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The Sport Psychologist, 2013, 27, 92-102 © 2013 Human Kinetics, Inc. www.TSP-Journal.com

PROFESSIONAL PRACTICE

Jouper is with the Dept. of Sport Science, School of Health and Medical Sciences, Örebro University, Örebro, Sweden. Gustafs-son is with the Faculty of Health, Science and Technology, and Swedish Winter Sports Centre, Mid Sweden University Öster-sund, Sweden, and Karlstad University, Östersund, Sweden.

Mindful Recovery: A Case Study of a Burned-Out Elite Shooter

John JouperÖrebro University

Henrik GustafssonKarlstad University and Mid Sweden University

Research on how to recover from athlete burnout is scarce. The current aim is therefore to describe an interven-tion with an elite shooter suffering from burnout, and the use of mindfulness and Qigong to reestablish sport functioning as well as general well-being. The participant used mindfulness and Qigong exercise on a daily basis. Exercise frequency, exercise time, concentration level and Qigong state were noted daily, and levels of stress, energy and primordial force were self-rated weekly for 20 weeks, and followed up after 30, 40 and 50 weeks. The participant recovered from burnout to a state of general well-being (energy and primordial force changed from weak to strong), and her ability to stay concentrated in a Qigong state changed from weak to strong. Her capacity to shoot high scores was reestablished, even if her shooting endurance was not fully recovered. Mindfulness and Qigong techniques may be useful in the prevention of and recovery from athlete burnout.

A top athlete’s life is demanding. Besides training and competitions they may have sponsor activities, media interviews and pressure from coaches and teammates, in addition to maintaining a blog and sometimes worry-ing about their life after their sporting career. It is easy to get lost, to become part of a “spinning wheel”, and life becomes mindless, draining one’s energy, causing exhaustion and burnout (e.g., Gustafsson, Kenttä, & Has-smén, 2011; Kabat-Zinn, 1990). The skill to be mindful, to be aware in the present moment, and to recover one’s energy and health can be trained and improved.

Burnout among elite athletes is associated with great personal suffering, and can sometimes lead to the termination of the sports career (Gustafsson, Hassmén, Kenttä, & Johansson, 2008; Smith, 1986). Athlete burnout is defined by three core components: emotional/physical exhaustion, reduced sense of athletic accomplishment and sport devaluation (Gustafsson et al., 2011; Raedeke, 1997). This definition is based on the most common definition of occupational burnout (Maslach, Jackson, Leiter, & Schaufeli, 1996), and also has empirical support among athletes (Cresswell & Eklund, 2006a; Gustafsson et al., 2008). Emotional/physical exhaustion is the core

component of burnout and is associated with lack of energy, loss of zeal and a feeling of being overextended. Unlike occupational burnout, athlete burnout often also includes a physical component, probably closely related to overtraining syndrome (Gustafsson, Kenttä, Hassmén, Lundqvist, & Durand-Bush, 2007; Lemyre, Treasure, & Roberts, 2006). A reduced sense of athletic accom-plishment is fundamental in athlete burnout, whereby the athlete suffers from a lack of results and frustration. Finally, sport devaluation is described as a negative atti-tude toward training and competition, and a devaluation of the previously beloved sport.

Even if the etiology of burnout is not fully clear, the majority of research has adopted a stress perspective with a focus on both antecedents and symptoms (cf. Goodger, Gorley, Lavallee, & Harwood, 2007). The stress perspec-tive has considerable research support regarding burnout syndromes (Black & Smith, 2007; Gustafsson & Skoog, 2012; Raedeke & Smith, 2001; 2004); thus stress manage-ment should be a part of recovery and behavior-changing processes (Nigg, Borelli, Maddock, & Dishman, 2008).

