needs and challenges of athletes suffering from overuse injuries.

Regarding the format of the intervention, an individual set-up is advantageous for several reasons: (a) not all athletes like to express their feelings, thoughts, and values in front of a group; (b) it makes it easier to apply the intervention at a suitable timepoint in the athletes’ rehabilitation; (c) it makes it easier for the practitioner to take time for and respond to personal issues and discuss specific situations. Recognizing the usefulness of group interventions for being more resource-friendly, I believe that the present format, with most of the training done individually with the web-based program and only four face-to-face sessions needed, is still reasonable with reference to work resource per athlete.

In the present intervention, a specific web-based program is used. Similar programs are available in English and in other languages. I recommend that practitioners either look out for similar programs available in their language, use registered audio files that the clients can listen to at home, or refer clients to using apps (e.g., Headspace, Calm, Smiling Mind) to be able to fulfill the basic mindfulness training. To increase athlete’s motivation to engage in the intervention and in the mindfulness practice that should be done alone, it can be helpful to clarify that mindfulness- and acceptance-based techniques are also helpful in other contexts, for example in competitive situations.

As raised in Myall et al. (2023), mindfulness- and acceptance-based interventions should be delivered by qualified practitioners. This should include formal training in either ACT and/or mindfulness. Further, I recommend that practitioners implementing this intervention have a thorough background in psychological counseling, as well as good knowledge of the competitive sport context (e.g., through academic training in sport psychology). The latter is important to fully understand the context in which athletes are living and the challenges they encounter when dealing with injuries.

Acknowledgment

The author wants to thank Ola Schenström and Torbjörn Josefsson for their input and feedback during the development of the intervention.

Disclosure statement

The author has no conflicts of interest to disclose.

Appendix 1.

Content of individual sessions

Table

Session number	Session Goals	Session Outline
Session 1 (at the beginning of the intervention)	- Introduction to the intervention, practical information about how to proceed with the program - Understanding the concept of mindfulness, and its application to injury rehabilitation and sport performance - Understanding concentration and attention (relevant cues, maintaining focus, ability to shift, the wandering mind), handling of thoughts, and how this relates to injury rehabilitation and sport performance	- Introduction to the intervention and practical information (10 min) - Introduction to mindfulness & applications in sport and injury rehabilitation: discussing definition of Jon Kabat-Zinn; discussing picture with mindful vs mindfull state; introducing autopilot; mindfulness to be able to act purposeful in the break between stimulus and response (15 min) - Raisin exercise to learn how our mind can stay or wander; debriefing (15 min) - Discussion about thoughts and how to handle them: noticing thoughts instead of being caught in thoughts or trying to get rid of them (10 min) - Ending: summary, check for participants comprehension of content, discuss how to implement home exercise into daily life (5 min)
Session 2 (2 weeks into the intervention)	- Understanding body awareness, and its connection to attention - Understanding the impact of body awareness in relation to injury rehabilitation and sport performance - Clarify values for sport and life; and understand benefit for values in relation to injury rehabilitation and sport performance	- Review last session, reply to questions, ask about use of learned skills, discuss home program (5 min) - Discussion about body awareness: being in the body versus being in the mind, impact of the “cognitive filter” to bias our experience, discussion about the potential benefit of being aware of bodily signals in injury rehabilitation and in competitive life (10 min) - Introduction to values and committed actions: what are values, and what is the difference to goals; benefit to work with values in our lives (10 min) - Exercise “write your speech”: start with a breathing anchor, then visualize your 80^th birthday and see three close friends/family members having a speech about you and your life: how will you be remembered? What would you most of all like to hear in these speeches? Discussion about exercise, and follow-up questions to help participants identify values (15-20 min) - Discussion: how can you relate values to injury rehabilitation and sport performance? (5 min) - Ending: summary, check for participants comprehension of content, discuss how to hold motivation for home exercise (5 min)
Session 3 (5 weeks into the intervention)	- Define committed actions connected to values - Understanding the difference between avoidance and acceptance of inner experiences; and relate to the context of sport injury rehabilitation and sport performance - Understand the link between acceptance and engaging in valued behaviors	- Review last session, reply to questions, ask about use of learned skills, discuss home program (5 min) - Recall athletes’ life values, and help participants define concrete behaviors connected to these values (=committed actions); participant fills in form; short discussion about negative reinforcement, and how this mechanism can lead to an avoidance-driven life instead of a values-driven life (20 min) - Introducing the concept of acceptance, and explain what it is and what it is not (10-15 min) - Discussion about the link between acceptance of inner experiences and a values-driven life; discuss possible barriers that can hinder the participants to commit to their actions (10 min) - Discussion about the impact of acceptance in injury rehabilitation and performance (10 min) - Ending: summary, check for participants comprehension of content, discuss how to hold motivation for home exercise (5 min)
Session 4 (at the end of the intervention, around week 8)	- Understanding the concept of open awareness, and its relation to living in the present moment (versus living in the past or in the future) - Understanding the link between open awareness and injury rehabilitation and sport performance - Summarizing all aspects that have been mentioned, using the acronym SOAL (stop, observe, accept, let go or answer) as a process model - Reflection on how to continue practicing mindfulness	- Review last session, reply to questions, ask about use of learned skills, discuss home program (5 min) - Introducing open awareness, discuss link to injury rehabilitation and sport performance (15 min) - Discussion about the SOAL exercise as a possibility to use in difficult daily situations (10min) - Summary of intervention: ask participants to summarize what has been learned; practitioner completes if necessary; discussion about the different parts and how they can be implemented in injury rehab and for performance enhancement when back from injury (15 min) - Discussion about how to maintain regular mindfulness training (10 min) - Ending: summary, check for participants comprehension of content, explain further steps in study (5 min)