The Routledge Handbook of Mental Health in Elite Sport 0367567865, 9780367567866

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Contents
List of Figures
List of Tables
List of Contributors
Section A: Mental Health
Introduction to the Section
1. Mental Health in Athletes
Understanding of Mental Health in Contrast to Mental Illness
Ill or Not Ill? - Categorization of Abnormality
Dimensional Approach to Mental Health
Keyes' Two-Dimensional Model
Elements of Mental Health
Well-Being
Quality of Life
Assessment of Mental Health
Practical Implications
Research Perspectives
References
2. Thriving in Elite Athletes
Introduction
Theoretical Foundations of Thriving
A Humanistic Model for Thriving Through Being in Elite Sport
Guidelines for Practitioners
Practitioners as Exemplars of Thriving
Practitioners as Advocates for a Culture of Thriving
Business Models to Support Thriving
Processes of Thriving Sport Organizations
Practitioners as Enablers of Thriving through Interpersonal Relationships
Intrapersonal Strategy: Self-Awareness of the Opposites of UPR
Interpersonal Strategy: Direction of Relational Movement
UPR: A Secure Base from Which to Challenge
Unanswered Questions and Future Directions
Notes
References
3. Meaning and Meaninglessness in Elite Sport
Introduction
What Is Meaning in Life?
Meaning in Life and Health
Finding Meaning in Life
What Makes Athletes Particularly Vulnerable to a Lack of Meaning
Finding Meaning in the Athletic World
Conclusion
References
4. Resilience and Mental Health in Competitive Sport: A Narrative Review of the Literature
Introduction
Conceptualising Resilience and Mental Health
Summary of the Literature
Resilience and Mental Health
Resilience and Mental Ill-Health
Clinical Indices
Subclinical Indices
Critique of the Literature and Future Research
Practical Implications
Developing Personal Qualities
Strengthening Social Support
Coach-Created Facilitative Environment
COVID-19 Impact on Sport, Resilience, and Mental Health
Conclusion
References
5. The Social Network and the Coach
Introduction
Relevant Athlete Mental Health Frameworks
Keyes' (2002) Continuum of Mental Health and Illness
Neurobiopsychosocial Model
Relevant Athlete Mental Health Outcomes
Depression
Anxiety
Burnout
Relevance of the Athlete's Social Network, Including the Coach, to the Athlete's Mental Health
Key Sport-Based Social Actors
Environmental and Training Influences on the Athlete's Social Perceptions
Sport Culture and Stigma
Social Support and Negative Social Interactions
Mechanisms for Social Network Impact on Athlete Mental Health
Identification
Help-Seeking Behaviours
Referral to Mental Health Services/Sources
Coaches' Mental Health and Its Potential Influence on Athletes They Serve
Review of Relevant Social Network Research
Coach-Athlete Relationship
Coach's Impact on the Athlete's Mental Health Outcomes
Teammates' Impact on the Athlete's Mental Health Outcomes
Total Network Impact on the Athlete's Mental Health Outcomes
Practical Considerations
Social-Actor-Focused Mental Health Interventions
Social Network "Awareness" Trainings for the Athlete's Mental Health
Mental Health Intervention Impacting Knowledge and Behaviours
Integration of Social Actors within a Holistic Athlete Support Network
Future Research Directions
Longitudinal Tracking of Social Network Impact on Athlete Mental Health
Assessment of Mental Health Interventions
Assessment of Social Support Interventions
Social Network Analysis
Conclusion
References
Section B: Mental Illness
Introduction to the Section
6. Depression in Elite Athletes
Introduction
Definition of Depression in Athletes
Sport-Specific Considerations
Prevalence of Depression in Athletes
College Athletes
International Elite Athletes
Sport-Specific Differences
Assessment and Diagnostic
Self-Rating Questionnaires
Indirect Measurements
Aetiology
Important Vulnerabilities and Stressors
Stress and Stressors
Lack of Recovery
Psychological Vulnerabilities
Coping Strategies
Dysfunctional Attitudes and Perfectionism
Sport-Specific Mechanisms
Attribution Mediates Differences Between Individual and Team Sport
Practical Implications and Guidelines
Research Perspectives
Summary
References
7. Recognition, Prevention, and Treatment of Disordered Eating and Body Dissatisfaction in Athletes
Introduction
Historical Perspective of Disorder Eating and Associated Behaviours
Biopsychosocial Influences and Pressures of Athleticism
Types of Eating Disorders and Associated Dysfunctional Behaviours
Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder
Body Dysmorphic Disorder (BDD)
Orthorexia Nervosa (ON)
Case Vignette: What's Happening!
Summary of Key Components Regarding Case Vignette
Eating Disorders, Body Image, and Weight Control Actions
Health Risks, Well-Being, and Quality of Life
Individual and Team-Based Assessment, Prevention, and Treatment
Cognitive Behavioural Therapy (CBT)
Mindfulness
Support Groups for Eating Disorders
Conclusion
References
8. Addiction (Drugs and Gambling) Disorders in Athletes
Introduction
Definitions and Reasons for Use/Participation in Addictive Behaviours
General Prevalence
Specific Substances
Alcohol
Cannabinoids
Nicotine
Stimulants
Prescription Drugs
Sport-Related Gambling
Mental Health Symptoms and Disorders Associated with Problem Gambling
Prevention
Drugs
Gambling
Management
Drugs
Gambling
Practical Implications
Summary
References
9. The Role of Executive Functions in Elite Athletes' Mental Health
Introduction
Definition
Measurement
Elite Athletes
Impact on Mental Health
Implications for Practitioners
Conclusion
References
10. Personality Disorders in Elite Athletes
Introduction
Theoretical Approaches
History of Personality
Personality and Its Disorders Defined
Personality
Personality Disorders
Factors Involved in the Development of Personality and Its Disorders
Characterisation of Personality Disorders
Biopsychosocial Model (BPS)
Diagnosing Personality Disorders
Impact on Social-Emotional Functioning
Impact on Elite Athletes
Treatment of Personality Disorders
Practical Applications and Guidelines
Summary
Case Presentation
References
11. Anxiety Disorders Among Elite Athletes
The Spectrum of Anxiety in Elite Sport
Anxiety Disorders: An Overview
Prevalence Rates of Anxiety Among Athletes
Generalised Anxiety Disorder
Social Anxiety Disorder
Panic Disorder
Related Disorders
Contributing Factors to Athlete Anxiety
Assessment of Anxiety Disorders
Treatment of Anxiety Disorders
Non-Pharmacological Treatment
Pharmacological Treatment
Future Directions
Summary
References
Section C: Subclinical and Related Challenges
Introduction to the Section
12. Reducing Burnout in Athletes
Introduction
What Is Burnout?
How Does Burnout Develop?
Smith's (1986) Cognitive-Affective Model
Raedeke's (1997) Commitment Model
Deci and Ryan's (2002) Self-Determination Theory (SDT)
Why Is Burnout Important?
Reducing Burnout in Athletes
The Current Review
Overview of Meta-Analyses
Individual Interventions
Organisational Interventions
Individual and Organisational Interventions
Key Findings, Critical Considerations, and Recommendations
Summary
References
13. Depression, Athlete Burnout, and Overtraining: A Review of Similarities and Differences
Introduction
Depression
Burnout
Increased Complexity in Sport: The Overtraining Syndrome
Definition and Models
Similarities and Differences Between Depression, Burnout, and Overtraining
Definitional Similarities and Differences
Aetiological Similarities and Differences
An Integrative Model of Depression, Burnout, and Overtraining
Future Research
Practical Recommendations
Conclusion
References
14. Concussions in Athletes
Definition of Concussion
Causes of Concussions
Prevalence of Concussion in Elite Sport
Concussion in Professional Sport
Concussions in Collegiate Sport
Concussion Symptoms and Symptom Profiles
Diagnosis of Concussions
Clinical History
Physical Examination
Management of Concussions
Common Mental Health Symptoms Following a Concussion
A Model of the Anxiety and Mood Clinical Profile Following a Concussion
Persistent Post-Concussive Symptoms and Post-Concussion Syndrome (PCS)
Depression, Depressive Symptoms, and Anxiety
Other Mental Health Issues
Other Health-Related Problems Following a Concussion
Major Risk Factors of Concussion-Related Mental Health Symptoms
Sex, Race, and Sport
Repeated Concussions
Pre-Existing Mental Health Symptoms
Symptom Overlap Between Mental Health Disorders and Concussions
Strategies to Prevent and Mitigate Concussion-Related Mental Health Consequences in Elite Sport
Primary Prevention Strategies
Secondary Prevention Strategies
Tertiary Prevention Strategies
Implications for Future Research and Practice
Implications for Research
Implications for Practice
Medical Staff
Applied Sport Psychologists
Team
Conclusions
References
15. Fear and Anxiety in Elite Sport
Anxiety in Competitive Sport
Defining of Terms
Emergence of Anxiety
Forms of Anxiety in Sport
Competitive Anxiety
Injury Anxiety
Social Physique Anxiety
Relation of Anxiety with Performance, Well-Being, and Mental Health
Performance
Mental Health and Well-Being
Assessment of Anxiety in Sport
Determinants and Risk Factors
Person Factors
Situation Factors
Practical Implications
Prevention Strategies
Intervention Strategies
Future Directions
Summary
References
16. Stress in Elite Sport
Introduction
Stress in Sport
TCTSA-R Framework
TCTSA-R and Mental Health
Pre-Dispositions
Demands Versus Resources
Self-Efficacy
Control
Perceived Control
Emotion Control
Social Support
Achievement Goals
Physiological Indicators of Challenge and Threat
Conclusion
Practical Implications
Research Perspectives
Summary
References
17. Stigmatisation of Mental Illness and Seeking Sport Psychology Services
Introduction
Stigma Toward Mental Health and Sport Psychology Services
Important Others' Stigma Toward Seeking Service Provision
Intra and Interpersonal Strategies to Decrease Stigma and Enhance Personal Openness
Structural Efforts to Reduce Stigma
Evaluation and Assessment
Future Directions
References
18. Career Transitions in Sport
Introduction
What Are the Different Career Transitions Athletes Might Experience?
How Do Transitions Relate to Mental Health?
A Social Identity Approach to Career Transitions and Mental Health
Guidelines for Practitioners
Case Studies
Case study 1 - Responsive approach to a crises-coping transition
Case study 2 - Crisis-prevention approach using an athlete-centred perspective
Case study 3: Preventative approach using a holistic perspective
Overall Recommendations
Recommendation 1: It is Important to Use All of Athletes' Available Resources When Supporting Their Transition
Recommendation 2: Social Support Is One of the Most Crucial Coping Mechanisms That Can Be Called Upon by Athletes and This Is Something That Should Be Mobilised During Transition
Recommendation 3: Help Athletes Find Alternative Scope to Their Lives
Recommendation 4: Support for Transition Should Be Long not Short Term
Conclusion
References
19. Doping and Drug Misuse in Elite Sport
Introduction
Sport Organisation Policies
General Prevalence and Risk Factors for Use of Performance-Enhancing Substances
Specific Performance-Enhancing Substances/Methods and Their Impact on Performance and Side Effects
Androgens
Growth Hormone and Growth Factors
Stimulants
Beta Agonists
Beta Blockers
Methods to Increase Oxygen Transport
Nutritional Supplements
Other Prescription Drugs
Recreational Drugs
Other Non-Drug Performance-Enhancing Measures
Doping and Mental Health
Prevention
Management
Practical Implications
Summary
References
Section D: Application and Care
††††††††Introduction to the Section
20. Professional Considerations for the Clinician
Introduction
Competence and Appropriate Use of Referrals
Multicultural Competencies in Sport Psychology
Becoming an Effective Professional
Referrals
Confidentiality and Informed Consent
Telepsychology
Legal Issues Associated with Telepsychology
Ethical Issues Associated with Telepsychology
Multiple Role Relationships
Teacher-Clinician Multiple Role Relationships
Ethical Considerations Associated with Multiple Role Relationships
Ethical Issues Regarding Supervision
Supervision Implications for Client Welfare, Supervisors, and Trainees
Conclusion
References
21. Psychotherapeutic Applications in Elite Sport: Promoting Mental Health Among Athletes
Introduction
Psychotherapy
Individual Psychotherapy
Couples/Family Psychotherapy
Group Psychotherapy
Unique Challenges
Diagnostic Ambiguity
Barriers and Resistances to Help-Seeking Behaviours
Altered Expectations About Services
Personality Factors
Conclusion
References
22. Recovery as the Centrepiece for Mental Health Promotion in Elite Athletes
Introduction
The Impact of COVID-19 on Athletes
Mental Health in Athletes
The Relationship Between Recovery, Stress, and Well-Being
Recovery and Stress Monitoring for Mental Health Prevention in Athletes
Practical Implications
Summary and Future Directions
References
23. Injury Prevention and Rehabilitation
Introduction
Biopsychosocial Approach to Injury Prevention and Rehabilitation
iTeam for Injury Prevention and Rehabilitation
iTeam Checklist
Biopsychosocial and Interprofessional iTeam Considerations for Injury Prevention
Case Vignette 1: Achieving the Olympic Dream during a Pandemic
Case Summary and Guidelines for Practice
Biopsychosocial and Interprofessional iTeam Considerations for Injury Rehabilitation
Case Vignette 2: A Professional Cyclist's Recovery and Return to Racing
Case Vignette 2 Summary and Guidelines for Practice
Conclusion
Acknowledgment
References
24. Nature-Based Interventions in Elite Sport
Introduction
Theoretical Explanations
Nature Connectedness
What Are Nature-Based Interventions?
Nature-Based Therapies
Green and Blue Exercise Interventions
Technological and Virtual Nature
Application by Sport Typology
Potential Adverse Effects
Recommendations for Further Enquiry
Efficacy of Nature-Based Interventions
Acceptability of Approach
Actions for Researchers and Practitioners
Key Objectives
Conclusions
Funding Acknowledgement
References
25. Young Athletes' Mental Health and Well-Being
Introduction
Defining Elite Youth Athletes
What Is the Prevalence of Mental Health Symptoms in Elite Young Athletes?
Mental Health Stigma in Young Elite Athletes
Risk Factors for Mental Well-Being in Elite Young Athletes
Pressure to Perform and Perfectionism
Overtraining and Burnout
Parental and Peer Conflict
Athlete Abuse and Maltreatment
Injury and Concussion
Body Image Concerns
Sleep Disturbance
Applying Research into Practice: Bolstering Mental Well-Being in Elite Young Athletes
Responding to Risk Factors
Pharmacological Considerations
Summary
References
Index

Citation preview

ROUTLEDGE HANDBOOK OF MENTAL HEALTH IN ELITE SPORT

Mental health is a rapidly increasing topic in the field of sport psychology. As the relevance of athletes’ mental health has come to prominence through emerging research, there is a high demand for evidencebased practice in order to promote athletes’ mental health and prevent mental disorders as well as maladaptive syndromes. However, there is currently no comprehensive overview available that highlights the empirical evidence for the constructs of mental health, illustrating the latest developments in research, or that highlights implications for future science and practice. The Routledge Handbook of Mental Health in Elite Sports delivers such an understanding and overview for this field, offering students, researchers, mental health professionals, applied sport psychologists, and coaches a state-of-the-art and insightful summary of science in the newly emerged field of clinical sport psychology and mental health in athletes. This thorough volume covers major current and emerging topics on mental health and mental illness (e.g., depression), subclinical syndromes (e.g., burnout), as well as a comprehensive overview of research on prevention (e.g., green exercise) and treatment of mental health disorders in athletes and will be a vital resource for researchers, academics, and students in the fields of sport psychology, clinical psychology, sport coaching, sport sciences, health psychology, and physical activity and related disciplines. Insa Nixdorf is a professor of psychology at the International University of Applied Sciences, Germany. Raphael Nixdorf is a professor of health psychology at the International University of Applied Sciences, Germany. Jürgen Beckmann is a professor, Emeritus of Excellence, at Technical University of Munich, School of Medicine and Health, Munich, Germany; Honorary professor, School of Human Movement and Nutrition Sciences at the University of Queensland, Australia; an Adjunct Professor Dept. of Physical Education and Sport Sciences at the University of Limerick, Ireland. Scott B. Martin is a professor of performance psychology and Director of the Psychosocial Aspects of Sport and Exercise program at the University of North Texas, USA. Tadhg MacIntyre is an assistant professor at the Department of Psychology, Maynooth University, Ireland.

ROUTLEDGE HANDBOOK OF MENTAL HEALTH IN ELITE SPORT

Edited by Insa Nixdorf, Raphael Nixdorf, Jürgen Beckmann, Scott B. Martin, and Tadhg MacIntyre

Designed cover image: © Getty Images First published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 selection and editorial matter, Insa Nixdorf, Raphael Nixdorf, Jürgen Beckmann, Scott B. Martin, and Tadhg MacIntyre; individual chapters, the contributors The right of Insa Nixdorf, Raphael Nixdorf, Jürgen Beckmann, Scott B. Martin, and Tadhg MacIntyre to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. ISBN: 978-0-367-56786-6 (hbk) ISBN: 978-0-367-56788-0 (pbk) ISBN: 978-1-003-09934-5 (ebk) DOI: 10.4324/9781003099345 Typeset in Bembo by MPS Limited, Dehradun

CONTENTS

List of figures List of tables List of contributors

viii ix x

SECTION A

Mental Health

1

Introduction to the Section Tadhg MacIntyre

2

1 Mental Health in Athletes Insa Nixdorf, Raphael Nixdorf, and Tadhg MacIntyre

3

2 Thriving in Elite Athletes Lauren K. McHenry and Rebecca A. Zakrajsek

12

3 Meaning and Meaninglessness in Elite Sport Jürgen Beckmann

31

4 Resilience and Mental Health in Competitive Sport: A Narrative Review of the Literature Christopher Bryan, Jolan Kegelaers, and Mustafa Sarkar 5 The Social Network and the Coach J.D. DeFreese and Christine M. Habeeb

45

62

v

Contents SECTION B

Mental Illness

81

Introduction to the Section Scott B. Martin

82

6 Depression in Elite Athletes Insa Nixdorf and Raphael Nixdorf

83

7 Recognition, Prevention, and Treatment of Disordered Eating and Body Dissatisfaction in Athletes Cami A. Barnes, Keely N. Hayden, and Scott B. Martin

99

8 Addiction (Drugs and Gambling) Disorders in Athletes Claudia L. Reardon and Ryan Benoy

121

9 The Role of Executive Functions in Elite Athletes’ Mental Health Robert S. Vaughan, Jack Brimmell, and Bjoern Krenn

130

10 Personality Disorders in Elite Athletes Christopher M. Bader and LaTisha L. Bader

144

11 Anxiety Disorders Among Elite Athletes Courtney C. Walton, Simon Rice, Lisa Olive, Claudia L. Reardon, and Rosemary Purcell

159

SECTION C

Subclinical and Related Challenges

175

Introduction to the Section Insa Nixdorf and Raphael Nixdorf

176

12 Reducing Burnout in Athletes Daniel J. Madigan, Henrik Gustafsson, and Luke F. Olsson 13 Depression, Athlete Burnout, and Overtraining: A Review of Similarities and Differences Raphael Nixdorf, Daniel J. Madigan, Göran Kenttä, and Peter Hassmén

177

188

14 Concussion, in Athletes Jingzhen Yang, Robyn Recker, and Lindsay Sullivan

201

15 Fear and Anxiety in Elite Sport Felix Ehrlenspiel, V. Vanessa Wergin, and Jürgen Beckmann

226

vi

Contents

16 Stress in Elite Sport Jennifer A. Hobson, Martin J. Turner, and Marc V. Jones

244

17 Stigmatisation of Mental Illness and Seeking Sport Psychology Services Rebecca A. Zakrajsek, Scott B. Martin, Shane R. Thomson, and Amelia Gulliver

267

18 Career Transitions in Sport Robert Morris, Pete Coffee, Hee Jung Hong, Chris Hartley, and Nina Verma

287

19 Doping and Drug Misuse in Elite Sport Claudia L. Reardon and Ryan Benoy

300

SECTION D

Application and Care

311

Introduction to the Section Jürgen Beckmann

312

20 Professional Considerations for the Clinician Jack C. Watson II, Matthew Gonzalez, Brandonn Harris, and Valerie Wayda 21 Psychotherapeutic Applications in Elite Sport: Promoting Mental Health Among Athletes Mark A. Stillman, Hudson Farmer, and Ira D. Glick

313

329

22 Recovery as the Centrepiece for Mental Health Promotion in Elite Athletes Jahan Heidari and Michael Kellmann

339

23 Injury Prevention and Rehabilitation Rebecca A. Zakrajsek, Alexander G. Bianco, Taylor B. Casey, Keely N. Hayden, and Scott B. Martin

349

24 Nature-Based Interventions in Elite Sport Tadhg MacIntyre, Carina Nigg, Cassandra Murphy, and Violetta Oblinger-Peters

374

25 Young Athletes’ Mental Health and Well-Being Rosemary Purcell, Courtney Campbell Walton, Alan Currie, and Simon Rice

389

Index

406

vii

LIST OF FIGURES

1.1 1.2 2.1

6.1 7.1 11.1 11.2 13.1 13.2 14.1 15.1

16.1 17.1 17.2 23.1 23.2 23.3 23.4 24.1 24.2 24.3

Dimensional Approach to Mental Health According to Schinke et al., 2018 Two-Dimensional Model of Mental Health According to Keyes (2002) A Comprehensive Humanistic Model for Thriving Through Being in Elite Sport. (Adapted from Brown et al., 2017a; Rogers, 1959; Ryan & Deci, 2017; McHenry, 2021; McHenry et al., 2022.) A Vulnerability-Stress Model for Athletes by Nixdorf & Nixdorf (2022) Biopsychosocial Intervention and Observation of Disordered Eating (BIODE) Manifestations of Anxiety as Experienced by Elite Athletes Factors Influencing Anxiety among Elite Athletes. (Adapted from Reported Findings of Reardon et al. 2021 and Rice et al. 2019.) A Model of Overtraining and Possible Consequences. (Adapted from Kenttä, 2001.) An Integrative Model of Depression, Burnout, and Overtraining Syndrome. (Figure available from Nixdorf & Nixdorf, 2022 under a CC-BY4.0 license at https://osf.io/426rc.) Post-Concussion Anxiety and Mood Mechanisms Model. (Adapted from Sandel et al., 2017.) Anxiety in Elite Sport Revolves Mainly Around the Themes of Competition (“Competitive Anxiety”), Injury (“Injury Anxiety”), and of Presentation of Physical Attributes (“Social Physique Anxiety”). (Figure Available Under a CC-BY4.0 License at osf.io/et3b2/.) Processes Within the TCTSA-R and How They Might Relate to Mental Health Outcomes. (Adapted from Meijen et al., 2020.) Stigmatisation of Mental Health and Sport Psychology Ecological Model. (Modified from Javed et al., 2021.) Multidimensional Model of Sport Psychology Service Provision-Revised (M2SP2-R) Biopsychosocial Intervention and Observation Team Approach (BIOTA) Ecological Model: Inter-professional Team – Spokes of the Wheel. (Adapted from Bader & Martin, 2019.) iTeam Checklist Interprofessional – Therapeutic, Evaluation, Appraisal, & Management (I-TEAM) Process Hypothesised Modes of Nature Contact with Recommendations for Athletes Hypothesised Effects of Nature-Based Therapies for Athletes Examples of Indoor and Outdoor Sport Across Different Settings

viii

4 5

17 88 101 165 166 191 195 208

228 247 268 271 351 352 355 362 377 378 381

LIST OF TABLES

4.1 6.1 7.1 7.2 10.1 11.1 12.1 13.1 13.2 13.3 16.1 22.1 23.1 24.1

Studies of Resilience and Mental Health Symptoms of Depressive Episodes Assessment Inventory of Disordered Eating Determinants (AIDED) Healthy Eating and Actions for Lifetime Happiness (HEALTH) Guidelines Names and Characteristics of the Personality Disorders (PD) Overview of Key Anxiety Disorders Meta-Analyses Examining Randomised Controlled Interventions to Reduce Burnout The Different Stages Described by Meeusen et al. (2013) Comparison of Symptoms of Depression, Athlete Burnout and Overtraining Syndrome Summary of Symptom and Conceptual Similarities and Differences Between Depression, Burnout, and Overtraining in Athletes Key Terms and Definitions Guidelines for the Establishment of a Monitoring System in the Context of Sport Key Biopsychosocial Determinants, Potential iTeam Members, and Optimal Athlete Outcomes Pre- and Post-Injury Recommendations for a Sample of Sporting Activities

ix

48 84 103 114 149 160 181 190 193 197 245 345 368 382

LIST OF CONTRIBUTORS

Christopher M. Bader, assistant athletic director for Mental Health & Performance at University of Arkansas, Fayetteville, Arkansas, USA. LaTisha L. Bader, chief clinical officer, Denver Womens Recovery, Denver, Colorado, USA. Cami A. Barnes, Department of Kinesiology, Health Promotion, and Recreation, University of North Texas, USA. Jürgen Beckmann, professor, Emeritus of Excellence, Technical University of Munich, School of Medicine and Health, Munich, Germany. Ryan Benoy, psychiatry resident at the Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA. Alexander G. Bianco, assistant professor of exercise science at Ripon College, Wisconsin, USA. Jack Brimmell, School of Education, Language, and Psychology, York St John University, United Kingdom. Christopher Bryan, New York University Abu Dhabi, United Arab Emirates and American University of Sharjah, United Arab Emirates. Taylor B. Casey, owner and consultant of The Edge: Performance Psychology Consulting, LLC. Pete Coffee, Professor of Psychology in the Department of Psychology, School of Social Sciences, Heriot-Watt University. Alan Currie, consultant psychiatrist in the Regional Affective Disorders Service and Visiting Professor at the University of Sunderland, Department of Sport and Exercise Sciences, UK.

x

List of Contributors

J.D. DeFreese, teaching associate professor, Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA. Felix Ehrlenspiel, head of the Sport Psychology Unit, Technical University Munich, Munich, Germany. Hudson Farmer, Mercer University, College of Health Professions, Georgia, USA. Ira D. Glick, University – Emeritus Faculty Department: Psychiatry and Behavioral Sciences and Emeritus Faculty, Acad Council, Stanford, California, USA. Matthew Gonzalez, assistant athletic director of Catamount Sport Psychology and Counseling, University of Vermont, USA. Amelia Gulliver, Senior Research Fellow, Centre for Mental Health Research, Australian National University, Canberra, ACT, Australia. Henrik Gustafsson, professor of sport science, Karlstad University, Sweden and Norwegian School of Sport Sciences, Norway. Christine M. Habeeb, assistant professor at East Carolina University, Department of Kinesiology, Greenville, North Carolina, USA. Brandonn Harris, professor of sport and exercise psychology, Georgia Southern University, USA. Chris Hartley, Senior Lecturer in Sport Psychology in the Faculty of Health Sciences and Sport, University of Stirling. Peter Hassmén, professor of psychology at Southern Cross University, Australia. Keely N. Hayden, doctoral student, Department of Educational Psychology, University of North Texas, USA. Jahan Heidari, postdoctoral researcher in sport psychology, Faculty of Sport Science, Ruhr University Bochum, Germany. Jennifer A. Hobson, Lecturer in Sport and Exercise Psychology, Sheffield Hallam University, UK. Postgraduate Researcher, Staffordshire University, United Kingdom. Hee Jung Hong, Senior Lecturer in Sport Psychology in the Faculty of Health Sciences and Sport, University of Stirling. Marc V. Jones, Professor of Psychology, Faculty of Health and Education, Manchester Metropolitan University, United Kingdom. Jolan Kegelaers, Vrije Universiteit Brussel, Belgium, & Amsterdam University of Applied Sciences, The Netherlands.

xi

List of Contributors

Michael Kellmann, professor of sport psychology and head of the Fakultät für Sportwissenschaft, RuhrUniversität Bochum, Germany. Göran Kenttä, lecturer in sport psychology, Swedish School of Sport and Health Sciences and head of discipline for the Swedish Sport Confederation, Sweden. Bjoern Krenn, Centre for Sport Science and University Sports Department of Sport Science, University of Vienna, Austria. Tadhg MacIntyre, assistant professor at the Department of Psychology, Maynooth University, Ireland. Daniel J. Madigan, associate professor of health psychology, York St John University, United Kingdom. Scott B. Martin, professor of performance psychology at the University of North Texas, USA. Lauren K. McHenry, mental performance consultant, coach developer, Charlotte, North Carolina, USA. Robert Morris, Senior Lecturer in Sport Psychology and Deputy Head of Department of Sport in the Faculty of Health Sciences and Sport, University of Stirling. Cassandra Murphy, Department of Psychology, Maynooth University, Ireland. Carina Nigg, Institute of Sports and Sports Science, Karlsruhe Institute of Technology & Institute of Sport Science, University of Bern. Insa Nixdorf, professor of psychology at the International University of Applied Sciences, Germany. Raphael Nixdorf, professor of health psychology at the International University of Applied Sciences, Germany. Violetta Oblinger-Peters, Faculty of Human Sciences, Department of Sport Psychology and Research Methods, Universität Bern. Lisa Olive, faculty of Health, School of Psychology, Deakin University, Australia. Luke F. Olsson, Luke F. Olsson, lecturer in sport psychology, University of Essex, United Kingdom. Rosemary Purcell, professor, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia. Claudia L. Reardon, professor at the Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA. Robyn Recker, research scientist at the Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, OH, USA.

xii

List of Contributors

Simon Rice, associate professor at the Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia. Mustafa Sarkar, associate professor at the School of Science & Technology, Nottingham-Trent University, United Kingdom. Mark Stillman, clinical associate professor and director of Ccinical training for the Doctor of Psychology Program, Mercer University, College of Health Professions, USA. Lindsay Sullivan, assistant professor in the Division of Health Sciences, School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University. Shane R. Thomson, Department of Kinesiology, Recreation, and Sport Studies, University of Tennessee, Knoxville, TN, USA. Martin J. Turner, faculty of Health and Education, Manchester Metropolitan University, United Kingdom. Robert S. Vaughan, Senior Lecturer in Sport and Exercise Psychology, School of Education, Language, and Psychology, York St John University, United Kingdom. Nina Verma, Doctorate Student in Sport Psychology in the Faculty of Health Sciences and Sport, University of Stirling, United Kingdom. Courtney Campbell Walton, Elite Sport and Mental Health and Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia. Jack C. Watson II, professor of sport, exercise and performance psychology, West Virginia University, USA. Valerie Wayda, professor of athletic coaching education, West Virginia University, USA. V. Vanessa Wergin, Visiting Postdoctoral Scholar, School of Human Movement and Nutrition Sciences, University of Queensland, Australia. Jingzhen (Ginger) Yang, principal investigator at the Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children’s Hospital and Professor of Pediatrics and Epidemiology, The Ohio State University in Columbus, OH, USA. Rebecca A. Zakrajsek, associate professor of performance psychology at The University of Tennessee, Knoxville, TN, USA.

xiii

SECTION A

Mental Health

INTRODUCTION TO THE SECTION Tadhg MacIntyre

In this section, the complexity of mental health and well-being are explored from an array of dimensions. Although only recently subject to extant research in elite sport, their eminence is worthy of discussion from different perspectives, including that of the athlete and coach. The chapters are concerned with key topics including mental health and well-being, thriving and engagement, meaning, psychological resilience, and the role of the social network for coaches. This domain is critical to illuminating psychological aspects of sport beyond the myopic lens of mental illness. Understanding pathways to support mental health and psychological well-being are critical to influencing the protective factors against psychological disorder and mental illness. The complete state of the mental health model is introduced and evaluated in Chapter 1. Then, thriving and sport engagement are investigated, with an exploration of meaning and its role in ameliorating stressors and providing context for our state of mind is considered in Chapter 2. Subsequently, the construct of resilience is probed and differentiated from other explanations, including grit and mental toughness. In Chapter 5, an applied viewpoint is considered in how coaches and other actors can support the mental health of athletes.

2

DOI: 10.4324/9781003099345-2

1 MENTAL HEALTH IN ATHLETES Insa Nixdorf, Raphael Nixdorf, and Tadhg MacIntyre

Understanding of Mental Health in Contrast to Mental Illness The World Health Organisation (WHO, 2019) defines mental health and mental illness as: Mental health is a state of well-being, in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Mental disorders represent disturbances to a person’s mental health that are often characterized by some combination of troubled thoughts, emotions, behaviour and relationships with others. Examples of mental disorders include depression, anxiety disorder, conduct disorder, bipolar disorder and psychosis. It is clearly stated that mental health is more than only the absence of illness. Although widely recognised, mental health is still often understood with a clinical perspective. Many studies with mental health in their title focus on mental disorders (e.g. Gulliver et al., 2015; Reardon et al., 2021), instead of positive aspects such as well-being, meaning, or quality of life. This highlights the still widespread assumption that mental health is mainly a clinical issue with mental disorders at the centre of its scope. In this chapter, we are presenting mental health from a multidimensional perspective and highlight the often-overlooked, but important, positive aspects of mental health.

Ill or Not Ill? – Categorization of Abnormality Mental health is often viewed from a clinical perspective, with mental disorders as the centre of its attention. This perspective was for some time occupied with a distinct categorization of abnormality. Within this perspective, mental disorders are categorised as either healthy or ill and people have been diagnosed based on their symptoms. People with no mental disorder would thus not deviate from the normal range and be considered as healthy individuals. The question of abnormality is often based on four Ds: deviation, dysfunction, distress, and danger (Kring & Johnson, 2018). Those basic features of a mental disorder can help defining a person’s behaviour as normal or abnormal. However, the four Ds are, as well, mainly concerned with the question if a mental disorder is present or not. There is little to no explanation on the status of positive aspects and features. Furthermore, the Ds might help in finding diagnostic clarity and inform diagnostic manuals and DOI: 10.4324/9781003099345-3

3

Insa Nixdorf et al.

practitioners. But at the same time, the apparent problems of classification, such as loss of information or stigmatization may occur (Kring & Johnson, 2018). Thus, the general understanding shifted from a purely dichotomous to a rather fluid or dimensional approach.

Dimensional Approach to Mental Health In recent years, various changes fostered a more dimensional approach to abnormality. The newly installed ICD 11 offers, for example, a dimensional approach to personality disorders, which allows a broader range and understanding of mental disorders (World Health Organization, 2020). In the context of sport, recent position statements from the International Society of Sport Psychology, FEPSAC, and the International Olympic Committee promoted a dimensional approach to mental health, too (Schinke et al., 2018; Moesch et al., 2018; Reardon et al., 2019). Within this dimensional approach, individual differences in mental health are recognised and accounted for as it overcomes short-viewed categorisations into two entities: healthy and disordered athletes. Besides the nuanced perspective on mental disorders this also allows a more detailed focus on the positive range of syndromes. However, it still misses a highly important aspect: Within this assumption of one dimension from severe mental disorder to good mental health, mental health and mental disorders are conceptualised as either or. Athletes have either good mental health or a mental disorder. With the conceptualisation of Schinke et al. (2018) the aspect of performance is even included as the peak of the mental health dimension. Thus, athletes with psychological syndromes are separated from good mental health and most important from good performance (Figure 1.1). An athlete with a mental disorder would thus not be able to have a satisfactory social life or a high level of performance. This is not only clearly wrong for some athletes, who already proved that they could compete on the highest level, but suffer from psychological syndromes at the same time. It is also highly problematic, as it potentially increases stigmatisation of athletes with mental disorders or symptoms.

Keyes’ Two-Dimensional Model A research gap exists for accurate models distinguishing between mental health and mental illness in athletes. An alternative model from the research field of health and positive psychology introduced by Corey L.M. Keyes conceptualises mental health as a discrete syndrome of positive feelings and functioning, rather than just the absence of mental illness (Keyes, 2002). A battery of surveys assessing subjective measures of affective state and psychosocial functioning operationalises these mental health criteria, generating a composite score that places an individual on a mental health continuum ranging from “flourishing” to “moderate” to “languishing.” These classifications characterise conditions spanning from complete mental health and high levels of well-being to incomplete mental health characterised by emptiness and stagnation (Keyes, 2002). This mental health model integrates with a continuum of clinical mental illness to generate a twocontinua model. The two-continua model distinguishes between mental health and mental illness as two separate variables shown to be correlated, but still independent (Keyes, 2005). In this model, an individual may display clinically significant symptoms of mental illness but still demonstrate “flourishing” mental

Figure 1.1 Dimensional Approach to Mental Health According to Schinke et al., 2018

4

Mental Health in Athletes

Figure 1.2

Two-Dimensional Model of Mental Health According to Keyes (2002)

health. Analogously, one could be “languishing” with regard to mental health but present little to no mental illness symptoms at all (Figure 1.2). By challenging the idea that a decrease in mental illness does not immediately lead to an increase in the prevalence of mental health in the population or vice versa, the two-continua model highlights mental health as a separate condition which demands more targeted care in both prevention and treatment. The two-continua model promotes a more comprehensive understanding of the mental state of the general population, which has gained traction internationally (Keyes, 2006; Keyes et al., 2012). A 2009 report by the World Health Organisation voiced its support for the two-continua model (Friedli & World Health Organisation, 2009), and countries such as Scotland have transitioned towards formally measuring mental health in conjunction with mental illness (Parkinson, 2006). By challenging the assumption that those not suffering from mental illness demonstrate perfect mental functioning, the two-continua model encourages psychiatrists and researchers to examine more facets of an individual’s mental state, finding nuance even within the state of clinical mental illness. Despite these advances, the nuance of the two-continua model has been slow to gain traction in studies of mental health and illness in the athlete population. Though, as mentioned before, the International Society of Sport Psychology’s 2017 position statement indeed rejects the all-or-nothing framework of mental health or mental illness and even references the two-continua model, it still proposes a sport psychology-specific model of a single continuum ranging from active mental illness to peak performance (Schinke et al., 2018). This implies that, in athletes, mental health and optimal athletic performance cannot exist in the presence of mental illness and vice versa. Most other mental health disorder research within sport psychology follows this single continuum model (ranging from health to illness) according to a review by the European Federation of Sport Psychology (FEPSAC) (Moesch et al., 2018). However, a recent study validates the distinction between mental health and mental illness in a sample of Danish elite athletes, finding anxiety and depressive symptoms at rates similar to the general population coexisting 5

Insa Nixdorf et al.

alongside high levels of flourishing mental states (Küttel et al., 2021). This finding provides a foundation for future research exploring the validity of the two-continua model in other elite athlete populations, including those recruited to the present study. A first study using a more comprehensive framework of mental states in athletes, was conducted by Nixdorf and Nixdorf (2019) with the aim to overcome the theoretical shortcomings existing in sport psychology by defining mental health and mental illness in athletes as two independent, but not mutually exclusive, conditions. The two-continua model of mental health to an international sample of athletes to assess its validity in the athlete population is applied. In executing this method, the following research questions were addressed: (1) Does the two-continua model apply across cultures and athletic disciplines within an international sample of athletes? and (2) Does comparison of different continua-models using structural equation modelling support the two-continua model as the model of best fit for the mental states of athletes? The results show that the model comparison indicated that the two-continua model has the best fit, successfully verifying a two-continua model of mental health in athletes. These findings provide the first evidence to contradict the continued use of the single-continuum model to conceptualise athlete mental health and illness.

Elements of Mental Health Mental health includes various elements, such as subjective well-being, quality of life, or social connectedness. In this section, we will outline the two most important features: Well-being and quality of life. Further aspects, such as in personal meaning (see Chapter 3), thriving (see Chapter 2), resilience (see Chapter 4), or social aspects (see Chapter 5), are highlighted within separate chapters.

Well-Being Psychology as a profession has largely been concerned with mental illness, but in the past two decades, predominantly as a result of the emergence of the positive psychology paradigm (Seligman & Csikszentmihalyi, 2000), positive mental health and well-being have been more widely appreciated. Positive psychology broadly encompasses “the scientific study of the strengths that enable individuals and communities to thrive” or flourish (VanderWeele, 2017, p. 1). In this field, researchers distinguish between hedonic and eudemonic well-being, the former explained by a combination of affect (i.e. the presence of positive emotions with an absence of negative emotions) and a cognitive component (i.e. evaluations of life satisfaction). The latter dimension of well-being refers to subjective experiences associated with eudaimonia or living a life of virtue in pursuit of human excellence (Seligman & Csikszentmihalyi, 2000). They are typically measured using, for example, PANAS (Watson et al., 1988) and the Psychological Need Thwarting Scale (Bartholomew et al., 2011), respectively. Despite the prominence of this approach, there remains an array of conceptual and theoretical approaches to wellbeing. In the field of sport psychology, the construct is similarly opaque with both conceptual (Lundqvist, 2011) and methodological reviews (Giles et al., 2020) highly critical. Over a decade ago, Lundqvist (2011) concluded that studies of well-being in the field of sport psychology have been limited by conceptual ambiguity, reducing the ability to compare results across studies. They stated “well-being is treated as an unspecific variable, inconsistently defined and assessed using a variety of theoretically questionable indicators” (p. 118). More recently, Giles et al. (2020) reported that there should be a clear distinction between influencing factors, states of well-being (i.e. characteristics), and consequences of well-being (i.e., outcomes). They asserted that a sport-specific measure of well-being in sport performers should be developed to advance the field and the more effectively support athletes’ health and performance. 6

Mental Health in Athletes

Interestingly, the call to arms by Diener and Seligman (2004) that “well-being should become a primary focus of policymakers, and that its rigorous measurement is a primary policy imperative” (Diener & Seligman, 2004, p. 1), highlights that well-being requires prioritisation. Recently, the field of sport and exercise (Breslin, & Leavey, 2019) and other applied domains, including organizational psychology (Gritzka et al., 2020) are exploring this construct with regard to application. One such application is nature-based interventions, which we will discuss in Chapter 24.

Quality of Life The focus of different aspects of mental health brought attention to the general construct of quality of life. Especially with chronic conditions and severe diseases such as AIDS, cancer, or diabetes, success of therapy is often measured by quality of life. There is a broad consensus that quality of life is an important feature of health in general and in particular in mental health. However, defining quality of life is a complex issue (Renneberg & Lippke, 2006). The WHO’s understanding of quality of life considers a person’s subjective perception of their place in life, which is influenced by culture and the individual value system. This is based on a person’s goals, expectations, standards, and concerns (see Renneberg & Lippke, 2006, p. 29). This definition appears complex, which, however, also reflects the complexity of the construct itself. Quality of life consists of several dimensions and includes various assessments and standards of the personal life of an individual. Health-related quality of life (HRQOL) is of particular importance in connection with mental health and is also made up of different dimensions. Schumacher et al. (2003) defined the following dimensions to health-related quality of life: • • •

•

Illness-related, physical complaints: This refers to the individual complaints and symptoms that can usually also be assigned to specific illnesses. Mental health: This includes emotional well-being and also includes positive aspects such as happiness and general well-being. Functional limitations: This dimension relates to everyday limitations and the functional level in the different areas of life (occupation, partnership, leisure time, household, etc.). These are usually also related to illness-related limitations. Social dimension: This includes interpersonal relationships and social interactions. What is decisive is the individual opportunity to shape social relationships according to one’s own wishes. This can be limited by illness.

Overall, all aspects depend on an individual assessment. This is based on the respective ideas, goals, and needs of people. Accordingly, these evaluation processes can change over the life span and are, in terms of athletes, most likely related to their sport and career. Changes due to illnesses are also a major influencing factor and injuries play a vital role for athletes. Interestingly, in this concept, mental health is considered in a positive manner: Happiness and well-being are focused and can improve an athlete’s overall quality of life. On the other hand, functional limitations would impact athletes and their quality of life to a greater extent. This, however, would not necessarily end up in developing a mental disorder. The value of an athletic career for quality of life appears crucial. A metal-analysis comparing athletes with non-athletes revealed higher levels in HRQOL in athletes (Houston et al., 2016). However, injured athletes had lower HRQOL scores, which highlights the importance of sport-related aspects, such as the impact of previously mentioned functional limitations. This may last even beyond the athletic career and results from Simon and Docherty (2014) showed former athletes with lower HRQOL than non-athletes. Interestingly, physical and mental components might differ. Filbay et al. (2019) analyzed different studies and found that overall former athletes had similar physical components of HRQOL and better mental 7

Insa Nixdorf et al.

components. They advocate to distinguish between these components. They also revealed further specifics as risk factors for low levels of HRQOL, such as involuntary retirement and high-contact sport.

Assessment of Mental Health Capturing mental health is as complex as defining its components. Terms of mental health such as wellbeing or quality of life are often intermixed, whereas its clear definition and separation is yet to be determined (Skevington & Böhnke, 2018). However, there are several measurements that cover important aspects of mental health. Based on Keyes’ understanding of mental health, the Mental Health Continuum, which is also available in a short form questionnaire (Keyes, 2006; Keyes et al., 2008), covers important aspects of mental health. The questionnaire includes three subscales: (1) emotional well-being, or satisfaction and positive affect; (2) social well-being, such as social acceptance, integration, and cohesion; and (3) personal well-being, such as purpose in life and self-acceptance (Keyes et al., 2008; Westerhof and Keyes, 2010). As pointed out, the understanding of quality of life is complex and corresponding to this there is also a certain variety of operationalization and measurement of quality of life (Schumacher et al., 2003). For illustration, three common questionnaires, which had been used in an athlete sample for recording healthrelated quality of life, are presented here. A method used worldwide to measure health-related life satisfaction is the Short Form 36 Health Survey (see Beierlein et al., 2012). With 36 items, this covers the areas: vitality, physical functioning, physical pain, general health perception, physical role functioning, emotional role functioning, social functioning, and psychological well-being. In sport, the SF-36 was implemented as well and revealed higher levels of HRQOL for athletes. However, this was only the case for healthy athletes, while injuries accounted for a drop in an athlete’s level of quality of life (McAllister et al., 2001). The World Health Organization developed a survey for assessing quality of life, too. The World Health Organization Quality of Life, which is also available in a short version (WHOQOL-BREF; World Health Organization, 2004) assesses HRQOL in various dimensions, which are divided into the dimensions of physical well-being, psychological well-being, social relationships, and the environment. This questionnaire is also used in athletes to cover aspects of HRQOL (Ciampolini et al., 2017; Verkooijen et al., 2012). Another way of operationalization is implemented in the L-1. Here, the entire complexity of the construct is reduced to one question: “How satisfied are you at present, all in all, with your life?” (Beierlein et al., 2015, p. 1). The answer is given on a 10-point scale from 0 (= not at all satisfied) to 10 (= completely satisfied). Due to the economy, the questionnaire is often used in larger, social science surveys and, given its brevity, allows a fairly valid measurement of the construct of life satisfaction (Beierlein et al., 2014).

Practical Implications While mental illness does affect an individual’s life in a manner that may impact athletics and pose a threat to athlete performance, successful, elite-level performance and mental illness are not mutually exclusive. As mentioned above, there is strong support that mental illnesses exist among athletes, including those competing at the elite level, at rates comparable to or higher than the general population (Moesch et al., 2018; Nixdorf et al., 2013; Nixdorf et al., 2020; Yang et al., 2007). Application of the two-continua model to the field of sport psychology acknowledges the reality that a high-performing athlete could present clinical-level symptomatology without experiencing compromised performance. From another perspective, an athlete experiencing performance difficulties or dissatisfaction with their sport may present no clinical symptoms and have fine mental health outside of their sport; this does not discredit an athlete from receiving mental support. A main goal for everyone involved in working with athletes, reducing the 8

Mental Health in Athletes

stigma of mental illness should be a main priority. Advocating for a more comprehensive understanding of mental health and illness can be a key factor in achieving this goal. Also, by distinguishing between mental health and mental illness, an improvement of referral and treatment for athletes can be accomplished.

Research Perspectives Assessing mental health and well-being alongside mental illness or through a comprehensive model should shape future research. New perspectives in reducing stigma, deepening our understanding, and improving athletes’ support is not going to be accessible through a categorical or one-dimensional approach to the topic. Future research may concentrate on identifying determinants of mental health and pre-conditions to performance and therefore connecting the field to studies on resilience (Chapter 4) and sport sciences. Regarding a multidimensional framework of mental health and illness, future studies should continue to test the two-continua model against other models (with more than two dimensions) within broader athlete populations representing more diverse nationalities to further build support for bolstering mental health supports specifically for athlete populations. Mental health involves different variables such as well-being, flourishing, or quality of life and there is an ongoing debate how those variables are connected and if they capture essentially same features (Skevington & Böhnke, 2018). With regards to the field of sport, a sport-specific adaptation of those variables and constructs might be useful. In addition to the beforementioned variable of performance, other sport-specific variables such as injuries (see also Chapter 23) could be integrated into the concept of mental health and well-being. Specific measurements for athletes could improve understanding and reveal how sport-specific variables relate and impact athlete’s mental health.

