Injury in the Adolescent Athlete: A Developmental Disruption by Marsha H. Levy-Warren, Ph.D.

Introduction

Think of Olympic athletes. Some have spent their entire conscious lives preparing for the moment of their event. They fall and are seriously injured. They will never compete again. They have reached the pinnacle of their life’s trajectory, are not even 20 years old, and may never be able to compete again. What happens to them? What has happened to them? How have they grown up? What is their sense of who they are? And, who they will be?

MarshaLevyWarren_imgresThe issues demonstrated in this example are one edge of an extremely common circumstance. Kids grow up and get engaged in athletics. As they enter adolescence, an important aspect of who they are and what they do and with whom they associate is inextricably intertwined with being involved in their sport. They then get injured while playing the sport.

This relationship to being an athlete, what has become an important aspect of who they are, gets disrupted. Sometimes it is forever, sometimes it is temporarily; (though what adults may think of as “temporary” may feel like an eternity to an adolescent).

Knowing the characteristics of the sub-phase in adolescence when such a disruption occurs is critical for understanding its impact on the developing young person. The sense of “time” that an adolescent experiences at the time of the injury (i.e., whether they are living with an eye toward the past, are fully in the present, or living with a sense of the future), the role of the peer group at that time, the relation to the physical self, and the degree of differentiation (separation/individuation) in the adolescent’s development are all key components for understanding its impact.

The Body in Development

Let’s start where children do. The first sense of Self is a physical one. Just think of the way that babies are physically driven: how delighted they are by watching their own fingers manipulate a toy, or their own hands bringing a bit of food to their mouths. Who they are is their physical selves. As they grow, what they see, touch, and are able to do, physically, continues to define who they are.

Babies also live in the present. Their sense of time is immediate: they are what they need and feel in their bodies. Right now. The capacity to postpone may change a sense of time for young children, but they tend to live very much in the moment.

There are a number of bodily signposts for children’s development. The capacity to postpone satisfaction is one of them. Functions such as chewing, biting, or making sounds are others. These are followed by autonomous eating, and then control over their bladders and bowels.

Responsibility for physical well-being and regulation initially falls in the hands of caregivers. Sleeping, eating, bathing, and clothing are dictated by what these caregivers believe makes most sense. These beliefs form templates for what is expectable care for the developing child. In later life, they often form the standards for cleanliness, being well-fed, and being well-rested.

Throughout development, the relationship of one’s physicality to the sense of Self changes dramatically. It starts with physical preoccupations and the caregiving of others, and often ends – in our years as elders – with a similar situation, to more or less of a degree. In-between these periods of life, there are vast shifts.

Developing children are largely cared for by their caregivers. Adolescents and young adults increasingly take over those caregiving functions. This take-over process is a long one, with many bumps in the road.

         “Billy, you need a shower.”
         “Lay off, Mom – my girlfriend thinks I’m fine.”
         “Sally, your blouse is cut very low!?”
         “Oh, Dad, you are so over-protective! This is what all the girls wear?”

The relationship of the evolving Self to the body and physical activity is quite different from one sub-phase of adolescence to the next. The importance of this relationship, however, is critical throughout adolescence.

Sub-phase Development in Adolescence

Early adolescence is dominated by the need for greater bodily ownership, as part of the emerging sense of Self. As adolescents become pubertal (which is the beginning of this sub-phase), they generally take on more and more of their bodily care: e.g., how much they eat, choices about what they eat; whether they bathe or shower, and when; when they go to sleep (even though caregivers generally exercise opinions!), and how and when they wake up. This is an aspect of the separation process of this time: they are separating from their caregivers and the bodily care that is offered by the caregivers. The young adolescents are also separating from themselves as children: they are moving toward leaving their childhood sense of themselves behind and being able to imagine themselves in their now more adolescent bodies (Levy-Warren, 1996/2004; Levy-Warren 1999).

