Athletes and Eating Disorders: Redefining an Injury and Expanding Identity in Treatment
By Riley Nickols, Ph.D.
In the Victory Program at McCallum Place, athlete-patients are regularly reminded that an eating disorder is an injury – a metabolic injury. Similar to most physical injuries, eating disorders require proper treatment, rest, and rehabilitation to facilitate healing before it is safe and appropriate to return to sport. If an eating disorder is conceptualized as an injury, it can help to best inform treatment considerations (e.g., how and when to integrate training during treatment). Additionally, it is important to recognize that an eating disorder is an injury so that expectations during treatment and upon return to training or sport can be discussed and modified if needed.
Upon return to sport, a false sense of health and wellness can inappropriately be attributed to an athlete-patient by coaches, teammates, and sports medicine personnel due to the athlete-patient’s seemingly improved physical appearance after obtaining treatment to address complications from an eating disorder. Unlike a visible representation that can be apparent after an athlete sustains certain injuries (e.g., needing crutches after ACL surgery), a metabolic injury that results from an eating disorder is not always visible by the naked eye and, as a result, an athlete-patient may not appear as though he or she is still injured. Although metabolic injuries, such as eating disorders, can sometimes be more covert and the implications might be less observable compared to musculoskeletal injuries, individuals are in significant danger of relapse if treatment, support, and parameters upon returning to sport are not appropriate and consistent. Therefore, it is essential that coaches, athletic trainers, and sports medicine personnel are thoroughly informed by the athlete-patient’s treatment team about specific recommendations on how to best support an athlete-patient’s return to sport.
Similar to musculoskeletal injuries in sport, there are significant risks when sport training is incorporated too aggressively during eating disorder treatment as the athlete-patient remains physically and psychologically vulnerable. Additionally, a heightened risk for re-injury or relapse exists if sport training is introduced in an inappropriate or unsupported manner during the eating disorder treatment process. As such, it is imperative that a treatment team is sensitive and informed of how to best facilitate and support sport training into an athlete-patient’s treatment. Eating disorder treatment providers should remain current on recent research addressing recommendations for incorporating exercise into treatment and, if needed, obtain consultation from other experienced providers.
A serious injury can be both physically and psychologically traumatic for an athlete. A multitude of challenges are likely to follow after an athlete experiences an injury. For athletes who devote an immense amount of time, energy, and emotion to their sport and define their self-worth by their performance and success in athletics, a serious injury can be psychologically devastating. An athlete can experience a loss of identity as a result of needing to halt participation in sport due to an injury or eating disorder. An athlete is likely to encounter significant difficulties, especially if identity is largely, or entirely, comprised of “being an athlete” when participation in sport is abruptly stopped due to an injury (including an eating disorder). Specifically, if perceived value and worth are largely contingent on sport participation and accomplishments, an individual’s identity can be threatened when sport participation is disrupted by injury or when sport participation ends (e.g., retirement).
The need to abstain from sport training or competition can sometimes be similar to the stages of grief (i.e., denial, anger, bargaining, depression and acceptance; Kubler-Ross, 1969), therefore, providers must demonstrate sensitivity to the challenges the athlete-patient is likely to experience during treatment. Before identity is explored in treatment, it is critical the athlete-patient is able to mourn the temporary (or permanent) loss of sport. If an athlete-patient is not allowed to grieve the loss of sport, efforts to address his or her identity in treatment can inadvertently be interpreted as being dismissive of a distressing experience. Individuals who are either temporarily or permanently not able to participate in sport can perceive their identity as “an athlete” to no longer exist since they are not currently competing in sport. The factors that characterize an athlete are well-established, enduring traits that persist in the midst of an injury or after competitive sport participation ends. Recognizing that “being an athlete” is a trait, rather than a state, can be powerful in treatment, especially when an athlete-patient is unable to compete in sport or is not performing up to expectations.
A treatment team should be supportive and sensitive to the important role of sport in an athlete-patient’s life. In conjunction with supporting an athlete-patient’s identity as an athlete, an athlete-patient has a unique and important opportunity to develop a more expansive identity during treatment. With the help of an attuned clinician, an athlete-patient can recognize and develop other parts of his or her identity (e.g., sibling, son/daughter, cousin, student, friend, volunteer) that might have previously been superseded by an all-encompassing athlete identity.
The ability to develop a more robust identity and self-representation can help an individual securely answer questions such as, “Who am I without my sport?” when continued sport participation is in jeopardy or ends. This process is not intended to decrease the importance of sport in one’s life, but rather to increase the other parts of oneself that have been neglected or minimized in proportion to an individual’s athlete identity. When an individual is able to cultivate a broader sense of self, they are more likely to experience the setbacks and success in sport more easily than if their identity is solely as an athlete.