References Bartholomew, K., Ntoumanis, N., Ryan, R.M., & Thogersen-Ntoumani, C. (2011). Psychological need thwarting in the sport context: Development and initial validation of a psychometric scale. Journal of Sport and Exercise Psychology, 33(1), 75–102. 10.1123/jsep.33.1.75 Beierlein, C., Kovaleva, A., László, Z., Kemper, C.J., & Rammstedt, B. (2014). Eine Single-Item-Skala zur Erfassung der Allgemeinen Lebenszufriedenheit: Die Kurzskala Lebenszufriedenheit-1 (L-1). (GESIS-Working Papers, 2014/33). GESIS Leibniz-Institut fü r Sozialwissenschaften. https://nbn-resolving.org/urn:nbn:de:0168-ssoar-426681 Beierlein, C., Kovaleva, A., László, Z., Kemper, C.J., & Rammstedt, B. (2015). Kurzskala zur Erfassung der allgemeinen Lebenszufriedenheit (L-1). Zusammenstellung sozialwissenschaftlicher Items und Skalen, 33, 1–18. 10.6102/zis229 Beierlein, V., Morfeld, M., Bergelt, C., Bullinger, M., & Brähler, E. (2012). Messung der gesundheitsbezogenen Lebensqualität mit dem SF-8. [Measuring health-related quality of life with the SF-8: German norms from a representative self-administered survey]. Diagnostica, 58(3), 145–153. 10.1026/0012-1924/a000068 Breslin, G., & Leavey, G. (2019). Mental health and well-being interventions in sport: Research, theory and practice. Routledge. 10.4324/9781315147703 Ciampolini, V., Columna, L., Lapolli, B., Iha, T., Grosso, E.C., Silva, D.A.S., & Galatti, L.R. (2017). Quality of life of Brazilian wheelchair tennis athletes across competitive and elite levels. Motriz: Revista de Educação Física, 23(2). 10.1590/s1980-6574201700020014 Diener E., Seligman, M. (2004). Beyond money: Toward an economy of well-being. Psychological Science: Public Interest, 5, 1–31. doi: 10.1111/j.0963-7214.2004.00501001.x Filbay, S., Pandya, T., Thomas, B., McKay, C., Adams, J., & Arden, N. (2019). Quality of life and life satisfaction in former athletes: A systematic review and meta-analysis. Sports Medicine, 49(11), 1723–1738. 10.1007/s40279-01901163-0 Friedli, L. (2009). Mental Health, Resilience and Inequalities. World Health Organization. National Institute for Mental Health in England, Child Poverty Action Group, Faculty of Public Health & Mental Health Foundation. Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Giles, S., Fletcher, D., Arnold, R., Ashfield, A., & Harrison J. (2020). Measuring well-being in sport performers: Where are we now and how do we progress? Sports Medicine, 50, 1255–1270. 10.1007/s40279-020-01274-z

9

Insa Nixdorf et al. Gritzka S., MacIntyre T.E., Dörfel D., Baker-Blanc J.L., & Calogiuri G. (2020). The effects of workplace naturebased interventions on the mental health and well-being of employees: A systematic review. Frontiers in Psychiatry, 11, 323. doi: 10.3389/fpsyt.2020.00323 Houston, M.N., Hoch, M.C., & Hoch, J.M. (2016). Health-related quality of life in athletes: A systematic review with meta-analysis. Journal of Athletic Training, 51(6), 442–453. 10.4085/1062-6050-51.7.03 Keyes, C.L. (2002). The mental health continuum: from languishing to flourishing in life. Journal of Health and Social Behavior, 43(2), 207–222. https://www.ncbi.nlm.nih.gov/pubmed/12096700 Keyes, C.L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology, 73(3), 539–548. 10.1037/0022-006X.73.3.539 Keyes, C.L. (2006). Mental Health in Adolescence: Is America’s Youth Flourishing? American Journal of Orthopsychiatry, 76(3), 395–402. 10.1037/0002-9432.76.3.395 Keyes, C.L.M., Eisenberg, D., Perry, G.S., Dube, S.R., Kroenke, K., & Dhingra, S.S. (2012). The relationship of level of positive mental health with current mental disorders in predicting suicidal behavior and academic impairment in college students. Journal of American College Health, 60(2), 126–133. 10.1080/07448481.2011.608393 Keyes, C.L., Wissing, M., Potgieter, J.P., Temane, M., Kruger, A., & Van Rooy, S. (2008). Evaluation of the mental health continuum–short form (MHC–SF) in setswana‐speaking South Africans. Clinical Psychology & Psychotherapy, 15(3), 181–192. 10.1002/cpp.572 Kring, A.M., & Johnson, S.L. (2018). Abnormal psychology: The science and treatment of psychological disorders. John Wiley & Sons. Küttel, A., Pedersen, A.K., & Larsen, C.H. (2021). To Flourish or Languish, that is the question: Exploring the mental health profiles of Danish elite athletes. Psychology of Sport and Exercise, 52, 101837. 10.1016/j.psychsport.2020.101837 Lundqvist, C.(2011). Well-being in competitive sports-The feel-good factor? A review of conceptual considerations of well-being. International Review of Sport and Exercise Psychology, 4(2), 109–127. 10.1080/1750984X.2011.584067 McAllister, D.R., Motamedi, A.R., Hame, S.L., Shapiro, M.S., & Dorey, F.J. (2001). Quality of life assessment in elite collegiate athletes. The American Journal of Sports Medicine, 29(6), 806–810. 10.1177/03635465010290062201 Moesch, K., Kentta, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Nixdorf, I., Beckmann, J., & Nixdorf, R. (2020). Psychological predictors for depression and burnout among German junior elite athletes. Frontiers in Psychology, 11, 601. 10.3389/fpsyg.2020.00601 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. 10.1123/jcsp.7.4.313 Nixdorf, I., & Nixdorf, R. (2019). Applying a two-continua model of mental health to athletes [Conference presentation]. 15th European Congress of Sport & Exercise Psychology FEPSAC, Mü nster, Germany. Parkinson, J. (2006). Establishing national mental health and well‐being indicators for Scotland. Journal of Public Mental Health, 5(1), 42–48. 10.1108/17465729200600010 Reardon, C.L., Bindra, A., Blauwet, C., Budgett, R., Campriani, N., Currie, A., … & Hainline, B. (2021). Mental health management of elite athletes during COVID-19: A narrative review and recommendations. British Journal of Sports Medicine, 55(11), 608–615. doi: 10.1136/bjsports-2020-102884 Reardon, C.L., Hainline, B., Aron, C.M., Baron, D., Baum, A.L., Bindra, A., … & Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine, 53(11), 667–699. 10.1136/bjsports-2019-100715 Renneberg, B., & Lippke, S. (2006). Lebensqualität. In B. Renneberg & P. Hammelstein (Eds.), Gesundheitspsychologie (pp. 29–33). Springer. Schinke, R.J., Stambulova, N.B., Si, G.Y., & Moore, Z. (2018). International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622–639. 10.1080/1612197x.2017.1295557 Schumacher, J., Klaiberg, A. & Brä hler, E. (2003). Diagnostische Verfahren zu Lebensqualitä t und Wohlbefinden. Hogrefe. Seligman, M.E.P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14. 10.1037/0003-066X.55.1.5 Simon, J.E., & Docherty, C.L. (2014). Current health-related quality of life is lower in former Division I collegiate athletes than in non–collegiate athletes. The American Journal of Sports Medicine, 42(2), 423–429. 10.1177/036354 6513510393 Skevington, S.M., & Böhnke, J.R. (2018). How is subjective well-being related to quality of life? Do we need two concepts and both measures? Social Science & Medicine, 206(1982), 22–30. 10.1016/j.socscimed.2018.04.005 VanderWeele, T.J. (2017). On the promotion of human flourishing. Proceedings of the National Academy of Sciences, 114, 8148–8156. doi: 10.1073/pnas.1702996114

10

Mental Health in Athletes Verkooijen, K.T., van Hove, P., & Dik, G. (2012). Athletic identity and well-being among young talented athletes who live at a Dutch elite sport center. Journal of Applied Sport Psychology, 24(1), 106–113. 10.1080/10413200.2011.633153 Watson, D., Clark, L.A., & Tellegen, A. (1988) Development and validation of brief measures of positive and negative affect: The PANAS Scales. Journal of Personality and Social Psychology, 54, 1063–1070. 10.1037/0022-3514.54.6.1063 Westerhof, G.J., & Keyes, C.L.M. (2010). Mental illness and mental health: The two continua model across the lifespan. Journal of Adult Development, 17(2), 110–119. 10.1007/s10804-009-9082-y World Health Organization (2004). The world health organization quality of life (WHOQOL)‐BREF. https://apps. who.int/iris/bitstream/handle/10665/77773/WHO_HIS_HSI_Rev.2012.02_eng.pdf World Health Organization (2019). Mental health: Fact sheet. https://www.euro.who.int/__data/assets/pdf_file/0004/ 404851/MNH_FactSheet_ENG.pdf World Health Organization (2020). International classification of diseases - 11th revision. https://icd.who.int/en Yang, J., Peek-Asa, C., Corlette, J. D., Cheng, G., Foster, D. T., & Albright, J. (2007). Prevalence of and Risk Factors Associated With Symptoms of Depression in Competitive Collegiate Student Athletes. Clinical Journal of Sport Medicine, 17(6), 481–487. https://doi.org/10.1097/JSM.0b013e31815aed6b

11

2 THRIVING IN ELITE ATHLETES Lauren K. McHenry and Rebecca A. Zakrajsek

Introduction Accounts in research of athlete abuse by coaches and sport medicine staff (e.g., Kerr & Stirling, 2008; Kerr et al., 2019), loss of resources following Olympic performance (as discussed in the documentary The Weight of Gold; Rapkin, 2020), and performance-dependent funding of national governing bodies (Kerr et al., 2019) have all revealed a win-at-all-cost culture in elite sport. Unfortunately, in this culture, winning too often comes at the expense of elite athletes’ mental health and well-being (Kerr & Stirling, 2008; Santos & Costa, 2018). To counter such a culture, scholars have turned to the concept of thriving as the ultimate state of being to nurture within athletes and elite sport systems (e.g., Brown et al., 2017a; Kerr & Stirling, 2008; McHenry et al., 2022). Specifically, it is only when athletes experience sport success through and with holistic (i.e., physical, social, psychological) well-being that they are truly thriving (Brown et al., 2017a; Kerr & Stirling, 2008). To elaborate, Brown et al. (2017a) reviewed 13 operational definitions of thriving from scholarly works across disciplines and proposed the following cross-contextual definition: thriving is “the joint experience of development and success” (p. 168). Brown and colleagues (2017a) explained that, in their definition of thriving, development refers to the continuous expansion of holistic well-being and success refers to performance outcomes. Taken together, if an athlete is making marked progress in their sport performance and producing successful outcomes (i.e., performance success) but is not energised and experiencing a healthy perspective or adaptive mental functioning (i.e., holistic development), they are not thriving. In turn, if an athlete is experiencing healthy mental functioning but feels stagnant in their ability to produce successful outcomes in their sport, they are also not thriving (Brown et al., 2017a; Spreitzer et al., 2005). Perhaps the biggest challenge to the promotion of thriving within a win-at-all-cost culture is the fact that successful outcomes can and have occurred despite poor mental health (see Chapter 1). One of the most high-profile examples of this issue is exemplified by the U.S. gymnastics teams dominating global competition for decades despite ongoing sexual abuse by their team doctor, Larry Nassar, as well as verbal and emotional abuse by their coaches, Bela and Martha Karolyi (see, e.g., Fisher & Anders, 2020; Kerr et al., 2019). Athletes, among others, have spoken out in efforts to protect future generations from having to survive an environment that destroys well-being and mental health in order to achieve their gold-tinted dreams of sporting success. It is time for all gatekeepers within elite sport systems [e.g., mental performance consultants (MPCs), coaches, administrators, and sport medicine providers] to ask the question that 12

DOI: 10.4324/9781003099345-4

Thriving in Elite Athletes

Valerie Kondos-Field1 asked former president of USA Gymnastics in response to his prioritization of winning: “At what cost?” (Kondos-Field & Cooper, 2019, p. 6). Fortunately, a collection of recent findings on thriving in elite sport have demonstrated that athletes do not have to pay the price of their mental health for performance success (e.g., Brown et al., 2017a; Brown & Arnold, 2019; McHenry et al., 2022). To be sure, competition and the desire to win do not automatically compromise mental health. Rather, it is the methods used for the sake of winning that must be critically examined in terms of whether they are enabling or hindering thriving. The growing body of literature on thriving in elite sport has demonstrated that thriving results from certain processes that are ignited by the interaction of personal and contextual factors (see, e.g., Brown et al., 2017b; Brown et al., 2018; Brown & Arnold, 2019; McHenry et al., 2022; Rouquette et al., 2021). For example, an athlete’s proactive behaviors (e.g., personal factor; Sarkar & Fletcher, 2014) may interact with a coach’s unconditional positive regard (UPR; e.g., contextual factor; McHenry et al., 2022) to support the athlete’s challenge appraisal (e.g., process factor; Brown et al., 2021) which is positively associated with thriving (e.g., Flinchbaugh et al., 2015; Brown et al., 2021). Thus, in order for practitioners within elite sport contexts to support athlete thriving, they must understand both personal characteristics of the athlete and contextual enablers or barriers to thriving within the athlete’s environment. These professionals must, in turn, be open to collaborating to support the ways in which an elite sport system can enable thriving. With this goal in mind, this chapter provides a thoughtful discussion of what is currently known about thriving in elite sport, including its theoretical foundations and the process, personal, and contextual enablers for thriving that have been demonstrated in research. Within this discussion, a humanistic model for thriving through being is presented which integrates Ryan and Deci’s (2017) self-determination theory (SDT) and Rogers’ (1959) person-cantered theory (PCT) to more comprehensively understand how thriving can be cultivated. Guidelines for practitioners are then provided with practical strategies to bring this model to life in elite sport contexts. Finally, unanswered questions and key considerations for future research on thriving in elite sport are addressed.

Theoretical Foundations of Thriving Within Brown et al.’s (2017a) conceptual discussion of thriving, the authors identified specific process, personal, and contextual enablers of thriving that have been addressed in prior research across domains and contexts. Within the context of elite sport, Ryan and Deci’s (2017) self-determination theory (SDT) has been predominately used by scholars to understand one of the two key processes for how thriving is cultivated (see, e.g., Brown et al., 2017b, 2021; Gucciardi et al., 2017; Kinoshita et al., 2021). Specifically, SDT posits that satisfaction of the psychological needs autonomy, competence, and relatedness is a key process that results in fully integrated functioning through self-determined motivation (Ryan & Deci, 2017). On the other hand, when this key process is thwarted (i.e., psychological need thwarting), optimal functioning is hindered through controlled motivation (Ryan & Deci, 2017). As a result of qualitative interviews with elite athletes, coaches, and MPCs, Brown et al. (2018) suggested that the characteristics of thriving found in elite sport were representative of fully integrated functioning as described within selfdetermination theory. These characteristics included “being optimistic, focused, and in control; having an active awareness of areas for improvement; possessing high-quality motivation; experiencing holistic development; displaying upward progression; and having a sense of belonging” (p. 142). Drawing from SDT, with a sample of 535 athletes (including regional, national, and international competitors), Brown et al. (2017b) identified four latent profiles of thriving: (1) thriving, (2) above average, (3) below average, and (4) low functioning. Thriving was measured with a composite score of three variables: subjective vitality, subjective performance, and positive affect, representing the subjective experience of both holistic well-being and performance success. Brown and colleagues (2017b) found that participants with high levels of need satisfaction were most likely to be in the thriving profile compared to any other profile (i.e., 13

Lauren K. McHenry and Rebecca A. Zakrajsek

above average, below average, and low functioning). In turn, participants with high levels of need frustration were more likely to be in the below-average profile compared to the thriving profile. As another example, with a sample of 51 elite male hockey players, Brown et al. (2021) found that higher levels of need satisfaction six days prior to a hockey game were associated with higher perceptions of thriving (assessed via subjective vitality, subjective performance, and positive affect) during the hockey game. Collectively, the findings of Brown et al. (2017b, 2021) have provided evidence for basic psychological need satisfaction as a process enabler of thriving. Notably, Brown et al. (2017b) also examined two personal enablers of thriving (resilience and use of psychological skills) and two contextual enablers of thriving (perceived available social support in general and basic psychological need support from a coach). Regarding personal enablers of thriving, resilience significantly predicted membership in the thriving profile and psychological skills use significantly predicted membership in the thriving or above average profiles. Regarding contextual enablers, measures of social support and psychological need support from a coach did not significantly predict profile membership. However, Brown et al. (2017b) did not assess whether contextual enablers may have influenced the process (i.e., basic psychological need satisfaction) and personal (i.e., resilience and psychological skills use) enablers which did significantly predict profile membership. Researchers have previously found a predictive relationship between perceived need support from a coach and athletes’ basic psychological need satisfaction; and, for perceived need thwarting behaviours from a coach and athletes’ need thwarting (see, e.g., Balaguer et al., 2012; Bartholomew et al., 2011). Drawing from the framework of SDT (Ryan & Deci, 2017), it can be suggested that basic psychological need satisfaction (i.e., process enabler of thriving) may result from an interaction between autonomy-supportive behaviours from a coach (i.e., contextual enabler) and a person’s motivation and (i.e., personal enabler). However, SDT—specifically basic psychological need satisfaction—only explains one of the two key processes that enable thriving in elite sport contexts. The second process enabler of thriving in (and beyond) this context is the appraisal of stressors as challenges rather than threats (i.e., challenge appraisal; Brown et al., 2017a, 2021; Feeney & Collins, 2015; Freeman & Rees, 2009; Kerr et al., 2016; Lazarus & Folkman, 1984; O’Leary & Ickovics, 1995; Sarkar & Fletcher, 2014). Specifically, scholars have indicated that a personal enabler of thriving is the desire to actively seek out challenges (e.g., Feeney & Collins, 2015; Sarkar & Fletcher, 2014). Thus, Brown et al. (2017a) indicated that challenge appraisal—in which athletes evaluate situations based on potential gain as opposed to potential failure—may be a process that enables thriving in addition to basic psychological need satisfaction. Tellingly, Brown et al.’s (2017b) study with 535 athletes revealed that participants who perceived sport events as challenges rather than threats were significantly less likely to be in the low-functioning latent profile compared to the thriving profile. Furthermore, in Brown et al.’s (2021) study with 51 elite hockey players, challenge appraisal of a hockey game prior to play was significantly associated with higher perceptions of thriving during the game. Like need satisfaction, these findings provide evidence for challenge appraisal as the second process enabler of thriving. As mentioned previously, Brown et al. (2017b) also assessed perceived available social support as a contextual enabler for thriving, but this variable did not predict profile membership for thriving. However, again, Brown et al. (2017b) did not examine any possible relationship between social support and process enablers (i.e., challenge appraisal, need satisfaction) or personal enablers (i.e., resilience, psychological skills use), each of which did predict profile membership for thriving. Previous literature provides evidence to consider how perceived available social support, and perhaps the psychological safety associated with social support, may impact challenge appraisal. For example, Feeney and Collins (2015) suggested that significant relationships will serve as a source of strength (providing secure attachment and safety) for thriving through adversity and as a relational catalyst (providing encouragement and instrumental assistance) for thriving amidst goal pursuit. Providing empirical evidence for this hypothesis, Tomlinson et al. (2016) found that married couples’ high perceptions of relational catalyst support from their partner impacted their perceptions of social support which, in turn, predicted their general perceptions of available social support. Perceptions of available social support then predicted 14

Thriving in Elite Athletes

participants’ goal striving, actual goal achievement, and thriving (assessed via measures of self-growth, goal achievement, and self-esteem) within one year. From this finding, it could be suggested that participants’ self-efficacy beliefs (strengthened through perceived available social support) supported their challenge appraisal of the goal that they approached and ultimately achieved. Scholars have found similar results in the elite sport context. Among elite golfers, perceived available esteem support (a subscale within the latent construct of perceived available social support) was found to reduce threat appraisal in competition and improve objective performance (Freeman & Rees, 2009). And, across 52 National Collegiate Athletic Association Division I women’s basketball teams, Smittick et al. (2019) found that athletes’ sense of psychological safety on their team mediated the relationship between perceived coach civility and objective measures of team performance. Smittick and colleagues connected team psychological safety to processes that reflect challenge appraisal including risk-taking and asking for feedback. A strength in the findings of Freeman and Rees (2009) and Smittick et al. (2019) is that performance was measured objectively (shots taken in a golf match adjusted by course difficulty; and change in win-loss records across two years, respectively). Collectively, based on the prior findings we suggest that the presence of a secure relational base (e.g., the perception that an important other will be there for an individual no matter what) may be the key contextual enabler that contributes to the personal enabler of psychological safety to, in turn, result in challenge appraisal (i.e., process enabler of thriving). For further support of this notion, a secure relational base is reflected at the core of the contextual enablers of thriving that scholars have previously identified. For example, these contextual enablers have included secure relational attachment and trust (e.g., Brown & Arnold, 2019; Feeney & Collins, 2015; Spreitzer et al., 2005), a challenge environment (i.e., an appropriate balance of challenge and mastery; e.g., O’Leary & Ickovics, 1995), and support from family (e.g., Tomlinson et al., 2016), coaches (e.g., Brown et al., 2018; Brown & Arnold, 2019), employers (e.g., Paterson et al., 2014), and colleagues (e.g., Spreitzer & Porath, 2014; see also Brown et al., 2017a for further discussion of these contextual enablers). Thus, practitioners may benefit from a theoretical model that extends beyond self-determination theory to offer an understanding of how a secure relational base (with psychological safety) can be cultivated in the elite sports environment. Empirical evidence supports the viability of Rogers’ (1959) PCT as a framework for how to cultivate a secure relational base within elite sport settings (see, e.g., McHenry et al., 2021, 2022). While Ryan and Deci’s (2017) self-determination theory is a contemporary variant of humanistic psychology (DeRobertis & Bland, 2018), PCT is an originating theory of humanistic psychology. Examining the foundations of humanistic psychology as related to thriving can help us consider how these two theories may work together to support a more comprehensive understanding of how thriving is cultivated. Specifically, humanistic psychology arose as a movement to understand the fullness of human potential. While humanistic psychology reached its scientific “golden age” from the 1950s–1970s, its core concepts have been influenced by the works of philosophers, theologians, literary figures, and scholars across centuries. Prominent figures from Socrates and Aristotle to Martin Büber and Abraham Maslow have sought to understand how the highest reaches of human nature may be attained through holistic development and well-being (i.e., thriving), and each has influenced the core theories and concepts of humanistic psychology (Moss, 2015). One fundamental and cross-theoretical concept in humanistic psychology is selfactualization. That is, given the right environmental conditions, humanistic scholars assume that the natural human tendency is to self-actualize (i.e., to reach or grow continually towards one’s maximum potential; Feeney & Collins, 2015; Kerr et al., 2016; Spreitzer & Porath, 2014). Some scholars who have studied thriving have distinguished self-actualization from thriving (Spreitzer et al., 2005). Yet this distinction is based on a narrow interpretation of self-actualization within Maslow’s (1943) theory of motivation. That interpretation is that all safety (e.g., physiological) and psychological (e.g., belonging and esteem) needs must be satisfied before self-actualization can be attained. With this interpretation, self-actualization is considered an end-state while safety and psychological need satisfaction 15

Lauren K. McHenry and Rebecca A. Zakrajsek

are the means to get there. Contrasting this interpretation of self-actualization from thriving, Spreitzer et al. (2005, 2014) suggested that the experience of thriving does not require total satisfaction of safety and psychological needs, but rather indicates that one is on the path toward self-actualization. However, a closer evaluation across humanistic theories of personality, interpersonal relationship, and motivation offers a different interpretation of self-actualization (i.e., Angyal, 1941; Goldstein, 1939; Maslow, 1943, 1954; Rogers, 1959; Ryan & Deci, 2017). For example, prior to Maslow, Goldstein (1939) introduced the concept of self-actualization as the life organism’s fundamental drive to actualize its potentials, from which people’s creative fruition grows. Additionally, Rogers’ (1959) PCT depicted self-actualization as a process that occurs throughout the lifespan. According to Rogers, (1959) self-actualization involves both the drive to meet one’s own physiological needs (e.g., air, water, food, safety) as well as the drive to continually expand one’s development and effectiveness in maximizing one’s potential. Rogers’ (1959) likened the drive for continual expansion to one’s intrinsic motivation to create, explore, and approach challenges that align with one’s sense of purpose. Rogers’ depiction of self-actualization aligns with that of Ryan and Deci (SDT; 2017), who defined self-actualization as “a description of the overarching growth and integrative process of functioning effectively” (p. 251). With these interpretations, self-actualization is a continual growth process—a means in and of itself—rather than an end-state. Like self-actualization, thriving has been defined by some scholars as an end-state sense of achievement and prosperity (e.g., Cui, 2007; Jackson et al., 2011) and by others as a continual growth process (e.g., Benson & Scales, 2009; Kerr et al., 2016). Brown et al.’s (2017a) definition of thriving (i.e., “the joint experience of development and success;” p. 168) was intended to be applicable across contexts and time. Thus, with this definition, a person may fluctuate in their momentary states of thriving while also being on a continual upward trajectory that is—in and of itself—thriving. Taken together, self-actualization and thriving have both been considered to be momentary states of being and overarching processes. In addition, the two concepts encompass holistic well-being (i.e., development) in conjunction with maximizing one’s potential (i.e., success). When it comes to maximizing potential, it is noteworthy that both self-actualization and thriving also encompass a choosing of discomfort and challenge in order to grow into one’s potential. For example, describing self-actualization, Rogers (1959) stated that it involved “the seeking of pleasurable tensions, the tendency to be creative, the tendency to learn painfully to walk when crawling would meet the same needs more comfortably” (p. 196). Likewise, discussing thriving, Kerr et al. (2016) stated that thriving individuals are accepting of struggle; they “face challenges, hardships, failures, and life crises but emerge and grow from these experiences with greater self-awareness and understanding and strength” (p. 25). These descriptors of self-actualization and thriving are reflective of the personal enablers that scholars have identified for thriving. Specifically, personal enablers identified have included optimism and honesty toward one’s personal values (e.g., Park, 1998), self-esteem and self-efficacy (e.g., Lerner et al., 2011; Niessen et al., 2012; Park, 1998), self-determined and intrinsic motivation (e.g., Benson & Scales, 2009), proactive behaviours (e.g., Sarkar & Fletcher, 2014), religiosity or spirituality (e.g., Park 1998), continual learning (e.g., Niessen et al., 2012; Spreitzer et al., 2005), and resilience (e.g., Sarkar & Fletcher, 2014; see Brown et al., 2017a for an in-depth review of personal enablers of thriving). These personal enablers are also representative of Rogers (1959) description of a “fully functioning person” (p. 234) which included psychological maturity, adaptability, autonomy, self-awareness, and self-regulation. A theme that lies at the core of these personal enablers is alignment between an individual’s goals and actions with their personal values and life purpose. Such an alignment requires a consistent respect for (i.e., self-regard) and belief in (i.e., self-efficacy) oneself. Within SDT (Ryan & Deci, 2017), this may reflect integrated regulation (the highest form of self-determined motivation aside from intrinsic motivation). Conceptually parallel to integrated regulation, Rogers’ (1959) PCT refers to the full integration of one’s external experiences with his or her internal self-concept as congruence (Rogers, 1959). Both SDT (Ryan & Deci, 2017) and PCT (Rogers, 1959) allow us to suggest that integrated regulation, or congruence, represent 16

Thriving in Elite Athletes

personal enablers of self-actualization (i.e., thriving). And independently, each theory offers unique and meaningful explanations for what is necessary to cultivate integrated regulation or congruence. Yet Rogers’ (1959) PCT can help to extend current understandings within SDT about how such enablers of thriving (i.e., congruence) are developed. The extent to which the two theories complement each other—together providing a more comprehensive understanding of how to cultivate thriving—is worthy of consideration. Thus, a comprehensive, humanistic model for thriving through being in elite sport, drawing from both PCT (Ryan & Deci, 2017) and SDT (Rogers, 1959), will be discussed next (see also Figure 2.1).

Figure 2.1

A Comprehensive Humanistic Model for Thriving Through Being in Elite Sport. (Adapted from Brown et al., 2017a; Rogers, 1959; Ryan & Deci, 2017; McHenry, 2021; McHenry et al., 2022.)

17

Lauren K. McHenry and Rebecca A. Zakrajsek

A Humanistic Model for Thriving Through Being in Elite Sport Drawing from SDT (Ryan & Deci, 2017), we can understand that the satisfaction of autonomy, competence, and relatedness (i.e., process enabler of thriving) may result from an interaction between a needsupportive environment (i.e., contextual enabler) and a person’s motivation (i.e., personal enabler). And, while there is a wealth of literature within sport psychology on how to create an autonomy- or needsupportive environment (see, e.g., Bartholomew et al., 2010; Mageau & Vallerand, 2003; Mallett, 2005), PCT (Rogers, 1959) extends this information to offer how to cultivate a secure relational base (i.e., contextual enabler) as well as need satisfaction, challenge appraisal (i.e., process enablers), and congruence (i.e., personal enabler) within the space of growth-promoting relationships. To elaborate, while PCT is most notably applied to therapist-client relationships within psychology and counselling, Rogers’ (1959) paper actually presented PCT as a theory for any relationship in which the growth and development of a person is the goal (i.e., any growth-promoting relationship). Within the context of elite sport, the coach–athlete relationship has been identified as the most important and impactful growth-promoting relationship (see, e.g., Brown & Arnold, 2019; Côté and Gilbert, 2009; McHenry et al., 2021, 2022). However, it could be argued that an athlete’s relationship with any member of their physical, medical, or psychological support team (i.e., all gatekeepers within elite sport contexts) serves as a growth-promoting relationship for the athlete. According to PCT, in such relationships, a specific way of being is necessary to cultivate a person’s self-actualization (i.e., thriving). This way of being includes the joint provision and perception of authenticity, empathy, and unconditional positive regard (UPR; Rogers, 1959). It must be noted here that Ryan and Deci (2017) presented authenticity and UPR as “relatednesssupportive techniques” (p. 447). Further, adolescents’ perceptions of UPR from parents have been found to predict perceptions of the provision of two need-supportive behaviours (providing rationale and choices when directing behaviour) as well as adolescents’ autonomous motivation (Roth et al., 2016). In fact, Roth et al. (2016) found that higher perceptions of parent UPR strengthened the relationship between their children’s perceived need-support and autonomous motivation. Drawing from these findings, Ryan and Deci (2017) made the case that UPR “facilitates not only autonomy satisfaction (because it is noncontrolling) but also relatedness satisfaction” (p. 447). In the sport context, through qualitative interviews with retired elite figure skaters, the findings of McHenry et al. (2022) support this notion as athletes perceived their coaches to communicate UPR through an age-appropriate balance of allowing autonomy with the provision of guidance and structure. In turn, these elite athletes reported that their perceptions of UPR from coaches enhanced their “love for the sport and motivation to persist through challenges” (p. 14). However, SDT (Ryan & Deci, 2017) does not provide a comprehensive understanding of what UPR is and how it can be provided. For this, we must turn to Rogers’ (1959) PCT in order to more fully understand how to cultivate a secure relational base and need satisfaction through the provision of UPR. Specifically, scholars of PCT have suggested that UPR can only be accurately provided and perceived in tandem with authenticity and empathy (Rogers, 1959; Wilkins, 2000). This notion is directly supported by another significant finding by Roth et al. (2016). That is, parents’ self-reported authenticity predicted their children’s perceptions of their provision of UPR. Authenticity, a term used interchangeably with congruence, is defined as being fully oneself, such that one’s internal experience is congruent with their external way of being (Rogers, 1959; Thacker, 2016). As discussed previously, an authentic—or congruent—person is representative of a person who is fully functioning toward self-actualization (i.e., thriving). Thus, PCT (Rogers, 1959) prompts us to assume that a person must be thriving themselves in order to cultivate thriving in others through the provision of authenticity, empathy, and UPR to others (Moon et al., 2001; Standal, 1954). Further, PCT (Rogers, 1959) indicates that one’s development of unconditional positive self-regard (UPSR) is a precursor to congruence or authenticity. Evidencing this 18

Thriving in Elite Athletes

notion, scholars have found a significant positive relationship between UPSR and authenticity (Kim et al., 2020; Murphy et al., 2017) as well as a predictive relationship between conditional regard from significant others (an opposite of UPR) and lower levels of authenticity (Lynch & Sheldon, 2017). Meanwhile, empathy is defined as understanding another person’s internal frame of reference accurately, sensing the other’s feelings and perspective as if that experience were their own (Rogers, 1959). Regarding autonomy-supportive techniques, Ryan and Deci (2017) stated: “At its most foundational level, autonomy support begins by embracing the perspective of [the other]” (p. 443). Again, PCT (Rogers, 1959) with SDT (Ryan & Deci, 2017) extends our understanding of what it means to cultivate self-actualization (i.e., thriving) with autonomy-support through the joint provision of UPR and empathy. Rogers (1959) stated specifically that “in order for UPR to be communicated, it must exist in a context of empathic understanding” (p. 230). Thus, PCT helps us understand that the purpose of empathy is to communicate UPR. In sport, this has been demonstrated through elite figure skaters’ interpretations of UPR through reports of their coaches’ expression of “disappointment with them [as opposed to] disappointment at them,” indicating that their coaches were willing “to remain present and supportive through moments of adversity and failure even if those moments were difficult to endure” (McHenry et al., 2022, p. 444). Further, Rogers (1959) PCT can extend our understanding of how and why UPR—communicated through authenticity and empathy—is so important for the cultivation of self-actualization or thriving. To elaborate, there has been debate among scholars as to whether UPR is a change-agent itself (e.g., Bozarth, 2001; Freire, 2001; Moore, 2001) or whether it is a precursor to growth and change (e.g., Hendricks, 2001; Prouty, 2001; Watson & Steckley, 2001). Yet, there has been little debate as to whether UPR, experienced within growth-promoting relationships, is an essential factor to cultivating growth toward self-actualization (Bozarth & Wilkins, 2001). UPR is defined as relating to another “in such a way that no experience can be discriminated as more or less worthy of positive regard than any other” (Rogers, 1959, p. 208). Important for elite performance contexts, UPR does not equate to agreement, tolerance of unproductive behaviour, or even liking (Wilkins, 2000). Rather, UPR is an acceptance and acknowledgement of one’s momentary experiences (Rogers, 1959; Schmid, 2001), while—at the same time—seeing one’s potential to improve their experience and challenging them to move toward that potential (Rogers & Büber, 1960; Schmid, 2001). Such a foundational belief in elite athletes’ potential is reflected in a statement made by Sue Enquist2 when interviewed by Michael Gervais on the Finding Mastery podcast: I always say ‘be loyal to their potential’ … I’ve never heard a kid say, ‘Oh, I couldn’t stand Coach Enquist, she believed in us too much’ … I just believed in [my athletes] so much … and my job was to catch them doing it right every day. (Gervais, 2020) UPR has also been characterised by the term warmth. Often mistaken for “being soft,” “warmth” is really the provision of fully focused engagement with a person in moments of interaction (Freire, 2001; Wilkins, 2000). In the same episode of Finding Mastery, Gervais (2020) went on to suggest that “the art [Enquist described] is being able to imagine what’s possible for somebody, but the skill is to be so present that you catch it,” indicating that present-moment engagement allows for interactions that communicate belief in and challenge to rise to potential. Finally, while some may associate the term unconditional with a laissezfaire style, UPR can actually be communicated through challenging others “to transcend their status quo” (Schmid, 2001, p. 56). Based on findings from qualitative interviews with elite figure skaters, McHenry et al. (2022) coined the following definition of UPR as applied to coach–athlete relationships: “acceptance, respect, engagement, belief in, and challenge of [athletes] in times of both failure and success” (p. 436). Counter to a win-at-all-cost environment, elite athletes in McHenry et al.’s (2022) study indicated that 19

Lauren K. McHenry and Rebecca A. Zakrajsek

unconditionality was communicated most when their coaches continued to demonstrate these qualities during moments of failure in their sport as much as moments of success. Perhaps most relevant for the elite sport context was that coaches challenging athletes “in the context of acceptance, respect, engagement and belief—made [these athletes] feel … ‘worth something’” (McHenry et al., 2022, p. 447). As a result, these retired elite figure skaters reported being more open to receiving critical feedback and more capable of challenging themselves, demonstrating a greater likelihood to view competitive situations as challenges as opposed to threats (i.e., challenge appraisal). Neuroscientists have suggested that UPR may support challenge appraisal by way of cultivating psychological safety. For example, Lux (2010, 2013) suggested that the safe social connection fostered by UPR will increase levels of oxytocin, which is known to lower blood pressure, enhance generosity and trust, reduce the stress response and increase pain tolerance (Uvnä s-Moberg, 2003; Zak et al., 2007). The power of Rogers’ (1959, 1980) proposed way of being lies in the notion that UPR from significant others has been found to transfer to the recipient’s UPSR (Iberg, 2001). This was confirmed through qualitative interviews with elite figure skaters; multiple participants explained that their selfregard was “like a mirror” to how they perceived their coaches’ regard for them (McHenry et al., 2021, p. 432). As previously stated, PCT (Rogers, 1959) allows us to understand UPSR as a precursor to authenticity—or congruence—which is reflective of integrated regulation, the most internalised form of self-determined motivation, within SDT (Ryan & Deci, 2017). Congruence, in turn, has been connected to personal enablers for thriving. Yet, in order to cultivate congruence (i.e., personal enabler of thriving), PCT offers an understanding that elite athletes must first develop UPSR through the provision of UPR in growth-promoting relationships within their environmental contexts. On a neurobiological level, Silani et al. (2013) indicated that accurate self-perceptions and acceptance of one’s experiences represented by congruence or authenticity may produce similar patterns of neural pathways in the prefrontal cortex as is seen when a person is actively regulating their emotions. To be sure, emotion regulation has been identified as a characteristic of thriving (Gucciardi & Jones, 2012). And, from a PCT perspective, scholars have suggested that no matter what an individual is experiencing, UPSR allows one to rely on their own selfacknowledgement of their worth and potential as a source of strength to live to their highest potential (Rogers, 1959; Schmid, 2001). Meanwhile, PCT (Rogers, 1959) also offers an explanation for how UPSR can support thriving through the process-enabler of challenge appraisal. Specifically, Standal (1954) and Rogers (1959) considered the denial of self-regard under certain conditions to be maladaptive development (i.e., a block in self-actualization) and named it conditions of worth. The concept of conditions of worth is theoretically parallel to that of introjected regulation within SDT (Ryan & Deci, 2017). To elaborate, with conditions of worth, a person’s primary source of motivation is to avoid internalised rejection (i.e., rejection of self). Rogers’ (1959) PCT posited that when authenticity, empathy and UPR are only offered in certain conditions and withheld in others (i.e., conditional regard), then individuals will internalise the provision or denial of self-regard in those respective conditions. Thus, any potential outcome that falls outside of an individual’s own conditions of worth would be appraised as a deep threat to the self (Bozarth & Wilkins, 2001). For example, elite figure skaters interviewed by McHenry et al. (2021) indicated that conditions of worth (developed through experiences of conditional regard, negative regard, and/or disregard from coaches) “hindered their ability to be vulnerable or take risks, made them feel ‘less than,’ and led them to question or doubt their abilities and self-worth” (p. 432). Unfortunately—though not surprising within a win-at-all-cost culture—conditional regard has been reported to be a behaviour commonly used by professional coaches (Bartholomew et al., 2010). In fact, Cheval et al. (2017) found that elite youth soccer players’ higher perceptions of conditional regard from a coach predicted lower perceptions of relatedness (i.e., having a secure relational base) with that coach and lower perceptions of competence in their sport performance. In turn, Cheval and colleagues found lowered 20

Thriving in Elite Athletes

perceptions of competence to predict lower overall energy, lower self-esteem, and higher levels of burnout. While scholars have previously connected UPR to the satisfaction of both autonomy and relatedness (Ryan & Deci, 2017; Roth et al., 2009, 2016), Cheval et al. (2017) provided evidence to suggest that conditional regard may thwart satisfaction of competence. Consistent with the findings of McHenry et al. (2021), Cheval and colleagues’ results indicated that conditional regard may actually contribute to the opposite of thriving (e.g., poor holistic well-being and poor perceptions of competence that may likely lead to poor performance outcomes). In fact, McHenry et al. (2021) suggested that the opposites of UPR—including conditional regard (e.g., perceptions of acceptance, respect, and valuing from coaches IF the athlete met certain conditions), negative regard (e.g., experiences of verbal abuse, shaming), and disregard (e.g., experiences of being controlled or ignored and denied attention) may provide a language with which to “better name and understand the varied experiences of emotional abuse” (p. 438) of athletes by coaches, parents, MPCs, or sport medicine providers within elite sport contexts. We suggest that on most occasions, it is with the best of intentions that coaches or members of an athlete’s interprofessional support team (i.e., the gatekeepers in elite sport contexts) communicate conditional regard because they are trying to influence behaviour change to support successful performance outcomes. And, while it is true that there are examples of controlling, and even abusive, training environments—ripe with conditional regard, negative regard, and disregard—that have yielded successful sport outcomes (see, e.g., Kerr et al., 2019), this begs the question: What kind of success could have been achieved if those environments had supported well-being in tandem with the structure and standards necessary for performance success? In 2018, Simone Biles came forward as a survivor of sexual abuse by Larry Nassar (Grinberg, 2018). Of more than 140 gymnasts who joined her in speaking out as survivors of Nassar’s abuse under the guise of the Karolyi empire, Biles was the only one who continued to compete internationally following Nassar’s trial and conviction (Martin & Lane, 2021). Even though Biles achieved successful performance outcomes under the abusive conditions of the Karolyis’ reign, her performance improved beyond what many thought imaginable after Nassar’s conviction and the Karolyis’ training centre closing. For example, Biles landed two gymnastics moves that had never been done before at the 2019 World Championships and maintained scores with record margins above her competitors (McCarriston, 2019). And, while a case of the “twisties” prevented Biles from exhibiting performance gains at the 2021 Olympic Games, Biles did exhibit self-regard that was not contingent on winning through her decision to withdraw from all but one event for the sake of her mental health and physical safety (Park & Gregory, 2021). Perhaps Biles gives us a glimpse of what is possible for performance and mental health and well-being when winning is viewed as a by-product of wellness and athletes are respected for more than their outcomes. While still in its infancy, the empirical evidence related to conditional regard in coach–athlete relationships demonstrates that it does not allow the best outcomes to occur for athlete well-being, or even for performance. Comparison of athletes’ perceived outcomes of the opposites of UPR from coaches (McHenry et al., 2021) to perceived outcomes of UPR from coaches (McHenry et al., 2022) offers stark differences in the implications of each. Specifically, retired elite figure skaters who experienced at least one of the opposites of UPR (conditional regard, negative regard, or disregard) believed this led to loss of trust in their coach, loss of sport motivation, diminished sport performance, and negative self-regard or selfdisregard—altogether experiencing declines in both well-being and performance (McHenry et al., 2021). Meanwhile, those who experienced UPR believe this resulted in the development of their own positive self-regard (i.e., UPSR), trust in the coach–athlete relationship, sport motivation, and sport confidence that positively influenced performance—altogether reflective of thriving (McHenry et al., 2022).

Guidelines for Practitioners It is important to note the fact that SDT has been widely adopted by scholars and practitioners alike as an effective and applicable framework in elite sport contexts to cultivate well-being and performance success 21

Lauren K. McHenry and Rebecca A. Zakrajsek

(i.e., thriving, see, e.g., Mageau & Vallerand, 2003; Mallett, 2005; Bartholomew et al., 2010). Autonomysupportive coaching behaviours posed by Mageau and Vallerand (2003) included the provision of choice within limits, a rationale for tasks and limits, empathic acknowledgement, opportunities for initiativetaking, as well as the avoidance of controlling behaviours. (see, e.g., Nelson et al., 2014). Yet Ryan and Deci (2017) have since stated that “autonomy support is first and foremost an agapeic attitude of unconditional regard and the desire for the empowerment and self-actualization of [a person]” (p. 443). Thus, while applications of SDT in elite sport have, thus far, emphasised coaches and parents’ use of needsupportive behaviours, Rogers’ (1959) PCT offers a way of being, from which autonomy supportive behaviours may flow more authentically. For the purpose of cultivating thriving in elite sport—so that athletes no longer have to pay the price of their mental health for performance success—scholars and practitioners alike may consider the humanistic model for thriving through being as a viable comprehensive model for any practitioner who serves elite athletes by way of a growth-promoting relationship (e.g., MPCs, coaches, administrators, and sport medicine professionals). In the following sections, practical guidelines will be discussed including the importance of practitioners’ own thriving, the role of practitioners as advocates for thriving sport systems, and strategies that practitioners can apply to enable thriving within interpersonal relationships among an interprofessional team, including elite coaches and athletes.

Practitioners as Exemplars of Thriving To apply the humanistic model for thriving through being is to consider that any strategy that does not address elite sport practitioners’ and especially elite coaches’ own thriving—by way of UPSR and congruence—will be a band-aid approach to supporting athlete thriving. This is because of the notion that within growth-promoting relationships, a person must be thriving themselves in order to provide the contextual enablers that support thriving in others (e.g., Standal, 1954; Moon et al., 2001). Internationally recognised MPC, Jean François Ménard offers an example of this through his professional philosophy that “if you work with high performers, you need to be a high performer yourself” (Ménard & Malchelosse, 2021, p. 18). While some might assume this statement refers to physical or outcome-driven performance, we encourage readers to consider how important it is for elite athletes to see the members of their support team as exemplars of thriving—demonstrating high performance through mental health and well-being. This requires efforts to develop personal self-awareness and self-regard, to seek help when needed, and to regularly engage in self-care and professional development. For example, senior-level MPCs indicated that valuing self-care and engaging in reflective, spiritual, and/or mindfulness practices were key strategies to support their own well-being in order to better care for their elite athlete clientele (see, e.g., Quartiroli et al., 2019). In addition, scholars have evidenced that coaches’ use of MPC services for themselves has supported their intra- and interpersonal development, ultimately enhancing their own self-awareness, performance, and interactions with athletes (Sheehy et al., 2019). And, following participation in a professional development program designed to facilitate learning and application of PCT concepts with coaching and support staffs, an athletic trainer indicated that engaging in the learning and application of UPR supported their own sense of thriving at work (McHenry, 2021).

Practitioners as Advocates for a Culture of Thriving Another foundational guideline for applying PCT with SDT to cultivate athlete thriving is for practitioners to serve as advocates for a culture of thriving in elite sport. Athletes and scholars alike have recognised that athlete maltreatment is a systemic issue, rather than the fault of any one individual (see, e.g., Fisher & Anders, 2020; Kerr et al., 2019). For example, Kerr et al. (2019) pointed out that power dynamics within the microsystem of athlete and authority figure relationships (i.e., the gatekeepers), the exosystem of the sport organization, and the macrosystem of the sport culture all played a role in 22

Thriving in Elite Athletes

Nassar’s mass perpetration of athlete abuse. As stated in the introduction of this chapter, retired elite athletes are calling out to the gatekeepers within elite sport systems (e.g., MPCs, coaches, administrators, and sport medicine providers) to put a stop to the price of mental health for peak performance (see, e.g., The Weight of Gold directed by Rapkin, 2020). And, while athlete activism for social change outside of sport occurs regularly (see, e.g., David, 2020), we more commonly hear about athletes’ maltreatment within the sport system after athletes are retired and out of that system. This indicates that athletes continue to feel a lack of agency to speak up when they are still reliant on the sport system to achieve their goals. In turn, we suggest that strategies to support athlete thriving will also serve merely as band-aid approaches without meaningful efforts to advocate for thriving sport systems. David (2020) indicated that MPCs and mental health clinicians are in an apt position, and ethically obliged, to advocate for athletes through organizational and systemic intervention in conjunction with interpersonal intervention. Further, we recommend that coach developers be included within interprofessional support teams to advocate for athletes through the education and continuing professional development of coaches (see, e.g., McHenry, 2021).

Business Models to Support Thriving One practical challenge to countering a win-at-all-cost culture within elite sport is the very real financial cost of losing a sporting event when funding of the sport system (i.e., governing body, collegiate institution, or professional organization) is literally tied to winning within the $750 billion sport industry (Rein et al., 2014). However, based on their research on business strategies in the sport industry, Rein and colleagues have indicated that too much focus on winning is actually a losing longterm business strategy for sport organizations. Specifically, Rein et al. (2014) found that sport industry leaders who cultivated thriving sport systems have focused on controllable factors more than winning for the purpose of growing revenue. Examples of such controllable factors include constructing team or athlete narratives that can endure wins and losses, using new technologies to effectively reach fans, and grounding decision making in ethics (Rein et al., 2014). Thus, while it is true that winning does impact revenue (see, e.g., Gerritsen & van Rheenen, 2017), Rein and colleagues offer evidence that sport organizations do not have to place the bets of their bottom line on winning. In order to truly cultivate thriving at the cultural and systemic level within elite sport, we suggest that sport administrators—and those who work with them—consider controllable factors beyond winning from which to build revenue. In this way, coaches and athletes can be viewed as people who are part of the organization rather than pawns to be used, traded, and released.

Processes of Thriving Sport Organizations Offering an example of a thriving professional sport organization, Brown and Arnold (2019) interviewed professional rugby players who believed their club supported both their well-being and performance success. The two overarching themes across these interviews reflect the satisfaction of relatedness through secure connections with teammates (theme one) and secure connections with coaches and the organization (theme two). At the systemic level, participants identified the following processes that helped to cultivate an “honest and fear-free environment”: … the usage of exit interviews when players left the club, having a fair rule making process and selection policy, creating a leadership group to drive standards, introducing a trusted and reliable intermediary (acting between players and club), and providing a clear, honest, and constructive feedback process. (Brown & Arnold, 2019, p. 75) 23

Lauren K. McHenry and Rebecca A. Zakrajsek

Further, considerate treatment (i.e., regard) for teammates who were not on the starting roster, a focus on long-term player development and decreasing player turnover were additional ways in which the athletes in Brown and Arnold’s (2019) study believed their elite sport club could cultivate a secure connection between athlete and organization, and thus, enable athlete thriving. Brown and Arnold (2019) indicated that these strategies may develop mutual trust between athlete and organization as well as help players feel valued in their role—mechanisms that likely support satisfaction of relatedness, competence, and autonomy. Drawing from Rogers’ (1959) PCT, we suggest that such strategies may be enacted more congruently when an organization commits to authenticity, empathy, and UPR as a foundational way of being.

Practitioners as Enablers of Thriving through Interpersonal Relationships Finally, we suggest that all practitioners within elite sport contexts (i.e., MPCs, coaches, administrators, sport medicine providers) have an opportunity to enable thriving through their way of being in relationship with the athletes with whom they work. The strategies presented in this section were evaluated through a professional development program which aimed to facilitate the learning and application of UPR with authenticity and empathy (McHenry, 2021). The program, Thriving Through Being, was implemented with 53 professional coaches and members of their support staff (i.e., strength and conditioning coaches, athletic trainers, directors of operations, video coordinators, and MPCs) across 17 National Collegiate Athletic Association women’s basketball programs. Of note, participants reported higher levels of thriving (as measured via vitality and learning at work) during program participation compared to two months after program completion. In addition, participants reported a significant increase in UPSR from pre- to post-program participation, which was maintained two months later (McHenry, 2021).