In this process of separation, early adolescents often focus on how much they can do for and by themselves vis-à-vis their caregivers. With the arrival of middle adolescence, there is much more of a focus on how they define themselves among their peers and what they do with those peers. If one asks a middle adolescent who they are, the response will most often come in terms of the activities in which the adolescent participates: “I’m a soccer player,” “I’m an editor on the newspaper,” “I listen to hip-hop,” or “I’m a pothead.”

During middle adolescence, pubertal growth is (usually) largely over for females, and well along in its expression in males. With their newly-grown more clearly gendered and sexually defined bodies, these adolescents look to each other in a different way… as potential sexual partners and confidantes.

Middle adolescents live very much in the present; indeed, urgently so. Where early adolescents are in the present looking back at childhood, and late adolescents are living in the present but looking toward the future, middle adolescents are looking at this as the time to do what they need to do in the social-sexual world.

They are focused not so much on how they are the same and different from how they were, or who their caregivers and families are or were – but on who and how they are among their peers. Their coaches and advisors and teachers, and parents of their friends, often aid them in their process of separation from their own caregivers. They offer other adults’ ideas about the world and life.

The world of their peers, however, is paramount. What is valued in that world varies according to class, ethnicity, geographic location, and a host of other sociological factors. All of these have an impact of the role of athletics in a middle adolescent’s life.

So does historical time period. Think of how popular soccer is right now, internationally. Or how much more aware people are now of rugby. Or the role of the internet or satellites in making sports events available for millions of people who had not been able to see them in the past. All of these affect the dreams of adolescents, with respect to their sport.

The last of the sub-phases of adolescence, late adolescence, brings with it maturity in the physiological sphere. Adolescents have had the bodies they do now, in contrast to their childhood bodies, for many years. They have come to see themselves as having the bodies they do, and now focus on other aspects of their development. In particular, how – and with whom – they want to be moving into their futures.

The group-oriented qualities of middle adolescent identity formation move into a focus on individual factors: this age group is more personally focused than they are focused on affiliations. They need and want to figure out what they want to do and their personal values and tastes.

The Impact of Injury on Adolescent Athletes

Injury in an athlete during this time of development has the potential to interfere with the separation/individuation process. At the very time when adolescents are becoming more independent, an injury can create the need for greater dependence. The relation to the physical self, with respect to bodily ownership, identity formation, and the capacity to take over care-giving functions, can also be obstructed. Any of these can have a significant impact on the adolescent’s relationship to peers and to Self-definition.

I would like to offer three case vignettes to illustrate the influence of sub-phase development on understanding the impact of injury on adolescent athletes and its treatment.

Jessica
Thirteen-year-old Jessica comes from a family of high achievers. Her personal achievements are in the athletic sphere. She is a 3-sport athlete: soccer, basketball, and lacrosse; and excellent at all of them. She has had multiple knee injuries – and surgeries. After the most recent surgery, she was told that she could not participate in these active contact sports any longer.

Jessica is not an easy kid. She is shy, somewhat rigid, and very competitive. Her emotional organization seems more like that of a latency-age child. She thinks in black and white, concrete terms. Much is portrayed in absolutes. She is a “good girl” with an angry edge.

Her parents expected much independence from Jessica at an early age: she went back and forth to school on her own from the time she was in elementary school, she arranged her own social contacts, and she did her homework on her own. Her grades in school are in the “B and C” range, in a highly competitive school. Her school performance reflected more of a lack of interest than a lack of intellectual ability. Her older sibling was “the smart one;” she was “the athlete.”

Being told that she had to have another surgery – and following it, she could no longer expect to be able to run as she had been able to before – was devastating. She could not imagine how she would be or who she would be. All of her friends were athletes – among the best on their teams – and they formed an elite social squad. Jessica was sure that she would be ejected from this social circle. As she put it, “weakness is not acceptable. They will just laugh at me.”

