When winners need help

What connects these individuals: Frank Bruno, Dame Kelly Holmes, Marcus Trescothick [pictured] and Aaron Lennon? If you said are all are winners you would be correct; if you said all are elite sports individuals, again correct. But there is something else: they all reported having mental health concerns either whilst performing or shortly after retiring. Boxer Frank Bruno has bipolar disorder and depression and has been admitted to psychiatric wards several times since giving up the sport. Dame Kelly Holmes was battling depression in the lead-up to the 2004 Olympics. Marcus Trescothick was playing cricket for England when depression forced his retirement. In May this year Premiership footballer Aaron Lennon was detained under the Mental Health Act for his own protection and has been receiving treatment for a stress-related illness.

Mental health in elite sporting contexts

Elite athletes are perceived to be highly mentally functioning individuals, known for positive mental attributes such as resilience, focus, confidence and composure (Holland et al., 2010; MacNamara et al., 2010). However, there are an increasing number of anecdotal reports suggesting elite athletes, like the rest of us, are vulnerable to an array of mental illnesses such as depression, anxiety, eating disorders, obsessive-compulsive disorders, addictions and substance misuse. But why?

To discuss this question, it's important to consider the environmental and social contexts in which elite sport operates. Specifically, in elite sport, both competition and training environments are highly controlled and pressurised. Elite athletes often experience a loss of personal autonomy, disempowerment and unique pressures in the form of competitive achievement, the need to stay physically healthy, remain injury-free, retain or win a new contract, or be selected regularly by their coach. The elite sporting environment can facilitate identity foreclosure, whereby people shape and influence their view of self merely within the parameters of an athletic identity. Psychological distress and depression can follow when that identity is removed, for example, by competitive burnout (Cresswell & Eklund, 2007) injury (Appaneal et al., 2009) or retirement (Wippert & Wippert, 2008). Some elite sporting environmental cultures may also perpetuate maladaptive normative eating practices, particularly in lean appearance or weight-management-related sports. For example, Manchester City manager Pep Guardiola exiled some of his players from the first team when returning to pre-season training, until they met certain weight targets. There's also the dangers of hazardous drinking, drug use and pathological gambling in order to cope with mounting stress and anxiety (Reardon & Factor, 2010). Retired athletes may also be prone to distress and sleep disturbances (van Ramele et al., 2017).

From a social perspective, elite athletes are under great pressure for being positive role models, living up to fans' expectations and being media 'personalities'. With the advent of 24-hour news and social media, they are under increasing social scrutiny regarding their competitive endeavours and their personal lives, and the pressure to interact with fans may also be a significant stressor. Elite athletes, therefore, need to cope with continued professional and personal media interest and may need to adjust their everyday living and lifestyle decision-making, placing unique strain upon their personal life.

This toxic mix of environmental and social contexts can expose elite athletes to mental health issues, and it would be remiss of sport governing bodies and national governments to assume that the elite sporting communities are less vulnerable to mental illness, simply because of their elite status and perceived positive mental attributes (Junge & Feddermann-Demont, 2016). Mental health professionals operating in elite sport must understand the athletic context in order to develop and implement bespoke interventions that protect elite athletic populations from undue risk.

As it is, mental health and sport still tend to be linked in a rather different way. In March 2015, the then Deputy Prime Minister Nick Clegg launched the Mental Health Charter for Sport and Recreation, with numerous sporting bodies signing up to it. The charter was set up to promote wellbeing, the adoption of good mental health practices, and the prevention of discrimination on grounds of mental health. Primarily the charter was designed to raise awareness of mental health and to help promote the idea that sport and exercise can be used as a preventive measure in mental health.

In linking elite sports and elite sports personalities to this charter, and from the way much of the evidence was presented, an onlooker might conclude that individuals involved in elite sport must somehow be immune to mental health issues. The reality could not be further from the truth. There is no clear evidence to suggest that elite athletes have lower rates of mental health disorders than the general community (Gulliver et al., 2012). We are told consistently by the media and many government agencies that regular sport participation will help us live a longer, healthier life; and the facts appear to show that sport for most may help prevent or mitigate the effects of some aspects of mental health. But it remains clear that elite sport participation may be detrimental to mental health (see box).

Mental health and transitions in elite sport

According to the charity MIND, people aged between 16 and 34 have a one in four chance of meeting the clinical criteria for one or more mental health disorders. This is precisely the time when many elite athletes are in their early, mid or latter stages of their professional sporting career. Unsuccessful negotiation of transitions across the lifespan can potentially increase the risk of mental illness (Lee & Gramotnev, 2007a, 2007b).

Transitions can be understood as experiential and developmental. According to Schlossberg's (1981) seminal paper, experiential transitions can be triggered by physical, social or physiological changes that result in a change of assumptions about self and subsequent behaviour. For example, an elite adolescent athlete may experience a change in physical context (e.g. moving away from the family home), taking on a new social role (e.g. academy player), or experience physiological changes (e.g. puberty). In contrast, an older adult athlete may experience a move to a lesser-ranked team (i.e. physical context), find themselves used as a back-up/utility player (i.e. social role) and experience the onset of ageing and physical decline (i.e. physiological change).

It is important, then, that any experiential transitional change be viewed in relation to developmental changes. Wylleman and Lavallee (2004) have documented four athletic developmental transitions:
1.     initiation age (6–7): transition into organised competitive sports;
2.     development age (12–13): transition into intensive level training and competitions;
3.     mastery age (18–19): transition into highest level or elite sport, and
4.     discontinuation age (28–30): transition out of competitive sport.