Intrapersonal Strategy: Self-Awareness of the Opposites of UPR The first practical strategy that participants in McHenry’s (2021) program believed to be most effective for improving their way of being was to grow their awareness around their own unintentional use of negative regard or disregard. To do this, participants created a list of athlete behaviours that they loved and athlete behaviours that irritated them. They then reflected on their reactions to each behaviour and sought feedback from colleagues and athletes to learn how others perceived their reactions to each behaviour. This activity prompted participants to learn what it feels like to be coached, instructed, or led by them, thus gaining external self-awareness (see, e.g., Eurich, 2017). We emphasise that this strategy is not a behaviour to emulate, but rather a reflective exercise for practitioners to gain true awareness of their impact on the people around them. Enhanced awareness, in turn, allowed participants in this study to have more power over their impact. Specifically, participants in McHenry (2021) expressed that this awareness allowed them to “catch” themselves just prior to moments of reacting with negative regard or disregard. In turn, they described the enhanced ability to pause, reflect, and choose an alternative response that better supported what the athlete needed in the moment thus enhancing their effectiveness in their professional roles.

Interpersonal Strategy: Direction of Relational Movement The next practical strategy from McHenry (2021) that was most impactful for learning and resultant shifts in participants’ way of being was, again, not a behaviour to do but a reflective exercise on one’s way of being. Specifically, participants were prompted to label their own interactions with colleagues and athletes as either: moving away from (i.e., disregard), moving against (i.e., negative regard), moving toward (i.e., disregard for potential via over-accommodation or control), or moving with (i.e., UPR with authenticity and empathic understanding). Such distinctions allowed participants more clarity in understanding their impact in momentary interactions. Strategies to support moving with included seeking to understand the 24

Thriving in Elite Athletes

reasoning behind an irritating athlete behaviour and reflection upon the athlete’s physical, safety, and/or psychological needs for effective support and challenge. For example, one participant stated that this helped them in “just trying to think and dial it back to ‘What is [the athlete] feeling right now?’ instead of how I feel;” the interaction that resulted from this reflection led to the athlete “hit[ting] five out of her next six shots” (McHenry, 2021, p. 196).

UPR: A Secure Base from Which to Challenge Finally, in going through a professional development program that was grounded in Rogers’ (1959) PCT, participants indicated that they grew in their understanding that “holding UPR for a player does not mean always being positive with them” (McHenry, 2021, p. 188). Rather, they recognised that through UPR as a way of being, they could actually challenge their athletes more effectively. For example, one participant shared that because they were placing more emphasis on praising things done right in day-to-day training, “it has allowed me to have even more challenging conversations with [this athlete]!” (McHenry, 2021, p. 189). Such a shift in way of being, however minor it may seem, is a shift toward an environment that may facilitate both well-being and performance.

Unanswered Questions and Future Directions In closing, we offer considerations around unanswered questions and future directions for research and application related to thriving in elite sport contexts. First, we recognise that empirical evidence around thriving in elite sport, and in particular with a PCT (Rogers, 1959) perspective is still in its infancy. While there is a wealth of literature on PCT in other contexts (i.e., counselling, parenting, and teaching; see, e.g., Cochran & Cochran, 2015; Roth et al., 2016; Aspy et al., 2014), the elite sport context is unique. For example, the definition of UPR posed within McHenry et al. (2022) came directly from participant interviews. This helped to extend our understanding of how UPR is felt and interpreted by elite athletes in an elite performance context. Thus, within elite sport contexts, there is a need for researchers to examine the relationships between variables within the humanistic model for thriving through being presented in this chapter. For example, within quantitative research, scholars may consider exploring the relationship between athlete perceptions of UPR and autonomy-supportive behaviours with measures of athlete UPSR, congruence, and need satisfaction in elite sport contexts. In turn, empirical evidence is needed to understand how UPSR and congruence with need satisfaction may enable or enhance thriving. We also welcome scholars to explore contextual enablers of thriving as potential mediators for the relationships between personal and process enablers of thriving and thriving itself. Further, the most common method of measurement for thriving in elite sport contexts has been to assess subjective vitality with subjective performance and positive affect (see, e.g., Brown et al., 2017b, 2021). Yet, as Brown et al. (2017b) pointed out, there is a need for scholars to systematically improve measures of objective performance. Freeman and Rees (2009) and Smittick et al. (2019) have offered examples for how this may be done within specific sports. Meanwhile, additional qualitative research would benefit our depth in understanding what the variables within the humanistic model for thriving through being really look and feel like in elite sport contexts. Qualitative researchers may also explore how members of this context perceive these variables (i.e., perceived UPR and need support from gatekeepers within the sport system, UPSR, congruence, need satisfaction, and thriving) to relate to each other. Modelling Brown et al.’s (2018) study in which athletes, coaches, and MPCs were interviewed, future studies in which members up and down the hierarchy in an elite sport system (i.e., athlete, coach, parent, administrators, officials, sport medicine provider) could help to improve our understanding of how thriving sport systems are cultivated. And, interviews with coach–athlete dyads may offer a better understanding for how UPR, authenticity and 25

Lauren K. McHenry and Rebecca A. Zakrajsek

empathy are both provided and perceived in elite sport. Further, in both quantitative and qualitative research, there is a need to explore the model presented in this chapter across cultures. We call upon scholars—including ourselves—to account for specific barriers to thriving in elite sport that may result from systemic and institutionalised oppression based on race, gender, sexual orientation, body shape, and class within elite sport contexts in future research. Finally, with regard to practical application of concepts related to thriving in elite sport, it is time for scholars and practitioners to take ownership in building stronger bridges between research and practice. We suggest this can only be done by setting egos aside, striving to understand each other, and focusing on a common goal—that is, to promote a culture of thriving within elite sport. More comprehensive evaluations to assess how applied interventions at the individual, organizational, and systemic levels impact thriving (i.e., well-being and performance success) may be possible through collaborative partnerships between scholars, practitioners, and elite sport organizations. For such endeavours, we suggest the use of consistent methods of evaluation (e.g., realist evaluation; see Pawson & Tilley, 1994) to clearly assess two objectives of change within elite sport environments. Drawing from Desimone and Garet (2015), the first objective is change in organizational processes and practitioner and coaches’ knowledge, awareness, and skills related to PCT (Rogers, 1959) and SDT (Ryan & Deci, 2017). The second is to assess how organizational and practitioner changes influence athlete outcomes (i.e., well-being and performance outcomes). Scholars and practitioners, together, must improve the ways in which we connect changes in systemic processes and practitioners’ and coaches’ professional development to improvements in athlete outcomes related to thriving (McHenry, 2021). In conclusion, we believe there is sufficient evidence to demonstrate that the methods used for the sake of winning do not have to compromise the mental health and well-being of those involved in elite sport. In fact, thriving—the joint experience of well-being and success (Brown et al., 2017b)—is possible in elite sport. Thus, the gatekeepers within this context—administrators, practitioners, and coaches—have a choice. The choice is to stay comfortable within professional practices that are based on “the way things have always been done,” or to imagine what is possible—at the individual, interpersonal, organizational, and systemic levels—to cultivate cultures of thriving in elite sport. This chapter offers a new humanistic model for thriving through being—combining tenets of Ryan and Deci’s (2017) SDT and Rogers’ (1959) PCT—from which scholars and practitioners may gain a more complete understanding of how to cultivate thriving in elite sport. We have provided practical guidelines to bring this model to life at the individual, interpersonal, and systemic levels within elite sport systems.

Notes 1 Valerie Kondos-Field is a retired head coach of the University of California Los Angeles Division I gymnastic program, who led her team to seven National Collegiate Athletic Association Championships during her tenure. She discusses her process of winning without compromising the human spirit in her 2018 book, Life is Short, Don’t Wait to Dance, and in her 2019 Ted Talk, Why Winning Doesn’t Always Equal Success. 2 Sue Enquist, retired head coach of the University of California Los Angeles Division I softball program, led her teams to 11 National Collegiate Athletic Association Championships and developed 65 All-American and 15 Olympic athletes during her 27-year tenure as head coach.

References Angyal, A. (1941). Foundations for a science of personality. Commonwealth Fund. Aspy, D.N., Roebuck, F.N., & Aspy, C.B. (2014). Research on person-centered methods. In C.R. Rogers, C.H. Lyon, & R. Tausch (Eds.), On Becoming an Effective Teacher. London: Routledge, 10.4324/9780203725672 Balaguer, I., González, L., Fabra, P., Castillo, I., Mercé, J., & Duda, J. (2012). Coaches’ interpersonal style, basic psychological needs and the well- and ill-being of young soccer players: A longitudinal analysis. Journal of Sports Sciences, 30(15), 1619–1629. 10.1080/02640414.2012.731517

26

Thriving in Elite Athletes Bartholomew, K.J., Ntoumanis, N., & Thøgersen-Ntoumani, C. (2010). The controlling interpersonal style in a coaching context: Development and initial validation of a psychometric scale. Journal of Sport & Exercise Psychology, 32, 193–216. Bartholomew, K., Ntoumanis, N., Ryan, R., Bosch, J., & Thøgersen-Ntoumani, C. (2011). Self-determination theory and diminished functioning: The role of interpersonal control and psychological need thwarting. Personality & Social Psychology Bulletin, 37(11), 1459–1473. 10.1177/0146167211413125 Benson, P.L., & Scales, P.C. (2009). The definition and preliminary measurement of thriving in adolescence. The Journal of Positive Psychology, 4, 85–104. 10.1080/17439760802399240 Bozarth, J.D. (2001) A reconceptualization of the necessary and sufficient conditions for therapeutic personality change. In G. Wyatt., J. Bozarth & P. Wilkins (Eds.), Rogers’ therapeutic conditions: evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 173–179). PCCS Books. Bozarth, J.D., & Wilkins, P. (2001) Unconditional positive regard: towards unravelling the puzzle. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 220–230). PCCS Books. Brown, D.J., & Arnold, R. (2019). Sports performers’ perspectives on facilitating thriving in professional rugby contexts. Psychology of Sport and Exercise, 40, 71–81. 10.1016/j.psychsport.2018.09.008 Brown, D.J., Arnold, R., Fletcher, D., & Standage, M. (2017a). Human thriving: A conceptual debate and literature review. European Psychologist, 22, 167–179. 10.1027/1016-9040/a000294 Brown, D.J., Arnold, R., Reid, T., & Roberts, G. (2018). A qualitative inquiry of thriving in elite sport. Journal of Applied Sport Psychology, 30, 129–149. 10.1080/10413200.2017.1354339 Brown, D.J., Arnold, R., Standage, M., & Fletcher, D. (2017b). Thriving on pressure: A factor mixture analysis of sport performers’ responses to competitive encounters. Journal of Sport & Exercise Psychology, 39, 423–437. 10.1123/ jsep.2016-0293 Brown, D., Arnold, R., Standage, M., Turner, J., & Fletcher, D. (2021). The prediction of thriving in elite sport: A prospective examination of the role of psychological need satisfaction, challenge appraisal, and salivary biomarkers. Journal of Science and Medicine in Sport, 24(4), 373–379. 10.1016/j.jsams.2020.09.019 Cheval, B., Chalabaev, A., Quested, E., Courvoisier, D., & Sarrazin, P. (2017). How perceived autonomy support and controlling coach behaviors are related to well- and ill-being in elite soccer players: A within-person changes and between-person differences analysis. Psychology of Sport & Exercise, 28, 68–77. 10.1016/j.psychsport.2016.10.006 Cochran, J., & Cochran, N.H. (2015). The heart of counseling: A guide to developing therapeutic relationships. (2nd ed.) Thomson/Wadsworth. Côté, J., & Gilbert, W. (2009). An integrative definition of coaching effectiveness and expertise. International Journal of Sports Science & Coaching, 4(3), 307–323. Cui, Y. (2007). Striving and thriving: Women in Chinese national sport organizations. International Journal of the History of Sport, 24, 392–410. 10.1080/09523360601101378 David, J. (2020). #Imwithkap: The perceived role of sport psychology practitioners in the activist-athlete movement. ProQuest Dissertations Publishing. DeRobertis, E., & Bland, A. (2018). Tapping the humanistic potential of self-determination theory: Awakening to paradox. The Humanistic Psychologist, 46(2), 105–128. 10.1037/hum0000087 Desimone, L., & Garet, M. (2015). Best practices in teachers’ professional development in the United States. Psychology, Society & Education, 7(3), 252–263. 10.25115/psye.v7i3.515 Eurich, T. (2017). Insight: The surprising truth about how others see us, how we see ourselves, and why the answers matter more than we think. Crown Publishing Group. Feeney, B.C., & Collins, N.L. (2015). A new look at social support: A theoretical perspective on thriving through relationships. Personality and Social Psychology Review, 19, 113–147. 10.1177/1088868314544222 Fisher, L., & Anders, A. (2020). Engaging with cultural sport psychology to explore systemic sexual exploitation in USA gymnastics: A call to commitments. Journal of Applied Sport Psychology, 32(2), 129–145. 10.1080/10413200. 2018.1564944 Flinchbaugh, C., Luth, M., & Li, P. (2015). A challenge or a hindrance? Understanding the effects of stressors and thriving on life satisfaction. International Journal of Stress Management, 22(4), 323–345. 10.1037/a0039136 Freeman, P., & Rees, T. (2009). How does perceived support lead to better performance? An examination of potential mechanisms. Journal of Applied Sport Psychology, 21, 429–441. 10.1080/10413200903222913 Freire, E. (2001). Unconditional positive regard: The distinctive feature of client-centered therapy. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 145–155). PCCS Books. Gerritsen, D.F., & van Rheenen, S. (2017). The value of winning: Endorsement returns in individual sports. Marketing Letters, 28(3), 371–384. 10.1007/s11002-017-9422-9

27

Lauren K. McHenry and Rebecca A. Zakrajsek Gervais, M. (Host). (2020, February 19). Sue Enquist on What Makes a Great Coach. (No. 212). [Audio podcast episode] in Finding Mastery. https://findingmastery.net/sue-enquist/ Goldstein, K. (1939). The organism: A holistic approach to biology derived from pathological data in man. American Book Publishing. 10.1037/10021-000 Grinberg, E. (2018, January 16). Simone Biles says she, too, was abused by former USA team doctor. CNN. https://www. cnn.com/2018/01/15/us/simone-biles-larry-nassar Gucciardi, D.F., & Jones, M.I. (2012). Beyond optimal performance: Mental toughness profiles and developmental success in adolescent cricketers. Journal of Sport & Exercise Psychology, 34, 16–36. doi: 10.1123/jsep.34.1.16 Gucciardi, D.F., Stamatis, A., & Ntoumanis, N. (2017). Controlling coaching and athlete thriving in elite adolescent netballers: The buffering effect of athletes’ mental toughness. Journal of Science and Medicine in Sport, 20, 718–722. 10.1016/j.jsams.2017.02.007 Hendricks, M.N. (2001). An experiential version of unconditional positive regard. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 220–230). PCCS Books. Iberg, J.R. (2001). Unconditional positive regard: Constituent activities. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 109–125). PCCS Books. Jackson, D., McDonald, G., & Wilkes, L. (2011). Thriving in the workplace: Learning from innovative practices. In M. McAllister & J.B. Lowe (Eds.), The resilient nurse: Empowering your practice (pp. 105–114). Springer. Kerr, G., & Stirling, A. (2008). Child protection in sport: Implications of an athlete-centered philosophy. Quest, 60(2), 307–323. Kerr, G., Battaglia, A., & Stirling, A. (2019). Maltreatment in youth sport: A systemic issue. Kinesiology Review, 8(3), 237–243. 10.1123/kr.2019-0016 Kerr, G., Stirling, A., & Gurgis, J. (2016). An athlete-centred approach to enhance thriving within athletes and coaches. In S. Pill (Ed.), Perspectives on athlete-centered coaching (pp. 24–36). Routledge. Kim, J., Joseph, S., & Price, S. (2020). The positive psychology of relational depth and its association with unconditional positive self-regard and authenticity. Person-Centered & Experiential Psychotherapies, 19(1), 1–10. 10.1080/14779757. 2020.1717983 Kinoshita, K., MacIntosh, E., & Sato, S. (2021). Thriving in youth sport: The antecedents and consequences. International Journal of Sport and Exercise Psychology, 20(2), 356–376. 10.1080/1612197X.2021.1877327 Kondos-Field, V. & Cooper, S. (2019). Life is short, don’t wait to dance: Advice and inspiration from the UCLA athletic hall of fame coach of 7 NCAA Championship teams. New York: Center Street Hachette Book Group, Inc. Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer. Lerner, R., Lerner, J., & Benson, J. (2011). Positive youth development: Research and applications for promoting thriving in adolescence. Advances in Child Development and Behavior, 41, 1–17. 10.1016/B978-0-12-386492-5.00001-4 Lux, M. (2010). The magic of encounter: The person-centered approach and the neurosciences. Person-Centered & Experiential Psychotherapies, 9(4), 274–289. 10.1080/14779757.2010.9689072 Lux, M. (2013). The circle of contact: A neuroscience view on the formation of relationships. In J.H.D. CorneliusWhite, R. Pitrik-Motschnig, & M. Lux (Eds.), Interdisciplinary handbook of the person-centered approach, research and theory. Springer Science. 10.1007/978-1-4614-7141-7_2 Lynch, M., & Sheldon, K. (2017). Conditional regard, self-concept, and relational authenticity: Revisiting some key Rogerian concepts cross-culturally, through multilevel modeling. The Journal of Humanistic Psychology, 60(2), 168–186. 10.1177/0022167817696842 Mageau, G. & Vallerand, R. (2003). The coach-athlete relationship: A motivational model. Journal of Sports Sciences, 21(11), 883–904. 10.1080/0264041031000140374 Mallett, C.J. (2005). Self-determination theory: A case study of evidence-based coaching. The Sport Psychologist, 19(4), 417–429. 10.1123/tsp.19.4.417 Martin, W. & Lane, B. (2021). Simone Biles says her Olympic return is driven by a desire to use her voice to spotlight historic abuse in gymnastics. Insider. https://www.insider.com/simone-biles-olympics-spotlight-historic-gymnastics-abuse-2021-4 Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–396. 10.1037/h0054346 Maslow, A.H. (1954). Motivation and personality. Harpers. McCarriston, S. (2019, October 8). Simone Biles has two new signature moves that will be named after her following world championships performance. CBS Sports. https://www.cbssports.com/nfl/draft/news/2021-day-2-nfl-mock-draftkyle-trask-lands-in-nfc-east-panthers-pick-left-tackle-for-sam-darnold/ McHenry, L.K. (2021). A Realist Evaluation of the Professional Development Program Thriving through Being with Professional Coaches and Support Staff of NCAA Women’s Basketball. PhD dissertation, University of Tennessee, 2021. https:// trace.tennessee.edu/utk_graddiss/6547

28

Thriving in Elite Athletes McHenry, L.K., Cochran, J.L., Zakrajsek, R.A., & Fisher, L.A. (2021). Elite figure skaters’ experiences of harm in the coach-athlete relationship: A person-centered theory perspective. Journal of Applied Sport Psychology, 33(4) 420–440. 10.1080/10413200.2019.1689536 McHenry, L.K., Cochran, J.L., Zakrajsek, R.A., Fisher, L.A., Couch, S.R., & Hill, B. (2022). Elite figure skaters’ experiences of thriving in the coach-athlete relationship: A person-centered theory perspective. Journal of Applied Sport Psychology, 34(2) 436–456. 10.1080/10413200.2020.1800862 Ménard, J.F. & Malchelosse, M. (2021). Train (your brain) like an olympian: Gold medal techniques to unleash your potential at work. ECW Press. Moon, K., Rice, B., & Schneider, C. (2001). Stanley W. Standal and the need for positive regard. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 19–34). PCCS Books. Moore, J. (2001). Acceptance of the truth of the present moment as a trustworthy foundation for unconditional positive regard. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 198–209). PCCS Books. Moss, D. (2015). The roots and genealogy of humanistic psychology. In K.J. SchneiderJ. F. Pierson, & J.F. Bugental (Eds). The handbook of humanistic psychology: Theory, research, and practice (pp. 3–18). Sage Publications, Inc. https:// www-doi-org.proxy.lib.utk.edu/10.4135/9781483387864.n1 Murphy, D., Joseph, S., Demetriou, E., & Karimi-Mofrad, P. (2017). Unconditional positive self-regard, intrinsic aspirations, and authenticity: Pathways to psychological well-being. The Journal of Humanistic Psychology, 60(2), 258–279. 10.1177/0022167816688314 Nelson, L., Cushion, C., Potrac, P., & Groom, R. (2014). Carl Rogers, learning and educational practice: Critical considerations and applications in sports coaching. Sport, Education and Society, 19(5), 513–531. 10.1080/13573322. 2012.689256 Niessen, C., Sonnentag, S., & Sach, F. (2012). Thriving at work – A diary study. Journal of Organizational Behavior, 33(4), 468–487. 10.1002/Job.763 O’Leary, V.E., & Ickovics, J.R. (1995). Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women’s health. Women’s Health, 1, 121–142. Park, C. (1998). Stress-related growth and thriving through coping: The roles of personality and cognitive processes. Journal of Social Issues, 54(2), 267–277. 10.1111/0022-4537.651998065 Park, A. & Gregory, S. (2021, December 9). Time 2021 Athlete of the Year: Simone Biles. Time. https://time.com/ athlete-of-the-year-2021-simone-biles/ Paterson, T.A., Luthans, F., & Jeung, W. (2014). Thriving at work: Impact of psychological capital and supervisor support. Journal of Organizational Behavior, 35, 434–446. doi: 10.1002/job.1907 Pawson, R., & Tilley, N. (1994). What works in evaluation research? The British Journal of Criminology, 34(3), 291–306. Prouty, G. (2001). Unconditional positive regard and pre-therapy: an exploration. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 76–87). PCCS Books. Quartiroli, A., Etzel, E.F., Knight, S.M., & Zakrajsek, R.A. (2019). Self-care as key to others’ care: The perspectives of globally situated experienced senior-level sport psychology practitioners. Journal of Applied Sport Psychology, 31(2), 147–167, 10.1080/10413200.2018.1460420 Rapkin, B. (Director). (2020). The weight of gold [Film]. Podium Pictures. Rein, I., Shields, B., & Grossman, A. (2014). The sports strategist: Developing Leaders for a high-performance industry. Oxford University Press, Incorporated. Rogers, C.R. (1959). A theory of therapy, personality, and interpersonal relationships, as developed in the clientcentered framework. In S. Koch (Ed.), Psychology: A study of a science. formulations of the person and the social context (Vol. 3, pp. 184–256). McGraw-Hill. Rogers, C.R. (1980). A way of being. Houghton Mifflin. Rogers, C.R., & Büber, M. (1960). Martin Büber and Carl Rogers. Psychologia, An International Journal of Psychology in the Orient (Kyoto University), 3(4) 208–221. Roth, G., Assor, A., Niemiec, C.P., Deci, E.L., & Ryan, R.M. (2009). The emotional and academic consequences of parental conditional regard: Comparing conditional positive regard, conditional negative regard, and autonomy support as parenting practices. Developmental Psychology, 45(4), 1119–1142. 10.1037/a0015272 Roth, G., Kanat‐Maymon, Y., & Assor, A. (2016). The role of unconditional parental regard in autonomy‐supportive parenting. Journal of Personality, 84(6), 716–725. 10.1111/jopy.12194 Rouquette, O., Knight, C., Lovett, V., Barrell, D., & Heuzé, J. (2021). The positive association between perceived parental responsiveness and self-esteem, anxiety, and thriving among youth rugby players: A multigroup analysis. Journal of Sports Sciences, 39(13), 1537–1547. 10.1080/02640414.2021.1883311

29

Lauren K. McHenry and Rebecca A. Zakrajsek Ryan, R.M., & Deci, E.L. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. The Guilford Press. https://doi.org/10.1521/978.14625/28806 Santos, F. & Costa, V. (2018). Stress among sports coaches: A systematic review. Cuadernos de Psicología Del Deporte, 18(3), 268–292. Sarkar, M., & Fletcher, D. (2014). Ordinary magic, extraordinary performance: Psychological resilience and thriving in high achievers. Sport, Exercise, and Performance Psychology, 3, 46–60. 10.1037/spy0000003 Schmid, P.F. (2001). Acknowledgement: The art of responding. Dialogical and ethical perspectives on the challenge of unconditional relationships in therapy and beyond. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 49–64). PCCS Books. Sheehy, T., Zizzi, S., Dieffenbach, K., & Sharp, L. (2019). “ … Didn’t only change my coaching, changed my life:” Coaches’ use of sport psychology for their own development and performance. The Sport Psychologist, 33, 137–147. 10.1123/tsp.2018-0061 Silani, G., Zucconi, A., & Lamm, C. (2013). Carl Rogers meets the neurosciences: insights from social neuroscience for client centered psychotherapy. In J.H.D. Cornelius-White, R. Pitrik-Motschnig, & M. Lux (Eds.), Interdisciplinary handbook of the Person-centered approach, research and theory. Springer Science. Smittick, A., Miner, K., & Cunningham, G. (2019). The “I” in team: Coach incivility, coach gender, and team performance in women’s basketball teams. Sport Management Review, 22(3), 419–433. 10.1016/j.smr.2018.06.002 Spreitzer, G., & Porath, C. (2014). Self-determination as a nutriment for thriving: Building an integrative model of human growth at work. In M. Gagné (Ed.), The oxford handbook of work engagement, motivation, and self-determination theory (pp. 245–258). Oxford University Press. Spreitzer, G., Sutcliffe, K., Dutton, J., Sonenshein, S., & Grant, A.M. (2005). A socially embedded model of thriving at work. Organization Science, 16(5), 537–539. Standal, S.W. (1954). The need for positive regard: A contribution to client-centered theory. Unpublished doctoral dissertation, University of Chicago. Thacker, K. (2016). The art of authenticity: Tools to become an authentic leader and your best self. (1st ed.). John Wiley & Sons, Incorporated. Tomlinson, J.M., Feeney, B.C., & Van Vleet, M. (2016). A longitudinal investigation of relational catalyst support of goal strivings. The Journal of Positive Psychology, 11, 246–257. 10.1080/17439760.2015.1048815 Uvnä s-Moberg, K. (2003). The oxytocin factor: Trapping the hormones of calm, love, and healing. Da Capo Press. Watson, J.C., & Steckley, P. (2001). Potentiating Growth: An examination of the research on unconditional positive regard. In G. Wyatt., J. Bozarth, & P. Wilkins (Eds.), Rogers’ therapeutic conditions: Evolution, theory and practice, unconditional positive regard (Vol. 3, pp. 180–197). PCCS Books. Wilkins, P. (2000). Unconditional positive regard reconsidered. British Journal of Guidance & Counselling, 28(1), 23–36. 10.1080/030698800109592 Zak, P., Stanton, A., & Ahmadi, S. (2007). Oxytocin increases generosity in humans. PLoS ONE, 2(11), e1128. 10.1371/ journal.pone.0001128

30

3 MEANING AND MEANINGLESSNESS IN ELITE SPORT Jürgen Beckmann

Introduction Perceiving life as meaningful is frequently associated with being resourceful and resilient. It has been considered an indicator of well-being, a facilitator of adaptive coping and a marker of therapeutic growth (Steger et al., 2006). Therefore, meaning in life appears to be a major determinant of mental health and well-being. Several studies have supported the link between meaning in life, health, and well-being (e.g., Aftab et al., 2019; Mascaro & Rosen, 2005; Steger & Frazier, 2005). However, literature on meaning in life provides different conceptualisations that differ, for example, regarding the role of stability over time, the role of values, ultimate concerns, and spirituality. The interpretation of empirical findings is difficult because of the different definitions of meaning in life and the different measurement instruments (questionnaires) that have been developed based on these definitions. In this chapter, I will mainly follow the conceptualisations of meaning in life that have been addressed in positive psychology (cf. Wong, 2017). These are to a large degree based on the fundamental work of Viktor Frankl. For Frankl (1959), the will to meaning is a fundamental human motive. There is no single clear definition of meaning in life but the majority of researchers basically seems to follow what was outlined by Frankl (1959). Steger et al. (2008, p. 661) define the presence of meaning to “the degree to which people experience their lives as comprehensible and significant, and feel a sense of purpose or mission in their lives that transcends the mundane concerns of daily life”. Several determinants have been proposed as predictors of meaning in life but connected to Frankl considerations and Steger’s definition, four predictors of meaning appear to be most viable: autonomy, competence, relatedness, and beneficence (Martela et al., 2018). Whereas research in work life supports the positive effects of perceiving meaning (cf. Yeoman, Bailey, Madden, & Thompson, 2019), the perception of meaning in the athletic world has until now only marginally been addressed (cf. Breivik, 2021 ; Ronkainen et al., 2020). In general, one would probably assume that sport provides a variety of sources for the perception of meaning. Therefore, sport may be seen as a particularly good opportunity to find meaning in life. Consequently, given the connection of having meaning and health and well-being, one could conclude that athletes should perceive meaning in their life and flourish psychologically. However, this positive image has cracked in recent years as the dark side of elite sport became more and more visible (Newman et al., 2016). Certainly, the system of elite sport must be differentiated from other levels of commitment to sport. Elite sport is frequently described by those involved as implicating the ability to suffer, subordination, and DOI: 10.4324/9781003099345-5

31

Jürgen Beckmann

giving up almost everything for success. With this attitude, particularly professional athletes may be treated as objects with the sole purpose of delivering optimal performance. Such an orientation has a devastating influence on the self of the person and their intrinsic values and concerns (Kuhl, 2001). Looking at this dark side of elite sport, one may ask if elite sport could be described as a system which according to Frankl (1959, p. 47) “no longer recognised the value of human life and human dignity, which have robbed man of his will and had made him an object“? This may lead to the question if the traditional concept of elite sport is at all compatible with mental health and well-being? Roderick (2014, p. 143) perceives a “critical modern paradox: young athletes develop within a supposedly meritocratic sporting system in which their dreams are embedded and then made to feel as though their talents are indispensable and goals achievable. Yet their course leads undiscerningly into a monoculture in which, despite strong dedication, perfection is unobtainable and failure inevitable”. One should assume that addressing athletes’ experience of meaning would be obvious. However, the concept of meaning and its implications for athletes’ mental health and well-being have so far not been explicitly addressed. This chapter will present illustrative cases of loss of meaning and its consequences in elite sport and will address the conditions that make athletes particularly vulnerable. An important aspect to consider is that athletes’ lives continue after the end of their career. A strong athletic identity is closely associated with meaning in life. If the athletic identity is the sole source of meaning, a severe risk for mental health and well-being is given, particularly regarding athletes’ life after termination of their career. Based on these considerations and findings, perspectives for a sustainable development of athletes are suggested that focus on an increased salience of meaning, including mindful awareness, as well as the development of an autonomous personality to increase resilience.

What Is Meaning in Life? The experience of meaning in one’s life is a subjective experience or a personal construction. Hence, Frankl (2019, p. 64) states: “The quest that life gives us varies from person to person as well as with situations”. The experience of meaning is tied to an individual’s subjective values which constitute the essence of the individual’s self. This is particularly evident regarding “Beneficence”, “One’s sense of having a positive impact in the lives of other people (sometimes called prosocial impact)” (Martela et al., 2018, p. 1263). Landau (2017, p. 13) points out that commitment to values presupposes some categorization of how things should be and thus, what is of value and what is not: “A loss in comprehension undermines the attribution of value, and then one feels meaningless” (Landau, 2017, p. 13). He adds (Landau, 2017, p. 16) that the experience of meaninglessness is associated with the sense of emptiness which people attribute to the experience “that their lives are empty of issues of sufficiently high value”. Only values that individuals feel committed to are of significance. This is associated with seeing these values as constituent elements of their individual self. However, in addition to possessing values of sufficiently significant value, the second presupposition is that individuals have access to these values so that they can act in line with them and perceive the coherence. Without access to individual values, the perception of void or existential vacuum may result which was described by the German football legend Sebastian Deisler after he had announced suffering from depression: “With an expensive car parked outside my apartment, an expensive watch on my wrist, I felt completely empty, saw no meaning in my life” (Sebastian Deisler after Rosentritt, 2009). A lack of meaning was in fact, found to be related to the development of depressive episodes (Mascaro & Rosen, 2005), which are characterised by feeling sad, hopeless, helpless, and worthless. Some people perceive having meaning in their lives whereas others perceive having no meaning. Accordingly, Steger et al. (2008) differentiate between the presence of meaning and the search for meaning. Whereas for them “presence of meaning” relates to experiencing life as comprehensible and significant, they define “search for meaning” as “the dynamic, active effort people expend trying to establish and augment their comprehension of the meaning, significance, and purpose of their lives” (Steger et al., 2008, p. 661). 32

Meaning and Meaninglessness in Elite Sport

Meanwhile, numerous studies have have shown that the presence of meaning in life is associated with greater subjective well-being, and with positive emotions, including happiness, joy, love, and vitality (Ryff & Keyes, 1995). The search for meaning is frequently attributed to a lack of presence of meaning. Klinger (2017) attributes the search for meaning to people’s inability to engage with and resolve negative or challenging experiences. Therefore, it is seen as an indicator of maladjustment and psychopathology. Steger et al. (2006) found a 0.36 correlation of search for meaning with depression whereas presence of meaning was negatively correlated with depression (r = –.48). It is considered that search for meaning typically occurs in individuals whose needs for having meaning have been frustrated (Baumeister, 1991; Baumeister & Vohs, 2002; Klinger 2017). However, there are no consistent empirical findings on the relationship of presence of meaning and search for meaning. Steger et al. (2008) found a negative correlation between presence of and search for meaning. They conclude that search for meaning is a unique variable and that the different correlations found reflect that the relationship is dependent on several personality and cognitive style variables affecting search for meaning. A metaanalysis by Li, Dou, and Liang (2021) revealed a robust positive association between presence of meaning in life and subjective well-being, whereas search for meaning overall appeared to be adverse to subjective-well-being. The latter effect however was small and dependent on specific conditions (e.g., individualistic vs. collectivistic culture). Overall, researchers concur with Frankl’s (1959) assumption that quest of meaning is a central motivation for humans. Without it, individuals would show apathetic activity, inactivity, and psychopathology (Klinger, 2017). The presence of meaning in life is associated with psychological flourishing or well-being which requires according to Self-Determination-Theory (Ryan & Deci, 2000) that individuals meet three needs: autonomy, positive relationships, and competence. Meaning has been found to be positively correlated to these three needs in several studies and cultures (Church et al., 2014). Meaning was also found to be positively correlated with having a sense of personal control over one’s life, or locus of control (Ryff, 1989), as well as positive perceptions of the world itself (Sharpe & Viney, 1973).

Meaning in Life and Health For Frankl (1959), perceiving meaning in life enabled prisoners of concentration camps to survive the horrific conditions and experiences. Based on a study of Holocaust survivors Antonovsky (1987) addressed in his salutogenic approach factors that support mastering of such adverse conditions. Central to the model is what Antonovsky calls “sense of coherence” (SOC). SOC is related to resilience and defined as the pervasive, enduring though dynamic, feeling of confidence that one’s environment is predictable and that things will work out well. The model postulates generalised resistance resources (GRRs), which are all the resources that help a person to cope with stress and maintain health. The core question is whether or not the stress violates a person’s sense of coherence. Antonovsky defined Sense of Coherence (SOC) as: “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement” (Antonovsky, 1987, p. 19). The sense of coherence has three components: • • •

Comprehensibility: a belief that things happen in an orderly and predictable fashion and a sense that you can understand events in your life and reasonably predict what will happen in the future. Manageability: a belief that you have the skills or ability, the support, the help, or the resources necessary to take care of things, and that things are manageable and within your control. Meaningfulness: a belief that things in life are interesting and a source of satisfaction, that things are really worthwhile and that there is good reason or purpose to care about what happens. 33

Jürgen Beckmann

According to Antonovsky (1987), meaningfulness is the most important of these components. Without the perception of meaning individuals would not have the motivation to comprehend and manage events. Thus, in a nutshell, Antonovsky comes to the same proposition as Frankl, namely that maintaining and promoting health involves experiencing meaning in life as an essential component of a strong “sense of coherence”. Empirical research supported Frankl’s (1959) and Antonovsky’s (1987) assumption that meaning is not only associated with resilience but in fact can increase resilience. For example, Krok (2016) found that meaning in life made individuals more resilient against burnout. People with high levels of meaning report lower levels of perceived stress (Flannery & Flannery, 1990) and fewer symptoms of stress-related disorders, such as PTSD (DeViva et al., 2016). Generally there is a large body of research that supports the assumption that presence of meaning is important for human health, well-being, and psychological flourishing (Steger, 2018). In a meta-analytic review with 66 studies, Czekierda et al. (2017) found significant associations between meaning in life and physical health. Furthermore, Aftab et al. (2019) found that the presence of meaning in life to be associated with better physical and mental well-being. A number of studies further supports the assumption that meaning is positively related to broader indicators of subjective well-being (Debats et al., 1993), general well-being (Reker, 2002), psychological adjustment (O’Conner & Vallerand, 1998), and life satisfaction (Ryff, 1989). The opposite was found for a lack of perceived meaning. Research has revealed that people with a low presence of meaning in their lives report more hopelessness (Edwards & Holden, 2001), are found to have a higher degree of drug and alcohol-related problems (Nicholson et al., 1994), and to report stronger suicide tendencies (Henry et al., 2014). In contrast, individuals who perceive meaning in their lives report more effective coping (Debats et al., 1995). Heisel and Flett (2004) found that purpose in life and satisfaction with life accounted for variability in suicide ideation scores above and beyond that accounted for by the negative psychological factors alone. Purpose in life also mediated the relation between satisfaction with life and suicide ideation and moderated the relation between depression and suicide ideation. A shortcoming of existing research is that most studies investigated the effects of meaning only in a given moment or over short periods of time such as one month (e.g., Steger et al., 2006) or 2–3 weeks (Steger & Frazier, 2005). Regarding the question of how meaning affects health, these short-lived measures appear to be insufficient. However, one longitudinal study could provide evidence that meaning and life satisfaction are positively correlated over one year’s time (Steger & Kashdan, 2007). Steger, Frqzier, and colleagues (2008) found in line with Frankl’s (1959) report that people perceiving meaning in their lives reported to have grown psychologically, spiritually, or socially as a result of the experiences of trauma and tragedy. Overall, those who perceive more meaning also report having better health than others according to their subjective health ratings (Battersby & Phillips, 2016). They are even found to live longer lives (Boyle et al., 2009).

Finding Meaning in Life Luzzeri and Chow (2020), referring to Frankl, contend that meaning can be achieved through tasks that require effort. They believe that if those tasks can be completed, it would result in a sense that life is meaningful. Obviously, athletic tasks would therefore qualify for achieving meaning in life. But, according to the reports on athletes’ mental health issues and specifically Sebastian Deisler’s report on experiencing void, being successful on demanding tasks may not be enough. Another look at Frankl’s (2019, p. 64) conception reveals a broader perspective with three sources of meaning in life: • • •

Pursuing a goal, realizing a work Experiencing something such as nature, art, music, love If neither 1 nor 2 work, fighting adversity committing oneself to values 34

Meaning and Meaninglessness in Elite Sport

Similarly, Martela and Steger (2016), see purpose i.e., motivation regarding central goals giving life direction and significance, but they also see central values and having a life that is worth living, as central components. They include the experience of coherence, in which understanding and comprehension lead to the perception that life makes sense. A recent study by Schnell (2020) suggests that coherence, significance, orientation, and belonging are key aspects of the experience of meaning. The broader perspectives have the advantage of pointing out that finding meaning in life in the athletic world does not have to be limited to certain athletic tasks or even achievements such as winning a gold medal. One-dimensionality or a monothematic orientation on one’s sport alone is one of the risks in athletes’ lives. This becomes especially salient when the career ends. Thus, the broader perspective opens up a range of activities over the lifetime that could furnish meaning in the lives of athletes. Particularly regarding elite athletes, it is worthwhile to reflect upon Frankl’s (1959) emphasis that meaning in life is not connected to hedonism, to experiencing happiness. In support of this view, Baumeister and colleagues (2013) found that happiness and a meaningful life might be more different than similar. In the public view, professional football players making millions should be happy and experience their lives as meaningful. According to recent research by Murphy and Bastian (2019), the extremity of an event, rather than its valence, is thought to be crucial for deriving meaning. Both extremely painful and extremely pleasant events were found to be more meaningful than milder events. Furthermore, their findings suggest that this effect is partly mediated by shared features of extreme events, their emotional intensity and tendency to induce contemplation. Elite athletes should have opportunities to experience this kind of intensity in addition to the other benefits. Still, several studies point out that in spite of all this, professional football players as well as other professional athletes experience void. This is exemplified by Sebastian Deisler’s statement quoted above. The void frequently results in mental health issues during and after the end of the career as reported by Gouttebarge et al. (2015). How can this be explained? As pointed out above, Frankl would say that in essence meaning is not contingent on purposeful achievements and external experiences but rather on the uniqueness of the person. In that he comes close to Immanuel Kant’s concept of dignity. According to Kant (1785), in the kingdom of ends everything has either a price or a dignity. What has a price can be replaced by something else as its equivalent; what on the other hand is raised above all price and therefore admits of no equivalent has a dignity. Is athletes’ dignity sacrificed or at least jeopardised in the system of modern elite sport? However, a large number of studies identify positive affect as a seemingly strong predictor of meaning in life. King et al. (2006) found correlations of positive affect and meaning in life and that experimentally induced positive mood increased evaluations of meaning in life. Heintzelman and King (2014) propose that the feeling of meaning provides information about the presence of reliable patterns and coherence in the environment. It may thus be considered a blend of emotions or affect resulting from experiences that are made. This conception of meaning would imply a relative temporal experience, fluctuating based on daily experiences. Accordingly, Martela and colleagues (2018, p. 1263) assume that positive affect may result from the satisfaction of basic psychological needs which in turn could lead to an increased sense of meaning in life. In one study, they found in fact that positive affect was no significant predictor of meaning but satisfaction of needs for autonomy, competence, relatedness, and beneficence predicted both positive affect as well as meaning in life. Kuhl (2001) also sees affect as information. In his theory positive affect signals that everything is fine, while negative affect indicates potential threat in the environment. The positive affect then facilitates enactment of intentions that have been formed earlier whereas the latter motivates closer inspection of the environment for potential danger. Accordingly, negative affect blocks the execution of intentions and even access to the individuals’ personal needs and values (the implicit self). Hence, only with the experience of positive affect people would initiate activities with significance for their perception of meaning. With the experience of negative affect, they would rather experience void regarding meaning in life because they have no access to what meaning would be for them. According to the loss of autonomy 35

Jürgen Beckmann

cycle described by Kuhl and Beckmann (1994), continuously being forced to conform to rules and expectations imposed by others at the cost of suppressing one’s own needs requires high discipline. Over time conflict between duties and personal needs accumulates resulting in negative affect. Continuously getting stuck in this cycle will eventually entail the experience of emptiness or void. As stated in the previous section, a prerequisite for finding meaning in life is having access to one’s self with the values that are significant for the person. If a person does not have values or is not committed to values or has no access to the values, finding meaning will not be feasible. It is characteristic of the alienation cycle that individuals use self control to block access to what they would really like to do in order to be able to do what they have to do. For example, they may constantly turn down invitations to meet friends because they feel obliged to or are even forced to train instead. In the long run, this blocking of their very own needs can lead to the experience of an existential vacuum with mental health issues as a consequence (Riethof & Bob, 2019). Autonomy or self-determination seems to play an important role for accessing one’s self and therefore being able to experience coherence and significance. But elite athletes frequently report a lack of selfdetermination and autonomy (Cresswell & Eklund, 2007). Martela, and colleagues (2018) seem to approach a deeper level of understanding the foundations of experiencing meaning. The perception of the uniqueness of the person and its acts depend on whether or not what is done and what is achieved can actually be attributed to the person themselves. If they comply with some external source of control, whatever is achieved is not owned by the person themselves. “Ownership of one’s own actions” is the core of autonomy (Martela et al., 2018, p. 1263). Affect, positive versus negative, could be a mediator in this process of finding meaning.

What Makes Athletes Particularly Vulnerable to a Lack of Meaning It is generally believed that only mentally and emotionally strong athletes will succeed and be able to compete at the highest level. Therefore, elite athletes are generally attributed various positive mental attributes such as “focused’, “confident” and “resilient”. Competitive sport often places athletes under intense physical, psychological, and emotional demands (Crocker & Graham, 1995) and not all athletes possess sufficient mental strength to cope with the stress. In recent years, the media reported a number of extremely successful elite athletes suffering from mental health problems, such as Sebastian Deisler (football), Robert Enke (football), Michael Phelps (swimmer), Victoria Pendleton (cyclist), and Lindsay Vonn (alpine skier). These public cases show that elite athletes are vulnerable to mental health problems. In fact, several studies indicate that they may be particularly vulnerable. Studies report a large percentage of athletes (more than 40%) who experience symptoms of mental health problems (Brewer & Petrie, 1995; Gulliver et al., 2015; Petrie, 1995; Wolanin et al., 2016). Frank et al. (2013) noted that high-level athletes are highly vulnerable to developing depressive symptoms due to their status and the extreme pressure that they experience. The extreme physical challenges in sport such as intense training and injury can lead to psychological challenges (cf. Schinke et al., 2018) and health problems. These are frequently associated with overtraining, which is mainly due to underrecovery (Frank et al., 2018; Kellmann, 2002). Additionally, athletes also have to deal with personal challenges like the general population, such as relationship problems or traumatic life events. Hoyer and Kleinert (2010) point out that what makes elite athletes particularly vulnerable for depression is their special position in society and the high amount of stress they experience. Through their career, elite athletes are confronted on a daily basis with a unique array of stressors (Puffer & McShane, 1992). Any one of these stressors can lead to mental health problems in an individual. Research has addressed the following resources of stress: • •

Career termination, career transitions ( Beckmann et al., 2006; Walker et al., 2007) Overtraining (Kellmann, 2002) 36

Meaning and Meaninglessness in Elite Sport

• • • • • •

Insufficient recovery (Nixdorf et al., 2013) Injury (e.g., Walker et al., 2007) Loss of autonomy and experience of powerlessness (Cresswell & Eklund, 2007) Reduced opportunities for personality development (Cresswell & Eklund, 2007) Organisational factors, such as travelling and spending long periods away from home (cf. Moesch et al., 2018). Media scrutiny, including social media (cf. Rice et al., 2016)

The connection of stress and somatic and mental illness has for a long time been documented in numerous studies. Particularly, burnout and depression are negative mental illness consequences of stress (Monroe, & Reid, 2009). Meanwhile, the relationship of stress and depression has also been supported by a number of studies in elite sport (e.g., Nicholls et al., 2007). As Kellmann (2002; Kellmann et al., 2018) have frequently suggested, it is not the stress itself that impairs performance, health, and well-being but an imbalance of stress and recovery. Underrecovery alone can be a factor that may cause deficits in selfregulation (Balk & Englert, 2020; Beckmann & Kellmann, 2004). Self-regulation deficits can increase stress and interfere with coping attempts (Beckmann, 2002). As a result, individuals can experience void (Kuhl & Beckmann, 1994), as illustrated by the German football player Sebastian Deisler. In elite sport, everything seems to be about winning. Striving for perfectionism is mostly seen as essential (see Chapter 9, Vaughan et al., this volume). Ronkainen, Ryba, and Allen-Collinson (2020) note that elite sport has become more competitive than ever, with increasing pressure for adolescent athletes to specialise at a young age and prioritise athletic excellence over relationships, educational ambitions, and other dimensions of the self. But in the development of the young talents within the elite sport system, perfection “is unobtainable and failure inevitable” despite strong motivation, commitment, and dedication of the young athletes (Roderick 2014, p. 143). Speaking about “talent” in sport predominantly involves what Dweck (2016) refers to as a “fixed mindset”, which focuses on stable abilities. A fixed mindset associates failure with lack of ability. The problem related to a fixed mindset is alienation from one’s own true needs that was addressed in the previous section. Because an athlete is highly complying with the role demands in elite sport this may involve blocking access to their true needs or their implicit self. However, as stated before and pointed out by Lukas (1986), experiencing meaning requires achieving congruence which involves awareness of one’s true needs (implicit needs) as well as capacities and limitations. Several studies have shown athletes’ perception of lack of autonomy (Cresswell & Eklund, 2007). Particularly young athletes like youth football players face a very limited control over their future (Blakelock et al., 2016). As outlined above, the perception of a lack of autonomy is a major risk factor for finding meaning. If people do not perceive meaning in life, they will either search for meaning or focus on surrogates like pleasure, money, or power. Professional athletes may have sufficient opportunities to find these surrogates but eventually they may learn that the surrogates cannot replace meaning. Athletes who focus on the surrogates become disposed to what Frankl (1959) calls “existential frustration”, which involves the risk of becoming mentally ill. Athletic careers often involve what has been referred to as a monothematic orientation. The sole focus of an athlete is on their career. In fact, the prevalent deliberate practice orientation in sport favours this exclusive kind of “dedication”. However, a monothematic orientation or one-dimensionality involves the risk of lacking meaning in life if things go wrong. In a study with young football players in youth academies of German professional football clubs Harttgen and Milles (2004) found that one-dimensionality can even interfere with performance development. Particularly alarming was the finding that young players especially strive for external recognition with little respect for themselves. What made them particularly vulnerable was their one concern only approach (to become a football star) because this has a factual extremely low probability of success. One player who was confronted with the prospect of not receiving a contract said, “Then I am 37

Jürgen Beckmann

done. Then I will cease to exist” (Harttgen & Milles, 2004, p. 5). Whereas athletes who restrict their sense of meaning singularly to athletic success are left vulnerable when their career is going through a low or ending, athletes who are capable of sensing the unconditional meaning of life should have a chance to be more resilient and better prepared to master lows in their athletic careers (cf. Hill et al., 2018). At a higher level of sport, there is an exclusive focus on top performance. This implies a monothematic orientation in a specific area. Representatives of deliberate practice argue that, due to limited resources, top performance can only be achieved with an early, exclusive focus on one performance area (Ericsson & Charness, 1994). The Harttgen and Milles (2004) study shows that this might not even be beneficial for performance and does not create resilience to adverse experiences. In fact, a strong and exclusive athletic identity has been found to be particularly problematic for the adaptation to athletic retirement (Park et al., 2013). The research demonstrates that especially those athletes whose sporting careers are terminated involuntarily, so that they did not even have a chance to anticipate it and had not engaged in career planning (including preparation to life after the athletic career), can be at elevated risk of psychological distress. Qualitative research has shown that it can be extremely challenging for retiring athletes to craft a new narrative of their selves if their lives has solely revolved around sport (Sparkes, 1998). Thus, from a broader perspective on mental health and well-being, the implied striving for perfectionism and the (early) specialization on one performance area creates the highest vulnerability. The specialisation reduces the perception of meaning in life to one monothematic theme. Furthermore, it might imply the development of a generalised perfectionist orientation that then becomes evident in all aspects of the athletes’ lives, beyond sport (Carlisle and Marshall, 2013). The majority of athletes are socialised in a system emphasizing that only successful outcomes count. The question is whether elite sport is a system, “which no longer recognised the value of human life and human dignity, which have robbed man of his will and had made him an object” (Frankl, 1959, p. 47).