She became enraged with her body. She felt that it had failed her. She also felt humiliated in front of her coaches and teams. Her coach and team wanted her to remain on the team – but she could not bear to sit on the bench.

She also could not stand having to rely on her parents and others after the surgery. She felt that it ”turned her back into a child.”
 Jessica was lost. The person she had been was so defined by her athletic abilities that she had no idea of who she was any longer, and she was enraged at being thrown back into relying on the care of others.

Sean
Sean went through puberty later than his friends. He was a comparatively short guy until he was in the second year of high school. When he was in eighth and ninth grades, he was frustrated and distracted. He was tired of being teased – seen as a little brother by the girls, and a pipsqueak by the guys. He started drinking alcohol to show that he was no youngster, and soon began smoking marijuana as well. His group of friends was into the same thing. They got high, played video games, and hung out.

He was soon seen as that kid who did drugs and alcohol. He walked with a bit of a swagger, and acted as though he didn’t care what people thought of him.

At age sixteen, he shot up – he grew 7 inches in one year. He suddenly realized that perhaps he could try out for the basketball team, which had always been his dream. Historically, he had felt so thwarted by his height that he did not even try to play for the team.

He did make the team, where he found out that the coach had a zero tolerance rule: absolutely no alcohol or drugs were permitted during the basketball season.

Sean was worried. He knew he relied on the marijuana and alcohol to make socializing easier and that it gave him a certain status among his friends. He did not feel confident that he would maintain his social position, and he was worried that he was more dependent upon the substances than he had acknowledged.

His excitement at making the team, and the new group of friends he established through the team, was instrumental in his ability to proceed without using the intoxicants that had become an important part of his after school life. As it turned out, he was also an excellent basketball player – who became seen as a star.

His physical growth and his new social brand – as a basketball star in a school that highly valued the sport – put him in the position of having the attention of his classmates, both male and female. He was extremely happy, though privately feeling like a bit of a fraud. It had all happened so quickly – was it real? He sometimes felt that he was really a short guy in a tall, unrecognizable body.

Then, in the middle of his junior year of high school, he went up for a jump shot at the same time as another player – they collided – he fell and tore both ankle ligaments and sustained a serious concussion. He was out for the rest of the season and cautioned against ever playing again.

Sean was beside himself. He felt frightened by what had happened to him, physically; bewildered by the loss of his active participation on his team; and terrified that his relatively newly-found freedom from alcohol and drugs would be gone. He was also convinced that the girls who had been paying attention to him would no longer be interested in him.

His world felt topsy-turvy.
Craig
19-year-old Craig was a star football player. He had been recruited to an Ivy League college to play. He was successful there athletically, academically, and socially.

He had grown up in an underprivileged neighborhood and was invited to attend an elite private school on a full scholarship through a special program that recruited academically talented kids. He was African-American and very much in the minority in the school he attended. He played offense on the school football team, and was well-known as the major scorer for the team. He was fast, agile, and fearless.

His classmates loved him for this, which aided him enormously in the transition from his prior school – which was predominantly African-American and Hispanic, and his high school – which was 75% White.

At college, Craig was again known and admired for his role as a major scorer on the football team. Then, as a sophomore, he got slammed by a linebacker, pulverized his knee and femur, and was told he could no longer play football. His world collapsed.

During the long period of multiple surgeries and rehabilitation, he felt unrecognizable to himself. He had not been dependent on others for many years, and he had never been immobilized. He had no idea what he was going to do with his life (he had always assumed that he would play professional football), and no idea about how to see himself.

Discussion: Sub-phase Implications and Treatment

In each instance, the injuries sustained by these adolescent athletes created a developmental disruption. Development had been proceeding without major overt difficulty, the injury occurred, and development appeared to be interrupted. With each adolescent: where they were in the process of separation/individuation, who they were in the world of their peers, and how they saw themselves – their sense of Self – were all affected by the injury. These are major aspects of development during all the sub-phases of adolescence, and each of these were disrupted in each of the adolescents.

