Psychological Considerations for Paralympic Athletes
Summary and Keywords
The Paralympics are the pinnacle of sporting competition for athletes with physical and intellectual impairments. Most Paralympians have intellectual or sensory (e.g., visual) or physical (e.g., amputation, spinal cord injury, cerebral palsy) impairments. The Paralympics have become increasingly competitive and larger over the years as they have grown from two countries and 150 athletes in 1952 to 150 countries and about 4,000 athletes in 2012. In the last 10 to 20 years there has been significant interest and growth in the psychology of Paralympic athletes. Researchers are slowly starting to support the value of psychological skills training. Typically, a humanistic personal developmental model that equally values athletes’ well-being and their athletic performance has been advocated. Understanding the various influences on performance and well-being specifically for Paralympians is particularly important given the stress of the Paralympic experience. Research on Paralympians has focused on foundational qualities, which are psychological factors, such as feelings of control, self-awareness, self-esteem, and personality factors. Often these foundation qualities are framed as having an indirect influence on performance through factors like training quality and lifestyle choices (e.g., alcohol consumption).
In additional to foundational qualities, a second area of research targets the psychological methods that are used to develop mental skills and qualities. For instance, competition plans, positive self-talk, and goal setting are all methods used to enhance positive thoughts (e.g., confidence) and reduce negative affect (e.g., anxiety). A third area of focus has to do with facilitative and debilitative factors that influence Paralympic performance. For instance, many Paralympians have to manage chronic pain and avoid overtraining and injury. Many Paralympians have difficulty training, as sport facilities are not always accessible for training. Travel to competition sites, especially involving air travel (with effects such as jet lag), is particularly challenging and can negatively influence performance. Sleeping in the Paralympic village can also be difficult, with many athletes reporting inferior sleep quality. Finally, a small body of research has examined the challenges Paralympians face when retiring from sport.
The Paralympics, similar to the Olympics, are the pinnacle of sporting competition for athletes with sensory (e.g., visual), physical (e.g., amputation, spinal cord injury, cerebral palsy), or intellectual impairments. After a brief primer on the Paralympics, the major purpose of the following is to discuss the psychology of Paralympians. Many readers likely participate in or enjoying watching sport, see tremendous value in it, and admire elite athletes for their skill, accomplishments, and dedication. The able-bodied reader might be understandably surprised to realize that the Paralympics don’t enjoy universal acceptance, particularly among disability activists. The socio-cultural story of disability includes a history of marginalization and discrimination that is still present in the early 21st century. Rates of poverty, mental illness, victimization, loneliness, and depression are all higher among people with disabilities relative to nondisabled individuals (Watson, Roulstone, & Thomas, 2013). Within this context it is perhaps understandable to see how advocates for individuals with disabilities are dubious of the value of the Paralympics.
One observation of Paralympic television coverage is that an inaccurate stereotype of people with disabilities as ill and flawed is simply substituted with another inaccurate stereotype of the Supercrip hero: someone who “overcomes” their disability. Other individuals note that seeing Paralympians achieve outstanding athletic accomplishments might cause people to develop unrealistic expectations of what non-Paralympic individuals with disabilities can achieve by simply working hard. Hence, a potential paradox exists in which the empowerment of Paralympians results in the disempowerment of other disabled individuals. Of course how Paralympians are portrayed or how other people perceive Paralympians is beyond their control and they certainly cannot be faulted for their athletic accomplishments or the un-intended consequences that result from those accomplishments.
Disability activists are concerned with bettering the lives of all individuals with disabilities and reasonably question whether a two-week event, held every four years, can further that goal. The above consideration is also juxtaposed with the enormous amounts of money that are spent on the Paralympics, which are often seen as better spent on improving things like inadequate housing, education, and transportation. Other critics support the Paralympics but not how they are implemented. Bredahl (2011) reports that Paralympic funding by most countries is linked to their ability to win medals. Hence, from a purely economic and medal perspective, athletes with less severe disabilities who do not need a personal care attendant are favored and athletes with severe disabilities who need a personal care attendant face reduced opportunities. The above overview does not do justice to a controversial topic rife with complexities. However, the goal of presenting the above nonsport psychology information is to alert the reader to a complex and nuanced view of the Paralympics that often goes unspoken—particularly in a review of the psychology of Paralympians.
In regard to the major purpose of the following review, the last 10–20 years reveal significant interest and growth in disability sport psychology. Both applied and research-focused sport psychologists have begun to work with and learn about the psychological dynamics undergirding the training and performance of Paralympic athletes. Researchers are slowly starting to support the value of psychological skills training (PST) and examine the links between various psychological factors and then with performance (e.g., Martin & Malone, 2013; Martin, Malone, & Hilyer, 2011). Support for the importance of PST is best expressed by the following six of brief quotes by an elite wheelchair water-skiing athlete who had engaged in a two-month PST program (de Bressy de Guast, Golby, Van Wersch, & d’Arripe-Longueville, 2013).
I believe even more in my abilities. It’s not a dream anymore, now I know I can achieve.
I’m at ease with my new routine; it gave me a better feeling of control over my environment, which also improves self-confidence on the day of the event.
This new general positive feeling about myself and competing helps me to express my real abilities and perform at my true level.
Planning how to deal with injuries was a good thing to do, I now feel more confident about the future.
I use my fear as a positive motor, a strong boost. Jumping is again becoming a good thrill.
Thanks to visualization, I’ve improved the link between feelings and techniques.