Most individuals, on a daily basis, associate to feel-ings of stress and energy when explaining their mood and life situation (Thayer, 2001). For example, exhaustion is a state of decreasing energy. The subjective feeling of psychological energy has been found to be the core in descriptions of health and well-being, and energy level can be used as a barometer for health assessment (Dixon, Dixon, & Hickey, 1993). Thayer (2001) combined mea-surements of high-low stress (tension) and energy feelings

A Case Study of a Burned-Out Elite Shooter 93

into a tense-energy model. The four squares of the model are: tense energy (high tension and high energy), tense tiredness (high tension and low energy), calm tiredness (low tension and low energy), and calm energy (low tension and high energy) (Thayer, 2001, Figure 1). The tense-energy model is used as a “pedagogic tool” when discussing changes in levels of stress and energy with clients.

Stress and energy correlate negatively, meaning that energy decreases when stress increases (Jouper & Has-smén, 2008). This is illustrated in Figure 1, which shows a stress increase-energy decrease in the tense tiredness state (exhausted and burned out), and a stress decrease-energy increase in the calm energy state (energized and experi-encing vitality) (e.g., Jouper & Hassmén, 2008; Thayer, 2001). Stress and energy can be measured as a state situ-ation during the past week (Kjellberg & Wadman, 2002), or monitored hour to hour during the day and based on the fluctuations of the individual’s stress-energy curves, as shown in Figure 2 (cf. Thayer, 2001).

Mindfulness and Qigong are two frequently used methods in stress management. In this context, mind-fulness entails being aware of and paying attention to thoughts, emotions and body manifestations in the moment without judging or evaluating them (cf. Brown, Ryan, & Creswell, 2007). Brown and Ryan (2003) define mindfulness as a “receptive attention to and awareness of present events and experience”. Meditation is the main technique used to improve mindfulness (e.g., Williams et al., 2007), and Qigong is a meditation technique (Chen, 2007). The practice of mindfulness has been found to reduce stress symptoms (Baer, 2003; Grossman, Nie-mann, Schmidt, & Walach, 2004) and improve well-being (Brown & Ryan, 2003; Carlson & Brown, 2005) and physical health (Grossman et al., 2004). Furthermore,

recent studies also show that mindfulness is negatively associated with burnout (McCracken & Yang, 2008).

The Mindfulness schema (Figure 2) combines self-rated levels of stress and energy (vertical axis) hour-to-hour with self-rated mindfulness (being aware of thoughts, emotions, body sensations, and mainly performed activity) to show a “real life picture of the athlete”. The Mindfulness schema [chart] has been used in combination with a multimodal rehabilitation program for severe pain patients, who had reactions from “I already know how it is, I don’t want to fill in the chart” to “I understand how it is now” and used the chart several times during rehabilitation to check their recovery progress (Jouper, Denward Olah, & Engslätt Jansson, 2012). The patient chart was also used by the rehabilitation team when discussing rehabilitation strat-egies and which profession should go in first, as well when discussing the possible level of gainful employment among remitted doctor, responsible rehabilitation doctor, rehabilitation staff, employer, regional social insurance office and patient (Jouper et al., 2012). A single case, a 55–year-old female office worker, used the Mindfulness schema [chart] and Qigong practice to manage disturbed moods (Jouper & Johansson, 2012). After 12 weeks of intervention she had stabilized her mindfulness score, concentration ability, and subject feeling of wellness to a high level (Jouper & Johansson, 2012).

Qigong is a Chinese mind technique aiming to strengthen one’s energy or life force (Qi) through regular exercise (gong) (Chen, 2007). The philosophical idea is that the mind guides an organism’s Qi to a healthy state. If the Qi flow is disturbed, illness may occur (Chen, 2007). During Qigong exercise, the concentration on Qi flow cor-relates positively with a subjective feeling of energy and health, and negatively with a subjective feeling of stress

Figure 1 — Tense-energy four-square model (Thayer, 2001).

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(Jouper, Hassmén, & Johansson, 2006). Qigong practice has been found to reduce stress symptoms (Johansson, Hassmén, & Jouper, 2008; Lee, Ryu, & Chung, 2000) as well as improve well-being (Jouper et al., 2006) and physical health (Lee, Hong, Lim, Kim, Woo, & Moon, 2003). Summarizing the discussion above, mindfulness and Qigong practice is useful in stress reduction and may therefore be beneficial in recovering athletes from burnout.