Finding Meaning in the Athletic World The commonly accepted view is that sport is enjoyable, a self-determined activity providing an excellent opportunity for the athletes to find meaning in individual sport performance or in team activities. In fact, sport activities can provide this opportunity. Frankl (2019, p. 42) sees the core of the spirit of sport in creating difficulties in order to grow with them. In fact, Luzzeri and Chow (2020) found a significant relationship between perceived presence of meaning in sport and self-reported overall ability in sport as well as satisfaction with last performance. Interestingly however, enthusiastic commitment, a commitment based on intrinsic motivation, was positively correlated with presence of meaning in sport. In contrast, constrained commitment, i.e., showing obedience, was negatively correlated with presence of meaning. Furthermore, they found negative correlations between meaning (both presence and search for) and burnout. This is in essence what describes the development of void in Sebastian Deisler, ultimately leading to depression. When it comes to elite sport and particularly professional sport, the specific conditions may have detrimental effects on the perception of meaning for the specific athlete and thus render the athlete vulnerable for mental health issues. Complying with role expectations in the athletic world as in other areas of life often requires the suppression of individual needs. To a large degree, socialisation prepares individuals to function in society and not to live their dreams. Ryan, Deci, Grolnick, and LaGuardia. (2006) assume that many social values, norms, and behaviours are imposed or forced on individuals by others, and over time become so-called introjects i.e., become incorporated into the individual self. These introjects then guide individuals behaviour or the expression of socially prescribed meanings without being privately accepted or being coherent with the individuals’ needs and values. Personality research supports the view that personal congruence or coherence is an important factor in promoting individuals’ perceptions that their lives are meaningful (e.g., Cervone & Shoda, 1999). 38

Meaning and Meaninglessness in Elite Sport

When working as a sport psychologist with young players at a football youth academy, I used to ask the players what their dreams regarding their football career were. They mostly responded just what they had learned, namely that you have to be realistic. Through self-control even dreaming of ultimate goals was blocked because superiors or peers had told them to “remain realistic”. The perception of not acting in line with personal needs or concerns will eventually cause a kind of void, a perception of meaninglessness which is accompanied by an increase in negative affect. When I worked with a German first league football team, upon entering the stadium catacombs, I sensed an atmosphere of stress and negative affect. It seemed to affect players’ and particularly the coach’s creativity who had proven before to be highly innovative and strategically creative. The negative affect according to Kuhl’s Personal Systems Interactions theory (Kuhl, 2001) will further block access to the implicit self and ways to regulate one’s life in a meaningful way. This is especially the case if people start to ruminate about having failed something, or about not having acted in line with what they wanted to do. If they get caught in rumination loops (Beckmann, 1994), they may enter a kind of downward spiral and more self-control i.e., coercing oneself to fulfil one’s duty, is required (Kuhl & Beckmann, 1994). Not being able to cope with pain, anxiety, and negative affect because of rumination loops involves the risk of blocking the personal system that creates meaning (Kuhl, 2001). Sport performance, athletic success, and perceived athletic ability can be powerful sources of meaning for athletes. Athletes can focus on their individual performance as source for meaning, but also the support given to team members can provide meaning. However, the meaning derived from athletic performance does not have to be bound to success associated with social comparison but could also rely on perceived individual progress in mastering a sport. Dweck’s (2016) postulated that a growth mindset rather than a fixed mindset should promote perceiving meaning. In fact, personal growth was found to be a major source of meaning in life for younger adults (Grouden & Jose, 2014).

Conclusion The relationship of perceiving meaning in life and health and well-being has been supported by numerous empirical studies. Definition and theoretical underpinnings of meaning in life has been a hodge-podge of different suggestions for a long period of time. Only recently, more systematic and relatively encompassing approaches have been developed (cf. Martela et al., 2018). Surprisingly, the potential merits of addressing meaning have been almost completely neglected in sport. This chapter is an attempt to transfer the concept of meaning, the consequences of having meaning versus a lack of meaning, and opportunities to find meaning in the world of competitive sport. The system of elite sport makes athletes particularly vulnerable to mental health disorders. A major reason for this lies in the various specific stressors they experience in this environment. Experiencing meaning in what one is doing, and more generally, perceiving meaning in life, appears to promote resilience and thereby mental health and well-being. Existential psychology based on Frankl’s (1959) work provides a framework for a promising perspective for athletes’ mental health and well-being. Seligman (2012) suggests five key areas for positive well-being in his PERMA approach: positive emotions, engagement, positive relationships, meaning and achievement. Presence of meaning may just be one component of overall well-being (Ryff & Singer, 2008) but appears to be crucial to develop resilience as the study by Krok (2016) suggests. In fact, the other four elements mentioned by Seligman can be seen to contribute to the development of a broad perception of meaningfulness. A core element that seems to run through the entire topic of athletes’ experience of a meaningful life is self-determination. Unfortunately, as the study by Luzzeri and Chow (2020) shows, forced commitment is often found within the athletic context. Forced commitment was found to be associated with a reduced sense of meaning. The ultimate concern and thus major source for meaning in elite sport appears to be winning major events, world championships, and Olympic gold medals. Considering that only a minority of athletes have 39

Jürgen Beckmann

a chance to achieve this, putting all one’s eggs in one basket constitutes, as always, a major risk. The examples of gold medalists who developed mental health issues show that a monothematic focus on athletic success is not sufficient. In terms of finding meaning in life, for most people such “a one-sided specialization is not the best option” (Breivik, 2021). Therefore Breivik (2021) advocates a well-balanced life with many-sided involvement. Accordingly, the sport system and the involved sport psychologists should encourage athletes to develop a “multidimensional view” of themselves versus an “exclusive athletic identity,” which is singularly reliant on a narrow and precarious understanding of their self. Meaning in life can be fed from various sources. Csikszentmihalyi (1990) pointed out that the road to happiness lies in flow experiences which is characterised as being fully immersed in a feeling of energised focus, a complete absorption in what one does. He showed that even flow that lasts for a very short time, he called it “micro-flow”, can be effective. Flow is in essence associated with intrinsic motivation which according to Ryan and Deci (2000) requires self-determination. As has been described above, enthusiastic commitment involves self-determination and the experience of meaning whereas forced commitment, involves a lack of self-determination frustrating the need for autonomy. However, Ryan and Deci (2000) have pointed out that committing oneself to sacrifices may not conflict with the need for autonomy under certain conditions. If athletes perceive the sacrifices as being necessary for a self-determined goal of value and thus the sacrifices make sense for them and if they perceive that they ultimately retain control it should not make them vulnerable to a loss of perceived autonomy and hence a loss of meaning. According to Steger (2009), meaning can be derived from a vast array of experiences . One needs to interpret and organise these experiences, achieve a sense of own worth and place, identify the things that matter, and effectively direct energies. A growth mindset (Dweck, 2016), believing that failure is not indicative of lack of abilities and that one can always improve could support this. On the athletes’ side, this involves the development of psychological literacy which includes: access to one‘s own needs; know-how on how to manage stress/pressure and knowledge on individual adequate recovery. Furthermore, a change in the sport system needs to be initiated ensuring self-determination, personal responsibilities, appreciation, and respect, as well as social support, and alternatives for finding meaning in life. Recently, the concept of craftsmanship has been transferred from sociology to the study of meaning in sport. Thorlindsson, Halldorsson, and Sigfusdottir (2018) operationalised craftsmanship as comprising informal learning, tacit knowledge, intrinsic motivation, flow, holistic understanding, practice, and honing of skills. Obviously, this conceptualisation overlaps to a large degree with the approaches of Csiksentmihalyi and Ryan and Deci described above. Ronkainen and colleagues (2020) found that craftsmanship was a significant predictor of perceived meaningfulness in athletes. What has been said above provides suggestions as to how changes can be made in the development of young athletes, in the design of training, to give athletes the chance to experience meaning in their sport career. On a broader level, the system of elite and particularly professional sport should accept moral responsibility and adopt Kant’s perspective: Things have values but humans have dignity: even if athletes do not reach their athletic goals, even if their careers prematurely end, even if athletes’ performance declines, they do not lose their dignity. Kant (1785) already stated that Autonomy was the ground of the dignity of the human and of every rational nature. An elite sport system should give athletes opportunities “to find ways of self-expression through satisfaction of autonomy and competence, and self-transcendence through satisfaction of relatedness and beneficence, then that life should be filled with meaning and truly a life worth living” (Martela et al., 2018, p. 1279). This would render athletes more resilient to the performance pressure within the system and sustainably promote mental health and well-being. Life is not something, it is the opportunity for something. (Christian Friedrich Hebbel)

40

Meaning and Meaninglessness in Elite Sport

References Aftab, A., Lee, E.E., Klaus, F., Daly, R., Wu, T., Tu, X., Huege, S., & Jeste, D.V. (2019). Meaning in life and its relationship with physical, mental, and cognitive functioning: A study of 1,042 community-dwelling adults across the lifespan. Journal of Clinical Psychiatry, 81(1), 19m13064. 10.4088/JCP.19m13064 Antonovsky, A. (1987). Unravelling the mystery of health. Josey Bass Publishers. Balk, Y.A., & Englert, C. (2020). Recovery self-regulation in sport: Theory, research, and practice. International Journal of Sports Science and Coaching, 15, 273–281. 10.1177/1747954119897528 Battersby, A., & Phillips, L. (2016). In the end it all makes sense: Meaning in life at either end of the adult lifespan. The International Journal of Aging and Human Development, 83(2), 184–204. 10.1177/0091415016647731 Baumeister, R.F. (1991). Meanings of life. Guilford. Baumeister, R.F., & Vohs, K.D. (2002). The pursuit of meaningfulness in life. In C.R. Snyder & S.J. Lopez (Eds.), Handbook of positive psychology (pp. 608–618). Oxford University Press. Baumeister, R.F., Vohs, K.D., Aaker, J.L., & Garbinsky, E.N. (2013). Some key differences between a happy life and a meaningful life. The Journal of Positive Psychology, 8, 505–516. 10.1080/17439760.2013.830764. Beckmann, J. (1994). Ruminative thought and the deactivation of an intention. Motivation and Emotion, 18, 317–334. Beckmann, J. (2002). Interaction of volition and recovery. In M. Kellmann (Ed.), Optimal recovery: Preventing underperformance in athletes (pp. 269–282). Human Kinetics. Beckmann, J., & Kellmann, M. (2004). Self-regulation and recovery: Approaching an understanding of the process of recovery from stress. Psychological Reports, 95, 1135–1153. 10.2466/pr0.95.3f.1135-1153 Beckmann, J., Szymanski, B., Elbe, A., & Ehrlenspiel, F. (2006). Chancen und Risiken: Vom Leben im Verbundsystem von Schule und Leistungssport [Chances and Risks: Life in a cooperation network of boarding school and competitive sport]. Sportverlag Strauß. Blakelock, D.J., Chen, M.A., & Prescott, T. (2016). Psychological distress in elite adolescent soccer players following deselection. Journal of Clinical Sport Psychology, 10, 59–77. 10.1123/jcsp.2015-0010 Boyle, P.A., Barnes, L.L., Buchman, A.S., & Bennett, D.A. (2009). Purpose in life is associated with mortality among community-dwelling older persons. Psychosomatic Medicine, 71, 574–579. 10.1097/PSY.0b013e3181a5a7c0 Breivik, G. (2021). Sport as part of a meaningful life. Journal of the Philosophy of Sport, 49(1), 19–36. 10.1080/ 00948705.2021.1972814 Brewer, B.W., & Petrie, T.A. (1995). A comparison between injured and uninjured football players on selected psychosocial variables. Academic Athletic Journal, 10, 11–18. Carlisle, C., & Marshall, I. (2013). You Don’t Know Me, But … : A Footballer’s Life. Simon & Schuster. Cervone, D., & Shoda, Y. (Eds.) (1999). The coherence of personality: Social-cognitive bases of consistency, variability, and organization. Guilford. Church, A.T., Katigbak, M.S., Ibanez-Reyes, J., de Jesus Vargas-Flores, J., Curtis, G.J., Tanaka-Matsumi, J., Cabrera, H.F., Mastor, K.A., Zhang, H., Shen, J., Locke, K.D., Alvarez, J.M., Ching, C.M., Ortiz, F.A., & Simon, J.-Y.R. (2014). Relating self-concept consistency to hedonic and eudaimonic well-being in eight cultures. Journal of CrossCultural Psychology, 45(5), 695–712. 10.1177/0022022114527347 Cresswell, S.L., & Eklund, R.C. (2007). Athlete burnout: A longitudinal qualitative study. The Sport Psychologist, 21, 1–20. 10.1123/tsp.21.1.1 Crocker, P.R.E., & Graham, T.R. (1995). Coping by competitive athletes with performance stress: Gender differences and relationships with affect. The Sport Psychologist, 9(3), 325–338. 10.1123/tsp.9.3.325 Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. Harper & Row. Czekierda, K., Banik, A., Park, C.L., & Luszczynska, A. (2017). Meaning in life and physical health: Systematic review and meta-analysis. Health Psychology Review, 11(4), 387-41. 10.1080/17437199.2017.1327325 Debats, D.L., Drost, J., & Hansen, P. (1995). Experiences of meaning in life: A combined qualitative and quantitative approach. British Journal of Psychology, 86, 359–375. 10.1111/j.2044-8295.1995.tb02758.x Debats, D.L., Van der Lubbe, P.M., & Wezeman, F.R.A. (1993). On the psychometric properties of the Life Regard Index (LRI): A measure of meaningful life: An evaluation in three independent samples based on the Dutch version. Personality and Individual Differences, 14, 337–345. 10.1016/0191-8869(93)90132-M DeViva, J.C., Sheerin, C.M., Southwick, S.M., Roy, A.M., Pietrzak, R.H., & Harpaz-Rotem, I. (2016). Correlates of VA mental health treatment utilization among OEF/OIF/OND veterans: Resilience, stigma, social support, personality, and beliefs about treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 310. 10.1037/ tra0000075 Dweck, C.S. (2016). Mindset: The new psychology of success. Ballentine books. Edwards, M.J., & Holden, R.R. (2001). Coping, meaning in life, and suicidal manifestations: Examining gender differences. Journal of Clinical Psychology, 57, 1517–1534. 10.1002/jclp.1114

41

Jürgen Beckmann Ericsson, K.A., & Charness, N. (1994). Expert performance: Its structure and acquisition. American Psychologist, 49, 725–747. 10.1037/0003-066X.49.8.725 Flannery, R.B., & Flannery, G.J. (1990). Sense of coherence, life stress, and psychological distress: A prospective methodological inquiry. Journal of Clinical Psychology, 46, 115- 120. 10.1002/1097-4679(199007)46:43.0.CO;2-A Frank, R., Nixdorf, I., & Beckmann, J. (2013). Depression among elite athletes: Prevalence and psychological factors. Deutsche Zeitschrift für Sportmedizin [German Journal of Sport Medicine] 64, 320–326. Frank, R., Nixdorf, I., & Beckmann, J. (2018). Stress, underrecovery, and health problems in athletes. In M. Kellmann & J. Beckmann (Eds.), Sport, recovery, and performance. Interdisciplinary insights (pp. 119–131). Routledge. 10.4324/ 9781315268149-9 Frankl, V.E. (1959). Man’s search for meaning. Hodder & Stoughton. Frankl, V.E. (2019). Über den Sinn des Lebens [On the Meaning of Life]. Beltz. Gouttebarge, V., Backx, F., Aoki, H., & Kerkhoffs, G. (2015). Symptoms of common mental disorders in professional football (soccer) across five European countries. Journal of Sports Science & Medicine, 14(4), 811–818. Grouden, M.E., & Jose, P. (2014). How do sources of meaning in life vary according to demographic factors? New Zealand Journal of Psychology, 43(3), 29–38. Gulliver A., Griffiths K.M., Mackinnon A., Batterham P.J., Stanimirovic R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Harttgen, U., & Milles, D. (2004). Leistungsbereitschaft und Bewältigungsressourcen [Readiness to perform and coping resources]. Leistungssport, 34(4), 5–13. Heintzelman, S.J., & King, L.A. (2014). (The feeling of) meaning-as-information. Personality and Social Psychology Review, 18(2), 153–167. 10.1177/1088868313518487 Heisel, M.J., & Flett, G.L. (2004). Purpose in life, satisfaction with life, and suicide ideation in a clinical sample. Journal of Psychopathology and Behavioral Assessment, 26, 127–135. 10.1023/B:JOBA.0000013660.22413.e0 Henry, K.L., Lovegrove, P.J., Steger, M.F., Chen, P.Y., Cigularov, K.P., & Tomazic, R.G. (2014). The potential role of meaning in life in the relationship between bullying victimization and suicidal ideation. Journal of Youth and Adolescence, 43, 221–232. 10.1007/s10964-013-9960-2 Hill, Y., Den Hartigh, R.J.R., Meijer, R.R., de Jonge, P., & Van Yperen, N.W. (2018). Resilience in sports from a dynamical perspective. Sport, Exercise and Performance Psychology, 7(4), 333–341. 10.1037/spy0000118 Hoyer, J., & Kleinert, J. (2010). Leistungssport und psychische Gesundheit [Elite sport and mental health]. Psychotherapeutenjournal, 3, 252–260. Kant, I. (1785). Grundlegung einer Metaphysik der Sitten [Groundwork of the Metaphysics of Morals]. Hartknoch. Kellmann, M. (2002). Underrecovery and overtraining. In M. Kellmann (Ed.), Enhancing Recovery. Preventing Underperformance in Athletes (pp. 3–24). Human Kinetics. Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A., Duffield, R., Erlacher, D., Halson, S., Hecksteden, A., Heidari, J., Kallus, W., Meeusen. R., Mujika, I., Robazza, C., Skorski, S., Venter, R., & Beckmann, J. (2018). Recovery and performance: Consensus statement. International Journal of Sports Physiology and Performance, 13, 240–245. 10.1123/ijspp.2017-0759 King, L.A., Hicks, J.A., Krull, J.L., & Del Gaiso, A.K. (2006). Positive affect and the experience of meaning in life. Journal of Personality and Social Psychology, 90(1), 179–196. 10.1037/0022-3514.90.1.179 Klinger, E. (2017). The search for meaning in evolutionary goal-theory perspective and its clinical implications. In P.T.P. Wong (Ed.), The human quest for meaning: Theories, research, and applications (2nd ed.) (pp. 23–56). Routledge. Krok, D. (2016). Can meaning buffer work pressure? An exploratory study on styles of meaning in life and burnout in firefighters. Archives of psychiatry and psychotherapy, 18, 31–42. 10.12740/APP/62154 Kuhl, J. (2001). Motivation und Persönlichkeit. Interaktionen psychischer Systeme [Motivation and personality. Interactions of psychic systems]. Hogrefe. Kuhl, J., & Beckmann, J. (1994). Alienation. Ignoring one’s preferences. In J. Kuhl & J. Beckmann (Eds.), Volition and personality: Action and state orientation (pp. 375–390). Hogrefe. Landau, I. (2017). Finding meaning in an imperfect world. Oxford University Press. 10.1093/acprof:oso/978019065 7666.001.0001 Li, J.B., Dou, K., & Liang, Y. (2021). The relationship between presence of meaning, search for meaning, and subjective well-being: A three-level meta-analysis based on the meaning in life questionnaire. Journal of Happiness Studies, 22, 467–489. 10.1007/s10902-020-00230-y Lukas, E.S. (1986). LOGO-Test. Test zur Messung „innerer Sinnerfüllung“ und „existentieller Frustration“ [LOGO-Test. Test of inner fulfilment of meaning and existential frustration]. Deuticke. Luzzeri, M., & Chow, G.M. (2020). Presence and search for meaning in sport: Initial construct validation. Psychology of Sport and Exercise, 51, 101783.

42

Meaning and Meaninglessness in Elite Sport Martela, F., & Steger, M.F. (2016). The three meanings of meaning in life: Distinguishing coherence, purpose, and significance. Journal of Positive Psychology, 11, 1–15. doi: 10.1080/17439760.2015.1137623 Martela, F., Ryan, R.M., & Steger, M.F. (2018). Meaningfulness as satisfaction of autonomy, competence, relatedness, and beneficence: Comparing the four satisfactions and positive affect as predictors of meaning in life. Journal of Happiness Studies, 19, 1261–1282. Doi.org/ 10.1007/s10902-017-9869-7 Mascaro, N., & Rosen, D.H. (2005). Existential meaning’s role in the enhancement of hope and prevention of depressive symptoms. Journal of Personality, 73, 985–1013. doi: 10.1111/j.1467-6494.2005.00336.x Moesch, K., Kenttä, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Monroe, S.M., & Reid, M.W. (2009). Life stress and major depression. Current Directions in Psychological Science, 18, 68–72. doi: 10.1111/j.1467-8721.2009.01611.x Murphy, S.C., & Bastian, B. (2019). Emotionally extreme experiences are more meaningful. The Journal of Positive Psychology, 15(11), 1–12. DOI: 10.1080/17439760.2019.1639795 Newman, H.J.H., Howells, K.L., & Fletcher, D. (2016). The dark side of top level sport: an autobiographic study of depressive experiences in elite sport performers. Frontiers in Psychology, 7, 868. doi: 10.3389/fpsyg.2016.00868 Nicholls, A.R., Polman, R., Levy, A.R., Taylor, J., & Cobley, S. (2007). Stressors, coping and coping effectiveness: Gender, type of sport, and skill differences. Journal of Sports Sciences, 25, 1521–1530. doi: 10.1080/0264041070123 0479 Nicholson, T., Higgins, W., Turner, P., James, S., Stickle, F., & Pruitt, T. (1994). The relationship between meaning in life and the occurrence of drug abuse: A retrospective study. Psychology of Addictive Behaviors, 8, 24–28. 10.1037/ 0893-164X.8.1.24 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7, 313–326. 10.1123/jcsp.7.4.313 O’Conner, B.P., & Vallerand, R.J. (1998). Psychological adjustment variables as predictors of mortality among nursing home residents. Psychology and Aging, 13, 368–374. 10.1037/0882-7974.13.3.368 Park, S., Lavallee, D., & Tod, D. (2013). Athletes’ career transition out of sport: A systematic review. International Review of Sport and Exercise Psychology, 6, 22–53. http://doi.org/10.1080/1750984X. 2012.687053 Puffer, J.C., & McShane, J.M. (1992). Depression and chronic fatigue in athletes. Clinical Sports Medicine, 11, 327–338. 10.1016/S0278-5919(20)30534-2 Reker, G.T. (2002). Prospective predictors of successful aging in community-residing and institutionalized Canadian elderly. Ageing International, 27, 42–64. 10.1007/s12126-001-1015-4 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9),1333–1353. 10.1007/s40279-016-0492-2 Riethof, N., & Bob, P. (2019). Burnout syndrome and logotherapy: Logotherapy as useful conceptual framework for explanation and prevention of burnout. Frontiers in Psychiatry, June 14| 10.3389/fpsyt.2019.00382. PMID: 312584 90; PMCID: PMC6587911 Roderick, M. (2014). From identification to dis-identification: Case studies of job loss in professional football. Qualitative Research in Sport, Exercise and Health, 6(2),143–160. 10.1080/2159676X.2013.796491 Ronkainen, N., Ryba, T., & Allen-Collinson, J. (2020). Restoring harmony in the life-world? Identity, learning, and leaving pre-elite sport. The Sport Psychologist, 34(4), 268–275. 10.1123/tsp.2020-0009 Rosentritt, M. (2009). Sebastiabn Deisler: Zurück ins Leben [Sebastian Deisler: Back to life]. Edel. Ryan, R.M., & Deci, E.L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68 Ryan, R.M., Deci, E.L., Grolnick, W.S., & LaGuardia, J.G. (2006). The significance of autonomy and autonomy support in psychological development and psychopathology. In D. Cicchetti & D. Cohen (Eds.), Developmental psychopathology: Vol. 1: Theory and methods (2nd ed.) (pp. 795–849). Wiley. 10.1002/9780470939383.ch20 Ryff, C.D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological wellbeing. Journal of Personality and Social Psychology, 57(6), 1069–1081. 10.1037/0022-3514.57.6.1069 Ryff, C.D., & Keyes, C.L.M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719–727. 10.1007/s10902-006-9019-0 Ryff, C.D., & Singer, B.H. (2008). Know thyself and become what you are: A eudaimonic approach to psychological wellbeing. Journal of Happiness Studies, 9, 13–39. doi: 10.1007/s10902-006-9019-0 Schinke, R., Stambulova, N., Si, G., & Moore, Z. (2018). International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622–639. 10.1080/1612197X.2017.1295557 Schnell, T. (2020). The psychology of meaning in life. Routledge. 10.4324/9780367823160

43

Jürgen Beckmann Seligman (2012). Flourish: A visionary new understanding of happiness and well-being. Simon & Schuster. Sharpe, D., & Viney, I. (1973). Weltanschauung and the purpose-in-life test. Journal of Clinical Psychology, 29(4), 489–491. 10.1002/1097-4679(197310)29:4%3C489::AID-JCLP2270290429%3E3.0.CO;2-D Sparkes, A.C. (1998). Validity in qualitative inquiry and the problem of criteria: Implications for sport psychology. The Sport Psychologist, 12, 363–386. 10.1123/tsp.12.4.363 Steger, M.F. (2009). Meaning in life. In S.J. Lopez & C.R. Snyder (Eds.), Oxford handbook of positive psychology (2nd ed.) (pp. 679–687). Oxford University Press. 10.1093/oxfordhb/9780195187243.013.0064 Steger, M.F. (2018). Meaning and well-being. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of well-being (pp. 545–553). DEF Publishers. Steger, M.F., & Frazier, P. (2005). Meaning in life: One link in the chain from religion to well-being. Journal of Counseling Psychology, 52, 574–582. 10.1037/0022-0167.52.4.574 Steger, M.F., Frazier, P., Oishi, S., & Kaler, M. (2006). The meaning in life questionnaire. Assessing the presence and search for meaning in life. Journal of Counseling Psychology, 53, 80–93. 10.1037/0022-0167.53.1.80 Steger, M.F., Frazier, P., & Zacchanini, J.L. (2008). Terrorism in two cultures: Traumatization and existential protective factors following the September 11th attacks and the Madrid bombings. Journal of Trauma and Loss, 13, 511–527. 10.1037/0022-0167.53.1.80 Steger, M.F., & Kashdan, T.B. (2007). Stability and specificity of meaning in life and life satisfaction over one year. Journal of Happiness Studies: An Interdisciplinary Forum on Subjective Well-Being, 8(2), 161–179. https://doi.org/ 10.1007/s10902-006-9011-8 Steger, M.F., Kashdan, T.B., Sullivan, B.A., & Lorentz, D. (2008). Understanding the search for meaning in life: Personality, cognitive style, and the dynamic between seeking and experiencing meaning. Journal of Personality, 76, 199–228. 10.1111/j.1467-6494.2007.00484.x Steger, M.F., Kawabata, Y., Shimai, S., & Otake, K. (2008). The meaningful life in Japan and the United States: Levels and correlates of meaning in life. Journal of Research in Personality, 42(3), 660–678. 10.1016/j.jrp.2007.09.003 Thorlindsson, T., Halldorsson, V., & Sigfusdottir, I.D. (2018). The sociological theory of craftsmanship: An empirical test in sport and education. Sociological Research Online, 23, 114–135. 10.1177/1360780418754564 Walker, N., Thatcher, J., & Lavalee, D. (2007). Psychological responses to injury in sport: A critical review. The Journal of the Royal Society for the Promotion of Health, 127, 174–180. 10.1177/1466424007079494 Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50, 167–171. doi: 10.1136/bjsports-2015-095756 Wong, P.T.P. (Ed.) (2017). The human quest for meaning. Theories, research, and application. Routledge. Yeoman, R., Bailey, C., Madden, A., & Thompson, M. (2019). The oxford handbook of meaningful work. Oxford University Press. 10.1093/oxfordhb/9780198788232.001.0001

44

4 RESILIENCE AND MENTAL HEALTH IN COMPETITIVE SPORT: A NARRATIVE REVIEW OF THE LITERATURE Christopher Bryan, Jolan Kegelaers, and Mustafa Sarkar

Introduction In an ever-demanding sporting environment, athletes are continuously exposed to a wide range of potential stressors and adversities (Sarkar & Fletcher, 2014). The ability to effectively handle or recover from such stressors has been consistently identified as one of the crucial psychological factors for determining athletic development and success (Dohme et al., 2019). In light of such findings, the concept of psychological resilience has gained considerable research attention in sport over the last decade (for reviews, see Bryan et al., 2019; Galli & Gonzalez, 2015). The large majority of this burgeoning research literature has focused on understanding how resilience contributes to performance-related outcomes in response to experienced stressors (Bryan et al., 2019). For example, resilience has been discussed as one of the psychological factors predicting long-term Olympic success (Fletcher & Sarkar, 2012; Gould et al., 2002). Additionally, resilience serves as a moderator between stress and performance on competition day (Meggs et al., 2016) and facilitate performance recovery following failure feedback (Martin-Krumm et al., 2003) or performance slumps (Brown et al., 2020). Nevertheless, researchers are increasingly highlighting the potential deleterious impact of sport-related stressors (e.g., injury, performance failure) on athletes’ mental health and well-being as well (Kuettel & Larsen, 2020; Rice et al., 2016). Hence, it now seems necessary for resilience research to expand beyond its initial scope on performance-related outcomes and examine how resilience may be more appropriately integrated with mental health outcomes in athletes. In this chapter, we will review the small but accelerating research base, examining this potential relationship between resilience and mental health in sport, followed by an outline of a number of implications for future research and applied practice.

Conceptualising Resilience and Mental Health In advance of reviewing the resilience and mental health research, it is important to first clarify how resilience can best be viewed. Several authors have highlighted that the construct of resilience has often been marred by a number of myths, misunderstandings, and colloquialisms (Bryan et al., 2019; Fletcher & Sarkar, 2013; Kegelaers & Sarkar, 2021). Resilience in sport is often thought to embody a preferable characteristic or personality trait of successful athletes (Collins & MacNamara, 2012). Such a DOI: 10.4324/9781003099345-6

45

Christopher Bryan et al.

conceptualisation suggests that those athletes who previously could not persist or rebound in the face of adversity may lack the talent or innate qualities to do so (Kegelaers & Sarkar, 2021). However, contemporary resilience research in sport has demonstrated that personality traits reflect only one aspect of a much broader capacity for resilience, suggesting that resilience is further influenced by a multitude of cognitive demands, stress appraisal styles, mental states and strategies, and environmental influences (Fletcher & Sarkar, 2013, 2016). Moreover, research has shown that resilience reflects a temporally dynamic and changeable construct, showing fluctuations over time (Fletcher & Sarkar, 2013; Hill et al., 2018). Hence, resilience literature in sport has begun a shift towards acknowledging the inherent process of stress interactions, whereby individuals can maintain functioning or rebound through the use of facilitative resources and learned adaptations (Bryan et al., 2018). This shift towards resilience as a process is captured in a recent definition based on an extensive review of resilience research across both sport and work, which defines resilience as “a dynamic process encompassing the capacity to maintain regular functioning through diverse challenges or to rebound through the use of facilitative resources” (Bryan et al., 2019, p. 78). The contemporary conceptualisation of resilience as a dynamic and malleable process also recognises that this process emerges from continuous interactions between both personal and situational or environmental factors (Fletcher & Sarkar, 2016). Two decades ago, Masten and Reed (2002) highlighted that such personal and environmental influences can include factors that both impair or promote resilience, defined as risks and assets respectively. Pure risk factors are associated with more detrimental outcomes that have a negative effect on an individual’s capacity to demonstrate resilience if present (e.g., injury, loss of a parent). On the other hand, pure assets are associated with more positive outcomes and positively impact an individual’s capacity for resilience if present (e.g., positive role models, access to a sport psychologist). However, many factors might not easily be placed within such a dichotomous riskasset classification, but rather may operate along a continuum. The frequency, duration, or intensity of a factor on this continuum may determine whether it serves more as an asset or a risk factor. For example, within a coach–athlete relationship the coach may aim to support an athlete by controlling all aspects of a training session in detail; i.e., removing possible unpredictable strain thus allowing the athletes focus on the physical exertions. This coach behaviour can be seen as an asset factor in the short term. However, over time this coach behaviour may serve as a risk factor for resilience development; i.e., the athlete may be less adaptable to a broader spectrum of unpredictable stressors, especially if the coach is removed. In this regard, Masten and Reed (2002) proposed the use of a risk-asset gradient to better conceptualise additive models of possible risk and protective factors of resilience. Such a risk-asset gradient might be linear, but can also adopt exponential or asymptotic trajectories (Masten & Reed, 2002). The balance and compensatory effects of these factors over time may be instrumental in the process of resilience and collectively contribute to positive outcomes (e.g., mental health) in response to stressors or adversity. When addressing the potential relationship between resilience and mental health, it is also important to first explore mental health (see Chapter 1). Scholars have increasingly criticised mental health research in sport for being overly focused on the prevalence of common mental disorders, highlighting that mental health is more than simply the absence of symptoms of mental ill-health (e.g., Kuettel & Larsen, 2020; Poucher et al., 2021). In line with such criticisms, Keyes (2002) proposed a dual continua model of mental health, comprising both the absence of mental ill-health and the presence of positive emotional, psychological, and social functioning and well-being (i.e., flourishing). Both continua reflect related but essentially distinct dimensions, and collectively encompass a “complete state” of mental health (Kuettel & Larsen, 2020, p. 253). In relation to such a complete state of mental health, resilience might therefore not only be relevant as a protective factor reducing the risk of mental ill-health or common mental disorders, but also in contributing to a more positive state of well-being and functioning despite exposure to stressors or adversity.

46

A Narrative Review of the Literature

Hence, in this chapter, we will examine the current sport resilience literature relating to the dual continua of mental health. This will be achieved through a review of the first generation of work directly exploring the relationship between athletes’ resilience and mental health outcomes, including both mental ill-health and positive functioning and well-being. Moreover, we will look specifically at the identified risks and assets, situated on the risk-asset gradient, and how these predict resilience in relation to mental health. With this chapter, we hope to broaden the knowledge on resilience in sports, move away from a singular focus on performance-related outcomes, and inspire further research examining the potential role of resilience as a resource for athletes’ mental health.

Summary of the Literature Our database literature search spanned from June 2020–April 2021. The included papers were published between May 2008 and March 2021, although no specific timeframe limits were set. To note, research collected during the context of COVID-19 is not included in this sample due to the uniqueness of its collection during this unprecedented time. However, this research will be briefly discussed at the end of this chapter. The sample of resilience studies included are outlined in Table 4.1. These consist of a total of 19 original empirical papers. Five papers focused primarily on positive mental health outcomes, whilst the remaining 14 focused on mental ill-health outcomes across both clinical and subclinical indices. Only two studies adopted a qualitative design, using individual semi- structured interviews. The remaining quantitative studies consisted of 14 cross-sectional studies, two longitudinal studies, and one intervention study. Study participants ranged from youth sport athletes to elite athletes and spanned both individual and team sport, whereby 15 studies sampled participants from a variety of sport, one study focused on just two sport, and three studies focused on a single sport. Sample sizes ranged from 10–29 participants in the qualitative studies and 87–1547 participants in the quantitative studies. Within the quantitative studies the most prominent scale used was the Connor and Davidson (2003) resilience scale, which appeared in three separate forms: the original 25-item scale (four studies), the validated 10-item scale (four studies), and 2-item validated scale (one study). There were a further five remaining scales utilised; three of these scales capture a trait approach conceptualisation of resilience (Ego-resilience scale, Lee, 2013; The Resilience Scale for Adults, Friborg et al., 2003; Brief Resilience Scale, Smith et al., 2008) and the further two scales consisted of a sport-specific measure (The athletes, Ueno & Shimizu, 2012) and a generalised population scale adapted to the sport context (The resilience scale, Vigá rio et al., 2009).

Resilience and Mental Health As stated, only five papers to date have directly or indirectly considered resilience in relation to positive mental health outcomes. In one of the initial investigations of resilience, Galli and Vealey (2008) explored the applicability of the resiliency model (Richardson et al., 1990) in sport via interviews with current and former professional or college athletes. The authors found that, through a process of agitation, unpleasant emotions, and coping, participants were able to obtain positive outcomes despite considerable adversity (e.g., injuries, performance slumps). Although Galli and Vealey did not consider mental health outcomes directly, the reported positive outcomes demonstrated strong links with both psychological (e.g., personal growth and gained perspective) and social (e.g., increased realisation of support and willingness to help others) well-being dimensions. One of the key findings of this study is that resilience can be accompanied by a period of emotional distress and that this distress might even act as a catalyst for positive adaptation. Such a finding dispels common misconceptions of resilience as just “pushing through” adverse experiences and not demonstrating negative emotions (see also Kegelaers & Sarkar, 2021). Regarding assets and risk factors, Galli and Vealey identified a number of psychological traits and characteristics, including 47

Participants

48

218 Taiwanese collegiate athletes

670 Norwegian highschool athletes

Lu et al. (2016)

Moen et al. (2019)

Lee et al. (2017)

Quantitative Crosssectional Quantitative Crosssectional

321 adult & 199 youth Quantitative Australian Cricketers Crosssectional 139 Iranian university Quantitative athletes Crosssectional 346 Korean highQuantitative school athletes Crosssectional

Gucciardi et al. (2011)

Hosseini and Besharat (2010)

10 American current/ former college or professional athletes

Quantitative Crosssectional Qualitative Semistructured interviews

Study type

Galli and Vealey (2008)

Drew and 185 Irish university Matthews (2019) student-athletes

Authors

Table 4.1 Studies of Resilience and Mental Health

Athlete burnout

Athlete burnout

Athlete burnout

Psychological wellbeing and distress

Athlete burnout

Psychological and social well-being

Depression, anxiety, and stress

•

•

•

•

•

•

•

•

Resilience positively predicted wellbeing and negatively predicted psychological distress Resilience moderated the stressburnout relationship; and the burnout and athlete identity and athlete satisfaction relationships Resilience and coaches’ social support conjunctively moderated the stressburnout relationship Resilience mediated the relationship between the coach–athlete alliance and burnout Resilience was further predicted by sporting ambition

Resilient outcomes resulted from a process of agitation, unpleasant emotion, cognitive, and behavioural coping strategies Resilience was influenced by personal (i.e., optimism, determination, competitiveness, passion for sport) and environmental (i.e., social support, cultural background) resources Overcoming challenges can in turn develop personal resources Resilience was negatively associated with burnout

Resilience negatively predicted depression, anxiety, and stress

Key findings

2-item Connor-Davidson • Resilience Scale (CDRISC-2) The Resilience Scale for • Adults (RSA)

Connor-Davidson Resilience Scale (CDRISC) Connor-Davidson Resilience Scale (CDRISC) Ego Resilience Questionnaire (ERQ)

10-item ConnorDavidson Resilience Scale (CD-RISC-10) N/A

Mental health outcome(s) Resilience measure

Christopher Bryan et al.

63 Japanese university athletes

Ueno & Suzuki (2016)

49

87 Italian adolescent basketball & volleyball players

372 UK athletes

Wagstaff et al. (2018)

Quantitative Crosssectional

Quantitative Crosssectional

816 Australian Quantitative adolescent non-elite Intervention male athletes

Vitali et al. (2015)

Vella et al. (2021)

Quantitative Longitudinal

Quantitative Crosssectional

1547 Spanish athletes

Trigueros et al. (2020)

Sorkkila et al. (2019)

Raanes et al. (2019)

Quantitative Crosssectional 670 Norwegian high- Quantitative school athletes Crosssectional 491 Finnish adolescent Quantitative student‐athletes Longitudinal

139 Iranian university athletes

Nezhad and Besharat (2010)

Psychological Resilience Scale for University Athletes (PRSUA)

The Resilience Scale (RS)

The Brief Resilience Scale (BRS)

10-item ConnorDavidson Resilience Scale (CD-RISC-10) The Resilience Scale for Adults (RSA)

Athlete burnout

10-item ConnorDavidson Resilience Scale (CD-RISC-10)

Wellbeing & Distress, 10-item ConnorDepression & Davidson Resilience anxiety literacy, Scale (CD-RISC-10) Mental health stigma, Helpseeking behaviours Athlete burnout 10-item ConnorDavidson Resilience Scale (CD-RISC-10; adapted)

Burnout

Depression, anxiety, and stress

Sport and school burnout

Athlete burnout

Psychological wellbeing and distress

•

•

•

•

•

•

•

•

•

•

•

(Continued)

Resilience and hardiness conjunctively positively predicted well-being and negatively predicted distress The coach–athlete alliance, resilient factors, and perceived stress conjunctively predicted athlete burnout Resilience was higher in no-risk burnout profile compared to average or increased risk profiles Resilience negatively predicted depression, anxiety, and stress Coaches’ prosocial behaviours positively predicted resilience, whereas coaches’ antisocial behaviours negatively predicted resilience Resilience was negatively associated with burnout Temporal changes suggested a process of psychological recovery in highresilience participants A combined resilience and mental health literacy intervention had a positive effect on well-being The intervention also improved depression and anxiety literacy and help-seeking confidence and intentions Resilience, perceived competence, and mastery climate conjunctively negatively predicted reduced sense of accomplishments and sport devaluation dimensions of burnout Resilience moderated the relationship between organisational stressors and burnout

A Narrative Review of the Literature

579 Chinese athletes

626 Japanese university Quantitative athletes Crosssectional

185 Spanish footballers Quantitative Crosssectional

Wu et al. (2021)

Yamada et al. (2017)

Zurita- Ortega et al. (2018)

Quantitative Crosssectional

22 Australian female Qualitative youth gymnasts & 7 Semigymnastics coaches structured interviews

White and Bennie (2015)

Study type

Participants

Authors

Table 4.1 (Continued)

10-item ConnorDavidson Resilience Scale (CD-RISC-10)

N/A

50 Anxiety

Connor-Davidson Resilience Scale (CDRISC)

Symptoms of minor Psychological Resilience psychiatric disorders Scale for University Athletes (PRSUA)

Athlete burnout

Psychological wellbeing

Mental health outcome(s) Resilience measure

•

•

•

•

•

•

•

Positive interpersonal relationships, effective coach behaviours, and a challenging yet supportive training environment promoted resilience and well-being among youth gymnasts Resilience directly moderated the relationship between organisational stressors and different burnout dimension Resilience also indirectly moderated the relationship between organisational stressors and burnout via reduced competitive anxiety Resilience was negatively associated with most mental ill-health outcomes Resilience mediated the relationship between team unity and mental health Resilience was negatively associated with anxiety The inverse relationship between resilience and anxiety was stronger in uninjured compared to injured players

Key findings

Christopher Bryan et al.

A Narrative Review of the Literature

optimism, determination, competitiveness, and passion for sport as key personal resilience assets. Moreover, different types of available social support, including emotional, esteem, informational and tangible, were identified as environmental assets. Galli and Vealey also found that adversity in and of itself might be placed on the risk-asset gradient. Evidently, significant adversities can cause considerable distress and tax an athlete’s capacity for resilience. On the other hand, by successfully overcoming these adversities, athletes may develop key personal resources, thus strengthening their resilience against future adversities. Similarly, some participants identified their minority ethnic background as both an obstacle as well as a source of resilience. These findings support the notion that some adversity might actually help strengthen resilience and promote mental health (Seery, 2011). In a second qualitative study, White and Bennie (2015) examined how resilience can contribute to positive mental health outcomes in female youth gymnasts. In their study, interpersonal relationships, including both positive peer and coach relationships, were identified as a key resilience asset. Strong interpersonal relationships created a sense of belonging, increased athletes’ support networks, and built an environment in which athletes felt safe to ask questions and share personal information; demonstrating parallels with recent work on psychological safety (Fransen et al., 2020). Coach behaviours were also identified as a potential resilience asset. Through both their overall coaching style and the use of specific teaching strategies (e.g., competition simulation, self-talk), coaches can foster athletes’ problem-solving skills, build confidence, and create an environment of trust and safety. Finally, the sporting environment itself might be placed on the risk-asset gradient. For athletes, the competitive environment formed a potential source of setbacks, embarrassment, fear, and stress. At the same time, participants felt that opportunities to overcome setbacks in this sporting environment can actually strengthen athletes’ determination, confidence, and resilience; echoing findings from Galli and Vealey (2008). Moreover, establishing a “fun and friendly atmosphere” within the sporting environment was also believed to compensate for the pressures of competitive sport and helps fostering resilience (White & Bennie, 2015). Two additional quantitative papers examined the link between resilience and mental health (i.e., both well-being and psychological distress), drawing on the same sample of student-athletes (Hosseini & Besharat, 2010; Nezhad & Besharat, 2010). This sample used the Connor-Davidson Resilience Scale (CDRISC; Connor & Davidson, 2003) and the Mental Health Inventory (MHI; Veit & Ware, 1983) as measures for resilience and mental health respectively. Hosseini and Besharat (2010) found that resilience formed a significant positive predictor for well-being and a negative predictor for psychological distress, accounting for around 32% and 13% of the variance, respectively. Nezhad and Besharat (2010) found that resilience was also strongly correlated with the personality trait hardiness (r = .74), hinting at a potential role of hardiness as a resilience asset. Resilience and hardiness in combination predicted both well-being (R2 = .36) and psychological distress (R2 = .21) (Nezhad & Besharat, 2010). Finally, one recent intervention study examined the efficacy of a large-scale combined resilience and mental health literacy intervention among adolescent male athletes (Vella et al., 2021). Using a nonrandomised community-matched design, the impact of the sport-based intervention program on the mental health and related outcomes, including help-seeking intentions and behaviours, was evaluated. Results highlighted significant changes of group-time interactions, whereby greater increases in follow-up measures of resilience (F[1, 424] = 10.71, p = 0.001) and secondary mental health outcomes (depression literacy, F[1, 467] = 36.94, p < 0.001; anxiety literacy, F[1, 457] = 46.54, p < 0.001; intentions to seek help from formal sources, F[1, 468] = 7.17, p = 0.008; and confidence to seek mental health information, F[1, 450] = 5.00, p = 0.026) were found in those adolescents who took part in the intervention compared to those in the control group. Importantly, there was also a significant group-time interaction for wellbeing (F[1, 426] = 10.73, p = 0.001) compared with the control group, providing an important first indication that resilience-based interventions may indeed be effective at promoting positive athlete mental health (Vella et al., 2021). 51

Christopher Bryan et al.

Resilience and Mental Ill-Health Fourteen studies, all of which were quantitative, examined the relationship between resilience and mental ill-health outcomes, spanning both clinical and subclinical indices. Four studies investigated associations between resilience and symptoms of clinical common mental disorders, including both depression (see Chapter 6) and anxiety (see Chapter 11) (Drew & Matthews, 2019; Trigueros et al., 2020; Yamada et al., 2017; Zurita-Ortega et al., 2019). Additionally, all ten papers addressing subclinical issues focused on relationships between resilience and burnout (Gucciardi et al., 2011; Lee et al., 2017; Lu et al., 2016; Moen et al., 2019; Raanes et al., 2019; Sorkkila et al., 2019; Ueno & Suzuki, 2016; Vitali et al., 2015; Wagstaff et al., 2018; Wu et al., 2021).

Clinical Indices Four studies examined relationships between resilience and clinical indices of mental ill-health. Yamada et al. (2017) used the General Health Questionnaire 30 (GHQ-30), which assesses six categories of clinical symptoms including general illness, somatic symptoms, sleep disturbance, social dysfunction, anxiety and dysphoria, and suicidal depression. Overall, resilience was negatively associated with symptoms of mental ill-health (r = –0.33). Moreover, small-to-moderate correlations were found between both personal and environmental resilience resources and all clinical symptoms (–0.08 < r < –0.40), except for sleep disturbance. Further covariance structure analysis demonstrated that both environmental (ß = 0.62) and personal (ß = 0.77) resilience resources mediated the relationship between team unity and mental health (ß = –0.26), suggesting a potential role of team unity as a resilience asset. Zurita-Ortega et al. (2019) examined relationships between injury, resilience, and symptoms of anxiety. The authors found positive relationships between resilience and an absence of symptoms of anxiety, for both injured (r = 0.38) and non-injured athletes (r = 0.61). Moreover, based on the diminished relationship between resilience and anxiety in injured players, the authors suggested that injury might serve as a risk factor for resilience (Zurita-Ortega et al., 2019). Drew and Matthews (2019) examined resilience in relation to symptom prevalence and severity of depression and anxiety (see Chapters 6 and 11, respectively) within a sample of student-athletes. Separate linear regression analyses demonstrated that resilience was a significant negative predictor for both symptoms of depression (ß = –0.28) and anxiety (ß = –0.34). Finally, Trigueros et al. (2020) similarly studied links between resilience and symptoms of anxiety and depression, whilst also examining coaches’ social behaviours. Results indicated that prosocial coach behaviours positively predicted (ß = 0.48) resilience, whereas antisocial coach behaviours negatively predicted (ß = –0.38) resilience, highlighting that coaches’ social behaviours may be placed on the risk-asset gradient. Resilience in turn negatively predicted symptoms of anxiety (ß = –0.41), depression (ß = –0.39), and stress (ß = –0.55), demonstrating the mediating role of resilience between coaches’ social behaviours and symptoms of mental ill-health.