(de Bressy de Guast et al., 2013, pp. 352–356)
The above quotations illustrate PST benefits for confidence, control, self-esteem, and injury management, as well as the value in learning how to reframe negative emotions and implementing imagery use. According to United States Olympic Sport Psychologist Sean McCann (2008), “everything is a performance issue at the Olympic (Paralympic) Games.” McCann’s quote, anecdotal reports from Paralympians, and previous commentaries (Martin, 1999b, 2012a, 2012b; Martin & Wheeler, 2011) and research (Martin, 2002, 2008; Martin et al., 2011) all point toward a variety of psychological (e.g., resilience), social (e.g., coach behavior), and environmental influences (e.g., training facilities) on Paralympians well-being and performance.
Given the above perspective, the current chapter is structured around a humanistic personal developmental model that values athlete’s well-being and their athletic performance equally well. Additionally such a perspective views well-being and performance as complementary influences on each other. The focus on biopsychosocial influences is commensurate with the social-relational model1 of disability (Martin, 2013). Additionally, it is important to indicate that psychological research focused on individual psychological qualities (e.g., self-efficacy, resilience) is not synonymous with a medical model view that a person with a disability is flawed as suggested by Townsend and colleagues (Townsend, Smith, & Cushion, 2016). In fact, many sport psychology research endeavors are implicitly aligned with an affirmation model of disability sport. The current personal developmental model has been employed before (e.g., Martin, 1999b, 2012b). The following sections concern foundation qualities, psychological methods and skills, and facilitative and debilitative factors (see Figure 1). Research with athletes with intellectual impairments (II) is sparse and eclectic. However, a small body of knowledge is presented in the last section because these athletes are back competing in the Paralympics after a 12-year absence and athletes with II have often been ignored in previous reviews of elite athletes with impairments (e.g., Martin & Wheeler, 2011).
Understanding the various influences on performance and well-being specifically for Paralympians and potential Paralympians is particularly important because, in the words of British Sport Psychologist Jonathon Katz, the Paralympic experience is:
an intense, exciting, unremitting emotional roller coaster. It is also unforgiving and abrasive …
(Katz, 2007, p. 28)
Katz also reported that at the 2004 Athens Paralympic Games the two most common presenting issues were interpersonal (21%) and performance preparation issues (18%), providing further evidence that athletes have to prepare to manage challenges that on the surface are unrelated to their sport, yet can undoubtedly influence their performance. At the same time it is important to acknowledge that many Paralympians are satisfied with their experience at the Paralympic Games. For example, 250 Paralympians at the 2012 Games in London were asked to rate their experience across a host of Paralympic activities. Respondents rated their impression as “satisfied” to “very satisfied” for the following: the Paralympic village, transportation (e.g., from the airport), food, interactions with volunteers and staff, competition sites; various ceremonies, precompetition information, healthcare, and antidoping. These ratings do not reflect athlete’s performance or their ability to cope but reflect structural and organizational assessments that might have indirect performance implications.
The development of strong psychological skills will also be increasingly important in the future as the Paralympics is also becoming larger and more competitive. For instance, the Paralympics have grown from two countries and 150 athletes in 1952 to 150 countries and about 4,000 athletes in 2012 (Gold & Gold, 2007). The above statistics are also indicative of the increasing difficulty of making a Paralympic team. Hence, young Paralympians who make a 2016 team, for example, may find it much more difficult to make the 2020 team. Coaches have perceived that some experienced athletes have struggled with the increased expectations relative to the past when making a Paralympic team was easier. In practical terms, coaches noted that athletes struggled with adapting to practicing only a few times a week to regular individual daily workouts in addition to official team practices (Tawse, Bloom, Sabiston, & Reid, 2012). Objective measures such as world and Paralympic records and Paralympic winning times all show improvement over time (Prystupa, Prystupa, & Bolach, 2006). For instance, across the diverse events of powerlifting, the 50 meter swim, 100 meter run, long jump, and throws, most performances generally improved in a linear fashion across three Paralympics (i.e., 1996 to 2004; Prystupa et al., 2006). With this background in mind, the next section discusses foundational qualities.
Foundational qualities refer to non-sport-specific psychological factors such as feelings of control and self-worth. Typically, foundation qualities do not directly influence performance but often have an indirect impact through other behaviors such as training quality and lifestyle choices (e.g., alcohol consumption: Martin, 2012b). One foundational quality is self-determination and the notion that people need to feel in charge of their own lives. Many people with disabilities report feelings of powerlessness and invisibility as seen, for example, in the experience of one person with disability: “if you go to the supermarkets the older assistants just talk to the person beside you and often to my husband and not me.” Similarly, another person noted: “I went to the TV shop with my father and the shop keeper spoke to my dad while I was the customer” (Edwards & Imrie, 2003, p. 55). Fortunately, participation in disability sport and success and failure experiences can promote feelings of both empowerment and autonomy. Feelings of self-determination can also contribute to Paralympians ability to manage the stress of the Paralympics. In a study of Korean Paralympians, coaches were trained to be supportive of the athletes’ autonomy in the two months prior to the 2012 London Paralympics (Cheon, Reeve, Lee, & Lee, 2015). The results indicated that the athletes playing on the teams with coaches who received training grounded in self-determination theory (SDT) perceived an increase in autonomy support and a decrease in feeling controlled. In contrast, the control group of athletes playing for coaches who received no training experienced a decrease in autonomy support and an increase in feeling controlled (Cheon et al., 2015). Athletes who had coaches who undertook the training also outperformed control group athletes, as they won 27 medals, whereas control group athletes won 4 medals. Given the soundness of the research design (i.e., coaches were randomly assigned to the intervention and control groups), the above findings are encouraging as they support the role of self-determination.
