female wheelchair athletes and changes to body image

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Female Wheelchair Athletes andChanges to Body ImageRobert Thomas Sands a & Robyn Sandra Wettenhall aa Australian Catholic University , Locked Bag 4115,Fitzroy MDC, Victoria, 3065, AustraliaPublished online: 21 Jul 2010.

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International Journal of Disability, Development and Education, Vol. 47, No. 4, 2000

Female Wheelchair Athletes and Changesto Body ImageROBERT THOMAS SANDS & ROBYN SANDRA WETTENHALLAustralian Catholic University, Locked Bag 4115, Fitzroy MDC, Victoria 3065,Australia

ABSTRACT This paper examined the effect of a psychological intervention program onattitudes to body image of female wheelchair athletes. A single case, multiple-baseline studywas employed to examine the presentation of a brief, six session, cognitive behaviouralintervention program on six National female wheelchair basketball players over a period ofsix weeks. Initially the six wheelchair athletes’ satisfaction levels were compared to 20able-bodied basketball players on four measures: the Physical Self-Perception Pro� le,Multi-Dimensional Body Image Scale, Social Physique Anxiety Questionnaire, and theBody Parts Questionnaire. Results indicated that as a result of the cognitive behaviouralintervention program, physical self-perception increased for the wheelchair athletes and for50% of the wheelchair athletes on the multi-dimensional components of body image, usingthe non-parametric split-middle technique. Further analysis revealed a signi� cant effect ofself-perceived competence across time indicating post-hoc signi� cant differences betweenbaseline data and Week 6 of the intervention program. With reference to caution due to thenature of case study research, it is asserted that this study shows promise for improvingvarious aspects of body image satisfaction by means of a cognitive–behavioural approachand has potential for wheelchair athletes and other special populations.

Introduction

Sport for physically disabled individuals has experienced signi� cant growth in termsof opportunities and seriousness of competition (Asken & Goodling, 1986). How-ever, according to Asken (1991), the psychological impact of incurring a physicaldisability cannot be minimised. Much has been written about the psychologicaldif� culties experienced by able-bodied athletes as a response to injuries, most ofwhich are not permanent. Yet, a career-ending injury, as hard as that may be for anathlete to accept, does not carry the impact of one that results in permanent,complete, and profound loss of function (Asken, 1991). According to Asken, thestages of psychological response to athletic injury in able-bodied athletes such asdenial, anger, bargaining, depression, and acceptance come from the literature ondeath and dying and physical disability (see e.g., Kubler-Ross, 1969; Lynch, 1988).It may, therefore, be argued that because the physical component is such animportant factor in the development of the individual, physical handicap probably

ISSN 1034-912X (print)/ISSN 1465-346X (online)/00/040413-14 Ó 2000 Taylor & Francis LtdDOI: 10.1080/10349120020012717

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414 R. T. Sands & R. S. Wettenhall

affects the level of body satisfaction and self-concept formation most profoundly(Lawrence, 1991).

Although body dissatisfaction seems normative today, concern with physicalappearance is truly distressing and disabling for many people. It can interfere withdaily functioning and it has been reported to be associated with depression, socialintroversion, anxiety, and negative self-esteem (Rosen, Saltzberg, & Srebnik, 1989).

Body image, as one facet of self-concept, is an important construct that has playeda major role in contemporary research (see e.g., Cash & Pruzinsky, 1990; Cash,Winstead, & Janda, 1986; Fallon & Rozin, 1985; Fisher, 1986; Slade, 1994;Thompson, 1986). However, de� ning body image has been contentious, with someresearchers referring to the direct perception of the physical appearance of the body,whereas others have described it in terms of thoughts, feelings, and attitudes aboutthe body (Auchus, Kose, & Allen, 1993; Cash, 1994). Cash and Pruzinsky (1990),Helman (1995), Monteath and McCabe (1997), and Slade (1994) argue that bodyimage consists of both a perceptual and an attitudinal component. Slade (1994), inparticular, contends that body image is best viewed as a “loose mental representa-tion of the body’s shape, form and size, which is in� uenced by a variety of historical,cultural and social, individual and biological factors, which operate over varyingtime spans” (p. 502).