Burnout is a distressful experience, and recovery might take a long time due to the chronic nature of this syndrome (Shirom, 2005). However, very little is known about recovery from burnout among athletes (Gustafs-son et al., 2011). This indicates the importance of valid and reliable measures of recovery and rehabilitation. In addition, knowledge about successful interventions in occupational burnout is sparse. Interventions are based on both individual and organizational approaches (Schaufeli & Buunk, 2003), but changing organizations might be dif-ficult in elite sport and therefore the individual approach might be the most efficient. Research also supports the individual approach. In a meta-analysis, van der Klink, Blonk, Schene and Dijk (2001) found medium effect sizes for cognitive-behavioral and multimodal stress interven-tions, and significant but small effect sizes for relaxation techniques. It also appears that these interventions can reduce exhaustion but are less effective in reducing the other two components of burnout, reduced sense of accomplishment and depersonalization (sport devalua-tion) (Schaufeli & Buunk, 2003). Thus, research on how to recover from athlete burnout is needed.

Although recent research indicates the usefulness of mindfulness and Qigong for stress management (Baer, 2003; Brown et al., 2007) and application of these tech-niques have been described in therapeutic settings (Chen, 2007; Salmon, Sephton, & Dreeben, 2011), little is written about how mindfulness and Qigong can be used in sport settings (see Gardner & Moore, 2005 for an exception). The aim here is therefore to describe an intervention with an elite shooter suffering from stress induced burnout, and the use of mindfulness and Qigong to reestablish sport functioning as well as general well-being.

MethodCase Description

The participant is an international female top athlete in shooting, with several medals from international competi-tions. After some time of good performances, the atten-tion and pressure from the national team as well as from sponsors, the media and her civilian career increased. She described it as “the wheels turned quicker and quicker”. She had probably had symptoms of burnout during the past six months without noticing them before the ill-ness period started. At the beginning of August after a major competition she caught the flu, which developed into double-sided sinusitis. On August 8 she was given antibiotics and had her sinuses flushed. She had a high fever (39 degrees C) for over two weeks, and then had her sinuses flushed again on August 17. She lost weight, was very tired and had to rest the entire month of August. At the beginning of September she started some physi-

Figure 2 — Levels of stress and energy, hour for hour during one day, and noted thoughts, emotions, body sensations and main activities.

A Case Study of a Burned-Out Elite Shooter 95

cal exercise and balance training. But she started crying after 20 min of jogging because of her weakness, feeling tired and “small”. On September 9 she had a high fever again, with no other physical symptoms, and this con-tinued for four days. She was still tired and emotionally instable for the rest of the month. In October there was a major competition in a very hot country, and she was vaccinated on October 2. During the following days she had a minor fever, and after her arrival at the competition in mid-October she developed stomach flu with a high fever, became dehydrated and was hospitalized.

Back home she still had a stomach ache, and started to realize and accept that she had lost muscle strength and aerobic capacity. She took part in some minor competitions in November and performed remarkably well considering the circumstances, but had no positive feelings. December started with a two-day flu and fever. Besides this she felt a bit better, but was still tired and had no positive feelings. She had lost about 10 kg and could not gain weight; she felt like something was still “eating her from the inside”. At a family dinner on December 9, someone commented that she looked “skinny, tired and unengaged in the conversation”. On December 12 she had a major stomach ache with a high fever, and was hospitalized. No physical illness was found, and she felt a bit better. On December 17 she went abroad with the national team for a training camp, and it felt good to be in a warm, sunny place. Back home she had a long rest over Christmas and New Year. Traditionally, on Christmas Eve she plays Santa Claus for the children in her family. Now she was aware of how old, tired and gray this Santa Claus was, and understood that something had to change. In mid-January she phoned the first author and we decided to meet on February 8; she had stomach flu and a minor fever at the beginning of February. The case description is a summary from the athlete’s diary.