A second foundational quality is self-esteem. Athletes with disabilities, including Paralympians, may experience challenges to developing and maintaining healthy self-esteem. Athletes often have to manage both the presence of negative feedback and the absence of affirming feedback. Additionally, people with disabilities may have a tendency to engage in unfavorable (i.e., in terms of functionality) comparisons to able-bodied individuals, which can have negative self-esteem ramifications (Buunk, Zurriaga, & González, 2006; Schulz & Decker, 1985). Well-meaning encouragement in the form of “Supercrip” compliments appear positive, but can mask a patronizing attitude toward disability and ignore the athletic accomplishment.
“Supercrip” refers to a stereotype that people with disabilities are heroes for participating in everyday common life activities such as going shopping. The Supercrip identity also suggests that important achievements (e.g., winning a Paralympic medal) indicate that a person has “overcome” their disability. However, most people with disabilities do not view themselves as heroes by simply living their lives. Furthermore, people with disabilities often view disability as part of their identity and they do not view disability as something separate from themselves that they need to defeat to have success in sport or life (Martin, 2015). Until the public develops sufficient awareness and knowledge of disability, athletes with disabilities may have to develop coping skills (e.g., not to personalize such comments) to ensure such comments do not unduly cause frustration.
The third foundational quality refers to self-awareness as it is often thought to be valuable in promoting optimal well-being. A contemporary definition of self-awareness is self-knowledge of feelings (e.g., annoyance versus anger) and thoughts (e.g., goals) and how they impact behavior (Martin, 1999b, 2012b). All athletes (able-bodied and disabled) have common sport motivations such as wanting to win and to perform well. However, individuals with disabilities may develop goals linked to their disability. For instance, athletes have reported wanting to be acknowledged as both normal and beyond normal. Self-advocacy, fighting marginalization, promoting the disability sport movement, and developing a new disabled identity are motivations that are typically not found in able-bodied athletes, although certainly the Olympics has been the site of many social statements (e.g., the 1968 human rights salute: Smith & Steele, 2008).
Paralympians from Bermuda and Ghana reported motivations such as a sense of civic responsibility and a desire to give back to their community by helping to provide sporting opportunities to other athletes with impairments (Forber-Pratt, 2015). Understanding and clarifying such motivations may promote well-being and contribute to an athlete’s sport experiences in ways that exceed the achievement of sport goals. The above conceptualization is consistent with a eudaemonia perspective, which means happiness is based on finding meaning in life. Finding meaning in life is critical to well-being particularly when life meaning is grounded in overcoming difficulties (e.g., adjusting to a spinal cord injury (SCI); Ryff & Singer, 2008).
The last and fourth foundation quality, personality, is a new addition relative to Martin’s (1999b, 2012b) model. Personality is a relatively stable characteristic that is also thought to aid performance indirectly. The USA Paralympic gold medal (2004) women’s basketball team were more tough-minded and less anxious compared to the elite women who were the last athletes to be cut from the team at the national selection camp (Martin et al., 2011). The authors speculated that greater emotional stability (i.e., less anxiety) and resilience (i.e., mental toughness) may have contributed to superior practice prior to the Paralympic Games and optimal performance during the selection camp. Sensation seeking is also viewed as a personality characteristic (Zuckerman, 1994). Preliminary evidence suggests that some athletes with disabilities are motivated to explore the outdoors (e.g., skiing) because of the risk involved. Although little is known about sensation seeking in Paralympians, it is certainly plausible that some risky Paralympic winter sports (e.g., snowboarding and skiing) may attract athletes because of the danger involved. If the above observation has merit, athletes should consider whether they are prone to taking unnecessary risks inside and outside of sport.
Finally, a host of positive psychological constructs are also often portrayed as stable personality like traits and referred to as “personality-trait-like individual differences” (PTLID; Laborde, Guillén, & Mosley, 2016). In a recent study, Martin and colleagues examined the ability of grit, hardiness, and resilience to predict both life quality and sport engagement in wheelchair basketball athletes competing at a national level with Paralympic aspirations (Martin, Byrd, Watts, & Dent, 2015). Resilience, the ability to cope with stressors and manage difficult life situations, predicted both life quality and sport engagement. Grit, the compassionate commitment to long-term goals also helped predict sport engagement but was unrelated to life satisfaction. Hardiness, while unrelated to sport engagement, helped predict life satisfaction. The differential pattern of results involving three positive psychology constructs (i.e., grit, hardiness and resilience) in predicting life satisfaction and sport engagement suggests the potential benefits of these trait like qualities vary depending on the outcome targeted. In concluding this section, from a personal development model, foundation qualities are considered critical indirect performance influences and direct influences on quality of life. The next section discusses psychological methods.
In the following section, common psychological methods that are often used to directly improve performance and develop mental skills and qualities are described. In turn, enhanced mental skills and qualities are thought to aid outcome goals such as winning via improved performance.