Given the social pressures women are under to conform to speci� c body size andshape, it is not surprising that anxiety and body consciousness are more prevalent inwomen than men (Davis, 1997; Lutter & Jaffee, 1996). While men primarily derivetheir self-esteem from power, achievement, money, and community status, manywomen’s self-esteem is bound up with wanting to be attractive or desirable (Freder-ick & Morrison, 1996).

In addition, Davis and Cowles (1991) report that female athletes have also beenfound to be body conscious, overestimating their body size and idealising a thinnerimage. In many instances participation in physical activity and sport has beenunsuccessful in improving negative body perceptions for women. Similar research byAsken (1991) revealed a lack of body con� dence for non-sporting individuals witha disability.

While research evidence above indicates that persons with a disability and femaleathletes may experience negative perceptions with regard to body image, the sameassumptions could not be taken for granted with respect to self-concept, self-esteem,and body image perceptions of female athletes with a disability. With current interestin disability and sport, and with due concern to understand the multi-dimensionalityof body image, it was considered necessary in this investigation to focus on both thegeneral aspect of body image as well as the physical component of body image,referred to as physical self-perception. Speci� cally, this study aimed to establish ifwheelchair athletes were more or less satis� ed with their body image than able-bodied athletes. Secondly, with these � ndings determined, the investigation focussedon the capacity of a pre-planned cognitive–behavioural intervention program toespecially enhance body image, interest in participation in competitive sport, andcompetence in a chosen sport. Previously, investigators and practitioners haveestablished varying degrees of success in applied cognitive intervention programs

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Female Wheelchair Athletes and Body Image 415

(Butters & Cash, 1987; Grant & Cash, 1995; Rosen, Cado, Silberg, Srebnik, &Wendt, 1990; Rosen, Orosan, & Reiter, 1995; Rosen et al., 1989).

Speci� cally, it was hypothesised that (a) female wheelchair athletes would exhibithigher body image dissatisfaction than female able-bodied athletes of comparableability and age; (b) female wheelchair athletes would signi� cantly improve theirlevel of satisfaction on the Physical Self-Perception Pro� le (PSPP) and the Multi-Dimensional Body Image (MDBI) measures as a result of the intervention program;and (c) wheelchair athletes would exhibit enhanced interest in participation andexhibit greater perceived competence with regard to wheelchair basketball as a resultof the intervention program.

Method

Participants

The sample comprised six female wheelchair basketball players and 20 femaleable-bodied basketball players, all of whom participated at State and National levels.Only six wheelchair athletes were able to be recruited due to the small number ofNational players being located in Victoria, and the dif� culty of performing researchbased on intervention techniques with interstate athletes. Ages ranged from 18 to 33years for the wheelchair participants and 18 to 28 years for the able-bodiedparticipants. All participants completed four questionnaires and two additionalquestions described below. Only wheelchair athletes took part in the interventiondescribed in the Procedure.

Instrumentation

In order to examine the differences between able-bodied and wheelchair athletes ondimensions of body image, and ascertain the viability of a pre-planned interventionprogram over six sessions, the following measures were implemented.

Physical Self-Perception Pro� le (PSPP) (Fox, 1990). The PSPP was utilised in thisstudy as it was considered the most appropriate instrument to measure perceptionsof aspects of physicality (Cronbach alphas of .81 to .92 in male and female samples)across a range of groups (obese adults, college sample, high school) in the UnitedKingdom. The PSPP contains 30 items, comprising � ve subscales: sports com-petence, attractiveness of � gure, physical strength, physical conditioning, and physi-cal self-worth (Fox, 1990). The items were scored on a 4-point Likert scale, with ascore range of 30 to 120. Higher scores indicate greater satisfaction with one’s self.

Multi-Dimensional Body Image Scale (MDBI) (Sands, 1996). The MDBI was usedas the most appropriate instrument to represent the more non-physical performance,appearance-oriented domain of body image. It speci� cally provides a measure ofbody image which focuses on dimensions of body size, weight, muscle tone, shape,and physical attractiveness. It comprises � ve items, on a 5-point Likert scale, with

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a score range of 5 to 25. Higher scores indicate greater body image satisfaction.Psychometric properties across three research projects with pre- adolescent andadolescent samples of males and females indicate internal reliability co-ef� cientsranging from .77 to .81, split half reliability ranging from .76 to .85, and concurrentvalidity with silhouette discrepancy and Body Mass Index scores ranging from .36 to.54 (Grif� ths, 1999; Sands, 1996; Sands & Maschette, 1999).