It is important to note that burnout is a highly per-sonal experience (Gould, Tuffey, Udry, & Loehr, 1997; Gustafsson, Kenttä, Hassmén, Lundqvist, & Durand-Bush, 2007). However, the athlete’s diary and descrip-tions contain several indicators of burnout, including extreme fatigue and exhaustion (Gustafsson et al., 2008; Raedeke, 1997), fever and flu symptoms, stomach- and headache (Hendrix, Steel, Leap, & Summers, 1991) and negative mood and affect (Gustafsson et al., 2008), clearly indicating full-blown burnout. These symptoms had probably been evident for a long time due to their severity, but it is common that they tend to go unnoticed by the individual involved (Schaufeli & Buunk, 2003).

Ethics in Professional Practice

The American Psychological Association’s (2010) ethical code and standards were used. Participant was informed about the intervention, and that the results would be pub-lished in a scientific journal and not used for any other purposes. She was also told that the results would not be able to be traced to her, that her participation in the data collection was voluntary, and that she could quit at any

time during the study. She consented to take part in the data collection. The intervention is professional practice in sport psychology, and the coach is skillful, experi-enced, and well trained in the intervention techniques that were used and how to document properly (Hays 2006).

Intervention

The intervention had two purposes. The first aim, mind-fulness, was to improve awareness of thoughts, emotions and body sensations, in association with subjective feel-ings of stress and energy levels, hour for hour, for three normal days. The second aim was a long-term goal to improve recovery from athlete burnout through Qigong exercise. The athlete lived 500 km from the Sport Unit and there were a need to minimize face-to-face meetings. As extensive traveling is a source of stress in most elite ath-letes (Waterhouse, Reilly, & Edwards, 2004) the decision was made that adding even more traveling for the athlete would increase the total stress and potentially worsen the athletes condition Weekly phone meetings were planned to monitoring intervention process, and three face-to-face meetings to introduce every new intervention step.

Mindfulness. The Mindfulness schema (inspired by Thayer, 2001; see Appendix and Figure 2) was noted on three separate normal days, and mediated to a single “stress-energy curve”. An increased awareness of how behavior, thoughts, emotions and body sensations change with fluctuations of stress and energy levels during the day makes it possible to be present, to pay attention to the here and now, and to turn off one’s “autopilot” (cf. Brown et al., 2007).

Qigong. Three different Qigong exercise techniques were planned for the recovery process (see Appendix): Meridian relaxation (or body scanning), Emotional Qigong (five-element Qigong), and Mind Qigong (Three Dan Tian Qigong). The central part of Qigong exercise is concentration on the Qi flow in the organism (Jouper et al., 2006), and all exercise is done in a deep Qigong (deeply relaxed) state (Chen, 2007). Meridian relaxation, a 20- to 40-min exercise, aims to relax all tissues and internal organs in a systematic way to support organism recovery. It also works as a body scan, as body awareness training from a mindfulness perspective. The Emotional Qigong, a 20- to 60-min exercise, aims to balance and strengthen positive emotions (cf. traditional Chinese medical philosophy, Kaptchuk, 2000). The third step, Mind Qigong, aims to balance and recover the central nervous system. Qigong should initially be practiced twice a day when the purpose is rehabilitation, and should thereafter be modified to a functional and practical level (Jouper, 2009).

Measurements

The Athlete Burnout Measure (ABQ: Raedeke & Smith, 2001) was used retrospectively a year after the interven-tion started. Despite the limitations of retrospectively

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administer the ABQ, including less accuracy, these data are used to enrich the analysis (Flick, 2006; Yin, 2003). The Stress Energy Scale (Kjellberg & Wadman, 2002) was used to monitor changes over time as well as pri-mordial force (lost primordial force is the participant’s definition of what is wrong, and can be compared with self-rated health or energy). Exercise behavior was noted in an exercise diary (frequency, time, concentration, Qigong state).