Athletes with disabilities often need to anticipate difficulties in order to plan ahead. For example, at the Athens Paralympic Games, a sport psychologist anticipated needing a farrier to help the equestrian athletes. When a horse lost a shoe, such foresight proved prescient. All athletes benefit from becoming familiar with their competition sites. Familiarity helps athletes approximate the comfort of a home court or field and reduce the uncertainty that can cause anxiety. If physically accessing a location prior to competition is difficult, visual images (e.g., DVDs, pictures) can be helpful. Knowing where the headwinds and hills are on a marathon course can be helpful in developing a race plan for wheelchair marathoners. Additionally, mapping out where the turns are can ensure that wheelers traverse the shortest distance by always wheeling the tangents on a course (i.e., similar to bike and car racers). Understanding the nuances of a competitive setting, such as how the puck bounces off the end boards of an ice rink, is important for Paralympic sledge hockey players. In sports like sledge hockey, matching lines with the opponent is a strategy often used in professional able-bodied ice hockey that can provide a competitive edge (Walter & Johnston, 2010). Finally, in team sports it is important to understand your teammate’s strengths and weaknesses. A Paralympic athlete reported that because his team had such good team unity he knew that a teammate had a weaker left hand and therefore he should pass to his right hand (Caron, Bloom, Loughead, & Hoffman, 2016).
Positive and calming self-talk (e.g., smooth and steady) or energizing positive self-talk (e.g., go hard) can help athletes with disabilities modulate their energy up or down as needed. Self-talk can also be used for correct technique. For example, an archer might say to herself “Keep arm up” to prevent dropping the arm when fatigued. As a result of a PST program Paralympic wheelchair basketball players learned to become less self-critical (Henschen, Horvat, & Roswal, 1992). Negative self-talk surrounding past mistakes or potential negative future outcomes can divert athletes’ focus away from the present and “being in the moment.” In brief, the ability to recognize and reduce negative self-talk can have significant performance benefits. Mindfulness training has not been examined with Paralympians but has been supported in work with able-bodied athletes (Gardner & Moore, 2012). Mindfulness may be particularly suitable for athletes still struggling with identity issues related to becoming disabled or retirement issues, as it has also been an effective approach for clinical syndromes.
Goal setting is a robust and well-supported self-regulation skill across diverse settings. Effective goal-setting principles such as setting realistic and challenging goals are important to follow. Developing process (e.g., pull through the water), performance (e.g., swimming a personal best time), and outcome goals (e.g., finishing in the top 10) is also important. Finding social support for goals (e.g., from friends, spouse) and the development of short-, medium-, and long-term goals are both goal-setting strategies with sound research support. Having a flexible hierarchy of goals is important to allow for the influence of uncontrollable events (e.g., illness). Training goals, in addition to competitive goals, are important. Competitive (e.g., goalball, soccer) offensive and defensive goals can be set to take advantage of opponents’ weaknesses and to minimize their strengths, and such goals will likely vary on a game-to-game basis.
Athletes usually need to be confident in their fitness and ability in order to effectively taper for Paralympic competition. A meta-analysis of tapering procedures suggests reducing training volume by about 50% over a two-week period is best (Bosquet, Montpetit, Arvisais, & Mujika, 2007). However, the authors of a study of Paralympic swimmers suggested a larger than normal reduction in training volume during the taper may be best in order to elicit better performance (Fulton, Pyne, Hopkins, & Burkett, 2010). Athletes with disabilities should also set nutritional goals (Broad, 2014). Goals that advance lifestyle practices commensurate with an athletic lifestyle (e.g., adequate sleep, limiting alcohol consumption) are also valuable. In addition to individual goals, there is Paralympic research suggesting that team goals are also important:
Making the goals together is really good for team cohesion as everyone wants to have a say and it’s good to hear everyone’s thoughts.
(Falcão, Bloom, & Loughead, 2015, p. 213)
Although there is limited Paralympic research on team cohesion, a plethora of sport psychology research suggests that cohesion and performance enjoy a reciprocal relationship (Carron, Colman, Wheeler, & Stevens, 2002). In the next section, the most common psychological skills thought to influence training and competition are discussed.
Psychological Skills and Qualities
Psychological skills and qualities are valuable for performance-enhancement reasons and for motivational reasons that may minimize premature sport retirement. For example, in a study of elite level Paralympic wheelchair rugby players, comprehensive mental skills predicted athlete’s sport engagement (Martin & Malone, 2013). Athletes with strong mental skills (e.g., ability to concentrate, cope with adversity) were more likely to report being dedicated and enthused about their sport compared to athletes with weaker mental skills. This section elaborates on positive cognitions (i.e., self-efficacy), affect (i.e., mood), and negative affect (i.e., anxiety).
Self-efficacy is a form of situation- and task-specific self-confidence and has been researched extensively with able-bodied athletes. Self-efficacy for both training and performance, and efficacy for overcoming barriers to successful racing are positively linked to performance among wheelchair road racers (Martin, 2002). In a similar study (Martin, 2008), positive relationships were also found among training efficacy, performance self-efficacy, thought control self-efficacy, and resiliency self-efficacy with wheelchair basketball players. Both studies supported the generalizability of efficacy cognitions and relationships with affect. Finally, psychological skills, self-efficacy, and performance have all been positively associated in 15 elite amputee male soccer players participating in the Amputee World Cup. In summary, correlational research has supported the value of self-efficacy for elite-level disability sport athletes.