Jessica withdrew from her friends. She felt ashamed. She had no interest in going to school. Her parents were concerned. They had never seen her so despondent.

In our consultation, it became clear that Jessica had completely lost her way. She had no idea about who she could now be. Being a star athlete was her identity and her modus operandi. She felt disheartened about her fate and disillusioned with her body. She was deeply resentful about being forced to rely on her parents and others for help during the recovery from her surgery, and enraged about being told that she could no longer participate in sports that involved running.

She felt bewildered. And panicked. She hated her body. She began making small cuts with a razor on her upper thighs.

Jessica was pressed into early adolescence somewhat prematurely: perhaps more dictated by the needs of her parents than her personal development. She consolidated a rigid early adolescent identity, and was extremely disrupted in her sense of separation, bodily ownership and appreciation, and social identity when her last injury occurred. She had (shakily) established herself among her peers as an excellent athlete, but had little else to go on in her terms of her sense of who she was. This was buttressed by her family ethos.

Our work focused on her fear of dependence and the undercurrent of longing for someone to take care of her that buttressed this fear, her resentment at being so independent so young, and the valuing of her body and safety. She needed to think in more complex terms – not so much in the black and white ways that are typical of latency age thinking – so that she could reimagine herself as something other than the star athlete she had been (at least in the sports that she had played thus far). We worked at rounding out her sense of herself, calming her sense of urgency about defining who she was, appreciating her body and what it could do, and seeing how she had many qualities that she and her friends could see in her that were outside the athletic field.

This allowed Jessica to move more solidly from early adolescence into middle adolescence. Her concerns moved to how she wanted to look, to whom she was attracted, and what other activities suited her.

Sean’s entrance into middle adolescence was a shaky one. He had established himself as a druggie – only to have this social identity supplanted by that of being a basketball star. He was shaky in his new-found sense of himself and newly-hewn social image.

Sean had never consolidated who he was as a middle adolescent, and was completely thrown off course by his injury. He had tempered his disappointment with his lack of growth by turning to drugs and alcohol. This took on a life of its own, and soon became a way he regulated his moods and social anxiety.

His growth spurt, which ultimately helped to land him on the basketball team, gave him an opportunity to re-define himself socially and privately. This opportunity also forced him to regulate himself better, with regard to drugs and alcohol, but not in a way that was internalized very well before it was interrupted by his injury.

The accident left him feeling as though he had no foundation: he did not know how to see himself or place himself in his social milieu. He felt anxious and depressed.

His treatment focused on how he wanted to see himself and how he wanted to be seen by his peers. We addressed his social anxiety: in particular, how the alcohol and drugs alleviated it and how he had come to be so anxious. His path through development, as someone who reached puberty late, had made him feel like “less than a guy.” We spent quite a bit of time looking at what it meant to him to be male, and what kind of male he wanted to be among his contemporaries.

He felt haunted by his middle school life as the small guy, and still felt his new size seemed foreign to him. His gradual acceptance of his growth aided him tremendously in feeling more secure among his school-mates.

We talked about how many social roles he had occupied in his life, and how that had made him feel fragmented and unregulated. We also talked about how his basketball “stardom” had felt fraudulent. All of this allowed him to weave together a sense of himself as someone versatile and resilient.

This sense of himself gave him far greater comfort among his friends and in his social circles. He felt more solidly rooted in his middle adolescence.

Craig momentarily lost his way. He was well along in his adolescent development when his disruption occurred. He had already come to see himself as an individual, with a future and a firm social identity. The requirement that he stop playing football was an enormous blow to him. It interrupted a flow in his development that had felt continuous and positive.

In his initial years in his high school, he had to negotiate his social identity both at home and in school. At home, he was seen as someone who left his world for a world of greater privilege. In school, he was often regarded with skepticism, seen as someone who entered with a different process of admission. He had survived these difficulties, and proven himself as someone who was academically competitive, athletically talented, and socially fluent.