The Athlete Burnout Questionnaire (ABQ). This scale (Raedeke & Smith, 2001) is a 15-item self-report questionnaire containing three subscales: emotional/physical exhaustion (e.g., “I feel so tired from my training that I have trouble finding the energy to do other things”), a reduced sense of sport accomplishment (e.g., “It seems that no matter what I do, I don’t perform as well as I should”), and sport devaluation (e.g., “The effort I spend participating in my sport would be better spent doing other things”). The participant responded to burnout items on a five-point Likert scale ranging from: 1 (almost never), 2 (rarely), 3 (sometimes), 4 (frequently) to 5 (almost always). The ABQ has shown good construct validity (Cresswell & Eklund, 2006b; Raedeke & Smith, 2001) and the internal consistency is strong, with alpha coefficients typically above .80 (Raedeke & Smith, 2009).

Stress Energy Scale. The 12-item Stress Energy Scale (SES; Kjellberg & Wadman, 2002) contains six items for stress and six items for energy. Scores range from 0 (not at all) to 5 (very much). The instrument has been validated in strain studies, and the perceived neutral point is 2.7 on the energy scale and 2.4 on the stress scale (Kjellberg & Bolin, 1974; Kjellberg & Iwanowski, 1989).

Primordial Force. The subjective feeling of primordial force (participant’s definition) was rated on a ten-point Likert scale ranging from 1 (very weak) to 10 (very strong).

Exercise Diary. An exercise diary was used to follow daily exercise behavior as exercise frequency, exercise time and general notifications. Also recorded were the level of concentration (concentration on Qi flow or mind activity) and the depth of the Qigong state reached during exercise. Concentration and Qigong state were rated on a ten-point Likert scale ranging from 1 (not at all) to 10 (very much).

Meeting Feedback (Interviews). Meetings and phone conversations had a character of “sport psychology coaching, small talk” (reflecting upcoming exercise experiences, correcting exercise performance, listening to “life issues” and supporting intentions) instead of academic research conversation. Specific issues and events were noted in an interview log during conversations.

Procedure

At the first meeting, at the beginning of February, the par-ticipant was instructed on how to perform Qigong exercise

(meridian relaxation), register stress and energy curves, and be more mindful about her thoughts, emotions and body manifestations. She started practicing Qigong and writing in the exercise diary, and also wrote in the Mindfulness schema three days within the following two weeks. At the second meeting at the end of March, the participant learned five-element Qigong (emotional Qigong). Finally a third, follow up, meeting was held in June. Between the meetings, the first author kept weekly contact with the participant to support and monitor the recovery process. The active coaching process ended after 20 weeks and followed up after 30, 40 and 50 weeks by telephone.

Results

Evaluation of the Intervention

The situation during the illness period was measured retrospectively using the ABQ. The participant scored 2.8 on reduced sense of accomplishment, 3.4 on emotional/physical exhaustion, and 3.8 on devaluation, on a scale from 1 (not at all) to 5 (very much). This suggests that she was in the tense tiredness state (exhausted) according to the tense-energy model; see Figure 1.

At baseline, before the intervention started, the par-ticipant scored low on stress, energy and primordial force. She scored 0.8 on stress and 2.0 on energy, on a scale from 0 (not at all) to 5 (very much). Primordial force, rated on a ten-point Likert scale, was 3. This meant that the participant felt weak (low energy and primordial force) without tension (no stress, more apathetic feelings). This suggests that she was in the calm tiredness state (apa-thetic) according to the tense-energy model; see Figure 1.

The participant could follow her stress and energy curves during the day and be more aware of thoughts, emotions and body sensations corresponding to high or low energy peaks; see Figure 2.

Typical reactions to stress and energy fluctuations were: feeling sad, exhausted (low energy), calm or happy; singing (high energy); being frustrated or angry; and having a stomach ache (high tension).

During intervention, Qigong exercise frequency and time, level of concentration and Qigong state were recorded daily in an exercise diary, and stress, energy and primordial force were recorded weekly for 20 weeks. The same variables were also followed up in a telephone call 30, 40 and 50 weeks after the intervention started. A total of 142 Qigong exercise sessions were performed, with a mean of seven sessions per week during the first 20 weeks. Exercise sessions ranged between two and 14 per week. The first six weeks the exercise mean was 12 sessions per week, and for the last 14 weeks it was five sessions per week. Exercise session time had a mean of 27 min, and a standard deviation of 7.9 min per session. Session time ranged between 21 and 40 min per session.