In a series of three related studies with British Paralympic wheelchair athletes, 10 major sources of stress have been identified (Campbell & Jones, 1997, 2002a, 2002b). Paralympians were concerned about precompetition issues (e.g., poor fitness), poor competition preparation (e.g., malfunctioning equipment), on-court worries (e.g., playing out of position), after-competition stress (e.g., losing), negative aspects of a major event (e.g., not sleeping well), poor team cohesion (e.g., leadership vacuum), negative coaching behaviors (e.g., demeaning comments), relationship issues (e.g., concern over partner being alone), the demands of sport (e.g., cost of newest technology), and the lack of disability awareness (e.g., inaccessible bathrooms and showers). Athletes dealt with unique sport stressors, disability-related stress, and common sport worries.
In the final study in this line of research, Campbell and Jones (2002b) had athletes cognitively appraise their stress levels. Athletes who perceived stressors as challenging viewed the same stressors as controllable. This finding affirmed the value of framing stressful events as challenges instead of unmanageable difficulties. Athletes who viewed stressors as severe were also likely to rate them as threatening and harmful. Negative coaching and relationship issues, and the costs of wheelchair basketball were the most severe stressors. Finally, the demands of wheelchair basketball were the most frequent stressors. In summary, elite athletes with disabilities experience both sport-specific and disability-specific anxiety.
Mood states have been one of the more commonly researched topics in disability sport with a goal of determining if athletes report an “iceberg profile” indicative of positive mental health. The iceberg profile is characterized by scores above the norm for vigor and below the norm for anger, confusion, depressed mood, fatigue, and tension. In other words a healthy iceberg profile is more about a lack of negative moods compared to an abundance of positive moods.
In general, athletes have exhibited iceberg profiles, indicative of mental health. Mood responses have also been assessed during an intervention program designed to teach athletes coping skills. Of the 24 athletes invited to try out for the USA Paralympic basketball team, all reported a positive mental health profile. However, the nine athletes selected for the team reported less tension and anger compared to the 15 athletes who did not make the team. Mood responses among elite athletes with cerebral palsy have also been investigated. Athletes reported a decrease in tension and anger from the start to the end of the six-day camp, followed by an increase in tension and anger one month later at the Paralympic trials. Further, a comparison has been done of 75 male, visually impaired and 46 sighted beep baseball players competing in the World Series of beep baseball.
Visually impaired athletes were higher in depressed mood and tension and may have experienced more tension because of limited time to adjust to an unfamiliar competition site. Finally, in a review of 12 studies of both Olympic and Paralympic athletes, most indices of well-being were similar. Where differences existed, Paralympic athletes perceived stronger task motivational climates whereas Olympic athletes had stronger body image perceptions. However, absolute levels (e.g., mean levels relative to scale endpoints) tended to be high for both groups, suggesting neither group experienced a weak task climate or poor body image (Macdougall, O’Halloran, Shields, & Sherry, 2015). In summary, athletes with disabilities have typically reported iceberg mood profiles, suggesting that athletic participation might be associated with positive moods and buffer against negative mood states. In addition to sport-specific individual-based qualities, important non-sport-based individual factors, social, and environmental factors influence performance and these factors are discussed in the next section.
Facilitative and Debilitative Factors
This section on facilitative and debilitative factors includes individual, social, and environmental influences that are both sport- and non-sport-specific and unique to elite disability sport. The criteria used for presenting information in this section are that all of the factors discussed influence how well athletes train, prepare for competition, and perform. For instance, most athletes and sport personnel understand that sleeping and nutritional practices are important performance influences.
Injury, Illness, and Pain
Chronic pain is often a staple of living life with a disability. Athletes need to distinguish among sport fatigue, discomfort from the disability, chronic pain from secondary conditions (e.g., pressure sores), and an injury. Athletes with disabilities often have short careers and Paralympians may have only one chance at a Paralympic team. Hence, maximizing training time by reducing time lost to injury is critical.
Compared to able-bodied athletes, athletes with disabilities lose more training time due to injury. The International Paralympic Committee (IPC) has employed illness- and injury-surveillance techniques at the Paralympic games since 2002. During the summer 2012 Paralympics, the injury rate was 17.8 injuries compared to the Olympic injury rate of 12.9 injuries per 100 athletes. Research among athletes at the 1996 Paralympic Games indicated that visually impaired runners experienced lower leg overuse injuries that were similar in nature to their non-visually impaired counterparts. However, athletes with unilateral amputations (i.e., one leg) suffered a high incidence of injury in the ankle area of the nonamputated foot or leg. For many athletes, their disability condition, sport-specific stressors, and use of any adaptive, assistive, or guidance aids (e.g., prosthetic device) often interact, leading to the development of an injury. Shoulder injuries are the most frequent injuries among wheelchair athletes. The everyday lifestyle (e.g., shopping) demands of wheeling combined with wheeling for training often doesn’t allow enough time for rest and adaptation to occur.
Athletes with disabilities may also be at risk of upper respiratory tract infections (URTI). For instance, wheelchair marathon racers experienced more (19%) URTIs than did the able-bodied participants (15.4%) in the two weeks after a race. Racers who overtrained immediately after the marathon also experienced more URTI episodes compared to racers training less. Finally, there is an increased risk of heat exhaustion and related outcomes (e.g., heat stroke) for athletes with SCI’s because they have difficulty regulating body temperature, particularly when competing in high temperatures. With the 2016 Summer Paralympics in Brazil athletes were competing in high temperatures.