Social Physique Anxiety Questionnaire (SPAQ) (Hart, Leary, & Rejeski, 1989). TheSPAQ examines participants’ views about their body with respect to various socialsituations. It consists of 12 items, each being scored on a 5-pont Likert scale, witha score range of 12 to 60. Higher scores are indicative of greater body satisfactionin social settings. While this scale had no published psychometric details, the authorsclaim construct validity, test-retest reliability, internal consistency, and minimalsocial desirability bias. Concurrent validity was recently established at p , .0001level with the MBDI (r 5 .603), BSQ (r 5 .605) and a drive for thinness (r 5 .624)measure with an adolescent sample (male and female; n 5 40) (Sands & Maschette,1999).

Body Parts Questionnaire (BPQ) (Berscheid, Walster, & Bohrnstedt, 1983). TheBPQ was utilised as a measure of body satisfaction with regard to speci� c body parts(e.g., nose, hips, legs, thighs). It consists of 22 items, each being scored on a 5-pointLikert scale, with a score range of 22 to 110. Higher scores indicate greater bodysatisfaction. A recent investigation by Sands and Maschette (1999) con� rmedconcurrent validity with the MDBI (r 5 .637), drive for thinness (r 5 .582), andself-worth measures (r 5 .701), at p , .0001 in a sample of male and female adoles-cents (n 5 40).

Self-perceived ability and interest. Two 0 to 10 ratio-based items estimating theparticipants’ perceptions of their ability to play basketball and their degree of interestin the same sport were used to monitor the impact of the program over time. Forability, “I am a very weak player” and “I am an excellent player” represented theextreme ends of the continuum of this scale, while “I am not interested at all” and“I am extremely interested” represented the extreme limits for perceived interest.

Study Design

This type of design demonstrates the effectiveness of a treatment by showing thatbehaviours across more than one baseline change as a consequence of the introduc-tion of a treatment (Hersen & Barlow, 1976). According to Hersen and Barlow, thisdesign is most applicable for studies involving small numbers of participants as itallows for the detection of successful effects for individual participants that mayotherwise have been masked by the averaging across groups (Kendall, Hrycaiko,Martin, & Kendall, 1990). Furthermore, various researchers (Hersen & Barlow,1976; Kazdin, 1984) have suggested that single-case designs, such as the multiple-baseline design, are better suited than group designs for conducting research with

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skilled athletes, who are not likely to improve much from pre-test levels. With asmall number of participants in the sample and a desire to identify treatment trendsover time for each individual, a non-parametric, split middle technique (Hersen &Barlow, 1976) was implemented for assessing changes in behaviour for body imageand physical self-perception.

Procedure

Prior to commencement of the six week program, baseline data was gathered � vetimes for each participant (with approximately three days between each meeting).This involved the completion of four questionnaires and two single item self-perceived ability and interest questions. When Participant 1 had her second baselinedata collected, Participant 2 had her � rst baseline data collected. This staggeredmeasuring procedure continued for each participant throughout the baseline phase.Once Participant 1 completed all � ve baseline collections, she completed Session 1of the program. The following week Participant 2 completed Session 1 whileParticipant 1 completed Session 2. This pattern of staggered introduction continueduntil each participant had completed the six sessions. Content for the six sessions isbrie� y outlined as follows: Session 1 involved an educational lecture on the conceptsof body image, self-esteem, and psychological skills training; Session 2 comprisedrelaxation techniques; Session 3 comprised imagery training focussed on enhancingperformance and self-esteem; Session 4 utilised cognitive restructuring exercises andactivities aimed at reversing irrational beliefs about physical self-worth; Session 5involved behavioural modi� cation activities where participants learned to face situa-tions they had previously avoided; and Session 6 included goal-setting, with partic-ipants focussing on short- and long-term goals in regard to both performance andbody image objectives.