Concentration level during exercise had a mean of 5.5 (SD 1.6), and a range between 3.4 and 7.5 on a ten-point Likert scale. Qigong state was similar to

A Case Study of a Burned-Out Elite Shooter 97

concentration level, with a mean of 5.5 (SD 1.8) and a range between 2.8 and 8.5 on a ten-point Likert scale; see Figure 3.

During the intervention, the mean scores were: 2.0 for stress (SD 0.8; min 0.8, max 3.7); 3.2 for energy (SD 0.8; min 1.7 max 5.0; see Figure 4), suggesting that the participant was in a calm energy state (see Figure 1); and 6.0 for primordial force (SD 1.4, range 3–8 on ten-point Likert scale; see Figure 3). At the one-year follow-up, the participant scored 1.2 on reduced sense of accomplish-ment, 1.0 on emotional/physical exhaustion and 3.2 on devaluation, showing improvement compared with the retrospective measure.

Meeting Feedback

The participant felt she had improved in her awareness of thoughts, emotions and body sensations, and was able to notice when negative emotional loops occurred. She could thereby shorten her time spent in negative emo-tional loops and accept that they occurred. In a way, she was able to turn off the “autopilot” and be more present. It was difficult to be aware of the depth of her Qigong state, as being aware means leaving the deep Qigong state. After eight weeks of practice, when she felt recovered, the exercise frequency was changed. She was listening more to her internal body and letting her intuition decide how and when to practice Qigong, and it was more inte-grated into her daily life than a scheduled rehabilitation program. She was not prepared for the third Qigong exercise method, feeling she had had enough new expe-riences. She did not feel that primordial force was fully recovered, and had three minor dips in energy (weeks 7, 12 and 14). The three energy dips occurred due to family matters (worry regarding her parents’ health). She also had a minor fever for two days during Week 25. She had

not recovered her physical strength and balance to their previous levels or reached normal shooting endurance, but still achieved high single shooting results.

Discussion

The main purpose of this case study was to show how mindfulness and Qigong can be used in a sport context. In this case with an elite athlete in shooting, recover from exhaustion and burnout to a functional competitive level, and establish regained well-being. The participant is an international top athlete and thus has well developed coping skills (stress control). She is probably lower on the stress scale compared with subjects in strain stud-ies (Kjellberg & Wadman, 2002), which could explain the relatively low levels of stress at baseline. Another explanation is that she is in the calm tiredness state (see Figure 1), exhausted and more apathetic than having “no stress feelings”; thereby her low stress level. Shooters are also extremely trained in concentration, to stay focused, which is also a key skill in Qigong exercise (Jouper et al., 2006) and could explain a possible Qigong effect. It should be kept in mind that this participant is only a single case without a control group, and results may also have occurred after a period of rest. These results cannot be generalized to a common athlete burnout recovery strat-egy or guidelines for groups of athletes (Yin, 2003). At the same time, as it is unethical to induce burnout in athletes and therefore there are few studies of athletes suffering from more severe forms of burnout (Gould & Whitley, 2009; Gustafsson et al., 2008). Thus, the information from this single case is important as it describes the recovery process, which is missing in the literature (Gustafsson et al., 2011). Furthermore, stress management in practice is an idiographic application of theory (Woolfolk, Lehrer,

Figure 3 — Weekly scores for concentration, Qigong state and primordial force.

98 Jouper and Gustafsson

& Allen, 2007). Although there is an increasing evidence base of the benefits of mindfulness (Brown et al., 2007), the descriptions of the mindfulness and Qigong as stress management techniques in sport is absent.

Before the intervention started, during a period of six months the participant had been hospitalized twice and had several infections with high fever. She also felt exhausted with no energy (low primordial force). During the first 20 weeks of the intervention she had no fever and only three minor dips in energy level. In Week 25 she had a minor fever two days, and since then has been relatively stable in mood (stress and energy), has experienced no illness, and has had a high level of primordial force. She may perform some single top scores in shooting, but is not stable over several days of competition; she has not yet reached her previous shooting endurance level. This health recovery is in line with previous mindfulness (e.g., Bear, 2003) and Qigong (e.g., Lee et al., 2003) literature, and shows that it is possible to return to a functional competitive level.