Athletes may manage neuropathic pain with marijuana (Collier, 2008). Drug testing occurs at the Paralympics with over 600 athletes tested in Sydney so athletes run the risk of being banned. Paralympians often have to file exemptions because of the many medications they take for their disability condition and/or pain. Lifestyle adjustments may be required prior to the Paralympics in order to avoid a positive drug test (Nadarajan, 2000). For many athletes, the whole drug-testing experience may be a new, and therefore stressful, element of their sport experience. Testing at the Paralympics can also be more complicated relative to the Olympic, as many athletes with SCI may have to provide urine samples via catheters.
Research on Paralympic athlete’s perceptions of care is scarce and mixed. For instance, Polish Paralympians reported that they had no contact with a physiologist during the 2004 to 2012 Paralympic Games and they rated their medical care as poor during the 2004 and 2008 Paralympics. At the same time they viewed their standard of care from massage therapists and physiotherapists as mostly satisfactory (Sobiecka et al., 2015).
In concluding this section, it should be noted that in a recent review the authors stated that disability sport injury research was in a state of disarray. Their criticisms included a lack of consensus on how a sport injury was defined and inconsistent injury reporting guidelines. Therefore, making comparisons between the results and conclusions of research studies is suspect (Weiler, Van Mechelen, Fuller, & Verhagen, 2016, p. 1).
If you wanted to compete, and you were not in the city, you had to move somewhere enough guys lived. That way, you could all push and get one gym or tennis center set up where it was fully accessible. If you were isolated you couldn’t get the facilities.
(Cottingham, Carroll, Lee, Shapiro, & Pitts, 2016, p. 12)
As the above quotation illustrates, it is difficult for many athletes to find adequate training facilities. Most accessible facilities are university based as corporate fitness and training facilities are often lacking in various disability-related accommodations (e.g., wheelchair ramps, wheelchair-accessible showers and toilets; Rimmer, 2005). Most Paralympians, like Olympians, spent years’ training, which exacerbates the above difficulty. For instance, Polish Paralympians averaged about 11 years of training prior to being selected for the Paralympic Games in Athens, Beijing, and London (Sobiecka et al., 2015). For U.S. Paralympic teams, there are three Paralympic training centers (as of 2012) with the Lakeshore Foundation (LF) site considered the most desirable (Pate & Hardin, 2012). The LF is a nonprofit organization specifically geared to serve individuals with disabilities. The LF site is considered a premier training site because of its accessible training facilities and staff members who are familiar with disability conditions and issues. Paralympians are also welcome to train at 17 other Olympic (and Paralympic) training sites, but often those sites do not employ staff (e.g., trainers), who are knowledgeable about disability issues. Additionally, some Paralympians have perceived that Olympians training at the same sites have received preferential treatment (Pate & Hardin, 2012).
Traveling long distances to competition sites for extended periods of time can be difficult. For instance, athletes are unable to give or receive emotional support, which can cause stress and disrupt concentration. Travel-related issues may be viewed negatively and quite severely compared to other sources of stress. Traveling across time zones, dealing with foreign languages, and enduring different climates can all be stressful as the following athlete describes:
You’ve just sat in a seat on an airplane and it may be an hour before the plane takes off. You’ve been herded on board and thrown about all over the place and then you’ve got this long flight, and you know when you get to the other end you’re going to be last off, and then you’ve got to go and sort your baggage out.
(Campbell & Jones, 2002a, p. 89)
Bawden (2006) reported that his Paralympic client’s most stressful sport experience was managing a 26-hour global flight. Getting on and off the plane, transfers from wheelchair to plane seat, bathroom accessibility, and personal care aid during the flight were all concerns of the athlete. Athletes in the 2014 Paralympic Winter Games in Sochi competed in Krasnaya Polyana, 60 kilometers from their Paralympic accommodations in Sochi, which necessitated extensive travel. The alternative was staying at the competition site and missing the Sochi Paralympic atmosphere. Para-Equestrian Dressage riders in the 2008 Beijing Paralympics competed in Hong Kong and indicated that they missed the main Paralympic experience by being off-site (Martin, 2012a). The above two choices both involve pros and cons and can clearly influence the Paralympic experience and performance.
I am concerned as to whether I will be able to “live” with someone I have little in common with, other than an impaired embodiment, for the next three-and-a-half weeks. How will these living arrangements impact upon my performances on the track?
(Howe, 2008, p. 503)
The 2016 Paralympics in Brazil were slated for 12 days meaning many Paralympians spent a significant amount of time onsite at the Paralympic village. Athletes who performed near the end of the games spent the critical time leading up to their competition in unfamiliar settings and beds. Many sports, such as the para-equestrian, lasted multiple days. Poor sleep quality can clearly accumulate over time resulting in diminished performance capabilities especially if sleep deprivation occurs (Thun, Bjorvatn, Flo, Harris, & Pallesen, 2015). Researchers examined 64 Brazilian Paralympians at the 2000 Sydney Paralympics and a third of them expressed unhappiness with their sleep quality (De Mello, Esteves, Comparoni, Benedito-Silva, & Tufik, 2002). Silva et al. (2010) examined the sleep quality of Brazilian Paralympic athletes at the Beijing 2008 Paralympics and found that most athletes had poor sleep quality. Additionally, anxiety was associated with poor sleep quality as 72% of the athletes exhibiting poor sleep quality had medium levels of anxiety. In a third study of Brazilian Paralympians, Rodrigues et al. (2015) examined 40 Paralympians prior to the 2012 Paralympics. Almost half of the athletes were dissatisfied with their sleep quality and a little over half experienced excessive daytime sleepiness.