Results

Hypothesis 1: Female wheelchair athletes would exhibit higher body image dissatisfactionthan female able-bodied athletes of comparable ability and age

There is some controversy over the use of parametric analyses for ordinal data, “asif” it represents interval data on attitudinal and perceptual judgements. However,Gravetter and Wallnau (1992) argue “whenever the experimental data give you achoice between a parametric and non-parametric test, you always should choose theparametric alternative” (p. 513). Tabachnick and Fidell (1989) also argue thatparametric analyses on samples of small and uneven numbers are robust as long aslinearity and normality are preserved. However, caution in interpreting these resultsare advised. After initial data screening and checking for assumptions underlying useof parametric data analysis, independent one-tail t-tests with an established criticalp set at .005 (multiple use of data and unequal sample numbers) revealed nosigni� cant differences between the groups on the PSPP total scale, the � ve subscalesof the PSPP, SPAQ, MDBI, and BPQ measures.

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Hypothesis 2: Female wheelchair athletes would signi� cantly improve their level of satisfac-tion on the PSPP and MDBI measures as a result of the intervention program

For the Physical Self-Perception Pro� le, the split-middle technique demonstratedthat the intervention program contributed to a positive effect on each participant’sattitude toward her body image. This positive effect was demonstrated for all sixintervention data points appearing above the slope of the projected baseline data foreach participant. The binomial test, used to determine the probability of obtainingall six intervention data points above the projected baseline slope, yielded a p valueless than .05 for all six participants, also giving support to the effectiveness of theprogram (see Figures 1 to 6).

Three of the six participants demonstrated noticeable improvements on theMDBI scale as indicated by the results on the split-middle technique. The binomialtest revealed p values signi� cant to the alpha level of .05 for each of the threeparticipants.

Hypothesis 3: Wheelchair athletes would exhibit enhanced views on participation interestand exhibit greater perceived competence with regard to wheelchair basketball as a result ofthe intervention program

Data checking revealed normality of distribution and, therefore, an analysis ofvariance test was applied. The one-way repeated measures ANOVA for this ratio-

FIG. 1. Participant 1: PSPP scores.

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scaled item revealed no signi� cant main effect across time for participation interest.It must also be noted, however, that as participants’ initial self-perception scoreswere relatively high they may have been subject to a ceiling effect.

A one-way repeated measures ANOVA revealed a signi� cant increase in partici-pants’ level of self-perceived competency (ratio-scaled item) from baseline to Week6 of the program, F(3, 20) 5 9.58, p 5 .0004. To identify the nature of thesigni� cant differences a Tukey Honestly Signi� cant Difference test was employed.The differences were reported to be between the baseline and Week 6, and betweenWeek 1 and Week 6 of the intervention program, with an overall 22% averageincrease in self-perceived competence.

Discussion

Differential Level of Satisfaction between Wheelchair and Able-bodied Athletes

Wheelchair athletes indicated no signi� cant differences in body image dissatisfactionwhen contrasted with able-bodied athletes on all of the four measures administrated.Such � ndings could be due to sports contributing to enhanced body image. Forinstance, as Asken (1991) points out, sport may be a way for individuals with adisability to focus on the physical competency components of body image, thustaking the emphasis away from any concerns involving more appearance-oriented,

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affective judgemental aspects such as weight, shape, tone, size, and appearance.That is, it may act as a psychological compensatory mechanism.

Similar satisfaction levels were established between wheelchair and able-bodiedathletes on speci� c body parts and social physique anxiety. Findings reported in thisstudy are supported by Burns (1982), Harter (1985), and Forman (1988) whoargued that individuals may compensate for their disabilities by seeking ful� lment inareas of strength (such as sport), using different social comparison groups fordifferent aspects of their lives, and having a successful social life or lack of socialawareness to protect their “self” from an unfavourable social status. In a likemanner, Goodling and Asken (1987) and Sherrill (1986) reported that athletes witha disability see sport as a means of af� rming competence, status, and personalego-strength, with a focus on ability rather than disability. As a consequence, thoseindividuals with a disability become somewhat immune from their disability and feelcomfortable with themselves (Brewer, Van Raalte, & Linder, 1993). This latteraspect is supported by the results in the present study.

There may be many additional reasons for the noted similarity between athleteswith a disability and able-bodied athletes with respect to physical self-perception.For example, the challenge of competition, love of sport, � tness and health,demonstration of skill, and seeking of social approval are some of the motives foundin both able-bodied and athletes with a disability (Asken, 1989; Crocker & Bouffard,1992; Sherrill, 1986). Both groups of wheelchair and able-bodied athletes alsoappeared to have similar levels of con� dence in social settings with respect to socialphysique anxiety. This � nding may re� ect con� dence among this group ofwheelchair athletes, especially within their own athletic culture. They appear tofeel comfortable and supported with their disability in a specialised achievementenvironment in which they take their self-ef� cacy for granted. This notion issimilarly con� rmed in past research (Covington & Beery, 1976; Raviv & Stone,1991; Sullivan, 1953).