It has long been recognised that during adolescence, early adulthood and older adulthood, athletes must cope with events or issues that are typical of their phase of development (Arnold & Sarkar, 2015). As an example, a development transitional change from amateur-level competition to more professional intense academy-level competition is characteristic of an adolescent athlete, whereas a discontinuation transitional change is synonymous with an older adult athlete retiring from elite training and competition.

These transitions can adversely affect assumptions one has about oneself and those of the wider world. The adoption of an athletic developmental lifespan perspective should help foster a more nuanced understanding of mental health vulnerability across athletic age boundaries. In the general mental health literature, it is recognised that many first episodes of mental health disorders occur during mid- to late-adolescence and young adulthood (Rutter & Smith, 1995) and if left untreated can predict problems in later adulthood. It would appear sensible, then, that sports practitioners should closely monitor athletic experiential and developmental transitions of youth and academy-level athletes, and maybe make mental health checks as important as physical health to ensure young athletes remain both mentally and physically healthy.

To date, not enough is known about the prevalence and risk factors associated with mental illness across the lifespan of elite sports participation. Therefore, it is important that practitioners in the psychological community investigate critical transitional periods and associated mental health risk factors that are developmentally specific to elite athletes. Doing so will help inform and tailor mental health interventions to meet the developmental needs of the elite athletic population.   

The difficulty of seeking help

There are several barriers to seeking help for mental health issues, not just within elite sports but also within the general public. Poor health literacy is one such barrier: not having sufficient knowledge about where to seek help is a major obstruction to recovery (Abram et al., 2008). Individuals may find it difficult to distinguish between real distress and normal distress, and may lack the necessary psychological awareness to disentangle these issues (Boyd et al., 2007). In other words, at what point do you call for help? This is a difficult question to answer. Often knowing when to call for help depends on the individual and what 'normal' behaviour looks like. There also maybe a lack of awareness about where or who to ask for help (Gulliver et al., 2012).

Stigma has been implicated as one of the major barriers to seeking help, particularly amongst those living in small social populations (Abram et al., 2008), such as elite sports communities. Sometimes the very people around you, the ones that you should be able to turn to for help, are the very ones it's most difficult to confide in. Athletes may be stigmatised by fellow athletes and coaches as being weak, or even by the general public (Kamm, 2005). Indeed, professional coaches are reluctant to refer athletes to a mental health professional because of the apparent stigma (Watson, 2006). Research also suggests that some people may avoid reporting issues of mental health due to self-stigma and negative attitudes for seeking help (Lannin et al., 2016). Male athletes, in particular, have reported negative assessment of other males who seek counselling from a psychotherapist, but not from a sport psychologist; the former being an expert in clinical mental health, while the latter has expertise in performance enhancement (Gulliver et al., 2012).

Several organisations in the UK have recognised that mental health is an important issue. The Professional Footballers Association (PFA) has set up a 24-hour hotline so that professional footballers can seek help regarding their mental health. They have an impressive website dedicated to those in professional football who feel they may benefit from support. But recently goalkeeper Steve Harper was critical of the PFA for not doing enough for players in relation to mental health concerns: for this he was labelled 'emotional' by Pat Lilly of the PFA. Pat Lilly says his comments were taken out of context: nevertheless, a professional footballer felt unsupported, and abandoned when he needed help, and was derided publicly for talking about mental health provision. It's also possible that a website may not be the most appropriate platform: maybe the message and support needs to be available at a more local (i.e. dressing room) level.

Conclusions

Taking part in sport can be beneficial for physical health, and mental health. However, there are an increasing number of anecdotal and empirical reports suggesting elite athletes, like the rest of us, are vulnerable to an array of mental illnesses such as depression, anxiety, eating disorders, obsessive-compulsive disorders, addictions and substance misuse. They work in a highly competitive, performance-driven and controlled environments that shapes their personal identity, dealing with many transitions.

If success in sport is a formula it would most certainly include components such as devotion to training and competition over many years, constantly portraying a mentally tough persona, and living up to the expectations of both fans and the media. If this is what it takes to be a winner in elite sport, then the formula needs addressing. At the very least it should include recognising and supporting the early signs of mental ill-health, and making it something that the elite sporting community can talk about, openly.

BOX: 'I have no reason to be depressed'

Allison Schmitt, an Olympic swimmer, had every reason to feel proud of her achievements. She had won silver in the London 2012 400-metre freestyle, gained bronze in the 4 x 100 metre freestyle relay, and a gold medal in the 200-metre freestyle having led the pack from the beginning. She walked away from the pool with a new American record, as an American hero, wearing a broad grin.

This feeling of euphoria soon melted away: just a few months later Schmitt started to notice classic symptoms of depression. Last year, she told Huffington Post journalist Maddie Crum: 'I didn't really understand it… everything had always seemed to go my way… I had great friends, great family, I had success in the sport… but at the same time I wasn't happy… I couldn't understand why I was unhappy… why would I be depressed? … I have no reason to be depressed.'

In the same article, sport psychologist Scott Goldman of Michigan University stated that feelings of loss are common after a major sporting event. When years of effort suddenly materialise, it seems logical to emerge underwhelmed or confused by what the future holds.

- Derek Larkin is a senior lecturer at Edge Hill University
[email protected]

- Andy Levy is Reader in Psychology at Edge Hill University
[email protected]

- David Marchant is Reader in Sport & Exercise Psychology at Edge Hill University
[email protected]

- Colin R. Martin is Professor of Mental Health at Buckinghamshire New University  
[email protected]

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