Subclinical Indices The ten papers adopting subclinical indices all examined resilience in relation to athlete burnout (see Chapter 12 for more information on burnout). Athlete burnout is typically viewed as a multidimensional concept, consisting of three components: a reduced sense of accomplishment in sport, devaluation of the sport experience, and emotional/physical exhaustion (Raedeke & Smith, 2001). The earliest study reporting on the relationship between resilience and burnout was carried out by Gucciardi et al. (2011). They examined burnout as a measure of convergent validity in a validation study of the CD-RISC (Connor & Davidson, 2003) in sport. The authors identified moderate negative correlations between the abbreviated CD-RISC-10 and the different burnout components (–0.26 < r < –0.40) of the athlete burnout questionnaire (ABQ; Raedeke & Smith, 2001). Vitali et al. (2015) also used an adapted version of 52

A Narrative Review of the Literature

the CD-RISC-10 to examine relationships between resilience, motivational climate, and athlete burnout. The authors found that resilience negatively predicted both reduced sense of accomplishment (ß = 0.27) and sport devaluation (ß = 0.28) dimensions of burnout. Moreover, resilience was positively correlated (r = 0.39) with a coach-created perceived mastery (i.e., task-involving) climate, hinting at the potential of motivational climate as a resilience asset in sport. Four studies examined resilience as a moderating factor of the stress-burnout relationship. Lu et al. (2016) investigated associations between life stress, resilience (CD-RISC- 2), coaches’ social support, and burnout among a population of collegiate athletes. They found that resilience was negatively associated with burnout (r = –0.24). Moreover, resilience in conjunction with coaches’ tangible (R2 = 0.25) and informational (R2 = 0.27) support moderated the stress-burnout relationship. In a sample of high school student-athletes, Lee et al. (2017) examined the moderating role of ego resilience on the relationship between life stressors, burnout, athlete identity, and athlete satisfaction, using multigroup structural equation modelling. The authors found that athletes who were higher in ego resilience showed a weaker relationship in the pathways from stress to burnout (ß = 0.32, p < 0.01 versus ß = 0.52, p < 0.001) and from burnout to athletic identity (ß = –0.53, p < 0.001 versus ß = –0.39, p < 0.001) and overall sport satisfaction (ß = –0.57, p < .001 versus ß = –0.48, p < 0.001). Wagstaff et al. (2018) equally found that resilience demonstrated a negative association with athlete burnout (r = –0.46) and moderated the relationship between organisational stressors and burnout (ß = –0.22, t[373] = 85.46, p < 0.001), further highlighting its potential as an important protective resource against mental ill-health outcomes. Finally, Wu et al. (2021) studied the relationships between organisational stressors, resilience, competitive anxiety, and burnout. A series of mediation analyses demonstrated that resilience significantly moderated the relationship between organisational stressors and the different burnout dimensions directly (–0.06 < b < –0.08), as well as indirectly via reduced competitive anxiety (b = –0.07). The authors discussed that lower resilience may cause athletes to perceive environmental demands such as organisational stressors more as threats and together with higher competitive trait anxiety and that may lead to symptoms of burnout. A further two papers investigated relationships between resilience, the coach–athlete working alliance, stress, and burnout, using a single sample of junior athletes (Moen et al., 2019; Raanes et al., 2019). Within this sample, the resilience scale for adults (RSA; Friborg et al., 2003) was used, measuring six intraand interindividual resilience resources including perceptions of self, planned future, social competence, family cohesion, social resources, and structured style. Raanes et al. (2019) found that perceived stress, planned future (i.e., maintaining a positive outlook), structured style (i.e., achievement goals), personal bond with the coach, level of ambition, and gender were conjunctively associated with athlete burnout (R2 = 0.47). Moreover, small to moderate correlations (0.14 < r < 0.43) between the different components of the coach–athlete relationship and the resilience dimensions seemed to suggest that the coach–athlete working alliance might play a role as a resilience asset. Moen et al. (2019) expanded on this finding by demonstrating that individual resilience mediated the relationship between the coach-athlete working alliance (ß = 0.55) and burnout (ß = –0.51). Moreover, resilience scores were significantly affected by sporting ambitions, whereby junior athletes with ambitions to become future elite athletes recorded higher resilience levels than athletes with no such ambitions (Moen et al., 2019). Finally, two studies adopted a longitudinal approach to follow the relationship between resilience and burnout over time. Ueno and Suzuki (2016) followed athletes over an entire competitive season (three timepoints), suggesting that resilience was negatively associated with burnout. More specifically, burnout scores of athletes with high resilience were significantly lower than scores of athletes with low resilience, both at the start (d = 4.32) and the end (d = 3.33) of the competitive period, although no such difference was present during the mid-season measurement point. This study suggests that (a) resilience develops as a function of time and (b) that resilience might not necessarily prevent the occurrence of psychological distress, but rather contributes to a more efficient recovery from such stress (see also Galli & Vealey, 2008). A second longitudinal study by Sorkkila et al. (2019) followed a sample of student-athletes over three years 53

Christopher Bryan et al.

(four timepoints) in order to understand how resilience affects the likelihood of dropout due to school or sport burnout. The authors identified three latent group profiles based on their level and development of school and sport burnout. Mean individual resilience scores differed significantly across the three profiles, with resilience being highest in student-athletes of the non-risk burnout profile (M3) compared with the average-risk burnout profile (M2) and the increased burnout risk profile (M1) (M1 = 3.12, SE = 0.07; M2 = 3.83, SE = 0.05; M3 = 4.21, SE = 0.12). Moreover, athletes in the increased burnout risk profile were more likely to drop out of sport, although no such difference was found for school dropout.

Critique of the Literature and Future Research Studies examining the relationship between resilience and mental health have only recently started to emerge. Over seventy-five percent of the studies included in this review were published within the past six years. Hence, the literature reviewed here presents the first generation of research alluding to the potential protective role of psychological resilience for athletes’ mental health. Nevertheless, a number of criticisms of the current literature and avenues for future research can be formulated. First, there seems to be an overreliance on quantitative cross-sectional research designs. Evidently, such cross-sectional designs can elucidate potential relationships between key variables of interest, but they fail to demonstrate any direct causal links between resilience and mental health outcomes. Moreover, such “snapshot” approaches to data collection may be incompatible with contemporary process conceptualisations of resilience, as they fail to account for dynamic temporal fluctuations in functioning in relation to experienced adversity (Hill et al., 2018). As such, we suggest future resilience research should incorporate this process conceptualisation and account for temporal dynamics within study design. One particularly fruitful avenue might be to use more longitudinal research to capture how resilience processes unfold over time. For example, Hill et al. (2018) advocated for the use of dense individual time-series measurements to directly assess idiosyncratic responses to stressors. Additionally, scholars might also complement quantitative approaches with more qualitative or mixed method research. Overall, qualitative approaches can advance our understanding of resilience, by (a) uncovering unnamed risk or asset factors, (b) increasing contextual understanding, and (c) exploring idiosyncratic differences in athletes’ responses to stressors or adversities (Ungar, 2003). Notably, such qualitative research approaches can be advanced beyond typical cross-sectional semi-structured interviews and be more aligned with dynamic process conceptualisations by incorporating other data collection methods, including diaries, timelines, or ethnographic engagement. Such strategies can create an information-rich approach to understanding the resilience process towards greater mental health. Second, in addition to adopting research designs which are more in line with the concept of resilience as a process, there is also a need to advance resilience measurement approaches. The majority of quantitative resilience measures used in the review studies were developed for use in more general or clinical populations. Moreover, most measures did not align with contemporary process conceptualisations of resilience and rather focused on internal trait-like aspects of resilience. Hence, we echo previous calls for the development of a novel sport-specific resilience measure, which accounts for dynamic personenvironment interactions (Gucciardi et al., 2011; Sarkar & Fletcher, 2013). For instance, Den Hartigh et al. (2022) recently proposed that biopsychosocial data can be collected from athletes on a daily basis. Such data may subsequently be used to detect resilience losses and early warning signals before more chronic effects can be observed on athletes’ mental health. Thirdly, we contend that research should continue to examine the relationship between resilience and a variety of mental health outcomes across different athletic populations. Throughout the entire sample of included papers, a notable majority of studies were concerned with resilience and burnout. This perhaps is linked to the predictive relationship burnout tends to have with competitive sport dropout (Sorkkila et al., 2019). However, this focus seems to detract from an array of clinical mental health problems that elite athletes 54

A Narrative Review of the Literature

may also be vulnerable to and struggle with, such as anxiety, depression, eating disorders (see Chapter 7), obsessive compulsive disorders, and substance abuse (Rice et al., 2016). Similarly, student-athlete populations were most regularly utilised in the reviewed studies. This may potentially limit the generalisability of the findings towards the general athlete population, as student-athletes may present a distinct subsection of athletes with unique experienced demands (Kegelaers et al., 2022). Therefore, more research is needed to explore if and how resilience might prevent or ameliorate symptoms of mental ill-health in athlete populations beyond student-athletes. Moreover, accounting for the whole state of mental health, future research should further explore how resilience is not only associated with symptoms of mental ill-health, but also contributes to positive states of emotional, psychological, or social well-being. Fourth, we also want to highlight that within the research reviewed in this chapter, there seem to be indications of “salami slicing”. Such salami slicing refers to the segmentation and separate publication of data originating from the same original study. This is commonly accepted as poor research practice as it (a) tends to exaggerate research findings; (b) skews the evidence base; and (c) wastes valuable time and resources from journals, editors, reviewers, and readers (Jackson et al., 2014). As such, we would strongly call for resilience researchers to avoid multiple publications from the same data set and clearly signpost previous work when multiple publications are considered appropriate. Finally, although the majority of the reviewed papers recommended some form of resilience development, only a single intervention study was found in relation to resilience and mental health (Vella et al., 2021). Hence, future research should continue to design and implement resilience-building interventions (e.g., Fletcher & Sarkar, 2016) and evaluate how such interventions could positively impact both athletes’ performance and mental health. The following section will discuss practical implications drawn from this review as well as current related resilience development literature in an attempt to outline potential future multidimensional resilience interventions towards the promotion of better mental health in sport.

Practical Implications Evidence from several performance domains have highlighted that an individuals’ capacity for resilience can be developed over time (e.g., Joyce et al., 2018; Robertson et al., 2015). Resilience interventions can focus on reducing risk factors, but more commonly target the development of key resilience assets, thereby expanding the flexible “bandwidth” of an individual’s response to stressors or adversities (Fletcher & Sarkar, 2016). For example, developing mental health literacy through team attendance of a prominent guest speaker may facilitate a supportive training environment, where, athletes are encouraged to openly discuss mental health difficulties. This may further lead to increased athlete relationships and help buffer regular chronic stressors of sport (Souter et al., 2018). As stated though, intervention studies targeting resilience development have remained largely absent within the context of sport (for exceptions, see Kegelaers et al., 2021; Vella et al., 2021). In the absence of more experimental work, some scholars have offered theory-based suggestions to develop resilience (e.g., Fletcher & Sarkar, 2016; Schinke & Jerome, 2002), whereas others have drawn on qualitative approaches (e.g., Kegelaers & Wylleman, 2019; Sarkar & Hilton, 2020; White & Bennie, 2015) and case studies (e.g., Cox et al., 2016; Deen et al., 2017; Pierce et al., 2020) to examine how resilience is fostered within applied sport settings. Drawing on this body of work as well as the studies reviewed in this chapter, we tentatively propose three overarching principles that might strengthen athletes’ resilience and promote mental health: (a) developing personal qualities, (b) fostering social support, and (c) creating a coach-created facilitative environment.

Developing Personal Qualities A first overall approach to resilience development might be to target the development of personal resilient qualities. Such positive personal qualities might be developed through traditional mental or life skills 55

Christopher Bryan et al.

approaches. For example, Cox et al. (2016) presented a golf-based life skills program aimed towards developing a number of key resilient qualities (e.g., goal setting, emotion management, reflection) through the use of workshops, coupled with on-field exercises. Similarly, the resilience intervention presented by Vella et al (2021) centred around the development of personal resilience qualities identified in earlier research (Fletcher & Sarkar, 2012), through the combined use of in-person workshops and online modules. In addition to the use of traditional life or psychological skills development interventions, scholars have also advocated the use of cognitive behavioural therapy (CBT) techniques to develop resilient qualities. To illustrate, Schinke and Jerome (2002) presented a case intervention to develop optimistic attribution styles, based on CBT techniques such as evaluating personal assumptions, decatastrophising, and disputing negative thoughts. Turner (2016) proposed the use of a resilience credo to promote rational and flexible beliefs in the face of adversity. Deen et al. (2017) subsequently found support for the use of CBT and credos as an approach to develop resilience, through the use of a multiple baseline quasi-experimental design. Finally, in recent years, mindfulness-based interventions have also gained attention within sport psychology (Henriksen et al., 2020). Although such interventions have yet to be linked to resilience outcomes in sport, research in general psychology suggests that such mindfulness-based interventions might be effective in developing resilience (e.g., Joyce et al., 2018). As such, researchers and practitioners might explore the use of similar strategies to develop resilience at the individual level.

Strengthening Social Support Although a key component of resilience-building, interventions directed solely at developing personal resilient qualities risk neglecting the crucial role of the environment (Fletcher & Sarkar, 2016). Resiliencebuilding interventions should therefore equally aim to develop assets at the environmental level. As evidenced by the literature reviewed in this chapter, social support forms one of the most salient environmental-level assets (Vitali et al., 2015; White & Bennie 2015; see also Chapter 5). Such findings are consistent with a review across both sport and work contexts, wherein social support emerged as the most commonly reported asset contributing towards individual resilience (Bryan et al., 2019). Practitioners may therefore look to educate athletes on the different types of social support, help them recognise the available sources of support, create a sense of group belonging and identity, and build athletes’ social skills to engage with different support providers (Freeman et al., 2009; Gonzalez et al., 2016). In addition to helping athletes recognise their own sources of social support, interventions might also target key individuals around the athlete, including parents or coaches, and strengthen these individuals in their supporting role (Vella et al., 2021). Coaches in particular might act as an important source of social support (Fletcher & Sarkar, 2012). Several papers reviewed in this chapter highlighted the importance of the coach–athlete relationship to develop resilience in relation to mental health outcomes (Lu et al., 2016; Moen et al., 2019; Raanes et al., 2019; Trigueros et al., 2020 and White, 2015). Such findings are consistent with recent research demonstrating the importance of establishing a quality relationship to foster resilience more broadly (Kegelaers & Wylleman, 2019; Sarkar & Hilton, 2020). As such, practitioners may look to educate coaches on their importance within the social support network of the athlete and strengthen their emotional intelligence and social skills to establish a strong coach–athlete relationship (Jowett, 2017).

Coach-Created Facilitative Environment As highlighted, coaches form an important source of social support to develop resilience in relation to mental health. However, their role in fostering resilience might expand beyond adopting a supportive role (Kegelaers & Wylleman, 2019). Several studies have emphasised the role of the coach-created climate in the development of resilience (e.g., Vitali et al., 2015; White & Bennie, 2015). Fletcher and 56

A Narrative Review of the Literature

Sarkar (2016) proposed that such a facilitative environment relies on the careful balance between challenge and support. Coaches might therefore consider the careful and timely introduction of small specific challenges (i.e., planned disruptions) within the daily training context. The process of resilience pertains to the disruption, reintegration and growth of resilience capacities following distress related to consequential loss or attainment of associated resources (Bryan et al., 2018). As such, athletes’ struggles and attempts to work through challenging situations might help in creating awareness about typical responses under stress, the development and training of personal or collective resources, as well as building athletes’ confidence in the use of these resources (Galli & Vealey, 2008; Kegelaers et al., 2020, 2021). In the autobiography of multiple Olympic Champion Michael Phelps, the author describes how Michael’s coach, Bow Bowman, created a practice environment that allowed him to perform and make mistakes under simulated pressure, in order to prepare him for actual real-life performances (Arnold, 2012). Although such small challenge experiences might provide an avenue to develop resilience (Galli & Vealey, 2008; Kegelaers et al., 2021), such interventions should always be embedded within a sufficiently supportive environment to avoid creating an unrelenting or unhealthy training environment (Fletcher & Sarkar, 2016). Coaches therefore have a crucial role in creating such a supportive environment that enables “people to develop their personal qualities, and helps to promote learning and build trust” (Fletcher & Sarkar, 2016, p. 141). Scholars have related elements of such a supportive environment to the creation of a mastery-oriented climate (Vitali et al., 2015), using humour and facilitating positive peer relations (White & Bennie, 2015), fostering team cohesiveness (Yamada et al., 2017) and psychological safety (Fransen et al., 2020), and promoting challenge mindsets and reflective behaviours in response to adversities (Kegelaers & Wylleman, 2019). In sum, resilience interventions can best be established as multidimensional approaches, reflecting the complexity of interactions between resilience risks and assets at both the individual and environmental level (Fletcher & Sarkar, 2016; Vella et al., 2021). Drawing on the current literature, we would suggest that such interventions should focus on (a) developing personal resources, (b) strengthening different sources of social support, and (c) developing a coach-created facilitative environment. Further research remains necessary though to evaluate the efficacy of such multidimensional interventions to develop resilience and promote mental health.

COVID-19 Impact on Sport, Resilience, and Mental Health Over the past years, the COVID-19 pandemic has affected nearly every aspect of our lives. As in many other populations, the pandemic and its associated stressors and uncertainties had a profound impact on athletes’ mental health and well-being (Reardon et al., 2021). During this unprecedented time, a number of studies were carried out to better understand the relationship between resilience and athletes’ mental health during the pandemic. Studies by both Madsen et al. (2021) and Kilic et al. (2021), among elite male football players and female Australian professional footballers respectively, found resilience to be a protective factor of mental health. Knowles et al. (2021) explored the impact of the pandemic on the mental health of athletes and non-athletes. While they found no difference in resilience between the athlete and non-athlete samples, their results suggested that the large reduction in competitive sport opportunities was challenging for those athletes with strong athletic identities and led to an increased risk of poor well-being and loneliness beyond that of the general population. This finding suggests that athletes’ resilience may be circumstantial and resilience developed in one context may not necessarily apply to another. Finally, in a study with elite rugby players, Myall et al. (2021) found that mindfulness skills were associated with resilience, and predicted lower levels of both anxiety and depression. These findings add to the body of literature discussed in this chapter and contribute to a coherent understanding of resilience and mental health across an array of adverse experiences. 57

Christopher Bryan et al.

Conclusion In this chapter, we aimed to review the first generation of research examining the relationship between resilience and mental health. Overall, the literature suggests that resilience could be a relevant factor towards promoting athletes’ complete state of mental health, including ameliorating symptoms of both clinical and sub-clinical indices. However, it is clear that future resilience research requires a shift in perspective away from resilience as a trait related to sport performance and towards resilience as a process influenced by a multitude of asset and risk factors. Future research strategies should also focus on more process-based interventions, aimed at developing resilience qualities through interactions in a facilitative environment created and supported by coaching and support staff.

References Arnold, R. (2012). Review of the book No limits: The will to succeed, by Phelps, M., & Abrahamson, A. (2008). Journal of Sport Psychology in Action, 3(2), 155–157. 10.1080/21520704.2012.683094 Brown, C.J., Butt, J., & Sarkar, M. (2020). Overcoming performance slumps: Psychological resilience in expert cricket batsmen. Journal of Applied Sport Psychology, 32(3), 277–296. 10.1080/10413200.2018.1545709 Bryan, C., O’Shea, D., & MacIntyre, T. (2019). Stressing the relevance of resilience: A systematic review of resilience across the domains of sport and work. International Review of Sport and Exercise Psychology, 12(1), 70–111. 10.1080/ 1750984X.2017.1381140 Bryan, C., O’Shea, D., & MacIntyre, T. (2018). The what, how, where and when of resilience as a dynamic, episodic, self-regulating system: A response to Hill et al. (2018). Sport, Exercise, and Performance Psychology, 7(4), 355–362. 10.1037/spy0000133 Collins, D.M.A. (2012). Rocky road to the top: Why talent needs trauma. Sports Medicine, 42(1), 907–914. 10.1007/ BF03262302 Connor, K.M., & Davidson, J.R. (2003). Development of a new resilience scale: The Connor‐Davidson resilience scale (CD‐RISC). Depression and Anxiety, 18(2), 76–82. Cox, H., Neil, R., Oliver, J., & Hanton, S. (2016). PasSport4life: A trainee sport psychologist’s perspective on developing a resilience-based life skills program. Journal of Sport Psychology in Action, 7(3), 182–192. 10.1080/2152 0704.2016.1240733 Deen, S., Turner, M.J., & Wong, R.S.K. (2017). The effects of REBT, and the use of credos, on irrational beliefs and resilience qualities in athletes. The Sport Psychologist, 31(3), 249. 10.1123/tsp.2016-0057 Den Hartigh, R.J.R., Meerhoff, L.R.A., Van Yperen, N.W., Neumann, N.D., Brauers, J.J., Frencken, W.G.P., Emerencia, A., Hill, Y., Platvoet, S., Atzmueller, M., Lemmink, K. and Brink, M.S. (2022). Resilience in sports: A multidisciplinary, dynamic, and personalized perspective. International Review of Sport and Exercise Psychology, 1–23. 10.1080/1750984X.2022.2039749 Dohme, L.-C., Piggott, D., Backhouse, S., & Morgan, G. (2019). Psychological skills and characteristics facilitative of youth athletes’ development: A systematic review. The Sport Psychologist, 33(4), 261. 10.1123/tsp.2018-0014 Drew, B., & Matthews, J. (2019). The prevalence of depressive and anxiety symptoms in student-athletes and the relationship with resilience and help-seeking behavior. Journal of Clinical Sport Psychology, 13(3), 421–439. 10.1123/jcsp.2017-0043 Fletcher, D., & Sarkar, M. (2012). A grounded theory of psychological resilience in Olympic champions. Psychology of Sport and Exercise, 13(5), 669–678. 10.1016/j.psychsport.2012.04.007 Fletcher, D., & Sarkar, M. (2013). Psychological resilience: A review and critique of definitions, concepts, and theory. European Psychologist, 18(1), 12–23. 10.1027/1016-9040/a000124 Fletcher, D., & Sarkar, M. (2016a). Mental fortitude training: An evidence-based approach to developing psychological resilience for sustained success. Journal of Sport Psychology in Action, 7(3), 135–157. 10.1080/21520704.2016. 1255496 Fletcher, D., & Sarkar, M. (2016b). An introduction to the special issue: Developing resilience. Journal of Sport Psychology in Action, 7(3), 133–134. 10.1080/21520704.2016.1251754 Fransen, K., McEwan, D., & Sarkar, M. (2020). The impact of identity leadership on team functioning and well-being in team sport: Is psychological safety the missing link? Psychology of Sport and Exercise, 51. 10.1016/j.psychsport.2020. 101763 Freeman, P., & Rees, T. (2009). How does perceived support lead to better performance? An examination of potential mechanisms. Journal of Applied Sport Psychology, 21(4), 429- 441. 10.1080/10413200903222913

58

A Narrative Review of the Literature Friborg, O., Hjemdal, O., Rosenvinge, J.H., & Martinussen, M. (2003). A new rating scale for adult resilience: What are the central protective resources behind healthy adjustment? International Journal of Methods in Psychiatric Research, 12(2), 65. 10.1002/mpr.143 Galli, N., & Vealey. (2008). “Bouncing back” from adversity: Athletes’ experiences of resilience. The Sport Psychologist, 22(3), 316–335. Gonzalez, S.P., Detling, N., & Galli, N.A. (2016). Case studies of developing resilience in elite sport: Applying theory to guide interventions. Journal of Sport Psychology in Action, 7(3), 158–169. 10.1080/21520704.2016.1236050 Gould, D., Dieffenbach, K., & Moffett, A. (2002). Psychological characteristics and their development in Olympic champions. Journal of Applied Sport Psychology, 14(3), 172–204. 10.1080/10413200290103482 Gucciardi, D.F., Jackson, B., Coulter, T.J., & Mallett, C.J. (2011). The Connor-Davidson resilience scale (CDRISC): Dimensionality and age-related measurement invariance with Australian cricketers. Psychology of Sport and Exercise, 12(4), 423–433. Henriksen, K., Hansen, J., & Larsen, C.H. (2020). Mindfulness and acceptance in sport: How to help athletes perform and thrive under pressure. Routledge. Hill, Y., Den Hartigh, R.J.R., Meijer, R.R., De Jonge, P., & Van Yperen, N.W. (2018). The temporal process of resilience. Sport, Exercise, and Performance Psychology, 7(4), 363– 370. 10.1037/spy0000143 Hosseini, S.A., & Besharat, M.A. (2010). Relation of resilience with sport achievement and mental health in a sample of athletes. Procedia - Social and Behavioral Sciences, 5, 633–638. 10.1016/j.sbspro.2010.07.156 Jackson, D., Walter, G., Daly, J., & Cleary, M. (2014). Multiple outputs from single studies: Acceptable division of findings vs. ‘salami’ slicing. Journal of Clinical Nursing, 23(1), 1–2. 10.1111/jocn.12439. Epub 2017 May 26. PMID: 28813341. Jowett , S. (2017). Coaching effectiveness: the coach-athlete relationship at its heart Curr Opin Psychol, 16, 154–158. 10.1016/j.copsyc.2017.05.006 Joyce, S., Shand, F., Bryant, R.A., Lal, T.J., & Harvey, S.B. (2018). Mindfulness-based resilience training in the workplace: Pilot study of the internet-based resilience@work (RAW) mindfulness program. Journal of Medical Internet Research, 20(9). 10.2196/10326 Kegelaers, J., & Sarkar, M. (2021). Psychological resilience in high-performance athletes: Elucidating some common myths and misconceptions. In A.E. Whitehead & J. Coady (Eds.), Myths of sports coaching. Sequoia Books. Kegelaers, J., & Wylleman, P. (2019). Exploring the Coach’s role in fostering resilience in elite athletes. Sport, Exercise, and Performance Psychology, 8(3), 239–254. 10.1037/spy0000151 Kegelaers, J., Wylleman, P., Bunigh, A., & Oudejans, R.R.D. (2021). A mixed methods evaluation of a pressure training intervention to develop resilience in female basketball players. Journal of Applied Sport Psychology, 33(2), 151–172. 10.1080/10413200.2019.1630864 Kegelaers, J., Wylleman, P., Defruyt, S., Praet, L., Stambulova, N., Torregrossa, M., Kenttä, G., & De Brandt, K. (2022). The mental health of student-athletes: A systematic scoping review. International Review of Sport and Exercise Psychology, 1–34. https://10.1080/1750984X.2022.2095657 Kegelaers, J., Wylleman, P., & Oudejans, R.R.D. (2020). A coach perspective on the use of planned disruptions in high-performance sports. Sport, Exercise, and Performance Psychology, 9(1), 29–44. 10.1037/spy0000167 Keyes, C.L.M., & Lopez, S.J. (2002). Toward a science of mental health: Positive directions in diagnosis and interventions. In C.R. Snyder & S.J. Lopez (Eds.), Handbook of positive psychology (pp. 45–59). New York, NY, US: Oxford University Press. Kilic, Ö., Carmody, S., Upmeijer, J., Kerkhoffs, G.M.M.J., Purcell, R., Rice, S., & Gouttebarge, V. (2021). Prevalence of mental health symptoms among male and female Australian professional footballers. BMJ Open Sport & Exercise Medicine, 7(3). 10.1136/bmjsem-2021-001043 Knowles, C., Shannon, S., Prentice, G., & Breslin, G. (2021). Comparing mental health of athletes and non-athletes as they emerge from a covid-19 pandemic lockdown. Frontiers in Sports and Active Living, 3. 10.3389/fspor.2021. 612532 Kuettel, A., & Larsen, C.H. (2020). Risk and protective factors for mental health in elite athletes: A scoping review. International Review of Sport and Exercise Psychology, 13(1), 231–265. 10.1080/1750984X.2019.1689574 Lee, J.S. (2013). Ego resilience scale development and validation of athletes. Korean Journal of Sport Psychology, 24(3), 65–86. Lee, K., Kang, S., & Kim, I. (2017). Relationships among stress, burnout, athletic identity, and athlete satisfaction in students at Korea’s physical education high schools: Validating differences between pathways according to ego resilience. Psychological Reports, 120(4), 585–608. 10.1177/0033294117698465 Lu, F.J.H., Lee, W.P., Chang, Y.K., Chou, C.C., Hsu, Y.W., Lin, J.H., & Gill, D.L. (2016). Interaction of athletes’ resilience and coaches’ social support on the stress-burnout relationship: A conjunctive moderation perspective. Psychology of Sport and Exercise, 22, 202–209. 10.1016/j.psychsport.2015.08.005

59

Christopher Bryan et al. Madsen, E.E., Krustrup, P., Larsen, C.H., Elbe, A.-M., Wikman, J.M., Ivarsson, A., & Lautenbach, F. (2021). Resilience as a protective factor for well-being and emotional stability in elite-level football players during the first wave of the COVID-19 pandemic. Science and Medicine in Football, 5(1), 62–69. 10.1080/24733938.2021.1959047 Martin-Krumm, C.P., Sarrazin, P.G., Peterson, C., & Famose, J.-P. (2003). Explanatory style and resilience after sports failure. Personality and Individual Differences, 35(7), 1685–1695. 10.1016/S0191-8869(02)00390-2 Masten, A.S., & Reed, M.-G. J. (2002). Resilience in development. In Handbook of positive psychology (pp. 74–88). New York, NY, US: Oxford University Press. Meggs, J., Golby, J., Mallett, C., Gucciardi, D., & Polman, R.C. (2016). The cortisol awakening response and resilience in elite swimmers. International Journal of Sports Medicine, 37(02), 169–174. 10.1055/s-0035-1559773 Moen, F., Hrozanova, M., Stiles, T., & Stenseng, F. (2019). Working alliance in the coach-athlete relationship and athlete burnout: The mediating role of athlete resilience. International Journal of Sport Psychology, 50. 10.7352/IJSP. 2019.50.338 Myall, K., Montero-Marin, J., & Kuyken, W. (2021). Anxiety and depression during covid-19 in elite rugby players: The role of mindfulness skills. International Journal of Environmental Research and Public Health, 18(22). 10.3390/ ijerph182211940 Nezhad, M.A.S., & Besharat, M.A. (2010). Relations of resilience and hardiness with sport achievement and mental health in a sample of athletes. Procedia - Social and Behavioral Sciences, 5(0), 757–763. 10.1016/j.sbspro.2010.07.180 Pierce, S., Martin, E., Rossetto, K., & O’Neil, L. (2020). Resilience for the rocky road: Lessons learned from an educational program for first year collegiate student-athletes. Journal of Sport Psychology in Action, 12(3), 167–180. 10.1080/21520704.2020.1822968 Poucher, Z.A., Tamminen, K.A., Kerr, G., & Cairney, J. (2021). A commentary on mental health research in elite sport. Journal of Applied Sport Psychology, 33(1), 60–82. 10.1080/10413200.2019.1668496 Raanes, E.F.W., Hrozanova, M., & Moen, F. (2019). Identifying unique contributions of the coach–athlete working alliance, psychological resilience and perceived stress on athlete burnout among Norwegian junior athletes. Sports, 7(9), 212. 10.3390/sports7090212 Raedeke, T.D., & Smith, A.L. (2001). Development and preliminary validation of an athlete burnout measure. Journal of Sport and Exercise Psychology, 23(4), 281–306. Reardon, C.L., Bindra, A., Blauwet, C., Budgett, R., Campriani, N., Currie, A., Gouttebarge, V., McDuff, D., Mountjoy, M., Purcell, R., Putukian, M., Rice, S., & Hainline, B. (2021). Mental health management of elite athletes during COVID-19: A narrative review and recommendations. British Journal of Sports Medicine, 55(11), 608. 10.1136/bjsports-2020-102884 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Richardson, G.E., Neiger, B.L., Jensen, S., & Kumpfer, K.L. (1990). The resiliency model. Health Education, 21(6), 33–39. 10.1080/00970050.1990.10614589 Robertson, I.T., Cooper, C.L., Sarkar, M., & Curran, T. (2015). Resilience training in the workplace from 2003 to 2014: A systematic review. Journal of Occupational and Organizational Psychology, 88(3), 533–562. 10.1111/joop.12120 Sarkar, M., & Fletcher, D. (2013). How should we measure psychological resilience in sport performers? Measurement in Physical Education and Exercise Science, 17(4), 264–280. 10.1080/1091367x.2013.805141 Sarkar, M., & Fletcher, D. (2014). Psychological resilience in sport performers: A review of stressors and protective factors. Journal of Sports Sciences, 32(15), 1419–1434. 10.1080/02640414.2014.901551 Sarkar, M., & Hilton, N.K. (2020). Psychological Resilience in Olympic medal–winning coaches: A longitudinal qualitative study. International Sport Coaching Journal, 7(2), 209–219. 10.1123/iscj.2019-0075 Schinke, R.J., & Jerome, W.C. (2002). Understanding and refining the resilience of elite athletes: An intervention strategy. Athletic Insight, 4(3), 1–13. Seery, M.D. (2011). Challenge or threat? Cardiovascular indexes of resilience and vulnerability to potential stress in humans. Neuroscience and Biobehavioral Reviews, 35(7), 1603- 1610. 10.1016/j.neubiorev.2011.03.00 Smith, B.W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The brief resilience scale: assessing the ability to bounce back. International Journal of Behavioural Medicine, 15, 194–200. 10.1080/107055 00802222972 Sorkkila, M., Tolvanen, A., Aunola, K., & Ryba, T.V. (2019). The role of resilience in student‐athletes’ sport and school burnout and dropout: A longitudinal person‐oriented study. Scandinavian Journal of Medicine & Science in Sports, 29(7), 1059–1067. 10.1111/sms.13422 Souter, G., Lewis, R., & Serrant, L. (2018). Men, mental health and elite sport: A narrative review. Sports Medicine Open, 4(1), 57. 10.1186/s40798-018-0175-7

60

A Narrative Review of the Literature Trigueros, R., Mercader, I., Gonzá lez-Bernal, J.J., Aguilar-Parra, J.M., Gonzá lez-Santos, J., Navarro-Gó mez, N., & Soto-Cá mara, R. (2020). The influence of the trainer’s social behaviors on the resilience, anxiety, stress, depression and eating habits of athletes. Nutrients, 12(8). https://www.mdpi.com/2072-6643/12/8/2405 Turner, M.J. (2016). Proposing a rational resilience credo for use with athletes. Journal of Sport Psychology in Action: Developing Resilience, 7(3), 170–181. 10.1080/21520704.2016.1236051 Ueno, Y., & Shimizu, Y. (2012). Development of psychological resilience scale for university athletes. The Japanese Journal of Health Psychology, 27(1), 20–34. 10.11560/jahp.27.1_20 Ueno, Y., & Suzuki, T. (2016). Longitudinal study on the relationship between resilience and burnout among Japanese athletes. Journal of Physical Education and Sport, 16(4), 1137–1141. 10.7752/jpes.2016.04182 Ungar, M. (2003). Qualitative contributions to resilience research. Qualitative Social Work, 2(1), 85–102. 10.1177/ 1473325003002001123 Veit, C.T., & Ware, J.E. (1983). The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology, 51(5), 730–742. 10.1037/0022-006X.51.5.730 Vella, S.A., Swann, C., Batterham, M., Boydell, K.M., Eckermann, S., Ferguson, H., Fogarty, A., Hurley, D., Liddle, S.K., Lonsdale, C., Miller, A., Noetel, M., Okely, A.D., Sanders, T., Schweickle, M.J., Telenta, J., & Deane, F.P. (2021). An intervention for mental health literacy and resilience in organized sports. Medicine and Science in Sports and Exercise, 53(1), 139–149. 10.1249/MSS.0000000000002433 Vigá rio, I., Serpa, S., & Rosado, A. (2009). Traduç ão e Adaptaç ão da Escala de Resiliê ncia Para a Populaç ão Portuguesa; Universidad de Té cnica de Lisboa, Facultade de Motricidad Humana; Universidade de Lisboa: Lisbon, Portugal. Vitali, F., Bortoli, L., Bertinato, L., Robazza, C., & Schena, F. (2015). Motivational climate, resilience, and burnout in youth sport. Sport Sciences for Health, 11(1), 103–108. 10.1007/s11332-014-0214-9 Wagstaff, C., Hings, R., Larner, R., & Fletcher, D. (2018). Psychological resilience’s moderation of the relationship between the frequency of organizational stressors and burnout in athletes and coaches. The Sport Psychologist, 32(3), 178. 10.1123/tsp.2016-0068 White, R.L., & Bennie, A. (2015). Resilience in youth sport: A qualitative investigation of gymnastics coach and athlete perceptions. International Journal of Sports Science and Coaching, 10(2-3), 379–393. 10.1260/1747-9541.10.2-3.379 Wu, D., Luo, Y., Ma, S., Zhang, W., & Huang, C.-J. (2021). Organizational stressors predict competitive trait anxiety and burnout in young athletes: Testing psychological resilience as a moderator. Current Psychology, 41, 8345–8353. https://doi.org/10.1007/s12144-021-01633-7 Yamada, K., Kawata, Y., Kamimura, A., & Hirosawa, M. (2017). The effect of unity in sport teams on athletes’ mental health: Investigating the mediating role of resilience. International Journal of Sport and Health Science, 15, 55–64. 10.5432/ijshs.201509 Zurita-Ortega , F., Chacón-Cuberos , R., ofre-Bolados C, C., Knox , E., & Muros, J.J. (2018, Nov 26). Relationship of resilience, anxiety and injuries in footballers: Structural equations analysis. PLoS One, 13(11), e0207860. doi: 10.1371/journal.pone.0207860. Erratum in: PLoS One. Zurita-Ortega, F., Chacó n-Cuberos, R., Cofre-Bolados, C., Knox, E., & Muros, J.J. (2019). Correction: Relationship of resilience, anxiety and injuries in footballers: Structural equations analysis. PloS One, 14(2), e0212083. doi: 10.1371/ journal.pone.0212. Erratum for: PLoS One.

61

5 THE SOCIAL NETWORK AND THE COACH J.D. DeFreese and Christine M. Habeeb

Introduction A growing body of literature on human health and well-being suggests the interactions athletes have with the people in their social network have a potential impact on their mental health outcomes (Reiss, 2001). For athletes, the relevant sport based social actors can be broad, including teammates, family members, friends, significant others, sport medicine and other support personnel, sport administrators and, of course, coaches. Individuals within the athlete social network, whether they know it or not, have an important impact on athlete mental health through a myriad of social interactions, support, conflict, and/or resources provided (Udry et al., 1997). Unfortunately, not all athlete interactions and perceptions of the social network are positive for athlete mental health. Negative social interactions including conflict, autonomy usurping behaviours, and a lack of social support/resource provision can contribute to the development of athlete mental health concerns (Newman & Roberts, 2013). Conversely, social actors in sport also have the potential to influence athlete help-seeking behaviours. Seeking help for a mental health concern is an important behaviour within athlete mental health self-care. Social actors can impact athletes’ willingness to seek help through identifying mental health problems, creating a relationship in which athletes’ feel comfortable disclosing mental health concerns, and referring athletes that may benefit from interaction with an appropriately trained mental health professional. Overall, the impact of social others on the mental health of athletes cannot be ignored and will be a primary focus of this chapter. Notably, we will begin with exploring how contemporary theories of athlete mental and physical health are relevant to the athlete social network.

Relevant Athlete Mental Health Frameworks Keyes’ (2002) Continuum of Mental Health and Illness Keyes (2002) describes mental health as a continuum ranging from poor mental health (i.e., marked distress or serious impairment), to emotional problems/concerns (i.e., moderate distress affecting functioning or mild distress involving temporary impairment), and ideally to good/optimal mental health (i.e., well-being, thriving, or resilience). A broad overview of this theory is beyond the scope of this chapter and can be found in Chapter 1 on mental health. We briefly review it, however, to specifically discuss the relevance of the sport-based social network to where an athlete falls on 62

DOI: 10.4324/9781003099345-7

The Social Network and the Coach

this continuum. The primary impact of social actors to an athlete’s place on the mental health continuum is through a myriad of social interactions that are supportive (or not) to good/optimal health. For example, providing social support to an athlete in the time of stress is promotive of optimal mental health. On the other hand, a lack of supportive behaviours and open communication will not necessarily cause poor mental health but can exacerbate symptoms of emotional problems/concerns when already present. Further, lack of support (or direct negative social interactions such as conflict) can certainly heighten athlete stress which has a relation with athlete mental health concerns such as depression, anxiety, and burnout. As a secondary consideration, the extent that members of the athlete’s social network understand the mental health continuum may also indirectly contribute to athlete mental health via influence on potential helping behaviours. Teammates, coaches, and/or other social network members may, for example, have misperceptions that mental health is a binary outcome (i.e., poor or good mental health only) and that poor mental health signifies a lack of “mental toughness,” a commonly described position by coaches in particular (DeFreese & Shannon, 2022). These misconceptions about athlete mental health indicate some social members’ inabilities to recognise moderate-to-poor mental health and to help an athlete progress toward optimal mental health via important helping behaviours such as identification, recognition, and/or referral to an appropriate mental health provider. Notably, using a positive psychology perspective (Seligman & Csikszentmihalyi, 2000) any athlete can benefit from sport psychology and/or clinical mental health services, not just those experiencing a diagnosable poor mental health outcome. Thus, the social network is relevant to all points on the mental health continuum regardless of whether a specific negative outcome is present.

Neurobiopsychosocial Model A second relevant model to understand how the athlete social network relates to athlete mental (and physical) health is the biopsychosocial model of patient care for sport injury and rehabilitation (BorrellCarrio, 2004; Engel, 1980). This model posits a complex understanding of athlete mental health with a focus on the interplay between mental and physical experiences for the athlete/patient (DeFreese, 2017). Of particular relevance to this chapter is the model’s focus on the impact of psychosocial factors on all phases of injury occurrence, recovery, and rehabilitation. Psychosocial factors, including social support, have a central position in the model with potential for contributions to initial injury response, intermediate, and longer-term injury rehabilitation outcomes. The ultimate rehabilitation outcomes of interest to this model include mental (i.e., satisfaction with treatment), physical (i.e., functional performance), and dual mental-physical outcomes (i.e., quality of life, readiness to return to sport). Social support, therefore, represents a key variable in the overall health and well-being of athletes, both injured and healthy, with implications for mental health outcomes central to this model and beyond. Depression, anxiety, and burnout represent additional outcomes relevant to treatment satisfaction, readiness to return to sport, and, ultimately, performance. Moreover, calls (i.e., McCrea et al., 2015) for expansion of the biopsychosocial model to include neurological outcomes (i.e., neurobiopsychosocial model) have added further complexity to this social impact of athlete injury and recovery. Overall, athlete perceptions of social support within sport have important implications for athlete mental health outcomes.

Relevant Athlete Mental Health Outcomes Athletes, like the general population, may experience a variety of mental health challenges during their athletic careers. Poor mental health in athletes can commonly come in the forms of depression, anxiety, burnout, eating disorders, substance abuse, mania/bipolar, and suicidal ideation/self-injury. For example, Larson et al. (1996) found that 71% of surveyed athletic trainers reported their athletes commonly dealt with anxiety and 53% reported that they have athletes that experience significant emotional distress. We discuss 63

J.D. DeFreese and Christine M. Habeeb

the most common mental health topics in sport, depression, anxiety, and burnout, because it is important to understand the specific mental health issues the social network will likely encounter and impact.

Depression Depression is a mental health disorder characterised by depressed mood and related symptoms including sadness, irritability, feelings of emptiness, loneliness, hopelessness, fatigue, changes in appetite/sleep, and/or social withdrawal (American Psychiatric Association [APA], 2013). In more extreme cases, depression can be related to suicidal ideations (Kroenke et al., 2001). The prevalence of depression is approximately ~5% in adult men and ~8% in adult women in the United States with rates varying across age groups (National Institute of Mental Health, 2019). Studies have shown varying rates of depression in athletes with rates approximating 25% in active athlete samples (Armstrong, 2007; National Collegiate Athletic Association [NCAA], 2016; Yang et al., 2007). However, rates of depression in athletes may not actually be higher than the general population. For example, one systematic review and meta-analysis in American collegiate athletes found that student-athletes were less likely to experience depression than their non-athlete peers (Armstrong et al., 2015). Notably, variation in measurement across studies is an important limitation of comparisons across such work, which is discussed in more detail in Chapter 6 on depression in athletes. That said, it is clear that depression is relevant to athletes at levels similar (potentially higher or lower) than general population rates in the United States and abroad. Certainly, its importance to athlete performance, well-being, and mental and physical health should not be ignored when considering important mental health outcomes to sport and their relevance to the athlete social network. Moreover, its comorbidity with anxiety is another important clinical mental health consideration.

Anxiety Anxiety is characterised by excessive and/or unrealistic worry about everyday tasks or events (APA, 2013). The prevalence of anxiety is approximately ~14% in adult men and 23% in adult women in the United States with rates varying across age groups (National Alliance on Mental Illness, 2019). Studies have shown varying rates of anxiety in athletes with rates as high as 40% in athlete samples (NCAA, 2016). Notably, measurement variation is especially relevant to the study of anxiety in sport as some studies focus on clinical symptoms, whereas others focus on performance-specific anxiety or anxiety otherwise not defined as a clinical mental health concern. Similar to that of depression, and potentially more so based on published rates and the performance context of sport, anxiety is an extremely important mental health concern to understand and prevent, if possible, for athletes across sport and competitive levels (see also Chapter 11 and 15). Its relevance to performance, training, and uncertain context-specific occurrences such as injury and rehabilitation further heighten its salience both clinically and for performance outcomes in sport (i.e., non-clinical). The social environment of sport further lends itself to understand this specific mental health outcome.

Burnout Athlete burnout is a cognitive-affective syndrome characterised by dimensions (i.e., symptoms) of emotional and physical exhaustion, reduced sense of accomplishment, and sport devaluation (Raedeke, 1997). Burnout is not a clinically diagnostic mental health concern for athletes; however, it has been shown to be positively associated with both anxiety and depression symptoms in athletes and has clear implications for performance and athlete well-being (Goodger et al., 2007). Though hampered by sampling issues, research on athlete burnout suggests the prevalence could be as high as 1 in 10 in athlete populations (Gustafsson et al., 2017). That said, any degree of burnout-related perceptions is conceptualised as maladaptive for an individual 64

The Social Network and the Coach

athlete, so even moderate levels of burnout are important to consider as a maladaptive athlete outcome (see Chapter 12 for further information). Regardless of prevalence, research on athlete burnout has highlighted its clear association with athlete social perceptions including negative associations with various social support types (DeFreese & Smith, 2013, 2014) and positive associations with negative social perceptions (e.g., Pacewicz & Smith, 2022; Smith et al., 2010). Additionally, a secondary social variable of autonomy (as considered within self-determination theory, Deci & Ryan, 2008) has also been shown to be consistently negatively associated with burnout in both cross-sectional and longitudinal research designs (e.g., BarczaRenner et al., 2016). Cumulatively, athlete burnout continues to grow in interest by researchers, clinicians, and athletes/coaches alike and represents an important sub-clinical mental health outcome to continue to consider within the socially driven environment of competitive sport.

Relevance of the Athlete’s Social Network, Including the Coach, to the Athlete’s Mental Health While mental health factors arise within individual athletes, these factors are also impacted by social influences that stem from key social actors and the sport environment/culture (Henriksen et al., 2020; Moreland et al., 2018). As discussed, the social network provides both positive and negative social interactions through specific mechanisms (i.e., identification, helping, referral) that can act as barriers or facilitators for athletes obtaining optimal mental health.

Key Sport-Based Social Actors The sport-based social network of athletes is vast and includes a long list of social actors that can impact not only athlete performance, but also athlete mental health and well-being outcomes. The social network of athletes includes head and assistant coaches, teammates, sport medicine staff (e.g., athletic trainers/physios), psychologists (sport/clinical/counselling), and sport managers/administrators (e.g., director of operations). Beyond this sport-specific focus, parents, family members, non-teammate friends, and significant others (e.g., religious leaders) also represent important individuals who can impact the athlete’s mental health. Ultimately, the neurobiopsychosocial model (Borrell-Carrio, 2004; Engel, 1980) and mental health continuum (Keyes, 2002) are both conceptual perspectives that emphasise the importance of relevant social actors to personal health and well-being. Moreover, social neuroscience perspectives further suggest the importance of one’s social network to mental health outcomes such as stress (Adolphs, 2010). Consideration of athletes’ relationships to the members of their social network requires consideration of any hierarchy, quantity/quality of interaction, and trust within the relationship. The hierarchy between a coach and athlete, for example, can lead to athletes fearing how their coach will react to disclosing a mental health problem (Bissett & Tamminen, 2022; Watson, 2005). Athletes’ fears of losing status with a coach and being stigmatised for seeking help are one aspect that keeps athletes’ mental health concerns unresolved (Delenardo & Terrion, 2014). The interaction athletes have with those in their social network can also vary in quantity and quality and this can impact who in the network has more or less social influence. The coach–athlete relationship, for example, is likely high in quantity of interaction due to the amount of time spent together in training. The coach–athlete relationship can vary, however, in quality of interaction as some athletes feel more connected to their coaches than others (Habeeb et al., 2022). On the contrary, most elite athletes have high-quality relationships with their close family and friends but are limited in the amount of time they spend together due to sport commitments. Teammates, as a final example, likely are high in both quality and quantity of interaction because of the shared stressors and time demands on and off the field. Above all, the trust an athlete has in others, to keep issues confidential, for example, will determine how athletes connect with certain members of their social network and how their relationships with 65

J.D. DeFreese and Christine M. Habeeb

others can change over time. A coach or teammate having breached confidentiality, a type of mistrust, is the greatest barrier to an athlete seeking help in the future (Bissett & Tamminen, 2022). Trust in a coach to prioritise athletes’ best interests and keep issues confidential is particularly relevant for athletes because of their high dependence on coaches to perform (Habeeb et al., 2017). Relationships associated with more mutual dependence, high quantity and quality of interaction, and established trust are the strongest social assets to positively impact athlete mental health.