Responses to the BSQ also indicated a lack of difference between wheelchair andable-bodied athletes. This may be partially explained by self-perceptions ofcon� dence which emerge as a result of achievement within a highly competitivesports setting. That is, the wheelchair athletes may be rede� ning satisfaction withbody parts as a result of increasing competency and participation in a trainingprogram. For instance, being involved in weight training programs and trainingcamps may have enhanced the athletes’ strength and tone in many body parts,leading to satisfaction that is equally relevant to them and able-bodied athletes(Hallinan, Pierce, Evans, DeGrenier, & Andres, 1991).

The Effect of the Intervention Program on Wheelchair Athletes’ Body Image Satisfaction

Evidence indicated that each participant signi� cantly improved their level of physicalself-perception (PSPP), while half of the participants signi� cantly improved theirappearance-oriented attitudes (MDBI), over the time of the intervention program.Also, those who had noted low levels of body image satisfaction on entry to theprogram were as likely to improve their satisfaction levels as those initially presenting

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with high levels of satisfaction. A major in� uential factor in achieving heightenedsatisfaction levels for each of the participants appears to be the purposeful use ofcontent of the intervention program. The program focused on helping each partici-pant to understand their own self-awareness and views placed on body image inboth sporting situations and life in general. Many researchers (Butters & Cash,1987; Rosen, Reiter, & Orosan, 1995) speci� cally studying the enhancement ofbody image satisfaction, have reported similar success in their research. In a likemanner, the use of combined techniques such as cognitive and behavioural tech-niques as utilised in this study, has been successfully applied elsewhere (Hanrahan,1995; Owen & Lee, 1987; Travis & Sachs, 1991). In particular, other researchershave reported the ef� cacy of cognitive–behavioural therapy over six to elevensessions to treat patients with a disturbed body image (Butters & Cash, 1987; Grant& Cash, 1995; Rosen et al., 1989, 1990, Rosen, Reiter, & Orosan, 1995). As inthis study, these researchers particularly incorporated therapy sessions in relationto relaxation, cognitive restructuring, behavioural modi� cation, and forms of goal-setting.

The Effect of the Intervention Program on Competency and Interest Levels

The intervention program was found to enhance participants’ self-perceived sportcompetence over time. It must be acknowledged, however, that confounding exter-nal variables may have also played a major role or at least had some in� uence on thesigni� cant improvement. For instance, the wheelchair athletes were involved intraining camps and numerous training sessions throughout the period of the inter-vention program, possibly contributing to enhanced feelings of competence.

Many researchers using a similar cognitive–behavioural intervention program(Burton, 1989; Clark & Sachs, 1991; Hanrahan, 1995; Travis & Sachs, 1991) havealso reported improved objective performances for athletes with a disability alongwith enhanced perceived competency. Such improvements may have occurredbecause of the focus on increased self-awareness, positive self-talk, and setting goals,all of which are anticipated to assist in enhancing self-esteem, greater competency,and performance outcomes.

Future Research

Many issues related to body image and physical self-perception interventions remainto be resolved. For instance, it is uncertain as to the appropriate sequence of thevarious psychological techniques. Of particular concern also is the individualisationof such intervention programs in order to meet speci� c needs. For example, someindividuals may bene� t from the more cognitive techniques, such as restructuringnegative thoughts into positive, whereas others may require the behavioural tech-niques such as visualisation and modifying avoidance behaviour. In addition,research with a larger sample size would enhance the validity and reliability ofexamining the effectiveness or ineffectiveness of the intervention program.

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Conclusion

A single-case, multiple-baseline cognitive-behavioural intervention appeared effec-tive with participants in enhancing physical self-perception (PSPP) and, for some,body image (MDBI). Importantly, athletes who presented with either relatively lowor high levels of body image satisfaction improved their views and satisfaction. Theprogram may have also been conducive in enhancing wheelchair athletes’ self-perceived basketball competency over time.

Finally, and with some caution due to the small sample size, these results showpromise for applying such an intervention program to many other special andnormal populations.

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female wheelchair athletes and changes to body image

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