British National team members have also reported that poor sleep was a source of stress (Campbell & Jones, 2002a). Athletes were concerned with a lack of sleep in general, whom they might have to share a room with and, critically, the need to perform after a poor-quality sleep the night before. Finally, according to Rosa et al. (2016), some Olympic competitions were held at night when athletes would normally be sleeping and suggested that various physiological, attentional, decision making, and mood states could have been disrupted. In addition to impaired performance, late at night competitions, in turn, disrupt sleep patterns, which can then negatively impact future competitions. If athletes are competing in various preliminary events the sleep deprivation could accumulate. As a result the most deleterious effects of poor sleep quality could occur at the most inopportune time—the final and most important Paralympic event.
In the current model of classification, athletes are often graded based on their capability to perform physical tests. As a result, athletes with different disabilities may compete against each other if they have the same classification. This classification system has been met with some controversy in the Paralympic sport world and is undergoing rigorous scientific investigation and challenges (Mills & Krassioukov, 2011). Regardless of the fairness of the system used, the classification procedure can be both stressful and boring, as the following quote by a Paralympian illustrates:
It is the waiting and uncertainty that bother me with regards to classification. From time to time the classification process has been engaged in too close to my races but at least this time we are a couple of weeks away from my first competition. Here we go! It is my turn next after four hours in this sterile room. The wait is over. My classification begins.
(Howe, 2008, p. 502)
In particular, if athletes are reclassified at a different level they could compete against athletes with a less severe level of impairment, who can, presumably, perform better. Other athletes may try and cheat by underperforming in order to receive a more favorable classification (Howe, 2008). U.S. Paralympic coaches have also indicated that athlete’s performances have been negatively influenced by worries about classification (Dieffenbach & Statler, 2012). The classification procedure is unique to disability sport and is a potential stressor.
Contrary to some commentaries (Townsend et al., 2016), sport psychology researchers have made significant contributions to the knowledge base in disability sport coaching. As many athletes know, coaches often have a profound influence on athlete’s experiences and their performance. Although tentative, it appears that Paralympic swimmers will benefit most if their coaches view them as “elite swimmers” versus coaching a “swimmer with a disability.” Such an approach appears to be consistent with coaches having high expectations of their swimmers. The coach-athlete interpersonal relationship is also important. A study of eight swimmers with disabilities revealed that all the athletes indicated that the positive outcomes they experienced in sport were linked to a very personal and close relationship with the coach.
In related research, disability sport athletes who viewed their coaches as supporting their autonomy had strong relationships with their teammates and had a strong sense of control over their sport investment (Banack, Sabiston, & Bloom, 2011). Athletes who viewed their coaches as supporting their desire to be independent had higher levels of intrinsic motivation relative to athletes who perceived their coaches as less supportive. The above research on Canadian athletes has been replicated with Jordanian national-level athletes. Athletes viewed their coaches as endorsing effective leadership behaviors (e.g., training and instruction, social support, positive feedback) from “occasionally” to “often.”
Athletes satisfied with their training, personal treatment, and team and individual performances had coaches who provided social support, positive feedback, democratic behavior, and training and instruction. Cumulatively, the findings suggest that democratic behavior is positively linked to various forms of athlete satisfaction and that athletes who have coaches who focus on providing high-level instruction (e.g., who specify what is expected of athletes, correct mistakes, explain what to do, etc.) will perform better than athletes with less astute coaches. Coach influence on team cohesion is important in Paralympic sports as Paralympic team athletes often live in different parts of the country. Thus team cohesion development is difficult to foster. Sports like soccer, where strategic and set plays are common, need to be learned in a short time span prior to the Paralympics. In brief, coaches can have significant influence on team task and social cohesion.
Disability sport coaches can also influence important athlete factors like confidence and anxiety. For example, coaches who simultaneously support and challenge their athletes to become better are more likely to develop confident athletes. Elite athletes have viewed negative coaching behavior as one of the most anxiety-inducing sport stressors they encountered. Behavioral evidence of the role of effective coaching can be seen in a study where video and race analysis data helped Australian athletes develop sound race strategies (e.g., even pacing) that lead to a 10% performance improvement that eventually produced a world record.
Athletes will also benefit from coaches who embrace sport psychology. Ten Portuguese Paralympic disability sport coaches believed that psychological preparation and psychological skills were invaluable. In summary, coaches can promote positive psychological states in their athletes (Banack et al., 2011) and help athletes manage the stress of the Paralympic experience (Cheon et al., 2015).
I think I took it too far and I really burnt myself out, physically and mentally as well. I put so much pressure on myself that by the time I had to stop I was a mess, an absolute mess.
(Australian Paralympian: Macdougall, O’Halloran, Sherry, & Shields, 2015, p. 12)
Yeah. I don’t think I would have retired unless I had a job. Cause we had a baby so I wouldn’t have been able to—I would have carried on doing sport [sport] until I had a job or income so that I could retire…. When I was competing I was quite well paid…. If you’re in that position it is quite difficult to retire.
(Retired Paralympian: Ashfield et al., 2016)
The first quotation introducing this section is a common example found in the sport retirement literature as it highlights an athlete who had difficulty adjusting to leaving sport. In contrast, the second quotation reveals a less common scenario: an athlete who remained in his sport, despite some misgivings, because it was a well-paid job. The above scenario is illuminating for two reasons. First, it is indicative of the professionalization of disability sport for elite-level Paralympians. Second, it points to a potentially new research agenda.