Environmental and Training Influences on the Athlete’s Social Perceptions Sport Culture and Stigma The elements of elite sport that normalise the denial of physical pain likely encourage athletes to ignore mental health problems, too. The sport ethic, as described by Coakley (2015) refers to a set of criteria that sport participants use to define what it means to be a “real” athlete. These criteria indicate that being a real athlete involves: making sacrifices for the game; striving for distinction; accepting risks and playing through pain; and refusing to accept limits in the pursuit of possibilities. Generally, these criteria glorify the “‘mentally tough’” athlete and can impact athlete welfare when adhered to too strongly. Many athletes and the people in their social network believe that poor mental health contradicts the perceived ideal of “mental toughness”, and therefore mental health problems have no place in sport (Gucciardi et al., 2017). For many athletes, experiencing a mental health problem is perceived as a sign of weakness, which is not well received in the social environment of sport. Coaches and support staff can be particularly important to minimizing the association between poor mental health and weakness. Their role is important because the more that athletes feel pressure to conform to the sport ethic by their social network, the more likely they will ignore a mental health problem. Habeeb et al. (2022) found that the businesslike culture and toughness values within sport are key reasons athletes will not seek help, but the connection athletes have with their coach can have a far greater impact on whether or not they will seek help. The sport ethic and the real or perceived social pressure to conform to this ethic can be a deterrent to athlete helpseeking, too. Informed by sport culture, stigma represents another potential deterrent to mental health disclosure and help-seeking for athletes. Athletes’ concerns over being stigmatised for having a mental health problem may be grounded in a fear of losing celebrity status, playing time, and being devalued by others (Brewer et al., 1998; Linder et al., 1991; Watson, 2005). Athletes report fears of being stigmatised by teammates, coaches, and fans because admitting to having poor mental health may be viewed as a sign of weakness. Examples of death threats on social media towards American college athletes indicate the societal stigmas are strongly linked in how fans interact with athletes (MacPherson & Kerr, 2021). Unfortunately, athletes that perceive greater levels of stigma from others are more likely to have greater self-stigma (Bird et al., 2018). This means that the attitudes and views expressed by an athletes’ social network have implications for how an athlete views his or her own mental health. That is, perceived stigma from others can be internalised by athletes leading to additional problems with self-esteem and less willingness to seek help (Delenardo & Terrion, 2014). Some evidence indicates that a coach’s stigma towards help-seeking for a mental health problem outrank teammates, family members, and friends (Gulliver et al., 2012). It seems that athletes pay particularly close attention to how their coaches communicate about mental health, which can impact where athletes fall on the mental health continuum.

Social Support and Negative Social Interactions With the environmental control and impact directed within sport, coaches represent a highly influential social actor of interest to the mental health outcomes of athletes. Coaches are viewed as both a source and 66

The Social Network and the Coach

barrier to optimizing athlete mental health. This is because they create high performance demands and pressure, but within the sporting environment, coaches have a clear pathway to influence athlete levels of psychological stress (McGee & DeFreese, 2019). Though stress is not a cause of mental health concerns, it has the potential to exacerbate symptoms and has been shown to be positively associated with the development of athlete burnout (DeFreese & Shannon, 2022). Stress and coping theory would support this supposition, meanwhile the myriad of ways that coaches can cause, mitigate, and or teach athletes ways to cope with sport-based stressors makes this a clear mechanism for a mental health impact. Second, coaches represent a key figure that can impact athlete’s own social perceptions including social support and negative social interactions. Coaches may directly impact athlete social support by the provision of support themselves as well as in the environmental/sport culture they create in sport, which may promote/ facilitate social support from teammates and other social actors in sport. Moreover, athletes may develop negative social interactions in sport as a result from interactions with the coach. In a converse relationship with mental health outcomes, negative social interactions may exacerbate mental health outcomes including anxiety, depression, and burnout. Social support, or positive social interactions intended to induce positive outcomes, have an important impact on athlete mental health outcomes as described in the mental health continuum and the neurobiopsychosocial theoretical models. Social support represents a key buffer against maladaptive athlete mental health outcomes, including burnout (e.g., DeFreese & Smith, 2014). Social support perceptions can be examined from typologies, including perceived support availability, received support, and social support satisfaction (Bianco & Eklund, 2001). Perceived support involves individual perceptions of whether support is available when needed, whereas received support involves the individual whether support has been tangibly been provided when needed. Finally, social support satisfaction involves perceptions of overall satisfaction with support from within the context of relevance (i.e., sport environment). All the aforementioned social support types have been previously examined in athlete populations with a primary focus on their association with athlete burnout (DeFreese & Smith, 2013). However, research both in and out of sport suggests the importance of social support as a negative social determinant of mental health concerns, including depression and anxiety (Ioannou et al., 2019; Lavallée & Flint, 1996). Beyond social support, negative social interactions and other social perceptions variables (e.g., conflict, autonomy support) represent other mechanisms by which social perceptions impact athlete mental health outcomes. For example, social conflict has been found to be associated with burnout in an adolescent athlete sample (Smith et al., 2010). That said, continued work is needed to further elucidate the direct impact of negative sport-based social interactions and their short- and long-term impacts on athlete mental health outcomes. Such data would provide the appropriate empirical knowledge to support long held suppositions, based on anecdotal reports and cross-sectional survey work, that negative social interaction can negatively impact athlete mental health outcomes. Altogether, coaches have a prominent influence on sport culture including how social actors interact with one another, a key mechanism by which they may influence athlete mental health. Ultimately, the understanding of and measurement of positive and negative athlete social perceptions represents a critical present and future social determinant inflection point in tracking, diagnosing, and preventing maladaptive athlete mental health outcomes.

Mechanisms for Social Network Impact on Athlete Mental Health Identification Mental health stigma represents a prominent concern in sport that can negatively impact athlete mental health outcomes and athletes’ and other social actors’ (coaching staff, teammates, parents, etc.) mental health knowledge (Reardon & Factor, 2010). Specifically, views that mental health is a taboo topic can make it more difficult to identify athletes that may be experiencing poor mental health or moderate 67

J.D. DeFreese and Christine M. Habeeb

distress. Coaches, for example, may not be attuned to the social cues that might help identify depression or anxiety. At the same time athletes might, to a greater extent, suppress social cues about feeling hopeless or fatigued if they know that their coach has a personal stigma about mental health. Both aspects, a coach’s inability to identify poor mental health and an athlete’s suppression of such cues, lend themselves to increased mental health problems in athletes. Research has shown mental health stigma can be ingrained within sport culture as well as that male athletes and athletes of colour may have potential to perceive heightened mental health stigma within sport (Bauman, 2016; Martin et al., 1997). Individual differences among athletes, such as gender and race/ethnicity, are important to consider because it can directly impact how athletes interact with their social network, especially for interactions with those in positions of power (e.g., Simiyu, 2012). Importantly, coaches, teammates, support staff, and administrators each have the potential for direct influence on stigma promotion (or deletion) and this represents a key mechanism (i.e., identification) by which the social network may influence athlete mental health outcomes.

Help-Seeking Behaviours Sport-specific mental health stigma, perpetuated by the work ethic and toughness culture of sport, can be particularly damaging to athletes in terms of reporting mental illness versus keeping it to oneself (Habeeb et al., 2022). Often for fear of looking “weak” to others in sport, athletes that believe they require professional help will not always seek that help (Drew & Matthews, 2019). Help-seeking refers to actively seeking help from the social network or a mental health clinician with the goal to gain advice, information, understanding, treatment, and/or support for a mental health problem (Rickwood et al., 2005). Help-seeking behaviours are also related to attitudes toward/intention to use available athlete mental health resources and the actual utilization of such resources. The athlete’s social network, including the coach, may facilitate positive athlete mental health outcomes and help-seeking through how they interact with athletes. According to Habeeb et al. (2022), athletes are more likely to seek help when they feel understood and cared about by people in positions of power. Specifically, coaches’ verbal and nonverbal behaviour towards the athlete and demeanour with other athletes indicate authentic care about athletes’ well-being, resulting in a trusting relationship that lends itself to help-seeking. Unfortunately, some coaches will model strategies and use communication styles that heighten athlete psychological stress, promote negative social interactions, and directly or indirectly promote a team culture that stigmatises discussion, identification, and resource utilization for athlete mental health concerns. These negative behaviours have the potential to contribute to the development of athlete anxiety, depression, and/ or burnout symptoms by discouraging athlete help-seeking behaviours.

Referral to Mental Health Services/Sources Finally, beyond their potential contribution to athlete mental health symptom development, coaches represent a key bystander/gatekeeper with the opportunity to directly refer athletes at all levels to specific mental health services/resources (Gulliver et al., 2012). Specifically, with the amount of time coaches spend with athletes, they are in a prominent position to notice potential signs/symptoms of mental health concerns, have engaging discussions, and direct athletes to the appropriate team or community resources to facilitate mental health treatment (Bissett & Tamminen, 2022). Thus, coaches have opportunities to champion the mental health of their athletes and make key decisions and implement important strategies that can promote athlete mental health and well-being for those currently experiencing symptoms and/or proactively trying to learn skills to prevent symptom occurrence. This unique coach–athlete relationship, therefore, has the opportunity to be leveraged as a key social resource to promote athlete mental health. 68

The Social Network and the Coach

Coaches’ Mental Health and Its Potential Influence on Athletes They Serve Modelling represents another mechanism whereby athletes may understand that well-being is adaptive for health and performance in sport. While we often think of modelling from coaches as the mechanism to promote physical skill learning, it also has great potential to provide evidence to athletes regarding the importance of stress management, self-care, and seeking help for mental health concerns (i.e., depression, anxiety, burnout) when needed. Similar to athletes, coaches experience personal, performance, and organizational stressors. These include intensive time demands, job insecurity, scrutiny from the media, selfdoubt, and pressure to produce a winning performance from their athletes (Olusoga et al., 2009). Unfortunately, these stressors have the potential to impact coach mental health outcomes. Studies have noted depression, anxiety, and burnout as important outcomes to coach populations (Bentzen et al., 2016; Kegelaers et al., 2021). Two recent studies have identified the prevalence of mental health concerns in elitelevel coaches. Kim et al. (2020) found that 14% of New Zealand coaches experienced at least moderate levels of depressive symptoms. Perhaps more alarming are the rates reported by Kegelaers et al. (2021). They found that 39.5% of national head and assistant coaches (from the Netherlands and Flanders) experienced symptoms of depression and/or anxiety, while about a quarter experienced disrupted sleep. Interestingly, while coaches reported they perceived performance stressors to have the most impact on their mental health (i.e., lack of athlete commitment, poor performance, and poor competition preparation), organizational factors were what uniquely contributed to levels of depression/anxiety within quantitative analyses. In the specific case of burnout, researchers have suggested the possibility that coach burnout may be associated with similar burnout outcomes in athletes (Price & Weiss, 2000). Moreover, coaches have meaningful insight into athlete burnout development (Raedeke et al., 2002). Accordingly, potential modelling and/or social contagion processes represent important mechanisms to support understanding of mental health outcomes in both coach and athlete populations. These mechanisms offer an important future research-to-practice area for study.

Review of Relevant Social Network Research The aforementioned concepts, relevant to how the athlete social network impacts mental health in both positive and negative ways, stand on a foundation of empirical evidence. We have alluded to this important work in our conceptual and practical discussion to this point. However, it is also important to review the relevant literature more directly in these areas that inform this chapter. The research on salient chapter topics is reviewed subsequently.

Coach–Athlete Relationship Conceptualizations of the coach–athlete relationship have existed since early sport science research. However, Jowett and colleagues (e.g., Jowett & Shanmagum, 2016) have largely been credited with defining this relationship for study as well as linking it to athlete outcomes including those of psychological health (McGee & DeFreese, 2019). More specifically, the coach–athlete relationship is defined as the situation in which coaches’ and athletes’ emotions, thoughts, and behaviours are mutually and casually connected (Jowett & Ntoumanis, 2004). This includes specific dimensions of closeness (i.e., how the coach and athlete feel emotionally close to each other), commitment (i.e., individuals’ intentions to maintain their relationship over time), and complementarity (i.e., extant that coaches and athletes work cooperatively). A litany of research in this area has confirmed the importance of this relationship to multiple athlete outcomes including those of mental health and well-being (Jowett & Shanmagum, 2016). Further, some research has highlighted factors that contribute to the quality of the coach–athlete relationship. Stephen et al. (2022), for example, found that performance-related factors of athlete and coach 69

J.D. DeFreese and Christine M. Habeeb

efficacy (and the congruence of these) predict perceptions of the coach–athlete relationship, potentially linking performance related factors to mental health concerns via the coach–athlete relationship. Overall, this body of literature suggests a clear need to examine and potentially intervene upon this relationship as a means to influence athlete outcomes beyond performance including anxiety, depression, burnout, and help-seeking behaviours that may deter and/or treat these mental health concerns.

Coach’s Impact on the Athlete’s Mental Health Outcomes The relationship between coach and athlete is, at least for some athletes, a primary outlet for seeking help for moderate distress or poor mental health. Maniar et al. (2001) reported that athletes prefer seeking support from coaches compared to mental health professionals, family, and friends. On the other hand, Bird et al. (2018) concluded that athletes prefer to seek help from personal relationships (e.g., friends, intimate partners) compared to other social agents (e.g., coaches, psychologists). The mix of evidence indicates that the coach–athlete dynamic is important and potentially complex. Altogether, coaches, as well as other sport-based social actors, have the potential to be both barriers to as well as facilitators of prevention, recognition, and referral relative to athlete mental health outcomes. These dualities of potential positive and negative social network impact are reviewed below. The importance of this coach–athlete relationship certainly suggests its opportunity to positively influence athlete mental health knowledge, recognition, and resource utilization. A supportive and nurturing coach–athlete relationship characterised by heightened levels of closeness, commitment, and complementarity has potential to positively impact athletes’ emotions, attitudes (i.e., thoughts), and behaviours (i.e., help-seeking resource utilization, communication with providers). Such a constellation of psychosocial factors linked to this relationship could represent a true facilitator of adaptive athlete mental health outcomes. Alternatively, low levels on these coach–athlete relationship dimensions (or potentially on some dimensions individually) have the potential to represent a true barrier to athletes feeling comfortable seeking mental health education, disclosing symptoms where warranted, and seeking care for mental health concerns (e.g., anxiety, depression, burnout). To date, literature supporting this idea has largely been limited to athlete burnout (e.g., McGee & DeFreese, 2019). However, this represents a key area for potential research-to-practice implications because, despite not explicitly referring to closeness, commitment, or complementarity, there is empirical support that coaches that display authentic concern for their athletes’ well-being are better able to connect to athletes for non-performance issues (e.g., Habeeb et al., 2022). For example, athletes who have lowered perceptions of these coach–athlete relationship facets could ultimately feel less comfortable discussing mental health within the sport environment. Ultimately, it may be through this coach–athlete relationship that important, positive change in athlete culture surround mental health can be made. Ultimately, coaches are often viewed as gatekeepers to support services because they can provide service information, encourage utilization, and relieve time pressures, which all play a vital role in whether an athlete seeks help (Gulliver et al., 2012). Further, the attitudes held by coaches will impact athletes’ likelihood to seek help (Moreland et al., 2018; Picco et al., 2016). Accordingly, coaches are the strongest social asset for encouraging help-seeking because beliefs about a coach’s attitude towards help-seeking outrank friends, teammates, and family (Gulliver et al., 2012). Moreover, their overall potential impact on the mental health of the athletes they serve cannot be understated.

Teammates’ Impact on the Athlete’s Mental Health Outcomes Coaches are far from the only social actors that can positively impact or impede upon athlete mental health behaviours. Teammates represent an impactful, peer-oriented (both in age and power structure) relationship. The importance of teammate relationships to athlete mental health has become more evident in recent 70

The Social Network and the Coach

studies reporting that 58–82% of athletes report they are likely to seek help from a teammate compared to only 37–50% that are likely to seek help from their head coach (Bird et al., 2018; Habeeb et al., 2022). It appears that teammates are becoming primary help givers in the sport environment and this informal helping is a key relationship to foster optimal athlete mental health. Similar to coaches, teammates have the opportunity to create a facilitative environment for understanding, disclosure, and resource utilization relative to athlete mental health. Additionally, the difference in the power dynamic between coaches and teammates may be such that athletes feel more comfortable disclosing issues of mental health with teammates and being more confident in providing appropriate help to one another (Habeeb et al., 2017; Habeeb, 2020). This comfort, however, can be easily undermined due to trust and stigma regarding other athletes (Gulliver et al., 2012; Rickwood et al., 2007). Accordingly, clinicians and researchers alike should also consider this relationship as a potential mental health informant and key gatekeeper relative to athlete information. Importantly, the relationships amongst teammates can also be influenced by the environment created by the coach (Stuntz & Spearance, 2007). That is, an ego-involving climate that fosters competition among athletes may be susceptible to teammate rivalry and poor relationships and, ultimately, adversely impact athlete mental health outcomes.

Total Network Impact on the Athlete’s Mental Health Outcomes The sport-based social network may be best understood by examining the complex interplay among multiple, potential mental health gatekeepers (e.g., coaches, athletes, parents, and significant others) when attempting to promote a culture of holistic athlete care, including considering mental health in the same vein as one’s physical health. Habeeb et al. (2022) found that when athletes perceived their sport culture required appearing tough, athletes were more likely to seek help from individuals outside the sport network. They argued that this is a positive finding that athletes will seek help from other members of their social network if they do not feel comfortable bringing mental health concerns to coaches’, teammates’, or managers’ attention because it offers a comfortable relationship for initial help. Relatedly, research on social support during injury and rehabilitation indicates that the number of social actors and satisfaction with those actors changes over time (e.g., Yang et al., 2010). Because athletes will depend on different members of their social network for different needs and at different times there may exist a need-social network member match approach to better utilise the total social network. Compatibility between athlete and a social network member is based on the individual tendencies, personalities, and preferences of both the athlete and the other member, as well as a relationship component that encompasses how well the individual components coexist and coincide (Habeeb et al., 2017). At least with coaches, the relational component accounts for a significant amount of athlete satisfaction in social support (Coussens et al., 2015). This supposition merits further empirical investigation relevant to athlete mental health outcomes and other members of the social network. Such innovative hypotheses, once confirmed by carefully considered research studies, also have potential to inform mental health interventions designed specifically for athletes.

Practical Considerations The contributions to scientific literature have advanced knowledge and understanding of how the social network relates to athlete mental health. In this section, we outline implications for the applied field and examples of where practical considerations are currently being utilised.

Social-Actor-Focused Mental Health Interventions An athlete’s relationship with their coach, as well as other sport-based relationships (i.e., teammates) represent key targets for various mental health interventions. First, these interventions could solely target 71

J.D. DeFreese and Christine M. Habeeb

the mental health knowledge of coaches, with the intent that if knowledge is increased then adaptive communication and help-seeking behaviours will follow. Second, interventions could move beyond knowledge and focus on self-efficacy or other mediating variables (e.g., intention; Ajzen, 1991) known to potentially lead to adaptive behavioural change. Finally, gatekeeper interventions which target key informants have been shown to be effective strategies for direct mental health behavioural change outside of sport. Examples of relevant interventions include Mental Health First Aid (Kitchener & Jorm, 2002) and QPR (Question, Persuade, Refer; Burnette et al., 2015), which specifically targets suicide. These interventions, largely showing success in non-sport settings to this point, merit consideration for adaptation to aid sport-based social actors such as coaches, teammates, parents, and sport medicine personnel in effectively identifying, communicating with, and acting relative to athlete mental health concerns where warranted. Benefits of such an approach involve taking some of the burden of symptom disclosure and care of off the impacted athlete initially as well as creating an overall supportive (of mental health promotion and resource utilization) sport culture.

Social Network “Awareness” Trainings for the Athlete’s Mental Health Promoting a duality of high-performance expectations and high concerns for health and well-being may occur intuitively for some coaches, but not necessarily for others. As with individual athletes, education and awareness of what is maladaptive (i.e., depression, anxiety, burnout) and adaptive (i.e., resilience, well-being) varies across individual coaches and other athlete social network members. Accordingly, building on the central relationship between an athlete and a coach, mental health and well-being training raises awareness and improves knowledge that may represent fruitful avenues for future applied sport psychology practice. Notably, a focus on depression, anxiety, burnout, and other mental health concerns could be important. That said, as has become common within organizational psychology (Robertson et al., 2015), a focus of such applied work on positive outcomes of the mental health continuum (e.g., resilience) could also be beneficial. Too often the burden of recognizing and initiating mental health care, whether reactive or proactive, is placed on the individual or the sport medicine staff. Such applied interventions with coaches may serve as needed environmental buoys to help those athletes struggling with mental health concerns or interested in proactively promoting adaptive mental health outcomes before they get to the point of clear distress and/or diagnostic concern. Rice et al. (2016) argued athletes are sensitive to whether their sport organization is supportive of addressing mental health problems. This view has led some researchers to focus on providing coaches and support staff with the tools to better address mental health. Sebbens et al. (2016), for example, found evidence that a brief in-person workshop increased support staff’s knowledge and confidence to help an athlete who may be experiencing signs and symptoms of a mental health problem. Similarly, Kroshus et al. (2019) found that completion of a NCAA online module increased coaches’ mental health knowledge, reduced their stigma, and increased their intentions to communicate and respond appropriately with their athletes about mental health problems. Educating sport coaches are important steps, yet the extent to which educational training impacts athletes’ impressions of the sport culture, and specifically a helpseeking culture, requires further investigation.

Mental Health Intervention Impacting Knowledge and Behaviours Knowledge certainly represents an important target variable for any coach-driven, athlete mental health training. A change in knowledge, however, does not always lead to a change in health action as evidenced within many physical and mental health behaviours (e.g., Register-Mihalik et al., 2013). Therefore, there exists an additional opportunity to design and carefully evaluate coach-based mental healthcare interventions which target specific behaviours such as direct communication with athletes on mental health 72

The Social Network and the Coach

issues, knowledge of how to enact local sport medicine and/or respective mental health resources, as well as specific referral behaviours. A proximal variable worth targeting in such work may also be the selfefficacy of the coach to engage in such behaviours and other-efficacy athletes have in their coach being helpful in such efforts relative to their mental health (Habeeb, 2020). Eventually, sport psychology practitioners may be well placed to initiate such interventions with coaches via a variety of training modalities. Modalities could include one-on-one or group-based psychoeducation models and/or Internet- or web-based applications suitable for individual study (e.g., Van Raalte et al., 2015), as with many human resource trainings in many fields. Models for such training are beginning to develop, including some of our own work, and represent great opportunities to move the field forward relative to mental health practice for athletes.

Integration of Social Actors within a Holistic Athlete Support Network Coaches are not the only potential intervention target from within the athlete social network worth exploring to promote athlete mental health. One of the most exciting things about a deeper understanding of athlete social networks is the myriad of ways in which members of these social networks may be leveraged in meaningful ways to improve athlete mental health and well-being. Such work has potentially important short- and long-term implications for holistic health care and social integration. Given that impactful members of the sport-based social network have a clear impact on athlete affect, cognition, and behaviours, it is plausible that stronger integration of members of this support network has potential to improve recognition and communication of athlete mental health and referrals to appropriate healthcare providers (i.e., sport medicine staff, team physician), including clinical sport psychology professionals. Understanding and communicating with their athletes is the hallmark of a strong coach, and the communication skills within this important social relationship have great potential to continue to improve athlete mental health even with demanding training and participation environments. Said another way, it is entirely possible for a coach (and other social actors such as parents and teammates) to demand high levels of training and performance from an athlete but still be extremely cognizant of their mental (and physical) health in the process. In the search for finding ways to cultivate a help-seeking culture it is important to recognise that athletes have relationships inside and outside of their sport. Many of these relationships may serve an important role in the likelihood an athlete seeks help. Generally, young people tend to prefer to seek help from informal sources (e.g., friends and family) before relying on formal help-seeking outlets (e.g., teachers, clergy, and mental health professionals; Boldero & Fallon, 1995). Drew and Matthews (2019) found that 78% of athletes reported speaking about their personal problems with someone informally, making it clear that social agents such as friends and family provide an important support network for athletes. Athletes who do not engage in informal help-seeking from friends and family, however, are more likely to report higher levels of depression symptoms (Delenardo & Terrion, 2014). It is important, as a consequence, to understand what factors contribute to athletes’ help-seeking from the various sources including sport coaches, administrators, other athletes, professional psychologists, and personal relationships.

Future Research Directions A variety of research directions, including the evaluation of aforementioned intervention types, represent key next steps in the research on athlete mental health within the sport-based social network. Extension into longitudinal research that incorporates evaluation of mental health interventions and more precise tracking of the social network. Moreover, such work may be aided by contemporary data analytic approaches facilitating the answering of complex and innovative research questions in this important realm of inquiry. 73

J.D. DeFreese and Christine M. Habeeb

Longitudinal Tracking of Social Network Impact on Athlete Mental Health In conjunction with the important applied efforts described above, there also exist some specific future research directions considering the sport-based social network including the coach which we feel will positively impact the landscape of athlete mental health. First, prospective, longitudinal monitoring of athlete mental health outcomes (e.g., depression, anxiety, burnout, well-being) are necessary to best understand the progression of athlete mental health outcomes when considering salient environmental moderators. Such moderators could include training load, seasonal considerations (e.g., offseason, inseason, post-season), social factors (e.g., coaching practices, sport-based social support), and individual athlete factors/traits (i.e., trait affect, personality, perfectionism, etc.). Ultimately, good empirical progression has been made in understanding the development of athlete mental health symptomology over time. However, more systematic longitudinal research protocols are necessary in more diverse athlete samples. For example, a large cohort study that follows amateur, semi-professional (i.e., American collegiate), and professional athletes over large periods of career time could be instrumental in not only understanding athlete mental health outcome progression within seasons but also across seasons and, ultimately, the life span of an athlete into and beyond career transition.

Assessment of Mental Health Interventions A secondary future research direction with a potential lasting impact is to carefully evaluate interventions designed to positively impact athlete mental health. As noted in the previous section, a variety of educational and or behavioural change interventions could be useful to improve knowledge, help-seeking behaviours, supportive communication actions, and/or self-care behaviours for athletes themselves as well as key social agents of change (e.g., coaches, teammates, parents). Such interventions necessitate randomised (preferred) or quasi-randomised (often useful in applied research) research designs to isolate potential intervention change effects from those not receiving the protocol. Despite this being relatively common in many settings, such designs are not common in mental health literacy or behavioural interventions in sport science. Additionally, the use of appropriate theoretical/conceptual frameworks to guide such work (i.e., theory of planned behaviour, self-efficacy theory, relevant motivational theories; Ajzen, 1991; Bandura, 2001; Deci & Ryan, 2014) is key to choosing and evaluating focal variables to assess intervention effectiveness via targeted psychological outcomes beyond simply assessing athlete mental outcomes. Additional intervention work focused on creating stronger coach connection is clearly needed. Providing coaches and administrators with the tools to increase confidence to have subjectively tough and sometimes awkward conversations with athletes about mental health would provide real change in sport environments (Habeeb et al., 2022).

Assessment of Social Support Interventions As a result of its importance to athlete mental health outcomes, social support itself represents a third key intervention target point to promote positive outcomes of athlete mental health. Social support interventions have been used more extensively in general health and general mental health settings (Hogan et al., 2002). However, their utility for promoting adaptive mental health outcomes for athletes merits further understanding. Accordingly, the adaptation and evaluation of social support interventions represent a third potentially fruitful research direction. Social support interventions in non-sport settings come in a myriad varieties/structures including individual- and group-based interventions led by a clinician, social support resource psychoeducational interventions, and/or bystander interventions targeting potential sport-based social support providers (Hogan et al., 2002). Mixed-methods research could be potentially useful relative to social support interventions as more information is needed from athletes 74

The Social Network and the Coach

(and other social network providers) on the types of social support interventions desired as well as insight on how to conduct such interventions most ecologically in a variety of athlete populations. While psychoeducational interventions are important first steps to minimizing stigma, it requires a societal shift in attitudes and does not directly minimise stigma around seeking help (Bird et al., 2018). From coaches’ perspectives, it appears these types of interventions help coaches more comfortably communicate about mental health to their athletes (e.g., Sebbens et al., 2016; Kroshus et al., 2019). This study contributes strategies, from the athlete perspective, that can augment and extend coach interventions on stigma, awareness, and confidence around dealing with mental health (Gulliver, et al., 2012; Van Raalte et al., 2015). That is, creating connections so that athletes feel heard is clearly important to elite athletes, and in turn, creates an appropriate culture that welcomes help-seeking. Moreover, stigma around help-seeking can be minimised by increasing trust and deemphasizing a performance-based athlete culture. Athletes’ high dependence on the coach indicates that the power to create connection stems from the coach and associated administrators (Bissett & Tamminen, 2022). It is clear from the athletes in this study that genuineness of the programming and buy-in from coaches plays a fundamental role in their willingness to seek help. This is an encouraging finding that warrants additional research on the specific actions sport coaches/managers can make to foster a help-seeking culture.

Social Network Analysis Finally, an alternative conceptual and methodological perspective to athlete mental health research could be fruitful to further understanding the impact of the athlete social network on outcomes such as depression, anxiety, and well-being. Social network analysis, an often-used social science methodology in sociological and psychological research, has been used sparingly to examine athlete mental health outcomes and primarily with burnout as the target outcome variable (e.g., Nixon, 1993). Though a detailed explanation of the intricacies is beyond the scope of this chapter (see Kenny et al. (2006) and Lusher et al. (2010) for useful reviews), social network analysis (briefly) focuses on the construction of the social network structurally via examination of ties (i.e., linkages among social network members). The constellation of these ties is assessed via a variety of variables including number of ties (or lack thereof), the strength of ties, the density of ties, as well as the overall structure of relationships among ties (e.g., how individuals connected to a specific athlete are connected to each other). Variables reflecting the structure of athletes’ (and potentially multiple athletes’) social networks can then be compared both cross-sectionally and over time with athlete mental health outcomes including depression, anxiety, and burnout. Limited research in this area outside of sport represents a guide for this potential research direction on other or multiple athlete mental health outcomes simultaneously. Importantly, with the use of social network analysis, is the selection of which social network members to target (e.g., coaches, teammates, clinicians, parents, etc.) as well as the method for gathering ties which can include asking for a limited number of ties (e.g., top ten network members relevant to mental health) or other broader free response options. Some techniques suggest triangulation of the network structure via reports from other members of the social network who observe whom the athlete interacts with in the sport environment. Ultimately, this technique has potential to bring a unique lens to the ways in which sport scientists may understand which members of the athlete social network are most influential to athlete mental health outcomes across different points in the competitive season as well as across the life span of one’s athletic career.

Conclusion Athlete mental health outcomes are a distinctly important albeit complex set of variables to be examined by sport science practitioners. The sport-based social network, including the coach, represents a key means by which to understand, track, and intervene upon athlete mental health outcomes including 75

J.D. DeFreese and Christine M. Habeeb

depression, anxiety, and burnout as a means to prevent and/or treat athlete mental health outcomes and promote psychological well-being. In this chapter, we hope to have sparked the interest of sport science researchers and clinicians alike in ways that research and practice on athlete mental health can mutually benefit each other going forward. Guiding conceptual frameworks such as the neurobiopsychosocial model inform this important work. Due to their importance within the athlete social network and relevant conceptual models, coaches represent a key social agent to target in this work by harnessing the centrality of the coach-athlete relationship to positively impact change via mental health knowledge and help-seeking behaviour promotion. It is with continued innovative and impactful athlete mental health research and practice efforts going forward that we hope meaningful change can be exerted within this important sport science frontier.

References Adolphs, R. (2010). Conceptual challenges and directions for social neuroscience. Neuron, 65(6), 752–767. 10.1016/ j.neuron.2010.03.006 Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. 10.1016/0749-5978(91)90020-T American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Armstrong, S. (2007). Social connectedness, self-esteem, and depression symptomatology among collegiate athletes versus noncollegiate athletes ages 18 to 24: A comparative study. (Unpublished thesis). Texas Women’s University, Denton, TX, USA. Retrieved from https://twu-ir.tdl.org/handle/11274/3552 Armstrong, S., Burcin, M., Bjerke, W., & Early, J. (2015). Depression in student-athletes: A particularly at-risk group? A systematic review of the literature. Athletic Insight, 7(2), 177–193. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52(1), 1–26. 10.1146/ annurev.psych.52.1.1 Barcza-Renner, K., Eklund, R.C., Morin, A.J.S., & Habeeb, C.M. (2016). Controlling coaching behaviors and athlete burnout: The mediating roles of perfectionism and motivation. Journal of Sport and Exercise Psychology, 38(1), 30–44. 10.1123/jsep.2015-0059 Bauman, N.J. (2016). The stigma of mental health in athletes: Are mental toughness and mental health seen as contradictory in elite sport? British Journal of Sports Medicine, 50(3), 135–136. 10.1136/bjsports-2015-095570 Bianco, T., & Eklund, R.C. (2001). Conceptual considerations for social support research in sport and exercise settings: The case of sport injury. Journal of Sport and Exercise Psychology, 23(2), 85–107. 10.1123/jsep.23.2.85 Bentzen, M., Lemyre, P-N., & Kenttä, G. (2016). Development of exhaustion for high-performance coaches in association with workload and motivation: A person-centered approach. Psychology of Sport and Exercise, 22, 10–19. 10.1016/j.psychsport.2015.06.004 Bird, M., Chow, G., Meir, G., & Freeman, J. (2018). Student-athlete and student non-athletes’ stigma and attitudes toward seeking online and face-to-face counseling. Journal of Clinical Sport Psychology, 12, 1–32. 10.1123/jcsp.201 7-0010 Bissett, J.E., & Tamminen, K.A. (2022). Student-athlete disclosures of psychological distress: Exploring the experiences of university coaches and athletes. Journal of Applied Sport Psychology, 34(2), 363–383. 10.1080/10413200.2020.1753263 Boldero, J., & Fallon, B. (1995). Adolescent help-seeking: What do they get help for and from whom? Journal of Adolescence, 18(2), 193–209. 10.1006/jado.1995.1013 Borrell-Carrio, F. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific Inquiry. The Annals of Family Medicine, 2(6), 576–582. 10.1370/afm.245 Brewer, B.W., Raalte, J.L.V., Petitpas, A.J., Bachman, A.D., & Weinhold, R.A. (1998). Newspaper portrayals of sports psychology in the United States, 1985–1993. The Sport Psychologist, 12(1), 89–94. 10.1123/tsp.12.1.89 Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. Rand Health Quarterly, 5(1), 16. Coakley, J. (2015). Sports in society: Issues and controversies. McGraw-Hill Education. Coussens, A.H., Rees, T., & Freeman, P. (2015). Applying generalizability theory to examine the antecedents of perceived coach support. Journal of Sport and Exercise Psychology, 37(1), 51–62. 10.1123/jsep.2014-0087 Deci, E.L., & Ryan, R.M. (2008). Self-determination theory: A macrotheory of human motivation, development, and health. Canadian Psychology/Psychologie Canadienne, 49(3), 182–185. 10.1037/a0012801

76

The Social Network and the Coach Deci, E.L., & Ryan, R.M. (2014). Intrinsic motivation and self-determination in human behavior. Springer Science+Business Media. DeFreese, J.D. (2017). Athlete mental health care within the biopsychosocial model. Athletic Training & Sports Health Care, 9(6), 243–245. 10.3928/19425864-20170703-03 DeFreese, J.D., & Shannon, J. (2022). The role of athletic identity foreclosure in the development of poor athlete mental health. In N. Campell, A. Brady, & A. Tincknell-Smith (Eds.), Developing and supporting the holistic well-being of athletes, Person first, athlete second (pp. 239–256). London: Taylor & Francis. DeFreese, J.D., & Smith, A. (2014). Athlete social support, negative social interactions, and psychological health across a competitive sport season. Journal of Sport & Exercise Psychology, 36(6), 619–630. 10.1123/jsep.2014-0040 DeFreese, J.D., & Smith, A.L. (2013). Teammate social support, burnout, and self-determined motivation in collegiate athletes. Psychology of Sport and Exercise, 14(2), 258–265. 10.1016/j.psychsport.2012.10.009 Delenardo, S., & Terrion, J.L. (2014). Suck it up: Opinions and attitudes about mental illness stigma and help-seeking behaviour of male varsity football players. Canadian Journal of Community Mental Health, 33(3), 43–56. 10.7870/ cjcmh-2014-023 Drew, B., & Matthews, J. (2019). The prevalence of depressive and anxiety symptoms in student-athletes and the relationship with resilience and help-seeking behavior. Journal of Clinical Sport Psychology, 13(3), 421–439. 10.1123/jcsp.2017-0043 Engel, G.L. (1980). The clinical application of the biopsychosocial model. The American Journal of Psychiatry, 137(5), 535–544. Goodger, K., Gorely, T., Lavallee, D., & Harwood, C. (2007). Burnout in sport: A systematic review. The Sport Psychologist, 21(2), 127–151. 10.1123/tsp.21.2.127 Gucciardi, D.F., Hanton, S., & Fleming, S. (2017). Are mental toughness and mental health contradictory concepts in elite sport? A narrative review of theory and evidence. Journal of Science and Medicine in Sport, 20(3), 307–311. 10.101 6/j.jsams.2016.08.006 Gulliver, A., Griffiths, K.M., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12(1), 157. 10.1186/1471-244X-12-157 Gustafsson, H., DeFreese, J., & Madigan, D.J. (2017). Athlete burnout: Review and recommendations. Current Opinion in Psychology, 16, 109–113. 10.1016/j.copsyc.2017.05.002 Habeeb, C.M. (2020). The tripartite model of relational efficacy beliefs in sport: A scoping review. International Review of Sport and Exercise Psychology, Published online ahead of print, 1–26. 10.1080/1750984X.2020.1815233 Habeeb, C.M., Eklund, R.C., & Coffee, P. (2017). It depends on the partner: Person-related sources of efficacy beliefs and performance for athlete pairs. Journal of Sport and Exercise Psychology, 39(3), 172–187. 10.1123/jsep.2016-0348 Habeeb, C.M., Warner, S., & Walsh, D. (2022). Managing mental health: Athlete help-seeking. Sport Management Review. 10.1080/14413523.2021.2018836 Henriksen, K., Schinke, R., Moesch, K., McCann, S., Parham, W.D., Larsen, C.H., & Terry, P. (2020). Consensus statement on improving the mental health of high performance athletes. International Journal of Sport and Exercise Psychology, 18(5), 553–560. 10.1080/1612197X.2019.1570473 Hogan, B.E., Linden, W., & Najarian, B. (2002). Social support interventions: Do they work? Clinical Psychology Review, 22(3), 381–440. 10.1016/S0272-7358(01)00102-7 Ioannou, M., Kassianos, A.P., & Symeou, M. (2019). Coping with depressive symptoms in young adults: Perceived social support protects against depressive symptoms only under moderate levels of stress. Frontiers in Psychology, 9, 2780. 10.3389/fpsyg.2018.02780 Jowett, S., & Ntoumanis, N. (2004). The coach-athlete relationship questionnaire (CART-Q): Development and initial validation. Scandinavian Journal of Medicine and Science in Sports, 14(4), 245–257. 10.1111/j.1600-0838.2003. 00338.x Jowett, S., & Shanmagum, V. (2016). Relational coaching in sport: Its psychological underpinnings and practical effectiveness. In R.J. Schinke (Ed.), Routledge international handbook of sports psychology (pp. 471–484). Routledge, Taylor & Francis Group. Kim, S.S.Y., Hamiliton, B., Beable, S., Cavadino, A., & Fulcher, M.L. (2020). Elite coaches have a similar prevalence of depressive symptoms to the general population and lower rates than elite athletes. BMJ Open Sport & Exercise Medicine, 6(1), e000719. PubMed ID: 32341800 doi: 10.1136/bmjsem-2019-000719 Kegelaers, J., Wylleman, P., van Bree, I.N.A. Wessels, F., & Oudejans, R. (2021). Mental health in elite-level coaches: Prevalence rates and associated impact of coach stressors and psychological resilience. International Sport Coaching Journal, 8(3), 1–10. 10.1123/iscj.2020-0066 Kenny, D.A., Kashy, D.A., & Cook, W.L. (2006). Dyadic data analysis. Guilford Press. Keyes, C.L.M. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43(2), 207–222. 10.2307/3090197

77

J.D. DeFreese and Christine M. Habeeb Kitchener, B.A., & Jorm, A.F. (2002). Mental health first aid training for the public: Evaluation of effects on knowledge, attitudes and helping behavior. BMC Psychiatry, 2(1), 10. Kroenke, K., Spitzer, R.L., & Williams, J.B.W. (2001). The PHQ-9: Validity of a brief depression severity Measure. Journal of General Internal Medicine, 16(9), 606–613. 2001Kr 10.1046/j.1525-1497.2001.016009606.x 10.1186/1471-244 X-2-10 Validity of a brief depression severity Measure. Journal of General Internal Medicine, 16(9), 606-613. 2001Kr 10.1046/j.1525-1497.2001.016009606.x Kroshus, E., Wagner, J., Wyrick, D.L., & Hainline, B. (2019). Pre-post evaluation of the “Supporting StudentAthlete Mental Wellness” module for college coaches. Journal of Clinical Sport Psychology, 13(4), 668–685. 10.1123/ jcsp.2018-0082 Larson, G.A., Starkey, C., & Zaichkowsky, L.D. (1996). Psychological aspects of athletic injuries as perceived by athletic trainers. The Sport Psychologist, 10(1), 37–47. 10.1123/tsp.10.1.37 Lavallée, L., & Flint, F. (1996). The relationship of stress, competitive anxiety, mood state, and social support to athletic injury. Journal of Athletic Training, 31(4), 296–299. Linder, D.E., Brewer, B.W., Van Raalte, J.L., & Lange, N.D. (1991). A negative halo for athletes who consult sport psychologists: Replication and extension. Journal of Sport and Exercise Psychology, 13(2), 133–148. 10.1123/jsep.13 .2.133 Lusher, D., Robins, G., & Kremer, P. (2010). The application of social network analysis to team sports. Measurement in Physical Education and Exercise Science, 14(4), 211–224. 10.1080/1091367X.2010.495559 MacPherson, E., & Kerr, G. (2021). Sport fans’ responses on social media to professional athletes’ norm violations. International Journal of Sport and Exercise Psychology, 19(1), 102–119. 10.1080/1612197X.2019.1623283 Maniar, S.D., Curry, L.A., Sommers-Flanagan, J., & Walsh, J.A. (2001). Student-athlete preferences in seeking help when confronted with sport performance problems. The Sport Psychologist, 15(2), 205–223. 10.1123/tsp.15.2.205 Martin, S.B., Wrisberg, C.A., Beitel, P.A., & Lounsbury, J. (1997). NCAA Division I athletes’ attitudes toward seeking sports psychology consultation: The development of an objective instrument. The Sport Psychologist, 11(2), 201–218. 10.1123/tsp.11.2.201 McCrea, M., Broschek, D.K., & Barth, J.T. (2015). Sports concussion assessment and management: Future research directions. Brain Injury, 29(2), 276–282. McGee, V., & DeFreese, J.D. (2019). The coach-athlete relationship and athlete psychological outcomes. Journal of Clinical Sport Psychology, 13(1), 152–174. 10.1123/jcsp.2018-0010 Moreland, J.J., Coxe, K.A., & Yang, J. (2018). Collegiate athletes’ mental health services utilization: A systematic review of conceptualizations, operationalizations, facilitators, and barriers. Journal of Sport and Health Science, 7(1), 58–69. 10.1016/j.jshs.2017.04.009 National Alliance on Mental Illness. (2019). Anxiety disorders. Retrieved from https://www.nami.org/About-MentalIllness/Mental-Health-Conditions/Anxiety-Disorders National Collegiate Athletic Association. (2016). GOALS Study of the student-athlete experience: Initial summary of findings. Retrieved from https://www.ncaa.org/sites/default/files/GOALS_2015_summary_jan2016_final_20160627.pdf National Institute of Mental Health. (2019). Major depression. Retrieved from https://www.nimh.nih.gov/health/ statistics/major-depression.shtml Newman, M.L., & Roberts, N.A. (2013). Health and social relationships: The good, the bad, and the complicated. Washington, DC: American Psychological Association. Nixon, H.L. (1993). Social network analysis of sport: Emphasizing social structure in sport sociology. Sociology of Sport Journal, 10(3), 315–321. 10.1123/ssj.10.3.315 Olusoga, P., Butt, J., Hays, K., & Maynard, I. (2009). Stress in elite sports coaching: Identifying stressors. Journal of Applied Sport Psychology, 21(4), 442–459. doi: 10.1080/10413200903222921 Pacewicz, C.E., & Smith, A.L. (2022). Teammate relationships, loneliness, and the motivational and well-being experiences of adolescent athletes. Journal of Clinical Sport Psychology, 1, 1–20. 10.1123/jcsp.2021-0015 Picco, L., Pang, S., Lau, Y.W., Jeyagurunathan, A., Satghare, P., Abdin, E., … & Subramaniam, M. (2016). Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and selfesteem. Psychiatry Research, 246, 500–506. 10.1016/j.psychres.2016.10.041 Price, M.S., & Weiss, M.R. (2000). Relationships among coach burnout, coach behaviors, and athletes’ psychological responses. The Sport Psychologist, 14, 391–409. Raedeke, T. (1997). Is athlete burnout more than just stress? A sport commitment perspective. Journal of Sport & Exercise Psychology, 19, 396–417. 10.1123/jsep.19.4.396 Raedeke, T.D., Lunney, K., & Venables, K. (2002). Understanding athlete burnout: Coach perspectives. Journal of Sport Behavior, 25(2), 181–206. Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Medicine, 40(11), 961–980. 10.2165/11536580-000000000-00000

78

The Social Network and the Coach Reis, H.T. (2001). Relationship experiences and emotional well-being. In C.D. Ryff & B.H. Singer (Eds.), Emotion, social relationships, and health (pp. 57–86). New York: Oxford University Press. Register-Mihalik, J.K., Guskiewicz, K.M., McLeod, T.C.V., Linnan, L.A., Mueller, F.O., & Marshall, S.W. (2013). Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study. Journal of Athletic Training, 48(5), 645–653. 10.4085/1062-6050-48.3.20 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Rickwood, D., Deane, F.P., Wilson, C.J., & Ciarrochi, J. (2005). Young people’s help-seeking for mental health problems. Australian E-Journal for the Advancement of Mental Health, 4(3), 218–251. 10.5172/jamh.4.3.218 Rickwood, D.J., Deane, F.P., & Wilson, C.J. (2007). When and how do young people seek professional help for mental health problems? Medical Journal of Australia, 187(S7), S35–9. 10.5694/j.1326-5377.2007.tb01334.x Robertson, I.T., Cooper, C.L., Sarkar, M., & Curran, T. (2015). Resilience training in the workplace from 2003 to 2014: A systematic review. Journal of Occupational and Organizational Psychology, 88(3), 533–562. 10.1111/joop.12120 Sebbens, J., Hassmén, P., Crisp, D., & Wensley, K. (2016). Mental health in sport (MHS): Improving the early intervention knowledge and confidence of elite sport staff. Frontiers in Psychology, 7, 911. 10.3389/fpsyg.2016. 00911 Seligman, M.E.P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14. 10.1037/0003-066X.55.1.5 Simiyu, W.W.N. (2012). Challenges of being a black student athlete on U.S. college campuses. Journal of Issues in Intercollegiate Athletics, 5, 40–63. Smith, A.L., Gustafsson, H., & Hassmén, P. (2010). Peer motivational climate and burnout perceptions of adolescent athletes. Psychology of Sport and Exercise, 11(6), 453–460. 10.1016/j.psychsport.2010.05.007 Stephen, S.A., Habeeb, C.M., & Arthur, C.A. (2022). Congruence of efficacy beliefs on the coach-athlete relationship and athlete anxiety: Athlete self-efficacy and coach estimation of athlete self-efficacy. Psychology of Sport & Exercise, 41. 10.1016/j.psychsport.2021.102062 Stuntz, C.P., & Spearance, A.L. (2007). Coach-athlete and teammate holistic relationships: Measurement development and prediction of motivational factors. Journal of Sport & Exercise Psychology, 29(Supplement), S206–S207. Udry, E., Gould, D., Bridges, D., & Tuffey, S. (1997). People helping people? Examining the social ties of athletes coping with burnout and injury stress. Journal of Sport & Exercise Psychology, 19, 368–395. Van Raalte, J.L., Cornelius, A.E., Andrews, S., Diehl, N.S., & Brewer, B.W. (2015). Mental health referral for student-athletes: Web-based education and training. Journal of Clinical Sport Psychology, 9(3), 197–212. 10.1123/ jcsp.2015-0011 Watson, J.C. (2005). College student-athletes’ attitudes toward help-seeking behavior and expectations of counseling services. Journal of College Student Development, 46(4), 442–449. 10.1353/csd.2005.0044 Yang, J., Peek-Asa, C., Corlette, J.D., Cheng, G., Foster, D.T., & Albright, J. (2007). Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sport Medicine, 17(6), 481–487. 10.1097/JSM.0b013e31815aed6b Yang, J., Peek-Asa, C., Lowe, J.B., Heiden, E., & Foster, D.T. (2010). Social support patterns of collegiate athletes before and after injury. Journal of Athletic Training, 45(4), 372–379. 10.4085/1062-6050-45.4.372

79

SECTION B

Mental Illness

INTRODUCTION TO THE SECTION Scott B. Martin

In this section, the authors address the counterpart of mental health: mental illness. Therefore, important mental disorders in the context of elite sport are discussed. Specifically, the chapters focus on depression, eating disorders and body appearance concerns, addiction disorders, cognitive and executive function, personality disorders, and anxiety disorders. Because bridging the science and practice of sport psychology is an important concept, the chapter authors review and scrutinise relevant research and theories that attempt to identify and explain the relationship between underlying mechanisms of the various disorders and their impact on athletic performance and quality of life, especially at the elite levels. When available, the prevalence rates of these disorders and associated health issues in athletes are highlighted. Through case examples and anecdotal evidence, the authors also examine the psychological benefits and potential negative consequences regarding the demands of performing in high-level sporting environments. In addition, issues related to recognition, assessment, prevention, and treatment are discussed. The chapter authors also discuss potential implications for athletes and their support system and provide recommendations for how today’s sport psychology professionals and other important sport personnel can work together with members of the community to advance the understanding and recognition of athletes’ risk and possible ways to help prevent negative incidents to promote quality of life during and after sport.