The first intervention step was to increase awareness of mood and body struggle by following stress and energy fluctuations during the course of a normal day, and to be aware of different thoughts, emotions and body sensa-tions. The participant was present in time and aware that an “issue” was experienced differently when her energy was high and her stress was low compared with the opposite, when experiencing high stress and low energy. Being present, the participant could pay attention to her thoughts and emotions as just thoughts and emotions, without evaluating or reacting to them. Doing this—turn-ing off the “autopilot”—is the main idea of the practice of mindfulness (Brown et al., 2007). This mindful work probably helped the participant to be aware of negative

thoughts and emotion loops that can cause stress, and symptoms of exhaustion and burnout, and also helped her stop these negative loops (c.f., Salmon et al., 2011).

The second step of the intervention strategy was to use Qigong as a relaxation technique and recovery method. The main idea is to go into a Qigong state, a state of deep relaxation, and perform some mind practice while there (Chen, 2007). In this Qigong state, and from a mindfulness perspective, if thoughts and emotions flow one should notice them, label them, and let them flow away (the participant was instructed to do this). The participant improved her awareness of negative emotional loops, and felt that the time she spent in an emotional loop was growing shorter during the year. The first Qigong technique was meridian relaxation (relaxing in one’s tissues and meridians in the direction of the Qi flow according to Chinese philosophy, e.g., Kaptchuk, 2000) and, from a mindfulness perspective, a “body scan exercise” (cf. Williams, Teasedale, Segal, & Kabat-Zinn, 2007) to become aware of body manifestations. Qigong philosophy says that “the mind guides the qi” (Chen, 2007). If the participant noticed any body struggle during meridian relaxation, she was coached to “guide the qi”, and focus her mind on this area, to be mindful in this area for a while, and thereafter continue exercising. She was successful in this exercise, and could feel her tension release as well as an increased warm feeling in the focus areas. Body scanning, struggle seeking and recovery also seemed to work well. The possible recovery effects are probably also supported through the elicitation of a relaxation response during the time spent in the Qigong state (Benson, Greenwood, & Klemchuk, 1975).

The third step of the intervention strategy was to use Qigong as a “mood stabilizing” technique (emotional

Figure 4 — Weekly scores for stress and energy.

A Case Study of a Burned-Out Elite Shooter 99

Qigong, five-element Qigong). It took some time to find the right emotional power and an image that supported this emotion. All five emotions were practiced several times at the beginning of this step according to a schedule, and thereafter the participant’s body intuition decided which emotion should be practiced. The participant combined these two methods as she felt best, or simply followed her intuition. For some individuals, it may be better to follow a fixed schedule than intuition. A third Qigong step was planned to be introduced, but the par-ticipant was not prepared to take another step and felt she needed to continue with the first two methods for a while.

In general, as well as in this study, frequency (Jouper et al., 2006) and session time (Johansson & Hassmén, 2008) have weak correlations with improved health (primordial force) and should not be stressed in coach-ing. Earlier research shows that concentration correlates positively with health, primordial force and level of Qigong state and negatively with stress, indicating that the quality aspect of concentration on Qi flow is prob-ably more important (Jouper et al., 2006) than exercise frequency for mood management. The findings (Figure 3) indicate the same relationship, and similar effects on concentration, wellness and mindfulness scores have been reported in mood recovery using Mindfulness and Qigong (Jouper & Johansson, 2012). At the same time, when using Qigong exercise for rehabilitation there are indications that the exercise frequency, the amount of exercise, is higher (Jouper, 2009). This was also the case in this study. During the first six weeks the participant practiced 12 times per week, thereafter six times a week, and later two to three times per week, and was able to keep her primordial force high through different amounts of exercise. This might be a good way of using Qigong exercise for recovery; to start rehabilitation with several exercise sessions per day and thereafter reduce it as long as it maintains its function.