Historically, researchers have examined athletes who retire but don’t want to. The second quotation points to a research agenda focused on examining the psychosocial ramifications of athletes who want to retire but cannot. Despite the above observation for future research, the current research base is on athletes who retire and their adjustment during that process. Many Paralympians with disabilities, like able-bodied professional athletes, often have short careers at the elite level (e.g., two to four years) that start shortly after an acquired disability. As Martin and Wheeler (2011) have noted, adjusting to a major life event (e.g., car accident) causing an acquired disability might take up to four years. This means athletes should prepare to cope with leaving sport while simultaneously still adjusting to an acquired disability that occurred two to four years in the past. Other athletes may successfully adjust because they were ready to leave but still have to deal with a chronic injury that can reduce their quality of life.
Some Australian Paralympians have reported a “lack of purpose” once their sport careers ended (Macdougall, O’Halloran, Sherry, et al., 2015). Martin and Ridler (2014) examined whether retirement status (i.e., will retire, contemplating retirement or not retiring) was related to the performance of Paralympic swimmers at the World Championships. They found that 45% of the athletes not considering retirement came within one second of their time goal. In contrast, only 17% of the athletes considering retiring were within one second of their time goal. Athletes considering retiring also had lower athletic identities (AI) compared to athletes not retiring. Although the sample was quite small (n = 17) the results point toward a potentially interesting double-edged sword. Athletes may have disinvested in their AI, which is often considered healthy in order to adjust to postathletic life. However, that same disinvestment in AI may have contributed to poorer performance (Martin & Ridler, 2014). Additionally, worries about postsport life may also have negatively influenced athlete’s performance preparation. The above speculation clearly warrants continued research.
In conclusion, all athletes are impacted by sport and nonsport life experiences. Paralympians face unique challenges in the areas of pain, injury, illness, classification, training, travel, and retirement. These unique conditions and challenges may pose barriers to superior sport performance and quality of life (Martin, 1999b).
Athletes with Intellectual Impairments
Sport psychology research on elite athletes with intellectual impairments is rare, with just a few published reports. One of the first studies in this area, Gorely, Jobling, Lewis, and Bruce (2002), examined the value of a PST program with 14 national-level Australian basketball players. Athletes were taught how to use cue words, employ positive self-talk, and to relax. Anecdotal reports from coaches and athlete interviews all pointed toward PST as valuable. PST with Special Olympics track and field athletes has also been examined. Athletes were able to learn goal setting, various types of self-talk, and imagery.
Research from related fields also has performance implications. For instance, in a study of over 300 high-performance athletes with II, researchers found that those with II had superior fitness in some areas (i.e., flexibility) but lacked fitness in other critical areas (i.e., endurance) compared to able-bodied athletes. Elite boccia athletes have experienced muscular fatigue resulting in impaired performance. This information suggests athletes in sports, like Boccia, that do not have a strong endurance component (e.g., distance running) might still benefit from endurance training, as well as skill-enhancement training. Training, however, should always be contingent on the unique demands and requirements of an athletes’ sport.
Gorely et al. (2002) and Gregg (2010) provide a number of useful suggestions for coaches and sport psychologists working with athletes with II. First, it is important to develop a realistic idea of the athlete’s capabilities and not to assume they are limited by virtue of their intelligence. For instance, in one study, swimmers with II were just as capable of streamlining their bodies as were elite nondisabled swimmers (Oh, Burkett, Osborough, Formosa, & Payton, 2013). Second, individuals with II often have quite varied communication capabilities, which make finding the appropriate level of instruction challenging. Third, while mental skill repetition is important, preventing boredom through variety and novel activities is also valuable.
Fourth, because athletes with II may have trouble making autonomous decisions, it is important that sport psychologists allow athletes to make their own decisions. Fifth, Gregg (2010) also advocates that specific and positive feedback is given frequently along with developing routines to manage stressors. Last, athletes understanding of mental skill development should be probed frequently through the use of open-ended questions. Simple “yes or no” questions should be avoided, as athletes with II might have tendencies to provide acquiescent types of responses. Clearly more research with elite-level athletes with II is needed.
This brief primer on the socio-cultural history of disability and the ramifications for the Paralympics provides a wider context for readers and future researchers interested in the psychology of Paralympians. In respect to the research covered, it is clear that emotional stability, healthy self-esteem, self-awareness, and self-determination all indirectly (and at times directly) influence performance and well-being. It is likely difficult for a Paralympian to train and compete for an extended period of many years and make a Paralympic team if they struggle with feelings of worthlessness, feel disempowered, display neuroticism, and lack self-awareness. While there are anecdotal stories of athletes overcoming many challenges in their personal lives (e.g., depression) and circumstances (e.g., poverty), most athletes fitting the above negative profile will be hard pressed to reach elite levels of performance.
As noted above, athletes employ psychological methods to achieve mental qualities and skills. Using goal setting and positive self-talk to self-regulate and enhance and maintain motivation and efficacy portrays the psychological method-skill connection. Athletes also have lives outside of sport and do not live in a vacuum. Hence, their sport, disability, coaches, and professional and personal experiences all influence their sport experiences.
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(1.) The social-relational model and the medical and social models are not theories or even models as most psychologists understand such things. As a result, they offer few testable hypotheses and are limited in their ability to guide empirical research efforts. However, they are useful as a type of shorthand to convey common perspectives and attitudes toward disability. They can also help researchers examine their own explicit and implicit assumptions and beliefs about disability and disability sport (Martin, 2011, 2013; Townsend et al., 2016).