82

DOI: 10.4324/9781003099345-9

6 DEPRESSION IN ELITE ATHLETES Insa Nixdorf and Raphael Nixdorf

Introduction Worldwide, depression affects around 280 million people and is a serious health condition (World Health Organization [WHO], 2021). Challenges such as personal suffering, economic losses, and suicide contribute to the rate of depression, with 700,000 deaths worldwide a year. It is, therefore, consequent to highlight depression in athletes with great caution and detail. Many forms of treatment are available, but the question with regards to athletes remains, whether they have access to high-quality treatment (EvansLacko et al., 2018). In general, athletes have a support system and sport psychology practitioners recognise the necessity to include mental health programs in sport to support mental health challenges such as depressive episodes (Schinke et al., 2018). Therefore, it is crucial that all professionals in the field of elite sport are aware of the importance of this challenge. This includes mental health professionals such as clinical psychologists, psychiatrists, as well as practitioners working with athletes such as sport psychologists, coaches, or officials in their sport. However, to treat and prevent depression in athletes, practitioners need to understand the mental disorder and must be informed about relevant factors, such as how it develops. This chapter highlights these issues by providing the current scientific understanding on depression in athletes, pointing out important specifics and mechanisms in this special population and provide useful information for practitioners in the field.

Definition of Depression in Athletes Depression is commonly recognised as a psychological disorder and the concept of depression is deeply rooted in medical history. Therefore, several types of depression are included in the current fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V, American Psychiatric Association, 2013). Depressive syndromes are characterised by symptoms of depressed mood, anhedonia, fatigue, feelings of guilt, and suicidal ideation (see Table 6.1). Furthermore, depression can be regarded as a multisystem disorder with affective, cognitive, and physiological manifestations (Insel & Charney, 2003; Lee et al., 2010). In addition to its symptoms and consequent increased risk of suicidal behaviour (Hawton et al., 2013), depression is a severe psychological disorder that can manifest itself in a long-lasting chronic problem associated with other comorbidities (Holzel et al., 2011). DOI: 10.4324/9781003099345-10

83

Insa Nixdorf and Raphael Nixdorf Table 6.1 Symptoms of Depressive Episodes DSM V ( American Psychiatric Association, 2013)

ICD 11 ( World Health Organization, 2022)

• •

Depressed mood Anhedonia (loss of interest and pleasure)

• • •

Depressed mood Anhedonia (loss of interests or pleasure) Fatigue or loss of energy

• • • • • • •

Fatigue or loss of energy Change in weight or appetite Insomnia or hypersomnia Feelings of worthlessness and/or guilt Reduced concentration or indecisiveness Suicidal ideation or acts Psychomotor agitation or retardation

• • • • • •

Change in appetite or sleep Ideas of guilt or unworthiness Reduced concentration or indecisiveness Suicidal ideation or acts Hopelessness psychomotor agitation or retardation

Note: Symptoms above the dashed line are considered major criteria.

Sport-Specific Considerations In athletes, these symptoms can however sometimes be complex due to the physical and emotional nature of competitive sport. For example, long-lasting, intensive physical stress induced by training is common and sometimes necessary to increase levels of performance. However, such prolonged training phases can potentially result in the syndrome of overtraining, which is characterised by symptoms largely associated with those of a depression (Meeusen et al., 2013). Another overlap can be found to athlete burnout, which also shares some important symptoms such as fatigue and tiredness. For further elaboration in the relation of these three syndromes, see Chapter 13. In terms of depression in the population of elite athletes, it is important to recognise such overlaps as it highlights some specific mechanisms which are unique or increased in the context of elite sport. Another important consideration is that athletes can, over time, get used to phases of exhaustion and fatigue due to habituation to such stages through their rigorous training. Thus, often athletes maintain their levels of functioning and can even compete in successful manner within their sport even though they suffer from depressive syndromes at the same time. In order to account for such specific issues in athlete samples, we highlight in the following the available data and describe important influences that may alter depressive syndromes and experiences in athletes.

Prevalence of Depression in Athletes Before highlighting different prevalence rates in various athletic samples, it is important to note that the time and way of assessment needs to be considered along with the prevalence rate. Different assessment methods (e.g., structured interview, self-rating) can influence the number of depressed athletes as well as the time of assessment during the season. These issues are explained later within this chapter in the sections sport specifics and assessment.

College Athletes Research on depressive symptomatology in elite athletes originated in U.S. colleges. Yang et al. (2007) surveyed 257 athletes reporting a prevalence of 21% for depressive syndromes in their sample. It is noteworthy that this study employed the Center for Epidemiological Studies-Depression (CES-D), a validated and widespread questionnaire for assessment of depressive syndromes. Yang et al. (2007) rated scores above 16 points as an indication of depression. This relatively low cut-off might contribute to the 84

Depression in Elite Athletes

comparatively high prevalence rate in their study. Armstrong and Oomen-Early (2009) reported a prevalence of 33.5%, using the same cut-off. In this study athletes were reported with significantly lower levels of depressive symptoms compared to non-athletes. Proctor and Boan-Lenzo (2010) used the same cut-off and reported lower rates of prevalence in athletes than in non-athletes, too. Further studies, for example Storch et al. (2005) who compared athletes with non-athletes, could not find empirical support for this difference. In their study a general, clinical instrument for assessment (Personality Assessment Instrument [PAI]) was used with a conservative cut-off of 32 points. The prevalence rate was rather low, and athletes did not differ significantly from non-athletes regarding depressive symptoms. In this sample, the athlete’s prevalence was between 10% (females) and 4% (males). Summarizing these results of studies addressing the topic of prevalence of depressive syndromes at U.S. colleges, the data seems to be rather inconsistent. A recent meta-analysis found that high-performance athletes were just as likely as nonathletes to report depressive symptoms (Gorczynski et al., 2017). They further argue that research needs to address this issue in a more consistent and structured way to also highlight clinically diagnosed depressive disorders. Furthermore, the data is not always gathered from a sample of elite athletes, which complicates the comparison to other countries without the collegiate system.

International Elite Athletes Research on elite athletes outside of the college athletes’ population gained traction around 2010, offering an internationally closer look on a vulnerable population. Schaal et al. (2011) conducted a representative study on psychological problems among elite athletes in France. They assessed the presence of a depressive episode with clinical interviews. In this study, 4% of the athletes indicated having a current depressive episode. Lifetime-prevalence was reported to be 11%. Nixdorf et al. (2013) assessed a prevalence rate of 15–20% for German elite athletes using a very conservative cut-off score of 23 in the CES-D. In Australia, Gulliver et al. (2015) assed over 200 elite athletes in an online survey assessing multiple mental health issues. They used the CES-D as well, but with a lower cut-off score (> 16). Results revealed a prevalence rate of 27% which were comparable to the general population according to the authors. Using the same questionnaire, Swiss football players showed a prevalence rate of 8% (Junge & Feddermann-Demont, 2016). Using a general health questionnaire (GHQ) with a combined score for depression and anxiety, Gouttebarge et al. (2015) found 38% of their international sample to report symptoms of depression or anxiety.

Sport-Specific Differences Obviously, there is a large range between the reported prevalence rates. Different ways of assessment as well as sport specifics are influencing prevalence rates. Thus, it is important to highlight such specifics and possibly understand how they affect depressive syndromes in athletes. Several studies indicated that depressive symptoms vary by sport type. According to these studies, athletes competing in individual sport disciplines were more prone to depressive symptoms than athletes competing in team sport (Nixdorf et al., 2013; Schaal et al., 2011). In a German sample, athletes competing in individual sport reported higher levels of depressive symptom than those competing in team sport. In a French sample, Schaal et al. (2011) found differences between sport disciplines, indicating higher scores in aesthetic sport (24%) and fine motor skill sport (18%) than in team ball sport (8%). In North America, Wolanin et al. (2016) found that athletes competing in track and field had the highest rate of depression scores, while lacrosse players had significantly lower levels of depression. Although these authors do not explicitly address a differentiation into individual sport and team sport, their results further support the assumption that higher depression scores are found in disciplines with competitions based mainly on an individual’s performance. Reasons for such a sport-specific effect will be highlighted later in this chapter, as it is connected to an aetiological model of development of depression. 85

Insa Nixdorf and Raphael Nixdorf

Another sport-specific effect is the difference in levels of depression by the time of assessment. Athletes have different phases in their sporting schedule according to the training periodization and the various competitions. Such phases seem to have an impact on athlete’s depressive responses as well. Hammond et al. (2013) assessed swimmers and found a very high prevalence rates of 68% right before their important competition. Prevalence dropped after the tournament, which illustrates a) the general high stress of their important competitions and b) the changes within a season. Therefore, it is very important to consider the time of assessment as this can severely influence the level of depressive syndromes.

Assessment and Diagnostic Since studies (Nixdorf et al., 2015, 2016) found clear relevance for sport-specific factors (stressors and sport discipline), it might be useful to adapt the measurement of depression to the context of elite sport. There also might be a benefit to adapting the definition of depression to the population and specific symptoms of elite athletes, similar to the new definition of athlete burnout and sport-specific assessment (e.g., by the Athlete Burnout Questionnaire, ABQ) by Raedeke and Smith (2001). However, in order to come to a formal diagnosis, the current diagnostic criteria (according to DSM or ICD) are required independent from a person’s occupation or background. Thus, general diagnostic guidelines should be followed when a formal diagnosis is the goal of an assessment. This would involve a licensed practitioner who is trained in this diagnostic process and is able to interview the athlete and integrate multiple sources such as a structural interview, questionnaires, and behaviour observation. Sometimes there are limited resources to go through such a rigorous process of diagnostics and data depends on self-rating questionnaires or even one-item-questions. The way of assessing a person’s level of depressive symptoms and determining the presence of a depressive episode is critical for its outcome. Different methods and questionnaires for assessing depression is vital since prevalence rates can be affected and in worst cases heavily biased depending on the method utilissed.

Self-Rating Questionnaires For screening or assessment of levels of depression in the applied field and research, self-rating questionnaires are a reliable method. Often used in sport is the Centre for Epidemiologic Studies Depression Scale (CES-D) from the National Institute of Mental Health (Radloff, 1977). The self-report scale has 20 items and is designed to measure depressive symptomatology in the general population, but was also repeatedly used to assess depression in athletes (e.g., Junge & Feddermann-Demont, 2016; I. Nixdorf et al., 2020; Yang et al., 2007). The scale is constructed, reliable, and standardised for the age range 11–90 years which makes it very applicable, especially for younger athletes. There are two cut-off scores available: a rather low cut-off score of 16 (sum score), which indicates a serious risk for a depressive episode, and a rather conservative cut-off score of 23, indicating severe risk of a current depressive episode. Another questionnaire, which specifically captures depressive symptoms is the Beck’s Depression Inventory (BDI II; Dozois, 2010). This 21-question multiple-choice self-report questionnaire is a commonly used inventory for assessing severity of depressive syndromes. A more general questionnaire can be used for screening purposes as well. For example, the Patient Health Questionnaire (PHQ), which includes a specific module for depressive symptoms PHQ-D (Kroenke et al., 2001), is a self-rating questionnaire that consists of only nine items and is rather short and more economic than, for example, the BDI-II.

Indirect Measurements Some studies approached depressive syndromes with indirect measurements. Machnik et al. (2009), for example, analyzed doping samples in athletes and focused on the use of antidepressants within their 86

Depression in Elite Athletes

sample. However, insights into actual prevalence rates are slim to none within this study. Breuer and Hallmann (2013) used another approach that examined depressive syndromes, alongside other issues in athletes, with the randomised response technique to reduce possible bias caused by stigma associated with mental health issues. However, reliability of the single question on whether athletes suffer from depression is still limited and depends largely on the actual knowledge of athletes if their symptoms match the criteria of an actual depressive episode. Another applied approach was taken by R. Nixdorf et al. (2020). The authors used psychological variables (coping strategies, dysfunctional attitudes, and recovery), which had been cross-sectionally and longitudinally connected to depressive symptoms (I. Nixdorf et al., 2020). These variables were used to estimate risk probabilities for a depressive syndrome. Results matched the prevalence rates from other samples and this approach provides useful implications for applied sport psychology. Topics like recovery and coping are often part of sport psychology counseling and, therefore, integrated in sport psychological assessments. Such results can then be used for the applied work with athletes, while at the same time provide screening for depression.

Aetiology The development of depression is often described by a vulnerability-stress model (e.g., Alloy et al., 2006; Haffel et al., 2005; Hyde et al., 2008). Here, certain vulnerabilities (genetics, social aspects, cognitive distortions, etc.) in combination with experience of stress (chronic or acute) may lead to depression (Lee et al., 2010). Although there are many definitions of stress, it is most often viewed as life events that disturb the mechanisms which maintain the stability of individuals’ physiology, emotion, and cognition (Ingram & Luxton, 2005). Research states a well-established link between stressful life events and the onset of depressive episodes (Mazure, 1998). The terms vulnerability and diathesis are often employed interchangeably. In this regard, a vulnerability is typically conceptualised as a predispositional factor. Ingram and Luxton (2005) suggest that “vulnerability is a trait, is stable but can change, is endogenous to individuals, and is usually latent” (p. 34). The idea of vulnerabilities as permanent and enduring is not always accurate, especially when psychological rather than genetic factors are considered. Ingram and Luxton (2005) point out that most psychological approaches rely on assumptions of dysfunctional learning as the genesis of vulnerability. And given such assumptions, vulnerability levels may fluctuate as a function of new learning experiences. Focusing on cognitive aspects of vulnerability-stress models, cognitive vulnerability-stress theories of depression have been the subject of intensive investigation (Alloy et al., 2006; Beck, 2005). These cognitive models of depression (e.g., Abramson et al., 1989; Beck, 1967; Ingram et al., 1998; NolenHoeksema, 1991) emphasise the role of negative inferential styles, information-processing biases, maladaptive emotion-regulation strategies, and dysfunctional beliefs as vulnerabilities for depression following stressful life events. In addition, a growing body of evidence suggests that such cognitive vulnerabilities do, in fact, increase the risk for depression (e.g., Abramson et al., 1999; Alloy et al., 1999; Clark et al., 1999; Ingram et al., 1998).

Important Vulnerabilities and Stressors As mentioned before, the development of depression is mostly described by a vulnerability-stress model (Alloy et al., 2006; Haffel et al., 2005; Hyde et al., 2008). In the context of elite sport, this framework has been applied and researched as well (I. Nixdorf et al., 2020). Thus, the following section gives an overview of important variables, which are structured and integrated in the overall framework of a vulnerability-stress model for athletes (see Figure 6.1). First, the topic of stress is highlighted and then the important vulnerability factors are discussed. 87

Insa Nixdorf and Raphael Nixdorf

Figure 6.1

A Vulnearbility-Stress Model for Athletes by Nixdorf & Nixdorf (2022). (Figure available under a CC-BY 4.0 license at https://osf.io/ta7gk.)

Stress and Stressors Every person is exposed to some sort of stress over the course of a lifetime. However, scholars argue, that athletes face often intense physical, psychological and emotional demands just because of their participation in competitive sport (Crocker & Graham, 1995). Whether one takes into consideration the important tournaments and potential sporting injuries (acute stress) or the frequency of tournaments and training sessions (chronic stress), the life of an athlete can be regarded as “stressful” (Wolanin et al., 2016). Recently, Hammond et al. (2013) reported very high prevalence rates of athletes before and after their important tournament. They further reported an increased susceptibility to depression, particularly in relation to failed performances and stress, highlighting how stressful such competitions can be perceived. Other important variables such as injuries (Appaneal et al., 2009), concussions (see Chapter 14) or career transitions (see Chapter 18), should be considered important stressors, too. Results support the general connection between stress and depression, indicating high associations between (chronic) stress and depressive symptoms (Frank et al., 2017; Gerber et al., 2018; Nixdorf et al., 2013). Further, connections between negative coping and depressive symptoms (Nixdorf et al., 2013) as well as greater levels of depression in athletes with less resilience (Gerber et al., 2018) highlight the importance of stress. Stress itself is an important factor for mental health (for discussion on stress, see Chapter 16). In the following section, we will address the question of which stressors are especially relevant for depression in athletes. Sources of chronic and acute stress can be in their personal environment (e.g., conflicts in relationship, financial issues), as well as being related to their sport discipline and specific sport setting. Research on stressors in the context of sport shows that stressors can be found in the competitive environment as well as in the organization an athlete is located in (Hanton et al., 2005). Organizational stressors, representing the environmental demands associated primarily and directly with the organization in which an individual operates, were shown to be multifaceted with dimensions such as interpersonal demands or stress due to roles within the sport organization (Fletcher et al., 2012). Furthermore, in addition to stressors clearly related to the sport organization or the competitive nature of elite sport, athletes are also exposed to stressors such as job insecurity, difficulties balancing

88

Depression in Elite Athletes

sport with study commitments (Noblet & Gifford, 2002), and/or the physical demands of training (Gould et al., 1993). Due to the nature of competitive sport, chronic training stress is another important aspect to consider. The impact of chronic training stress is mainly put in context with the overtraining syndrome (Kellmann, 2010; Lehmann et al., 1999), in which athletes undergoing a strenuous training schedule develop a significant decrease in performance associated with systemic symptoms or signs (see Chapter 13 for more information). However, the connection to depressive syndromes has been pointed out for years (Armstrong & Van Heest, 2002; Frank et al., 2013; Puffer & McShane, 1992). This highlights training loads as an important stressor with regards to depressive syndromes. As pointed out, sources for stress are plentiful in athletes. However, there is little knowledge on the question, which stressors are especially relevant for depressive syndromes. Nixdorf et al. (2015) followed up this question in a German athlete sample. They found three main categories of stressors: double burden highlighting the demands rooting from the challenge in both, the personal and athletic role, sport-specific demands representing the demands clearly associated with the sport (such as competitions and training load); and conditions, which represent the stressors from the athletic surrounding (team, coach, organization). Data analysis showed athletes with major stressors in the category sport-specific demands were found to have higher scores in depressive symptomatology than those in the other two groups. Thus, psychological and physiological challenges in the context of sport seem to have an especially important role for depressive syndromes in athletes.

Lack of Recovery To win competitions, achieve goals, and improve performances, athletes must push themselves more and more toward their limits. Increased training loads connected with physical and psychological stress tend to be common in professional athletes’ exercise plans. Yet, with increasing exercise loads, recovery becomes more important for athletes’ well-being, an aspect that is not always recognised. Recovery can be described as an inter- and intra-individual process that occurs over time for the reestablishment of performance abilities (Kellmann, 2002). This process, which includes psychological, physiological, and social factors, varies from person to person and situation to situation, and underlies intentional regulations. Beckmann (2002) described recovery as a process of self-regulation in which the subject should achieve detachment from a past activity followed by engagement in a new activity. He points out the importance to fully disconnect from the stressful activity. Otherwise, an imbalance may occur, and recovery can be impaired. According to this assumption, in the end the system may collapse, and illness, depression, burnout, or overtraining may result. Lack of recovery is therefore a critical issue and athletes suffering from exhaustion may experience symptoms such as frequent minor infections, sore muscles, change in sleep quality, loss of energy, loss of competitive drive, loss of libido, loss of appetite and weight, mood disturbance, anxiety, and irritability (Budgett, 1990; Budgett et al., 2000). Athletes often face intense exercise stress and while O’Connor et al. (1989) showed a connection between intense exercise loads in the corresponding training period and changes in tension, depression, anger, vigour, fatigue, and mood the importance of recovery becomes very clear. Therefore, it is imperative to recover properly from stress, especially the stress put on athletes by their training loads (for further information on recovery and its importance in prevention, see Chapter 22). With regards to its relation to depression, recent studies (Frank et al., 2017; Nixdorf et al., 2013) found that high levels of depressive symptomatology correlated with negative stress-recovery states (high scores in stress and low scores in recovery). Further studies investigated lack in recovery as a potential risk factors and showed prospective value for increases in depressive symptoms after lower levels in recovery (I. Nixdorf et al., 2020). These data support the protective importance of recovery for athletes not to develop depressive syndromes.

89

Insa Nixdorf and Raphael Nixdorf

Psychological Vulnerabilities Coping Strategies Coping is considered to be a personal skill or a group of strategies used to handle stress and deal with negative events (Schmidt & Caspar, 2009). Aspects of coping involve: (a) reducing the impact of harmful surrounding conditions; (b) improving the chances of recovery; (c) adapting to negative events or circumstances; (d) maintaining a positive self-perception; (e) supporting the safekeeping of emotional balance; and (f) enabling satisfying social contacts (Kohlmann & Eschenbeck, 2009). There is a significant difference in the use of coping strategies among healthy and depressed individuals and research revealed a positive correlation between depressive symptomatology and emotion-based coping strategies, and a negative correlation with problem-based coping strategies (Wingenfeld et al., 2009). Considering the enormous stress athletes are facing during their career, coping strategies become vitally important. This refers to the athletic success as well as to the maintenance of mental health. With regards to depression, adequate coping skills may reduce the risk of a depressive episode. Lending support to this hypothesis, studies in athletes (Crocker & Graham, 1995; Nixdorf et al., 2013) found correlations between coping strategies and depressive symptomatology. Nixdorf et al. (2013) more specifically showed that the frequent use of negative coping strategies (escape, resignation, and self-pity) correlated with high levels of depressive symptomatology and positive strategies (situation control and addressing oneself in encouraging tones) showed correlations with low levels of depressive symptomatology. A recent longitudinal study even pointed out, that negative coping, such as resignation, is a risk factor for higher levels of depressive symptoms after a sporting season (I. Nixdorf et al., 2020).

Dysfunctional Attitudes and Perfectionism In research on depression, negative cognition has been of particular interest as a vulnerability in the before mentioned vulnerability-stress models (Beck, 2005). Therefore, the concepts of dysfunctional attitudes and attribution have been of particular interest in clinical patients (e.g., Beck, 1967; Hull & Mendolia, 1991; Kim-Spoon et al., 2012; Weissman & Beck, 1978). Beck`s cognitive model (Beck, 1974) posits that people are depressed because their thoughts and conclusions are subjected to negative distortions. Such distortions can be characterised, for example by arbitrary conclusions, selective abstraction, overgeneralization, and over- or understatements. Distortions may be due to negative schemas or dysfunctional assumptions. Brown and Beck (2002) as well as Beck (2005) described that dysfunctional attitudes are a vulnerability for clinical disorders such as depression. Beck and colleague highlighted that distorted or negative thinking, overgeneralised assumptions and selective information processing are manifested in depressed patients. Perfectionistic thinking is closely related to dysfunctional attitudes (Ashby & Rice, 2002). Further, perfectionistic thinking can be considered a type of dysfunctional attitude (Beevers et al., 2007; de Graaf et al., 2009). Because of an ongoing assessment and evaluation of performance, especially in competitive sport, an identification of possible negative distortions and dysfunctional attitudes is particularly important. This is also a critical point of discussion in relation to the function of perfectionism in sport, where exceedingly high standards might be desired for personal peak performance. Thus, research within this domain debates adaptive and maladaptive aspects of perfectionism (Gotwals et al., 2012). With regard to depression in the general population, perfectionism is a well-known construct and research points out the potential negative impact of such attitudes (Cox & Enns, 2003; Hewitt & Flett, 1991, 1993; Hewitt et al., 1996). Recent studies investigated the connection between perfectionism, dysfunctional attitudes, and depression in athletes. Smith et al. (2018) found a connection between (socially prescribed) perfectionism and depression. It is noteworthy to highlight that in their cross-lagged panel analysis, depression appeared 90

Depression in Elite Athletes

as an antecedent to perfectionism. Here, further studies on its temporal connection are needed to provide a clear picture. With regards to dysfunctional attitudes, recent findings provide support for its relevance to depression in athletes. In a longitudinal study by I. Nixdorf et al. (2020), dysfunctional attitudes served as a significant predictor for increases in levels of depressive symptoms over the course of one sporting season. This indicates not only the importance of the factor, but also supports the general idea of vulnerabilitystress models and its adaptation in the sport domain.

Sport-Specific Mechanisms As pointed out, depression in athletes is subject to sport-specific circumstances such as failure, injuries, training loads, or pressure to perform at a constantly high level. Frank et al. (2013) and Wolanin et al. (2015) suggested depression in elite athletes is connected to such sport-specific mechanisms and factors. These authors assume that risk factors unique to an athletic population (i.e., injury, involuntary career termination, performance expectations, and possibly overtraining) may increase the risk of depression in athletes compared with the general population. It is therefore vital to point out and possibly understand such factors and influences. In the following section, we point out some sport-specifics and discuss psychological mechanisms for the found effects. Besides the factors unique to the context of elite sport, influences of other previously mentioned variables may be increased in the context of sport. Stress and coping are discussed in the general population and have been shown to be important factors in this regard. However, in the context of sport, the value of these factors might increase even more, considering the various stressors for athletes. The relevance to sport is even more obvious with regards to the effects of overtraining and recovery. Therefore, the sport-specific implications and mechanisms of these factors must be considered and investigated to best enhance the understanding of the mechanisms of depression in elite athletes. However, few such sport-specific factors are known. For example, Hammond et al. (2013) showed generally increased levels of depressive symptoms among swimmers during competition. Moreover, the study found that performance failure accounted for an increase in the levels of depressive symptoms. This could possibly lead to the importance of understanding how athlete handle failure within their sport. Another specific factor is injuries during the athletic career, which have been shown to predict depressive syndromes (Leddy et al., 1994). Within this study, injured athletes experienced depression not only within one week after an injury but also had significantly higher depression scores as much as two months’ post-injury. Appaneal et al. (2009) found similar results, with injured athletes having elevated depression scores from one week up to one month after injury when compared with healthy controls. Much evidence suggests that sport-related concussions (see also Chapter 14) can lead to changes in emotional state (Hutchison et al., 2009) and might be connected to depression (Kerr et al., 2012). But while there might be a significant connection between concussions and depression, evidence suggests that other sport injuries may have comparable or greater effects on mental health (Mainwaring et al., 2010).

Attribution Mediates Differences Between Individual and Team Sport Studies comparing different sport disciplines indicated higher levels of depressive syndromes in athletes in individual disciplines. This was highlighted in the prevalence section. However, the question remains why this difference was found in multiple studies (e.g., Nixdorf et al., 2013; Schaal et al., 2011; Wolanin et al., 2016). Looking at this effect, it becomes clear that other factors are necessary to explain the difference. Nixdorf et al. (2016) addressed this question by assessing possible mediators for the connection between the sport discipline and depression. First, the study was able to replicate the previously found differences in depressive symptoms between team- and individual sport athletes. They considered the attributional style, team cohesion, and perfectionistic expectations from others as possible mediators. While all possible 91

Insa Nixdorf and Raphael Nixdorf

factors correlated with depression, only attribution after failure was a significant mediator. Furthermore, it was concluded that due to the young age of the sample (i.e., junior), that the underlying meditating mechanism is inherent at an early stage in athletic careers. Attribution seems to play an important role in explaining the different vulnerability to depression in team and individual sport. Since success and failure in individual sport disciplines are more or less based on the individual athletes’ performance, the attributional style is of great importance. Hanrahan and Cerin (2009) showed that athletes competing in individual sport disciplines present the use of an internal attributional style more frequently. Summarizing the results with regards to mechanisms for depression in athletes, there are some studies, which highlight important variables. These variables can be integrated in the presented vulnerability-stress model (Figure 6.1). Although often applied outside of the context of sport, we highlighted by this sportspecific model the most relevant variables for athletes. The model features clearly sport related variables such as injuries, training loads, or pressure to perform. But even general sounding variables, such as chronic stress or dysfunctional attitudes, reveal a clear relevance for athletes, which has been outlined within this section. However, there are only few studies investigating mechanisms in athletes in a longitudinal study design. These studies are needed to further enhance knowledge on important variables contributing to depression in athletes.

Practical Implications and Guidelines Considering the presented prevalence rates, it is vital to educate, help, treat, and prevent depression in athletes. By highlighting the current research in the field, we outline meaningful routes for practitioners. First, it is noteworthy that reports of depressed athletes surprise people, even in the field of sport. Apparently, the role of an athlete is still one of attributes such as of being tough, aggressive, and getting things done (Biskup & Pfister, 1999), and depressive syndromes seem to fall out of line for the expectations within the sample of athletes (Stephan & Brewer, 2007). However, such a narrow understanding of athletes can possibly stigmatise depressed athletes (Bauman, 2016; Steinfeldt & Steinfeldt, 2012) and consequently hinder the access and treatment to professional health care. Thus, an athlete with depression is neither something shockingly dramatic, nor something that should be unrecognised. It simply demands our professional decisive action, preferably before reports in media deliver such information. Most important for addressing depression in athletes is prevention of this mental disorder. In classic categorization of prevention from Caplan (1964), this refers to primary prevention with the goal of stopping a problem behavior from ever occurring (Romano & Hage, 2000). In addition, aspects of a riskreduction framework according to Romano and Hage (2000) such as a) strengthening knowledge, attitudes, and behaviors that promote emotional and physical well-being and b) promoting institutional, community, and government policies that further physical, social, and emotional well-being would be the most reasonable course of action. Two important questions need to be addressed in this regard: 1) What puts athletes at risk for depression? and 2) How can we detect risk factors? Both questions have been covered in detail within this chapter. In the following we are now highlighting the practical implications of the current knowledge. In general, sport psychology approaches should include aspects of mental health such as building resilience or promoting well-being (Moesch et al., 2018). According to the presented findings, the vulnerability-stress model specific for athletes can be used as a guideline. Vulnerability factors can be addressed in sport psychological programs. Building adequate coping strategies, functional attitudes, and developing ways athletes can recover from their daily stress as well as from stressful events (e.g., injuries or failure) are important. Moreover, improving these competences can possibly protect athletes from depressive syndromes due to their predictive value (I. Nixdorf et al., 2020). In a case study of German swimmers, Nixdorf et al. (2019) implemented a program to promote coping, recovery, and attitudes, which resulted in improvements in levels of stress. Combining such programs 92

Depression in Elite Athletes

with useful topics for athletes (e.g., How can I deal with the stress in a competition?) might not protect them from depression, but may build a stronger mindset for their performance. Building such competences will prepare athletes for their challenges of facing pressure, experiencing failure, injuries, or stress in general. Furthermore, it will possibly develop those skills in general, build a stronger personality, and can be transferred to challenges in other aspects in life (e.g., school, family, career after sport). The other aspect of such programs is the possibility to provide screening and further treatment if needed. Using diagnostics, which is part of the standard sport psychological procedure (Gardner & Moore, 2006), screening for depression can be easily implemented. This can be operationalised by a questionnaire covering depressive syndromes or even indirect methods (R. Nixdorf et al., 2020) which are described in the section on diagnostics. Either way, results would have to be followed up and if necessary, referred to a mental health professional, who then would diagnose and deliver therapeutic treatment. Although we recommend that other healthcare professionals, other than the regular sport psychologist, perform such therapy, it is nevertheless vital to have this connection between sport psychology and medical healthcare professionals. A good network and support system increases the likelihood of athletes receiving adequate help. Actual therapy of depressed athletes should follow general guidelines on treatment of depression. However, it is crucial to understand athletes with their specific environment and demands. This applies to psychotherapy as well as to psychiatry. Consequently, therapeutic treatment must account for the specific needs of an athlete. Oftentimes athletes will outline their challenges within their sport, as they suffer from pressure to perform or cannot meet the physical demands in training (Nixdorf et al., 2015). This will often lead the unknown practitioner supporting routes against the sport, leading athletes away from their original goals.

Research Perspectives Studies on depression in athletes mostly focus on prevalence rates and cross-sectional associations. They highlight the importance of addressing depression in athletes and the need to further investigate this mental health challenge. To improve athletes’ situations, researchers need to better understand the underlying mechanisms and important variables, which contribute to exacerbation of depressive symptoms. Within this chapter, we pointed out the current knowledge on such variables and models of development. However, there are still many questions unanswered, and first studies need to be replicated and validated to provide sound answers for practitioners in the field of applied sport psychology, psychotherapy, and psychiatry. There is a strong need for a longitudinal assessment of depression to verify the validity of models, such as the vulnerability-stress model in elite sport, and to identify vulnerabilities that increase the risk of developing depression. In its theoretical conception, depression is explained by a temporal, stress-related process model assuming its development due to unfortunate factors, whether personal (e.g., dysfunctional attitudes, perfectionism, negative coping strategies) or environmental (e.g., conflicts in teams), which coexist with severe stressors (chronic stress). A longitudinal assessment of vulnerabilities and stressors can further help determine whether the structure of a process model (vulnerability-stress model) can be assumed with the assumption of temporal progression. If vulnerabilities are known, prevention can become specific, effective, and economical. In conclusion, further research is needed to establish how far the depressive syndrome is characterised by different symptoms in athletes compared to non-athletes, and to differentiate depression in athletes from burnout and overtraining. Findings of the prevalence of depression in elite athletes range from a low 4% (Schaal et al., 2011), 24% (Wolanin et al., 2016), and in some cases even up to 68% (Hammond et al., 2013). Thus, developing a definition, common understanding, and measurement accurately fitting the specific population would be meaningful, especially considering previously mentioned diagnostic challenges. With a validated and internationally standardised questionnaire with clear cut-off scores for athletes, prevalence rates 93

Insa Nixdorf and Raphael Nixdorf

could eventually be compared between studies. This would yield a robust diagnosis, which clearly distinguished between negative feelings (e.g., due to an experience of failure or a scheduled intensive training episode) and depressive symptomatology. In this line of thought, it is important to further investigate the sport specifics of clinical disorders, not only regarding depression. Further research on both vulnerabilities and stressors faces some critical challenges. Depression and its vulnerabilities mostly evolve during adolescence and early adulthood (Jacobi et al., 2004), and it is unclear how athletic challenges affect these factors in young, developing athletes. Thus, research on this matter would need to assess athletes at a very young age with multiple assessments throughout an athletic career. This would require a strong longitudinal study with a fairly large sample size, due to high dropout rates. Similarly, assuming that stressors change from junior (e.g., combining school and training schedules) to elite level (e.g., sponsoring, media presence), a study of stressors would need to cover a time frame of approximately 8 to 10 years to answer a developmental research question. Unfortunately, there still is a stigma surrounding mental disorders, especially in elite sport. Depression in particular, but mental health in general, has historically been used dichotomously to distinguish optimal from sub-optimal personal functioning (Schinke et al., 2018). Within this line of thought, those using the term would assume that an athlete either did or did not have a disease or disordered state (Murphy, 2012). This approach led to misconceptions and negative connotations that have been a barrier for appropriate and necessary help-seeking behaviours and helped raise a stigma regarding help-seeking (Gulliver et al., 2012; Watson, 2005). There are benefits for both, a conservative cut-off score to ensure the existence of a depression, especially when assessing prevalence, and a lenient collection of depressive symptoms to provide a sensitive measure and prevent a diagnosis to occur. When assessing depression with a lenient, low cut-off score, a linguistic distinction of at risk or risk factors can be helpful to avoid misconceptions. Building on this line of thought, see Chapter 1 on mental health. A broader way of understanding mental health can potentially decrease stigma.

Summary Depression is a very important and potentially detrimental mental disorder in athletes. Severity of symptoms may vary according to the discipline, time of assessment, and personal situation with possibly high levels of depressive symptoms in some cases. It is, therefore, vital to address this issue in a scientificdriven manner. Research has identified relevant psychological aspects and mechanism, which have been outlined in this chapter. However, further studies especially longitudinal investigations and intervention studies could help understanding this syndrome in the highly specific sample of athletes. The goal is to enhance athlete’s situation and promote those factors that build resilience against risk factors and depressive syndromes. We highlighted the most important tasks for the field of applied sport psychology and proposed ways of integrating aspects into regular sport psychology training and addressing sport-specific issues in further therapy.

References Abramson, L.Y., Alloy, L.B., Hogan, M.E., Whitehouse, W.G., Donovan, P., Rose, D.T., Panzarella, C., & Raniere, D. (1999). Cognitive vulnerability to depression: Theory and evidence. Journal of Cognitive Psychotherapy, 13(1), 5–20. 10.1891/0889-8391.13.1.5 Abramson, L.Y., Alloy, L.B., & Metalsky, G.I. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96(2), 358–372. 10.1037/0033-295x.96.2.358 Alloy, L.B., Abramson, L.Y., Whitehouse, W.G., Hogan, M.E., Panzarella, C., & Rose, D.T. (2006). Prospective incidence of first onsets and recurrences of depression in individuals at high and low cognitive risk for depression. Journal of Abnormal Psychology, 115(1), 145–156. 10.1037/0021-843X.115.1.145

94

Depression in Elite Athletes Alloy, L.B., Abramson, L.Y., Whitehouse, W.G., Hogan, M.E., Tashman, N.A., Steinberg, D.L., Rose, D.T., & Donovan, P. (1999). Depressogenic cognitive styles: Predictive validity, information processing and personality characteristics, and developmental origins. Behaviour Research and Therapy, 37(6), 503–531. 10.1016/S00057967(98)00157-0 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA. Appaneal, R.N., Levine, B.R., Perna, F.M., & Roh, J.L. (2009). Measuring postinjury depression among male and female competitive athletes. Journal of Sport & Exercise Psychology, 31(1), 60–76. 10.1123/jsep.31.1.60 Armstrong, L.E., & Van Heest, J.L. (2002). The unknown mechanism of the overtraining syndrome: Clues from depression and psychoneuroimmunology. Sports Medicine, 32(3), 185–209. 10.2165/00007256-200232030-00003 Armstrong, S., & Oomen-Early, J. (2009). Social connectedness, self-esteem, and depression symptomatology among collegiate athletes versus nonathletes. Journal of American College Health, 57(5), 521–526. 10.3200/JACH.57.5. 521-526 Ashby, J.S., & Rice, K.G. (2002). Perfectionism, dysfunctional attitudes, and self‐esteem: A structural equations analysis. Journal of Counseling & Development, 80(2), 197–203. 10.1002/j.1556-6678.2002.tb00183.x Bauman, N.J. (2016). The stigma of mental health in athletes: Are mental toughness and mental health seen as contradictory in elite sport? British Journal of Sports Medicine, 50(3), 135–136. 10.1136/bjsports-2015-095570 Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. University of Pennsylvania Press. Beck, A.T. (1974). The development of depression: A cognitive model. In R.J. Friedman & M.M. Katz (Eds.), The psychology of depression: Contemporary theory and research. John Wiley. Beck, A.T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62(9), 953–959. 10.1001/archpsyc.62.9.953 Beckmann, J. (2002). Interaction of volition and recovery. In M. Kellmann (Ed.), Enhancing recovery: Preventing underperformance in athletes (pp. 269–282). Human Kinetics. Beevers, C.G., Strong, D.R., Meyer, B., Pilkonis, P.A., & Miller, I.R. (2007). Efficiently assessing negative cognition in depression: An item response theory analysis of the Dysfunctional Attitude Scale. Psychological Assessment, 19(2), 199–209. 10.1037/1040-3590.19.2.199 Biskup, C., & Pfister, G. (1999). I would like to be like her/him: Are athletes role-models for boys and girls? European Physical Education Review, 5(3), 199–218. 10.1177/1356336X990053003 Breuer, C., & Hallmann, K. (2013). Dysfunktionen des Spitzensports: Doping, Match-Fixing und Gesundheitsgefährdungen aus Sicht von Bevölkerung und Athleten. Bundesinstitut für Sportwissenschaft. Brown, G.P., & Beck, A.T. (2002). Dysfunctional attitudes, perfectionism, and models of vulnerability to depression. In G.L. Flett & P.L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 231–251). American Psychological Association. Budgett, R. (1990). Overtraining syndrome. British Journal of Sports Medicine, 24(4), 231–236. 10.1136/bjsm.24.4.231 Budgett, R., Newsholme, E., Lehmann, M., Sharp, C., Jones, D., Peto, T., Collins, D., Nerurkar, R., & White, P. (2000). Redefining the overtraining syndrome as the unexplained underperformance syndrome. British Journal of Sports Medicine, 34(1), 67–68. 10.1136/bjsm.34.1.67 Caplan, G. (1964). Principles of preventive psychiatry. Basic Books. Clark, D.A., Beck, A.T., & Alford, B.A. (1999). Scientific foundation of cognitive theory of depression. Wiley. Cox, B.J., & Enns, M.W. (2003). Relative stability of dimensions of perfectionism in depression. Canadian Journal of Behavioural Science-Revue Canadienne Des Sciences Du Comportement, 35(2), 124–132. 10.1037/h0087194 Crocker, P.R., & Graham, T.R. (1995). Coping by competitive athletes with performance stress: Gender differences and relationships with affect. The Sport Psychologist, 9(3), 325–338. 10.1123/tsp.9.3.325 de Graaf, L.E., Roelofs, J., & Huibers, M.J. (2009). Measuring dysfunctional attitudes in the general population: The dysfunctional attitude scale (form A) revised. Cognitive Therapy and Research, 33(4), 345–355. 10.1007/s10608-0099229-y Dozois, D.J.A. (2010). Beck depression inventory-II. In I.B. Weiner & W.E. Craighead (Eds.), The corsini encyclopedia of psychology (pp. 1–2). John Wiley & Sons, Inc. 10.1002/9780470479216.corpsy0113 Evans-Lacko, S., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bruffaerts, R., Chiu, W.T., Florescu, S., de Girolamo, G., Gureje, O., Haro, J.M., He, Y., Hu, C., Karam, E.G., Kawakami, N., Lee, S., Lund, C., Kovess-Masfety, V., Levinson, D., … Thornicroft, G. (2018). Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: Results from the WHO World Mental Health (WMH) surveys. Psychological Medicine, 48(9), 1560–1571. 10.1017/s0033291717003336 Fletcher, D., Hanton, S., Mellalieu, S.D., & Neil, R. (2012). A conceptual framework of organizational stressors in sport performers. Scandinavian Journal of Medicine and Science in Sports, 22(4), 545–557. 10.1111/j.1600-0838.201 0.01242.x

95

Insa Nixdorf and Raphael Nixdorf Frank, R., Nixdorf, I., & Beckmann, J. (2013). Depression in elite athletes: Prevalence and psychological factors. Deutsche Zeitschrift fuer Sportmedizin, 64(11), 320–326. 10.5960/dzsm.2013.088 Frank, R., Nixdorf, I., & Beckmann, J. (2017). Analyzing the relationship between burnout and depression in junior elite athletes. Journal of Clinical Sport Psychology, 11(4), 287–303. 10.1123/jcsp.2017-0008 Gardner, F., & Moore, Z. (2006). Clinical sport psychology. Human kinetics. Gerber, M., Best, S., Meerstetter, F., Walter, M., Ludyga, S., Brand, S., Bianchi, R., Madigan, D.J., Isoard-Gautheur, S., & Gustafsson, H. (2018). Effects of stress and mental toughness on burnout and depressive symptoms: A prospective study with young elite athletes. Journal of Science and Medicine in Sport, 21(12), 1200–1205. 10.1016/j.jsams.2018.05.018 Gorczynski, P.F., Coyle, M., & Gibson, K. (2017). Depressive symptoms in high-performance athletes and non-athletes: A comparative meta-analysis. British Journal of Sports Medicine, 51(18), 1348–1354. 10.1136/bjsports-2016-096455 Gotwals, J.K., Stoeber, J., Dunn, J.G.H., & Stoll, O. (2012). Are perfectionistic strivings in sport adaptive? A systematic review of confirmatory, contradictory, and mixed evidence. Canadian Psychology/Psychologie canadienne, 53(4), 263–279. 10.1037/a0030288 Gould, D., Jackson, S., & Finch, L. (1993). Sources of stress in national champion figure skaters. Journal of Sport and Exercise Psychology, 15(2), 134–159. 10.1123/jsep.15.2.134 Gouttebarge, V., Aoki, H., & Kerkhoffs, G. (2015). Symptoms of common mental disorders and adverse health behaviours in male professional soccer players. Journal of Human Kinetics, 49(1), 277–286. 10.1515/hukin-2015-0130 Gulliver, A., Griffiths, K.M., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12(1), 157. 10.1186/1471-244X-12-157 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Haffel, G.J., Abramson, L.Y., Voelz, Z.R., Metalsky, G.I., Halberstadt, L., Dykman, B.M., Donovan, P., Hogan, M.E., Hankin, B.L., & Alloy, L.B. (2005). Negative cognitive styles, dysfunctional attitudes, and the remitted depression paradigm: A search for the elusive cognitive vulnerability to depression factor among remitted depressives. Emotion, 5(3), 343–348. 10.1037/1528-3542.5.3.343 Hammond, T., Gialloreto, C., Kubas, H., & Davis, H. (2013). The prevalence of failure-based depression among elite athletes. Clinical Journal of Sport Medicine, 23(4), 273–277. 10.1097/JSM.0b013e318287b870 Hanrahan, S.J., & Cerin, E. (2009). Gender, level of participation, and type of sport: Differences in achievement goal orientation and attributional style. Journal of Science and Medicine in Sport, 12(4), 508–512. 10.1016/j.jsams. 2008.01.005 Hanton, S., Fletcher, D., & Coughlan, G. (2005). Stress in elite sport performers: A comparative study of competitive and organizational stressors. Journal of Sports Sciences, 23(10), 1129–1141. 10.1080/02640410500131480 Hawton, K., Casanas, I.C.C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147(1-3), 17–28. 10.1016/j.jad.2013.01.004 Hewitt, P.L., & Flett, G.L. (1991). Dimensions of perfectionism in unipolar depression. Journal of Abnormal Psychology, 100(1), 98–101. https://www.ncbi.nlm.nih.gov/pubmed/2005279 Hewitt, P.L., & Flett, G.L. (1993). Dimensions of perfectionism, daily stress, and depression: A test of the specific vulnerability hypothesis. Journal of Abnormal Psychology, 102(1), 58–65. https://www.ncbi.nlm.nih.gov/pubmed/ 8436700 Hewitt, P.L., Flett, G.L., & Ediger, E. (1996). Perfectionism and depression: Longitudinal assessment of a specific vulnerability hypothesis. Journal of Abnormal Psychology, 105(2), 276–280. https://www.ncbi.nlm.nih.gov/pubmed/ 8723009 Holzel, L., Harter, M., Reese, C., & Kriston, L. (2011). Risk factors for chronic depression—A systematic review. Journal of Affective Disorders, 129(1-3), 1–13. 10.1016/j.jad.2010.03.025 Hull, J.G., & Mendolia, M. (1991). Modeling the relations of attributional style, expectancies, and depression. Journal of Personality and Social Psychology, 61(1), 85. 10.1037/0022-3514.61.1.85 Hutchison, M., Mainwaring, L.M., Comper, P., Richards, D.W., & Bisschop, S.M. (2009). Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries. Clinical Journal of Sport Medicine, 19(1), 13–19. 10.1097/JSM.0b013e318190ba06 Hyde, J.S., Mezulis, A.H., & Abramson, L.Y. (2008). The ABCs of depression: Integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychological Review, 115(2), 291–313. 10.1037/0033-295X.115.2.291 Ingram, R.E., & Luxton, D.D. (2005). Vulnerability-stress models. In B.L. Hankin & J.R.Z. Abela (Eds.), Development of psychopathology: A vulnerability-stress perspective (pp. 32–46). Sage Publications. Ingram, R.E., Miranda, J., & Segal, Z.V. (1998). Cognitive vulnerability to depression. Guilford Press. Insel, T.R., & Charney, D.S. (2003). Research on major depression: Strategies and priorities. JAMA, 289(23), 3167–3168. 10.1001/jama.289.23.3167