Losing the capability to exercise his athletic talent on the playing field felt to Craig like losing a part of his body, his being, and his social identity. Our work had to focus on how to re-establish his deepest sense of himself. The fact that he was academically successful and socially adept was critical to his being able to see himself in the broader terms that were necessary to put him back on his feet.

He needed to be able to imagine himself as something other than a professional football player – something he had dreamed of for the bulk of his adolescent life and a way others had seen him. Now he had to re-imagine himself.

He struggled with keeping a sense of himself as stable and competent. We talked a good deal about his middle adolescent years, when his place among his peers – both at home and in school – was shaky. He began to see himself as a problem solver and someone who was resilient; someone who had already survived social adversity and had the intelligence and sense to emerge from difficulty once again.

He decided he needed to hold onto a sense of himself as an athlete: that it had been part of his ticket into the social world in the past, and could be once again. He began to focus on sports education as a possible career path – with particular emphasis on the role of athletics in potentially bringing kids out of the world of poverty. He realized that there was much more to him than his athletic ability: that he was smart, personable, and a leader. All of this allowed him to be more solidly in his late adolescence – with an eye toward his personal development and his future commitments.

In conclusion

It is important that we pay attention to the sub-phase during which developmental disruptions occur during adolescence. This is for the purpose of having a rich understanding of which challenges were being faced by the adolescent during the time of the disruption. Disruptions might occur that involve emotional or physical injury, family crises, or sudden displacements. In any instance, focus on the sub-phase– and what aspects of normative growth might have gotten interrupted – helps to frame the treatment. The overall focus is on getting the adolescent back on developmental track; in order to do so, knowing (specifically) where the adolescent is in his or her development is critical.

An appreciation of the needs of the particular sub-phase of adolescence that each of the adolescents described earlier aided us in seeing what needed to get clarified for each of them in treatment. Attention to sub-phase development helped us to frame their treatments and get them back on their developmental paths with greater alacrity. Working with knowledge of sub-phase highlights what each adolescent needs to address when developmental disruptions occur.

Bibliography

Levy-Warren, M.H. (1996/2004) The Adolescent Journey: Development, Identity Formation, and Psychotherapy . Jason Aronson Publishers © 1996. Rowman Littlefield Publishing Group © 2004 (reissued)

Levy-Warren, M.H. (1999) “I Am, You Are, and So Are We: A Current Perspective on Adolescent Separation/Individuation Theory,” Adolescent Psychiatry, volume 24:3-24.

 


Marshalevy-WarrenMarsha H. Levy-Warren, Ph.D. is a clinical psychologist and psychoanalyst who writes, teaches, lectures, and consults both nationally and internationally. She is the author of The Adolescent Journey (Jason Aronson, 1996; reissued by Rowman and Littlefield, 2004), and numerous articles on clinical and developmental theory, adolescence, and various aspects of culture.

She is currently President of The Contemporary Freudian Society (CFS), a component society of the International Psychoanalytical Association (IPA), and a Training and Supervising Psychoanalyst in both the CFS and the IPA. She is also an Adjunct Clinical Associate Professor of Psychology and a Clinical Consultant in New York University’s Postdoctoral Program in Psychotherapy and Psychoanalysis. Dr. Levy-Warren has a clinical practice with adolescents and adults, and a consulting practice with parents on the Upper West Side of Manhattan.

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One thought on “Injury in the Adolescent Athlete: A Developmental Disruption by Marsha H. Levy-Warren, Ph.D.

  1. ARLENE RICHARDS

    This is so helpful in counselling adolescents at a time when psychoanalytic therapy needs to be brief and to help the adolescent to get back on the track of development. I especially like the vallue Dr. Levy-Warren places on the social life of the adolescent.

    Reply

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