A psychological approach called ACT (Acceptance and Commitment Therapy) is becoming increasingly popular in sport psychology. It is the approach I use – it can be a little hard to understand what the process is – so I saw this new paper from Laura Swettenham and Amy Whitehead summarising a case study of using ACT with an injured athlete and was curious. Here is a summary of their great paper.

I think it would be really helpful to students or trainee sport psychologists to see the process of using an ACT approach with an athlete and may also be helpful for athletes to see whether they feel this approach may be of interest to them.

The full paper is at: Swettenham, L., & Whitehead, A. (2022). Acting on Injury: Increasing Psychological Flexibility and Adherence to Rehabilitation. Case Studies in Sport and Exercise Psychology6(1), 94-101.

The client: A 17-year-old male academy footballer. Living away from home and struggling with uncomfortable thoughts and emotions following back pain from a partial stress fracture which meant he was not sticking to his rehab (he was trying to do too much too soon).

Goal: To increase the client’s psychological flexibility and decrease cognitive fusion so he would feel able to stick to his rehab plan and have better wellbeing.

Process: One-on-one sessions to help the athlete:

  • Practice engaging with the present moment
  • Exploring diffusion techniques
  • Clarify values
  • Commit to values-driven behaviours.

Practitioner’s values: Curiosity, self-awareness, acceptance, and collaboration.

Client’s values: integrity, learning, family, and fulfillment.

Guiding philosophy of the practitioner using ACT:

  • The culture and environment can shape and support psychological change.
  • The person and performer cannot be separated.
  • Thoughts are mental events that should not be changed or removed.
  • It is part of the human condition to experience uncomfortable thoughts and feelings.
  • We should have an acceptance of uncomfortable mental events in pursuit of a fulfilling life.

Issues and worries raised by the client around injury:

  • No clear diagnosis.
  • Limited amount of time to prove himself
  • Exercising as soon as pain subsided rather than waiting for physio all clear.
  • Fear of falling behind teammates.
  • A need to work harder than anyone else.

The practitioner identified that the client was working through a narrative of: I must work the hardest to be the best. And when we have a strong overriding narrative like that we see everything through that filter and are unable to be flexible – even if that would give us a much better outcome.

Why use an ACT approach?

ACT is based upon relational frame theory which suggests our language and thoughts are based on relational frames. The practitioner in this study gives the example of a relational frame for a bird (flying animals with feathers, wings, and beaks) so that whenever we see something with feathers, wings and beaks we assume it is a bird – even if we have never seen it before. This helps us with lots of shortcuts which cut down learning time but sometimes this may go askew and we create relational frames which are unhelpful and cause us irrational and negative thought processes:

  • I wasn’t loved by X therefore I am unlovable.
  • I am not good at maths, therefore I am unintelligent.
  • My mum prefers me when I do well, so I must be perfect at all times.

When we see the world through these lenses we can struggle to separate fact from thought.

ACT is about helping us ‘diffuse from these thoughts’ so we can think with more flexibility.

In the athlete’s case the frames he was using “work the hardest to be the best” and that “everyone will get better” were preventing him from holding back in his rehab. If he could diffuse from these frames and focus instead on his values he could be more flexible and follow rehab effectively.

Questionnaires used to find current level of psychological flexibility:

  • Acceptance and Action Questionnaire-2 (AAQII; Bond et al., 2011). This scores 0-49. Low score = high flexibility, High score = experiential avoidance.
  • Cognitive Fusion Questionnaire (CFQ; Gillanders et al., 2014). This scores 0-49. Low score = low cognitive fusion, High score = cognitive fusion.

Interventions used:

There was a weekly session to learn and reflect on interventions which stretched to 2-3 weeks over time.

  • Sport Lifeline (Dahl et al., 2009) to increase self-awareness around behaviour and provide a framework for the work.
  • Values card sort – to identify values and enable committed action.
  • Game plan (based on values of integrity, learning, family, and fulfilment: “To complete my rehab plan with integrity. To accept my injury and the difficult experience that comes with it by using my helpers. To view my injury as time to pursue my values such as spending time with my family.”
  • Quicksand metaphor: Explaining the more we struggle in quicksand, the further we sink and that thoughts and feelings are the same. When we stop struggling we get more space to reflect and act in a way that works for us.
  • The 3Rs process (recognize, release, refocus; Hansen & Haberl, 2019). Once you have recognised a thought you can release (deep breath in naming the thought and exhale releasing the thought) and then refocus on what is within your game plan to move closer towards a value.
  • The paper exercise: Writing uncomfortable thoughts a piece of paper and holding it close to face. Client realizes that all these unwanted thoughts, prevent them from  engaging with life in the way their would ideally want.
  • Blue sky metaphor: Cloud are thoughts and emotions, the blue sky is our mind. Clouds will all come and go in their own time and even if there are black clouds (unhelpful  thoughts and emotions) the blue sky is always there behind them, waiting to be seen again as the black clouds drift off.  
  • Control circle exercise: Circles covering: “within my control” and another outside it of “outside of my control.” Dropping in each element helps us focus only on what we can control.  

Interesting elements: The practitioner was working in a football academy so used an ‘open confidentiality agreement; so instead of assuming everything was confidential the client was asked which elements should remain confidential. This meant the practitioner could engage with physios and coaches to discuss his case and get a more complete picture (which alerted her to the fact the client was struggling with his rehab) but could limit how much he feel willing to share. In private practice full confidentiality is usually assumed.


  • Acceptance and action questionnaire-II fell from 20 to 12 suggesting the athlete had improved their psychological flexibility.
  • CFQ reduced from 26 to 18, suggesting much less cognitive fusion.
  • Adherence to rehabilitation improved and coach engagement increased.