Burnout among elite athletes renders personal suf-fering and sport devaluation (Gustafsson et al., 2008; Raedeke, 1997). The participant improved in sense of accomplishment (before 2.8, after 1.2) and emotional and physical exhaustion (before 3.4, after 1.0), which may indicate that she recovered to a general state of well-being, as her improved scores on primordial force and energy also might indicate. There was only a minor change in sport devaluation (before 3.8, after 3.2), which may indicate that she is not achieving the same shooting results as before her illness period and still does not fully accept her former burnout situation, or that she has not regained her motivation for sport. This is important, as amotivation is a sign of burnout (Cresswell & Eklund, 2005; Lemyre et al., 2006). Perhaps there was still a need for more mindfulness, awareness and acceptance practice to improve on her feelings of devaluation.

During the participant’s illness period, exhausted and burned out, she belonged to the tense tiredness state (high stress and low energy) according to the tense-energy model (Kjellberg & Wadman, 2002; Thayer, 2001), see Figure 1, and in the end, at baseline measure, she had

moved to a more apathetic situation in a calm tiredness state (low stress and low energy). After six to eight weeks of practice when her energy had returned, she moved into a recovery mood in a calm energy state (low stress and high energy). She also showed high stress and high energy during her competition weeks (weeks 9 and 19), being in a tense energy state, and instead of moving into a tense tiredness state she returned to a calm energy state. Being able to change between competition and recovery moods is an important skill for athletes.

Coaches could include awareness and recovery time in their programs to promote sport performance and prevent athlete burnout. This could be done through regular contemplation activities like mindfulness and Qigong, being in a relaxed state (Qigong state) eliciting a relaxation response (Benson et al., 1975), and increas-ing awareness of thoughts, emotions and body sensations (Williams et al., 2007). When implementing mindfulness, it is probably more efficient to have weekly face-to-face meetings compared with this intervention. This could be done as discussed above, or simply by rating athletes’ energy level on a ten-point Likert scale, and taking action to avoid exhaustion if they score between 3 and 5.

In conclusion, this sufferer from athlete burnout recovered from exhaustion, fatigue and frequent fever reactions, and improved her psychological feelings of energy and primordial force as well as sport functioning by adding mindfulness and Qigong techniques to her daily exercise routine.

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Appendix

Intervention InstructionsMindfulness Schema

Fill in the Mindfulness schema by noting thoughts, emo-tions, body awareness, mainly performed activity, levels of stress and energy, hour-to-hour, for three separate days for the following two weeks, and put them together into one “mean life-situation picture”.

Meridian Relaxation

Qi flows from chest to hand, from hand to head, from head to feet, and from feet to chest. Try to relax tissue-by-tissue and get a warm feeling when going through your body. Enter “Qigong state” by relaxing your whole body, and when you have done this, practice Meridian relaxation: relax inside your arms and hands, outside your hands and arms; relax in your neck, head, and face; relax in your chest, abdomen and internal organs; relax inside and on the front side of your leg and foot; relax in your foot, on the outside and the back side of your leg and bottom; relax in your back and shoulders, breathe into your pelvic floor for a couple minutes. End the session with self-massage of the body.

Besides the instructions on how to perform Meridian relaxation and fill in the Mindfulness schema, partici-

pants were told to strive for a feeling of wellness and to strengthen their “primordial force” during practice, and that “in rehabilitation studies they practice twice a day” but that she herself could practice at whatever rate was possible for her.

Emotional Qigong

Emotional Qigong is practiced as imagining a feeling together with a color, then filling one’s whole body with this image (for a number of minutes), and thereafter collecting this feeling and color into a (host) internal organ and keeping one’s mind focused there during the rest of the meditation. The elements/organs, colors and imaging emotions (the original emotions, according to Chinese philosophy, are expressed in parentheses [cf. Kaptchuk 2000]), are: wood/liver, green and strong “decision power” (anger), fire/heart, red and “loving kind-ness” (joy), earth/spleen-stomach, yellow and “glinting intellect” (rumination), metal/lungs, silver and “vitality” (depression), water/kidneys, black and “strong primordial force” (fright).

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