96

Depression in Elite Athletes Jacobi, F., Wittchen, H.U., Holting, C., Hofler, M., Pfister, H., Muller, N., & Lieb, R. (2004). Prevalence, comorbidity and correlates of mental disorders in the general population: Results from the German health interview and examination survey (GHS). Psychological Medicine, 34(4), 597–611. 10.1017/S0033291703001399 Junge, A., & Feddermann-Demont, N. (2016). Prevalence of depression and anxiety in top-level male and female football players. BMJ Open Sport and Exercise Medicine, 2(1), e000087. 10.1136/bmjsem-2015-000087 Kellmann, M. (2002). Underrecovery and overtraining: Different concepts-similar impact. In M. Kellmann (Ed.), Enhancing recovery: Preventing underperformance in athletes (pp. 3–24). Human Kinetics. Kellmann, M. (2010). Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scandinavian Journal of Medicine and Science in Sports, 20, 95–102. 10.1111/j.1600-0838.2010.01192.x Kerr, Z.Y., Marshall, S.W., Harding, H.P., Jr., & Guskiewicz, K.M. (2012). Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. American Journal of Sports Medicine, 40(10), 2206–2212. 10.1177/0363546512456193 Kim-Spoon, J., Ollendick, T.H., & Seligman, L.D. (2012). Perceived competence and depressive symptoms among adolescents: The moderating role of attributional style. Child Psychiatry and Human Development, 43(4), 612–630. 10.1007/s10578-012-0287-0 Kohlmann, K., & Eschenbeck, H. (2009). Stress und Stressbewältigung [Stress and Coping]. In W. Schlicht & B. Strauß (Eds.), Grundlagen der sportpsychologie [Basic principals of sport psychology] (pp. 635–680). Hogrefe. Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ‐9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x Leddy, M.H., Lambert, M.J., & Ogles, B.M. (1994). Psychological consequences of athletic injury among high-level competitors. Research Quarterly for Exercise and Sport, 65(4), 347–354. 10.1080/02701367.1994.10607639 Lee, S., Jeong, J., Kwak, Y., & Park, S.K. (2010). Depression research: Where are we now? Molecular Brain, 3, 8. 10.1186/ 1756-6606-3-8 Lehmann, M., Foster, C., Gastmann, U., Keizer, H., & Steinacker, J.M. (1999). Definition, types, symptoms, findings, underlying mechanisms, and frequency of overtraining and overtraining syndrome. In Overload, performance incompetence, and regeneration in sport (pp. 1–6). Springer. Machnik, M., Sigmund, G., Koch, A., Thevis, M., & Schänzer, W. (2009). Prevalence of antidepressants and biosimilars in elite sport. Drug testing and analysis, 1(6), 286–291. 10.1002/dta.49 Mainwaring, L.M., Hutchison, M., Bisschop, S.M., Comper, P., & Richards, D.W. (2010). Emotional response to sport concussion compared to ACL injury. Brain Injury, 24(4), 589–597. 10.3109/02699051003610508 Mazure, C.M. (1998). Life stressors as risk factors in depression. Clinical Psychology - Science and Practice, 5(3), 291–313. 10.1111/j.1468-2850.1998.tb00151.x Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., Raglin, J., Rietjens, G., Steinacker, J., & Urhausen, A. (2013). Prevention, diagnosis, and treatment of the overtraining syndrome: Joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Medicine and Science in Sports and Exercise, 45(1), 186–205. 10.1249/MSS.0b013e318279a10a Moesch, K., Kentta, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Murphy, S. (2012). The Oxford handbook of sport and performance psychology. Oxford University Press. Nixdorf, I., Beckmann, J., & Nixdorf, R. (2019). Prevention of burnout and depression in junior elite swimmers. In G. Breslin & G. Leavey (Eds.), Mental health and well-being interventions in sport (pp. 31–44). Routledge. Nixdorf, I., Beckmann, J., & Nixdorf, R. (2020). Psychological predictors for depression and burnout among German junior elite athletes. Frontiers in Psychology, 11, 601. 10.3389/fpsyg.2020.00601 Nixdorf, I., Frank, R., & Beckmann, J. (2015). An explorative study on major stressors and its connection to depression and chronic stress among German elite athletes. Advances in Physical Education, 5(04), 255–262. 10.4236/ ape.2015.54030 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. 10.1123/jcsp.7.4.313 Nixdorf, R., Beckmann, J., & Nixdorf, I. (2020). Risikoeinschätzung für depressive Syndrome anhand eines Screenings psychologischer Variablen. Zeitschrift für Sportpsychologie, 27(3), 95–105. 10.1026/1612-5010/a000305 Nixdorf, R. & Nixdorf, I. (2022). Mental health in elite athletes. https://osf.io/qwu9a/ Noblet, A.J., & Gifford, S.M. (2002). The sources of stress experienced by professional Australian footballers. Journal of Applied Sport Psychology, 14(1), 1–13. 10.1080/10413200209339007

97

Insa Nixdorf and Raphael Nixdorf Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569–582. https://www.ncbi.nlm.nih.gov/pubmed/1757671 O’Connor, P.J., Morgan, W.P., Raglin, J.S., Barksdale, C.M., & Kalin, N.H. (1989). Mood state and salivary cortisol levels following overtraining in female swimmers. Psychoneuroendocrinology, 14(4), 303–310. 10.1016/0306-453 0(89)90032-2 Proctor, S.L., & Boan-Lenzo, C. (2010). Prevalence of depressive symptoms in male intercollegiate student-athletes and nonathletes. Journal of Clinical Sport Psychology, 4(3), 204–220. 10.1123/jcsp.4.3.204 Puffer, J.C., & McShane, J.M. (1992). Depression and chronic fatigue in athletes. Clinics in Sports Medicine, 11(2), 327–338. 10.1016/S0278-5919(20)30534-2 Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. 10.1177/014662167700100306 Raedeke, T.D., & Smith, A.L. (2001). Development and preliminary validation of an athlete burnout measure. Journal of Sport and Exercise Psychology, 23(4), 281–306. 10.1123/JCSP.4.3.204 Romano, J.L., & Hage, S.M. (2000). Prevention and counseling psychology revitalizing commitments for the 21st century. The Counseling Psychologist, 28(6), 733–763. 10.1177/0011000000286001 Schaal, K., Tafflet, M., Nassif, H., Thibault, V., Pichard, C., Alcotte, M., Guillet, T., El Helou, N., Berthelot, G., Simon, S., & Toussaint, J.F. (2011). Psychological balance in high level athletes: Gender-based differences and sport-specific patterns. PloS One, 6(5), e19007. 10.1371/journal.pone.0019007 Schinke, R.J., Stambulova, N.B., Si, G.Y., & Moore, Z. (2018). International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622–639. 10.1080/1612197x.2017.1295557 Schmidt, L., & Caspar, F. (2009). Coping. In H. Häcker & K. Stapf (Eds.), Dorsch Psychologisches Wörterbuch [Dorsch psychological dictionary] (pp. 185). Huber. Smith, E.P., Hill, A.P., & Hall, H.K. (2018). Perfectionism, burnout and depressive symptoms in youth soccer players: A longitudinal study. Journal of Clinical Sport Psychology, 12(2), 1–34. 10.1123/JCSP.2017-0015 Steinfeldt, J.A., & Steinfeldt, M.C. (2012). Profile of masculine norms and help-seeking stigma in college football. Sport, Exercise, and Performance Psychology, 1(1), 58. 10.1037/A0024919 Stephan, Y., & Brewer, B.W. (2007). Perceived determinants of identification with the athlete role among elite competitors. Journal of Applied Sport Psychology, 19(1), 67–79. 10.1080/10413200600944090 Storch, E.A., Storch, J.B., Killiany, E.M., & Roberti, J.W. (2005). Self-reported psychopathology in athletes: A comparison of intercollegiate student-athletes and non-athletes. Journal of Sport Behavior, 28(1), 86–97. Watson, J.C. (2005). College student-athletes’ attitudes toward help-seeking behavior and expectations of counseling services. Journal of College Student Development, 46(4), 442–449. 10.1353/csd.2005.0044 Weissman, A.N., & Beck, A.T. (1978). Development and validation of the Dysfunctional Attitude Scale: A preliminary investigation. In Paper presented at the Annual meeting of the Association for the Advanced Behavior Therapy, Chicago, November. Wingenfeld, K., Mensebach, C., Rullkoetter, N., Schlosser, N., Schaffrath, C., Beblo, T., & Driessen, M. (2009). Relationship between coping with negative life‐events and psychopathology: Major depression and borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice, 82(4), 421–425. 10.1348/1476083 09X452416 Wolanin, A., Gross, M., & Hong, E. (2015). Depression in athletes: Prevalence and risk factors. Current Sports Medicine Reports, 14(1), 56–60. 10.1249/JSR.0000000000000123 Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50(3), 167–171. 10.1136/bjsports-2015-095756 World Health Organization (2022). International classification of diseases – 11th revision. https://icd.who.int/en World Health Organization. (2021). Depression fact sheet. Retrieved 15.11.2021 from https://www.who.int/newsroom/fact-sheets/detail/depression Yang, J., Peek-Asa, C., Corlette, J.D., Cheng, G., Foster, D.T., & Albright, J. (2007). Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sport Medicine, 17(6), 481–487. 10.1097/JSM.0b013e31815aed6b

98

7 RECOGNITION, PREVENTION, AND TREATMENT OF DISORDERED EATING AND BODY DISSATISFACTION IN ATHLETES Cami A. Barnes, Keely N. Hayden, and Scott B. Martin

Introduction Eating disorders (EDs) pose the risk of life-threatening medical complications with serious compromise in overall quality of life, affecting over 9% of the population worldwide (Arcelus et al., 2011; Conviser et al., 2018). In the United States of America (US), it has been estimated that 21 million people have had an ED during their lifetime and 7.8 million, currently alive, will develop an ED in the future (Deloitte Access Economics, 2020; Pater et al., 2019). Of the future cases, approximately 1.9 million will occur in children and adolescents before they are 20 years old (Deloitte Access Economics, 2020). These estimates indicate that EDs are among the deadliest mental illnesses, second only to opioid overdose, resulting in about 26% of people with EDs attempting suicide (Arcelus et al., 2011; Deloitte Access Economics, 2020). EDs are substantially different from common eating and body-related frustrations, better known as disordered eating behaviours (DEBs). Once established, these behaviours may not diminish without professional intervention and treatment (American Psychiatric Association [APA]1, 2013). Timely access to care is necessary to preserve health and minimise damaging effects of EDs. There is a greater prevalence of disordered eating (DE) in individuals striving for athletic success, especially at elite levels (e.g., club/select, college, Olympic, and professional), than those in the general population, particularly females and those in developing countries. In the United States, for example, ED rates vary from 6% to 45% in female athletes compared to 0% to 19% in male athletes (Glazer, 2008; Sundgot-Borgen & Torstveit, 2004). Rates of DE among athletes and non-athletes may be increasing due to the “selfie tag-along” culture that emphasises appearance-related social behaviours (Lonergan et al., 2020). The severity and inherent destructiveness of an ED to the body is undisputed, and the role of national governing bodies and professional organizations are essential (Hackert et al., 2020). National and international organizations (e.g., Australian Institute of Sport [AIS], American Psychological Association [APA]2, International Olympic Committee [IOC], National College Association of Athletics [NCAA], National Eating Disorders Association [NEDA], United States Olympic & Paralympic Committee [USOPC]) and initiatives (e.g., National Eating Disorders Collaboration [NEDC]; Strategic Training Initiative for the Prevention of Eating Disorders [STRIPED]) provide resources to promote the safety and wellbeing of athletes DOI: 10.4324/9781003099345-11

99

Cami Barnes et al.

(see Deloitte Access Economics; Wells et al., 2020). Although athletes often utilise these resources (e.g., online materials) and request assistance from professionals (e.g., nutritionists, psychologists, psychiatrists), many still struggle with inappropriate behaviours and thoughts related to food intake. Involvement in sport may exacerbate DEBs and distorted negative ideations. For example, according to a National Eating Disorders Association (NEDA) survey, those identifying as athletes reported a significantly greater likelihood of engaging in excessive exercise and more frequent episodes of excessive exercise than did non-athletes (Flatt et al., 2021). Although the percentages were similar, athletes were more likely to screen positive for an ED or subclinical (i.e., subthreshold) ED, or as a probable diagnosis for ED, than non-athletes. Since identification, evaluation, and management of DE is complex and poses great risk, athletes and those associated with them (parents, coaches, athletic trainers, mental performance consultants, etc.) need to be able to address their biological, psychological, and socio-cultural needs effectively and accurately. Therefore, this chapter describes the holistic biopsychosocial observation and interprofessional care to manage DE, weight control, and body dissatisfaction in elite athletes.

Historical Perspective of Disorder Eating and Associated Behaviours Many philosophers and physicians throughout history acknowledged the importance of physical fitness, nutrition, and the mind on personal health and well-being. For example, two physicians, Hippocrates (460-370 B.C.) and Galen (129–210 A.D.), were the first to acknowledge the importance of physical fitness, nutrition, and the mind through observation of athletes. Hippocrates, considered the father of medicine, was the first to introduce the notion that diseases arise from lack of exercise or excessive food, but when in balance they lead to good health. In fact, in his book On Dietetics (Περί Διαίτης), Hippocrates stated that “Eating healthily by itself will not keep a man well; he must also have physical exercise.” The teachings of Hippocrates and Galen dominated medical education and thought for almost fifteen centuries. Engel (1977) integrated these teachings into his biopsychosocial model, which features the importance of the interconnection between biological (genetic, biochemical, physical, neurological, etc.), psychological (behaviours, thoughts, emotions, personality, etc.), and social-environmental (cultural and social norms, familial, gender roles, medical, socioeconomic, etc.) factors that influence overall health and well-being. Consequently, health professionals often consider various biopsychosocial factors when making diagnoses, discussing healthcare information, and treating patients to enhance their quality of life. The Biopsychosocial Intervention and Observation Disordered Eating (BIODE) model (see Figure 7.1) illustrates the interconnection between biological, psychological, and socio-cultural factors that may be associated with malnutrition and DE. Predisposition to developing malnutrition and DE is dependent on a wide range of biological, psychological, sociocultural, and environmental factors (Sundgot-Borgen et al., 2013). From a biological perspective, EDs appear to aggregate in families in part due to genetics, but not all individuals with a genetic predisposition develop these disorders as other factors are involved (Anttila et al., 2018; Rantala et al., 2019). Similarly, from a socio-cultural perspective, individuals regularly exposed to societal or cultural pressures regarding weight or appearance may engage in DEBs, but again, not all will develop an ED (Izydorczyk et al., 2020; Swami et al., 2010). Increasing use of social media to interact with others and sedentary lifestyles lead to caloric surplus, which exacerbate DE (Rantala et al., 2019; Swami et al., 2010). Additionally, there are specific personality traits (e.g., perfectionism) and traumatic experiences (e.g., athletic injury) that can increase the likelihood of developing an ED (Blodgett Salafia et al., 2015). Hence, EDs are not simply disorders of eating, but rather conditions characterised by a persistent disturbance of eating or an eating-related behaviour, altering consumption or absorption of food, that significantly impairs social functioning and physical and mental health (APA1, 2013). Determining the proximate mechanism and the ultimate cause of DE is often challenging, which may impede prevention and treatment (Rantala et al., 2019). Thus, knowing the context in which individuals, especially athletes, experience DEBs and EDs is important for early recognition and treatment success. 100

Disordered Eating and Body Dissatisfaction

Figure 7.1

Biopsychosocial Intervention and Observation of Disordered Eating (BIODE)

Biopsychosocial Influences and Pressures of Athleticism Although organised sport and associated activities provide many physical, psychological, and social benefits, they may also require special diets that meet the energy and nutritional demands of training and competing, especially during adolescence for proper growth and development (Blodgett Salafia et al., 2015). As a result, there is a higher prevalence of EDs in both male and female athletes compared to the general population (Martinsen & Sundgot-Borgen, 2013). Like the general population, athletes experience a variety of socio-cultural ideals about appearance, food and exercise behaviour, and body size and shape through the media and what society deems acceptable. Societal and athletic fitness standards perpetuate body dissatisfaction, self-objectification, and thin-ideal internalization (Blodgett Salafia et al., 2015). These standards combined with certain personality characteristics, such as low self-esteem and perfectionistic tendencies, contribute to dysfunctional eating behaviours that increase the risk of developing EDs (Silverii et al., 2021). Risks for developing EDs increase during adolescence, a vulnerable stage in life when many physical and psychological changes occur, such as growth spurts and puberty (Klump, 2013, van den Berg et al., 2002). Participation in sport during this critical developmental period may result in additional physical and psychological demands, which may exacerbate the development of ED pathology (Coelho et al., 2014). 101

Cami Barnes et al.

Consequently, adolescents participating in sport, especially at the elite levels of their age group, may attempt to use inappropriate and dysfunctional strategies to alter their body weight and shape to appear more physically mature and achieve athletic performance success (Kontele & Vassilakou, 2021; Tamminen et al., 2012). Although some evidence exists that indicates participation in sport may protect against the development of EDs, elite athletic environments may trigger or perpetuate ED symptomatology (de Bruin & Oudejans, 2018). For elite athletes, ED symptoms are strongly associated with competitive performance stress – perceived or actual pressures to achieve a desired body weight and appearance (de Bruin & Oudejans, 2018). Psychosocial pressures from teammates and coaches may influence eating attitudes, dieting, and dysfunctional behaviours (e.g., vomiting after meals), and increase the risk for DEBs (Quinn & Robinson, 2020; Voelker et al., 2018). For example, female athletes indicate that training and competition performance pressures, team weigh-ins, and injuries are common triggers relating to ED onset (ArthurCameselle, 2017), whereas male athletes report triggers are related to negative comments from coaches and teammates about their self-worth and identity as an athlete regarding body appearance, dieting, injuries and trauma, and performance achievement (de Bruin, 2017). Therefore, it is imperative that healthcare and sport personnel know the signs and symptoms (e.g., physical, medical, psychological, and behavioural) and the associated consequences of EDs (e.g., premature osteoporosis, muscle weakness and injury, negative ideations).

Types of Eating Disorders and Associated Dysfunctional Behaviours The latest version of the Diagnostic and Statistical Manual of Mental Disorders, the Fifth Edition (DSM-5; APA1, 2013), describes EDs as Clinical Feeding and Eating Disorders (CFEDs). CFEDs includes Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge-eating disorder (BED), Other Specified Feeding or Eating Disorder (OSFED), Pica, Rumination Disorder (RD), Avoidant/Restrictive Food Intake Disorder (ARFID), and Unspecified Feeding or Eating Disorder (UFED). In addition, Body Dysmorphic Disorder (BDD) falls under Obsessive-Compulsive and Related Disorders in the DSM-5, which has common links to EDs (APA1, 2013). While the changes from the previous edition improve the interpretation of data and the ability to diagnosis various mental disorders, Orthorexia Nervosa (ON) was not formally included. Most mental health professionals recognise ON as a DE related dysfunctional condition that can negatively affect the health and wellbeing of individuals (Dunn & Bratman, 2016). Specific criteria for each disorder differentiate them from one another and from other mental health illnesses. Due to performance pressures and emphasis on body shape and size in many sport, athletes are susceptible to EDs and dysfunctional body appearance issues (Clifford & Blyth, 2018; Power et al., 2020). Table 7.1 provides an assessment inventory or checklist of several biological, psychological, and socio-cultural determinants related to AN, BN, BED, BDD, and ON in sport settings.

Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder Over the years and across the various DSM revisions, the most diagnosed ED with the highest health risks and consequences has been AN, which is a health condition associated with restricted food intake that leads to significant weight loss, fear of weight gain, and distorted body image (APA1, 2013). DSM-5 changed AN to be broader and more inclusive by eliminating the criterion of amenorrhea (i.e., loss of menstrual cycle), which allows proper diagnosis of adolescent and adult males with this health condition (Zayas et al., 2018). This change also allows for the inclusion of females who continue menstruating despite extreme weight loss and malnutrition (Estour et al., 2017). Likewise, the revision of the low weight criterion allows for more subjectivity and clinical judgment when assessing growth trajectory and weight history, especially through adolescence and young adulthood (Estour et al., 2017; Zayas et al., 2018). 102

Disordered Eating and Body Dissatisfaction Table 7.1 Assessment Inventory of Disordered Eating Determinants (AIDED) Response∗

Determinants Biological and Physical Age or stage (child, teen, adult, middle age, senior adult) Biological sex, gender identity, expression, orientation, presentation Stages of growth, development or puberty (e.g., Tanner stage 1–5) Family history of disordered eating behaviors Precocious growth of development Bone health and stress injuries Hormone dysfunction (e.g., dysregulated menstrual cycle, libido) Frequent illness Low body fat Dehydration Bad breath, sore gums or signs of enamel loss on teeth Swelling around jaws Skin effects (e.g., dry skin, fine facial hairs, calluses on knuckles) Unexpected weight gain beyond expected growth Dramatic or rapid weight loss or gain or fluctuation Chronic disease related to caloric use (e.g., diabetes, thyroid) Co-occurring conditions (e.g., coeliac disease, other gastrointestinal conditions) Food allergies and intolerances Nutritional deficiency

___ yrs of age Stage _______ ____________ ____________ □ Yes □ □ □ □ □ □ □ □ □ □ □ □ □

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

AN BN BED BDD ON BDD AN BN AN BN ON AN BN ON AN AN BN AN BN AN BN AN BN BED AN BED BED AN BN

□ Yes □ Yes

AN BN ON AN BN BED BDD ON

□ Yes □ Yes

AN BN BED BDD AN BN BED BDD ON AN BN BDD AN BN BED AN ON AN BN BED ON

Other Cognitive and Psychological Body image dissatisfaction and/or distortion Low self-esteem Perfectionism Impulsivity Obsessive-compulsive tendencies Neuroticism (depression, anxiety, emotional lability) Harm avoidance Heightened stress reactivity Inflexible, drive for order and symmetry Sensation seeking or risk-taking behavior Reward dependence Persistently poor and/or declining mental health Increased attention to and/or criticism of body Feeling out of control about food Stressful life experiences or traumatic experiences (e.g., PTSD) Fear of weight gain Increased irritability Socially withdrawn Other

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

AN BN BED BDD AN BN ON AN BN BN BED BDD AN BN BDD BN BED AN BN BED BDD AN BN BDD ON AN BED BDD ON AN BN BDD (Continued)

103

Cami Barnes et al. Table 7.1 (Continued) Determinants

Response∗

Behaviors or Actions Preoccupation with diet, food, calories, body shape and weight

□ Yes

Polarised or dichotomous thinking Avoidance of food-related social activities or events Restrictive eating, undereating, overeating Bathroom visits after meals Evidence of binge eating Secretive behaviors regarding food intake and/or exercise Increasing rigidity or inflexibility in situations Wearing baggy or layered clothing that hides body shape Relentless, excessive exercise (even when injured) Anabolic-androgenic steroid use Use of supplements, nutritional and ergogenic aids Regular body composition testing, weighing, and measuring Public displays of results (e.g., body performance or appearance) Eating of nonnutritive substances (e.g., nonnutritive sweeteners^) Other Social, Cultural, and Environmental Eating pressures/modeling Peer pressure regarding physical appearance or weight Media or social media pressure (e.g., focus on appearance, food) Ideal body type (e.g., thin ideal, muscularity ideal, fit ideal) Direct or perceived pressure to modify appearance or weight Weight and/or appearance-based teasing, bullying Social isolation Experiences of weight stigma (e.g., in healthcare, sport settings) Life and career transitions (e.g., marriage, divorce, retirement) Healthcare, sport or exercise environment Climate and/or season

□ □ □ □ □ □ □ □ □ □ □ □ □ □

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

□ □ □ □ □ □ □

Yes Yes Yes Yes Yes Yes Yes

□ □ □ □ □

Yes Yes Yes Fall Winter

AN BN BED BDD ON AN BN BDD ON AN BDD ON AN BN BED ON BN BN BED BN BED AN ON AN BN BDD AN BDD BDD AN BN BDD AN BN BDD AN BN BDD Pica

AN BN AN BN BDD AN BN BDD AN BN BDD AN BN BDD AN BN BED BDD AN BN BED BDD ON AN BN BDD ON AN BN BED BDD AN BN BDD ON □ Spring □ Summer

Other Note: ∗Last column provides list of possible EDs, including AN = Anorexia Nervosa, BN = Bulimia Nervosa, BED = BingeEating Disorder, BDD = Body Dysmorphic Disorder, Orthorexia Nervosa = ON, and Pica (^ Nonnutritive substances, such as sweeteners that are much sweeter than sugar so only small amounts are needed).

BN was also revised to no longer include the number of times a person binges and purges per week as a key criterion for a diagnosis (APA1, 2013). The criterion now necessitates that the binge eating and purging (i.e., self-induced vomiting or use of laxatives) or non-purging (i.e., fasting or excessive exercise) compensatory behaviours occur at least once per week for three months (APA1, 2013). Furthermore, DSM-5 criteria for BN includes feelings of loss of control and the individuals’ body weight having a significant impact on the way they view themselves. The severity of BN ranges from mild to extreme based on the average number of compensatory behaviours in a one-week time frame. Signs of BN in individuals do not always include the presence of severe thinness, as many individuals with BN are likely to be at a normal weight and in some cases even overweight (Harrington et al., 2015). Individuals with 104

Disordered Eating and Body Dissatisfaction

BN feel intense shame at their behaviour and often try to hide it, but will exhibit symptoms such as constant sore throat, dental issues, and dehydration resulting from repeated self-induced vomiting. Similar but not identical to non-purging BN is BED, which was officially recognised in DSM-5. This addition allows improved diagnosis and treatment for individuals who binge eat at least twice weekly over a period of six months and have marked distress. However, a diagnosis of BED requires an absence of a compensatory behaviour used to prevent weight gain, such as self-induced vomiting, use of laxatives, diuretics, or other medication. BED may now be the most common ED, affecting as many as 3% of the U.S. population, or roughly 10 million people, three times more than those diagnosed with AN and BN combined (Deloitte Access Economics, 2020). In addition, pica, rumination disorder, and avoidant/restrictive food intake disorder (ARFID) represent the section renamed CFEDs. For individuals who engage in DEBs but do not meet the criteria listed under DSM-5 CFEDs there are two classifications known as OSFED and UFED. OSFED applies to individuals who experience some or most of the symptoms of AN, BN or BED; not enough to meet the diagnostic criteria while still experiencing clinically significant distress and impairment in their daily lives. UFED covers issues that are not representative of any specific current category, or when the ED professional has limited information to reach a clinical diagnosis. Understanding the nature and differences of various EDs and unhealthy behaviours early may prevent negative future consequences.

Body Dysmorphic Disorder (BDD) In addition to DSM-5 CFEDs, athletes may also experience an excessive preoccupation with an imagined or small bodily imperfection in the hope of improving body image (Alfano et al., 2011). BDD is a condition defined in the DSM-5 as a preoccupation with a perceived bodily imperfection, deformity, defect, or flaw that is either slightly or not noticeable by others, despite all evidence to the contrary (APA1, 2013). BDD is especially important to consider when interacting with elite athletes due to their potential attention to body fat percentages and muscularity (Alfano et al., 2011; Badenes-Ribera et al., 2019; Grieve, 2007, Grieve & Shacklette, 2012). Evaluating the degree of self-perceived fatness and musculature often materialises through checking reflections in mirrors when weightlifting or viewing video analysis of their training or competition (Alfano et al., 2011; Olivardia et al., 2004). Identifying these incorrect perceptions of body fat percentage and level of musculature may also help prevent injuries. Eating as a prerequisite to leanness results in manipulating diets by using an anabolic or muscle building phase through high food consumption (i.e., period occurring within 45 minutes post-exercise), followed by a catabolic phase (i.e., period when food is digested, and the molecules break down for use as energy). This reduces fat and increases muscle distribution due to a diet restricted below normal energy maintenance levels, resulting in an increase susceptibility to injury (Cafri et al., 2005; Cafri, Blevins, & Thompson, 2006).

Orthorexia Nervosa (ON) Although not listed under a specific category in the DSM-5, many mental health experts view ON as another eating pattern that is dysfunctional. ON has been described as pathological obsession with eating foods one considers healthy (Bert et al., 2019; Dunn & Bratman, 2016). Unlike other EDs, ON mostly revolves around food quality, not quantity. Unlike AN or BN, athletes with ON are rarely focused on losing weight. However, like AN, ON involves restricting the amount and variety of foods eaten, making malnutrition more likely (Bert et al., 2019; Dunn & Bratman, 2016; Uriegas et al., 2021). Therefore, ON shares many of the same physical consequences as AN. ON involves compulsively checking nutritional labels to determine their health value and obsessively following food and ‘healthy lifestyle’ Internet blogs. While healthy and balanced eating is important for any person, especially for elite athletes, obsessive healthy eating fixations may increase the risk for EDs (Uriegas et al., 2021). Awareness and understanding 105

Cami Barnes et al.

of ON, in addition to EDs in athletes, is important to minimise the risk of its occurrence and future disorders and negative health consequences.

Case Vignette: What’s Happening! Nori, a Southern California high school soccer player selected as an All-American her sophomore year, had terrific speed and ball control. Her ability to score goals and make great passes that resulted in assists led to media recognition, which garnered the attention of many college coaches in the area and across the country. Although a key part of her team’s success, several of Nori’s teammates are also highly skilled and have the potential to play soccer at the collegiate level. Going into her junior year, Nori and her parents knew that college scouts would be attending games. Nori was excited for the new soccer season and looking forward to another successful year with her team. During the off-season, Nori spent much time playing in scrimmages and practicing ball control. At a recent scrimmage, Nori was on a fast break when an opposing player collided with her. Nori felt an intense pain in her ankle and immediately noticed swelling and discoloration after removing her cleat. An athletic trainer examined Nori’s injury, noting that it was likely a high ankle sprain and recommended that she not practice for the remainder of the week. Although Nori iced and elevated her ankle during the week, the pain had not subsided, and the swelling and bruising had worsened. Nori’s parents took her to a sport medicine physician for a follow-up evaluation. The X-rays showed that Nori had an avulsion fracture in her ankle. The physician told Nori that she would need surgery and that her recovery time would be 8 to 12 weeks. Nori is frustrated and depressed about missing the upcoming season and believes that this injury will cost her the chance to receive a college soccer scholarship. Following the operation, Nori’s frustration increases, and her interest being around teammates and completing schoolwork wanes. Nori’s brother, also a well-skilled soccer player, teases her about lounging around the house and gaining a few pounds. During that same week, as she watches her team practice, an assistant coach comments about her weight gain, which led Nori to feel embarrassed and guilty about not exercising and practicing. Later that day, her parents also commented about her weight gain. Due to these comments, and since she has not been able to run and workout with her teammates, Nori believes her body has changed and soccer skills are diminishing. As a second-generation Asian-American, Nori puts a lot of pressure on herself to achieve success. Her mother’s own experiences with body image issues have complicated matters regarding Nori’s diet. Because of these comments and expectations, Nori begins engaging in compensatory behaviours without her family, teammates, or coaches realizing. Following meals, Nori goes to the bathroom and forcibly vomits. Although her parents and teammates have not realised her purging tendencies, they have noticed that Nori seems withdrawn and lacks the energy she once had. Her teammates notice that Nori seems irritable and fidgety during lunch or when discussing food. With five weeks left of recovery, Nori’s parents grow concerned about her behaviours and confront her. Nori becomes angry and belligerent when confronted, leaving her parents confused and more worried. In response, her parents decide to seek help from a clinical sport psychologist. During the initial assessment, Nori mentions to the sport psychologist that she feels frustrated due to her inability to play soccer and keep her athletic physique. Nori indicates that she feels overwhelmed, hopeless, and anxious about the future. In addition, Nori confides that she does not know how to meet the expectations of her parents, teammates, coaches, and teachers. Following some discussion with the sport psychologist, Nori shares that she has been purging after meals but does not want anyone to know.

Summary of Key Components Regarding Case Vignette Although Nori does not meet the criteria for a specific disorder (see Table 7.1), Nori is presenting signs of OSFED due to the significant distress and impairment affecting her mental state. The sport psychologist 106

Disordered Eating and Body Dissatisfaction

aids her in informing her family about her OFSED and recommends that she seek treatment. Together, they inform her coach and make plans for treatment. Nori begins working with the sport psychologist to rebuild her confidence and self-esteem by implementing a mindfulness-acceptance-commitment (MAC) based therapeutic approach (discussed in more detail in later section). Because feelings of anger and sadness are common after experiencing an injury, the sport psychologist works with Nori to accept these feelings and respond positively. By using MAC exercises, Nori becomes more aware of her emotions and triggers that lead to compensatory behaviours. The sport psychologist also works with Nori to diffuse negative thoughts, which led to DEBs. Instead, Nori focuses on separating herself from the irrational thoughts to promote increased self-esteem and positive responses. Outside of her therapeutic sessions, Nori has also begun meeting with a dietician to set up a meal plan, which aims to promote a healthy relationship with food. By viewing her relationship with food more positively, Nori can avoid engaging in DEBs and respond effectively to triggers. The coaches and trainers received notice about the treatment plan and work to create a support system that motivates and instils confidence in Nori as she progresses through both injury and DE recovery. After several weeks of treatment and using mindfulness, Nori physically recovers from her injury and shows signs of increased confidence. She is less fearful of eating and expresses a positive view of her body. Nori’s awareness of her emotions and acceptance of what she has control of has helped her avoid compensatory behaviours. Nori feels excited to play soccer again and believes she has the support of her parents, coaches, and teammates.

Eating Disorders, Body Image, and Weight Control Actions Symptoms that do not necessarily meet the clinical diagnosis of EDs due to the frequency, intensity, or duration are also important to address (Joy et al., 2016). Recognizing these subclinical symptoms are vital because their occurrence may result in significant distress, impairment, psychological disturbance, and overtime lead to clinical EDs (Anderson & Petrie, 2012). Athletes tend to be at greater risk of ED compared to non-athletes due to the pressures to achieve a body composition that optimises their athletic performance (Joy et al., 2016). Elite adolescent athletes may be prone to developing DEBs and EDs compared to adult athletes. Adolescence is a vulnerable developmental period in which high-performing young athletes may face a variety of both general and sport-specific risk factors, such as growth, physical and psychological changes, societal pressures, athletic performance, and potential for discontinuity in sport due to injury or performance pressures (Giel et al., 2016). Prevalence of DEBs and EDs has shown to be significantly higher in athletes who participate in weight dependent sport, and sport where leanness is emphasised, such as aesthetic and endurance sport (e.g., running, swimming, gymnastics, and rowing) (Giel et al., 2016; de Oliveira et al., 2017; Veljković et al., 2020). Athletes who compete in weight dependent or weight-sensitive sport report higher rates of ED pathology due to the wide use of pathogenic weight control behaviours (Giel et al., 2016; Sundgot-Borgen et al., 2013). Typical weight control behaviours utilised by athletes include excessive exercise, fasting, dieting, self-induced vomiting, as well as the use of laxatives, diuretics, or performance- and image-enhancing drugs (Werner et al., 2013). DEBs may lead to a variety of negative outcomes, such as increased susceptibility to injury, muscle deficiencies, performance issues due to impairment of optimal athletic function, in addition to social and emotional problems such as elevated levels of self-reported depression and anxiety (Eichstadt et al., 2020; Giel et al., 2016). Although previously viewed as a female disorder, male athletes are also at risk for EDs (Joy et al., 2016). A variety of psychosocial factors contributes to what constitutes the ideal appearance or attractive body type. For females, this ideal focuses on a desire for thinness and leanness while also seeking the curvy and seamless “hourglass” figure. The ideal for male body types also emphasises leanness, but typically places greater emphasis on muscularity. These ideal body types may not always hold true for those competing in elite sport that emphasise aesthetics or those that feature physical contact or combative elements. For example, elite female athletes, particularly power-based female athletes, often resemble males in body 107

Cami Barnes et al.

checking for muscularity such as weighing themselves or comparing their body size to others (Alfano et al., 2011). Society’s ideals for what is an acceptable body type is further perpetuated through social media and comparison, which increases body dissatisfaction, lowers self-esteem, and potentially increases ED symptomatology (Santarossa & Woodruff, 2017). Although clinical level EDs do affect females at higher rates than males, particularly in female adolescent and young adult athletes under the age of 25 (Petisco-Rodriguez et al., 2020), both sexes are at risk for ED in sport that leanness offers a competitive advantage (Joy et al., 2016). In adult male elite athletes, reports indicate that ED prevalence rates range up to 32.5%, which is significantly higher than in the general population (Karrer et al., 2020). The most frequently associated factor in males experiencing DEBs or EDs was their participation in weight-sensitive sport where leanness plays a major role in performance such as weight class, combat, and antigravitation sport (Karrer et al., 2020; Joy et al. 2016). “Body talk” among male athletes also appears to be significantly associated with reports of ED symptoms, specifically when the conversations among teammates are fatfocused (Ahlich et al., 2019). For this reason, EDs have often been much more difficult to identify and diagnose in male athletes due to differing presentations of symptoms, as well as increased secretiveness or stigma around them (Eichstadt et al., 2020). A significant number of athletes report that they are either constantly trying to lose weight, or that they use one or more compensatory behaviours to maintain control over their weight (Giel et al., 2016). Common weight control behaviours that are utilised by athletes include activities that induce passive or active dehydration (i.e., sauna, wearing sweat suits); self-induced vomiting; excessive dieting; as well as the use of diuretics, laxatives, diet pills, and performance- and image-enhancing drugs (Piacentino et al., 2017; Werner et al., 2013). These weight control behaviours are associated with a variety of detrimental health consequences and the development of ED among athletes (Boudreault et al., 2021; Sundgot-Borgen et al., 2013). Weight control behaviours among athletes are particularly prevalent in female athletes and athletes who participate in weight-class dependent sport (Giel et al., 2016; Werner et al., 2013). One common risk factor for why athletes use weight-control behaviours is due to pressure from coaches to lose weight (Anderson & Petrie, 2012). Among adolescent athletes, the occurrence of weight-related maltreatment from coaches or parents was the strongest predictor of their use of extreme weight control behaviours (Boudreault et al., 2021). Athletes have even reported that they view the maltreatment they experience from coaches or parents as normal and a necessary part of the game to achieve success and protect themselves from the high-performance expectations around them (Fortier et al., 2020). The idea that this treatment and pressure from coaches is “normal” in sport environments further perpetuates the weight control issues and potential for development of ED in athletes. Another contributing factor to why athletes may use unhealthy practices (i.e., extreme weight control behaviour, overtraining, using performance enhancing substances, maltreatment from coaches) is because these practices are legitimised as normal in sport due to the dominant culture around performance (Boudreault et al., 2021). For example, collegiate wrestlers reported that controlling their weight was a source of pride and a way to demonstrate that they were striving to be the best (Coker-Cranney et al., 2018). The “slim to win” culture often seen through the experiences of many elite swimmers also highlights the culture of sport and the pressures that lead athletes to engage in weight control behaviours and contributes to struggles with DE (McGannon & McMahon, 2019). Male and female athletes often differ in their reasons for engaging in weight control behaviour. That is, male athletes typically report using weight control and compensatory aiming to change their body in ways that will improve their performance (Werner et al., 2013), whereas perfectionism and body dissatisfaction are usually major predictors of dieting and weight control behaviour in female athletes (Prnjak et al., 2019). Although athletes are not at greater risk for issues related to body image and body satisfaction compared to non-athletes, there are many factors relating to sport environments and societal expectations that contribute to the development of these issues in athletes. Body image refers to the mental image that individuals have of their bodies that is perceptual (i.e., what is seen) and affective (i.e., how one feels about 108

Disordered Eating and Body Dissatisfaction

what they are seeing) (Rudd & Carter, 2006). Issues relating to negative or distorted body image tend to be one of the most prominent underlying factors associated with the development and prevalence of EDs. Female athletes with EDs have higher body dissatisfaction even when they have similar body compositions than those without EDs, because they perceive themselves as “fatter” (de Bruin et al., 2011). However, elite athletes experience numerous pressures regarding body image, which are usually associated with gender stereotypes, sport environments, and type of sport (e.g., aesthetic sport, weight-class sport, physical contact sport). Consequently, there is often links between body weight, body fat, cultural views about femininity and masculinity, athlete body stereotypes, desired athletic characteristics regarding dysfunctional behaviour, individual and team performance expectations, and type of sport (e.g., Rudd & Carter, 2006). For instance, in a 2016 interview, Simone Biles, a U.S. Olympic gymnast, stated, “Going to public school nobody really had a body build that I did, and I was a girl, so the guys would sometimes make fun of me. I think they were just jealous because they didn’t have the muscle definition I did. I would try to hide my muscles, not show them, and I would always wear a jacket” (Murphy & Klosok, 2017). Unfortunately, there is a widespread belief among athletes that they perform better when they weigh a certain amount, or their body looks a certain way. The belief that both lower body weight and lean body mass improves performance leads to greater body dissatisfaction among athletes, which may lead to low energy availability among athletes, causing health and performance issues (Wasserfurth et al., 2020). Participation in sport places athletes, especially elite athletes, in a high-risk culture that overemphasises body and weight (de Bruin & Oudejans, 2018). Coaches play a significant role in their athletes’ beliefs that their body needs to look a certain way to perform at their best. Sport or training environments that require weigh-ins or coaches that simply make comments about athletic bodies contribute significantly to athletes’ dissatisfaction with their bodies (Arthur-Cameselle et al., 2017; Kampouri et al., 2019; Quinn & Robinson, 2020). Regarding athletic body stereotypes, female athletes’ participation in sport exposes them to the development of attributes associated with more masculine characteristics such as strength and power, while also being in a society that emphasises standards of what looks are associated with femininity which place importance on thinness (Steinfeldt et al., 2011). Cultural standards of femininity negatively influence body image, especially when female athletes perceive inconsistencies between their athletic physique and society’s ideals for the feminine body (Leavy et al., 2009; Steinfeldt et al., 2011). However, the NEDA estimates that 33% of male athletes in aesthetic sport (e.g., bodybuilding, gymnastics, swimming) and weight-class sport (e.g., wrestling, rowing) are affected by EDs (Flatt et al., 2021). Sport environments for male athletes tend to place great emphasis on certain traits associated with masculinity – muscular strength, explosiveness, aggressiveness, power, and leanness (DeFeciani, 2016; Karrer et al., 2020). Like female athletes, many male athletes have unrealistic body ideals that stem from society’s standards, presented daily in social media, television, movies, and advertisements. While female body ideals emphasise weight-reduction and thinness, male body ideals focus on weightlifting for muscular body ideals – strength and toning (DeFeciani, 2016). Furthermore, the type of sport male athletes participate in contributes to the presence of body image dissatisfaction as well. For example, characteristics of basketball players include being lean and tall, whereas horse jockeys are light and small. Consequently, jockeys may wear rubber suits, sit in hot saunas, self-induce vomiting, or take cocaine or amphetamines to suppress their appetite, whereas wrestlers may abuse diuretics, binge and purge, or take laxatives to make their weight requirements before a match and then binge after competing. Likewise, bodybuilders and baseball and football players may engage in bingeing and purging and use anabolic steroids (Chaba et al., 2021). The use of steroids is a sign that the athlete has become preoccupied with increasing muscle mass and is associated with BDD (i.e., muscle dysmorphia or “bigorexia”). Athletes who take steroids to improve performance will likely eat more as a result and then try to control their weight, which can result in an ED. In addition, sport that emphasise leanness, specific body weight, or aesthetics are most likely to experience body dissatisfaction, which also places athletes at risk for precursor behaviours related to the development of EDs (de Oliveira et al., 2017). The “fit” of uniforms to the athlete is another contributing 109

Cami Barnes et al.

factor that plays a role in athletes’ body image. Athletes in sport with tight fitting or revealing uniforms (volleyball, cross country, swimming, diving, wrestling, etc.) commonly report discomfort and doubt about the way they look (Nemeth et al., 2020). These athletes believe they must maintain a certain body type that is appealing and compatible with their uniform, which leads to body image concerns (Nemeth et al., 2020).

Health Risks, Well-Being, and Quality of Life Individuals affected by EDs often suffer from other mental health comorbidities such as anxiety, depression, obsessive-compulsive disorder, and substance abuse disorder (Joy et al., 2016). In addition to these mental health issues, there are also a variety of physical health consequences associated with EDs. EDs incur one of the highest mortality rates of any mental health condition. ED deaths are often a result of suicide or cardiac arrhythmia. Suicidal ideation is strongly associated with overexercising, which is common among competitive athletes with EDs (Arcelus et al., 2011). Cardiac arrhythmia may result from electrolyte imbalances associated with self-induced vomiting, as well as laxative or diuretic abuse commonly seen in individuals with BN (Crow et al., 2009). One of the most recognised health consequences associated with EDs in female athletes is the Female Athlete Triad, which involves three interrelated conditions – low-energy availability, menstrual dysfunction, and low bone mineral density. As highlighted through the triad, EDs in female athletes contribute to negative effects on both reproductive and skeletal health. Male athletes also suffer from health consequences associated with EDs and DEBs, such as low energy availability and lower bone mineral density, which may lead to increases susceptibility to injuries, as well as inconsistent performance, problems in recovery, muscular deficiency, and impairment of athletic functioning (Eichstadt et al., 2020). In addition to DE issues that occur during sport careers, many athletes develop or maintain EDs following sport retirement (Buckley et al., 2019). Unfortunately, there is a lack of information about how athletes assimilate back into regular exercise and eating patterns beyond their elite careers and into athletic retirement (Buckley et al., 2019). Nevertheless, the existing research indicates that athletes who experienced career dissatisfaction, career injuries or surgery, and inadequate social support are significantly (i.e., 2.4 times) more likely to develop ED symptoms in athletic retirement (Gouttebarge et al., 2017). Likewise, those competing in high-energy consuming sport may engage in compulsive exercise that match their pre-retirement energy output (Stirling et al., 2012). Body changes during athletic retirement may resemble other significant times of body change, such as puberty, pregnancy, and menopause (Buckley et al., 2019). Recognizing key factors related to continued DEBs or EDs during athletic retirement is important to reduce other negative health consequences (e.g., injuries). These key factors include: (a) continuing to focus on athletic identity; (b) establishing unrealistic expectations related to nutritional and body composition changes; (c) balancing significant energy balance changes or significant body composition shifts away from societal body ideals; (d) accepting the reason for retirement; and (e) time since retirement (Buckley et al., 2019; Karazsia et al., 2013). These factors, and possibly others, illustrate that the departure from sport does not always result in immediate remittance or prevention of dysfunctional eating concerns (Thompson et al., 2021). Consequently, various biopsychosocial factors related to the circumstances that unfold will influence the individual’s treatment needs and goals (see Figure 7.1).

Individual and Team-Based Assessment, Prevention, and Treatment Over the past three decades, the field of EDs has made remarkable strides in identifying, evaluating, and disseminating successful prevention and treatment programs (Ciao et al., 2015). Considered the “gold standard” for the assessment of ED, recent modifications to the Eating Disorder Examination (EDE, Fairburn & Wilson, 1993) reflect the DSM-5 updates. Several modified versions exist for use with 110

Disordered Eating and Body Dissatisfaction

children and their parents. Self-report questionnaires including the EDE-Questionnaire, Eating Disorder Diagnostic Scale, and Eating Disorder Inventory aid in diagnosing ED symptomatology in adolescents and young adults. However, self-report questionnaires may yield less valid data in comparison to semistructured diagnostic interviews, which may provide clinicians additional information. Consequently, using and evaluating EDs with various assessment tools (e.g., diagnostic imagery assessments and mental motor imagery tasks), may be beneficial. For example, Basile et al. (2021) used diagnostic imagery, a schema therapy-derived experiential approach, to acquire detailed descriptions of childhood memories and experiences (i.e., emotions and unmet needs) of ED patients. Likewise, the implicit mental motor imagery task to interrogate the body schema seems to provide information beyond traditional body shape self-report measures (Purcell et al., 2018). Therefore, incorporating diagnostic imagery and imagery tasks with traditional ED assessment measures may provide complementary information that helps determine body image distortion and dissatisfaction that are associated with DE. Any individual who works with athletes serves an important role in identifying and evaluating the presence of an eating disorder. This includes coaches, sport medicine physicians, athletic trainers, sport psychologists, sport dietitians, physical therapists and more. Given that identification and intervention in the early onset of ED often leads to better outcomes, those involved in sport need to be aware of the signs and symptoms (Joy et al., 2016). This is especially important as athletes tend to report high rates of eating pathology, but only 15% are likely to receive any form of mental health treatment due to perceived negative social stigmas, negative relationships with eating pathology, and negative perfectionism (Martin & Anderson, 2019). Importantly, athletes with an ED should receive support from important others, while their privacy and health diagnosis remain confidential. Showing sensitivity and respect toward athletes with EDs may help them ease performance pressures and feelings of guilt (Currie & Morse, 2005). A multidisciplinary team of healthcare professionals with DE knowledge and experience, as well as an extensive understanding of sport should be involved when planning treatments for athletes with EDs (Bratland-Sanda & Sundgot-Borgen, 2013; Joy et al., 2016). One of the first things that should be determined is the level of care needed for the athlete, which is dependent on the severity of their DE habits. Regular medical evaluations can help determine whether athletes with EDs should continue participating in sport throughout their treatment. Athletes who have recently initiated poor eating habits that are less frequent and have not caused serious impairment in their life, may need to receive education, encouragement, and continued follow-up. Conversely, athletes with more severe symptoms who have been engaging in DE behaviours for a longer period may need individual, group and potentially family therapy beyond their ED treatment as well, which may involve inpatient and outpatient care facilities that specialise in EDs (Currie & Morse, 2005). Once the multidisciplinary team members determine the level of care needed, then the treatment plan details the therapeutic intervention. Best practices for treatment planning include (a) communication within the multidisciplinary treatment team, (b) implementation of evidence-based practices, (c) weight and medical monitoring protocols, (d) guidelines for navigating levels of treatment, and (e) how to optimise the benefits of treatment and prevent relapse (Conviser et al., 2018). It is important to consider sport-specific determinants (see Table 7.1: AIDED) that exacerbate the development of ED and those that influence recovery.

Cognitive Behavioural Therapy (CBT) One of the most used therapeutic frameworks that has been effective in treating ED in athletes is Cognitive Behavioural Therapy (CBT; see Argas & Bohon, 2021), which can be utilised in individual and group settings based on the needs of the athletes. If working in a group setting, then all members should be athletes dealing with DE. That is, they may feel more comfortable and better able to relate to each other’s experiences. The tenets of CBT include the notion that behaviours and feelings can change when an 111

Cami Barnes et al.

individual is able to identify, evaluate, and challenge cognitive distortions and core beliefs. Through the CBT framework, athletes may be able to identify their DE triggers and learn new ways of thinking, and ultimately coping by addressing triggers and associated negative feelings. CBT has been successful when treating individuals with BN or BED by limiting or eliminating binge eating and purging, while also improving their maladaptive dieting practices and issues with distorted body image. One barrier to utilizing this framework is that CBT requires regular homework. Thus, clients need to be motivated to seek treatment (Chaba et al., 2021; Currie & Morse, 2005). Athletes may be initially resistant to seeking sport psychology services or receiving treatment for mental health related issues due to their sport socialization and the emphasis on being “mentally tough” and not wanting to show weakness (Martin, 2005; Martin & Anderson, 2019), especially those in masculine sport that require physical contact (Martin, 2005). Due to the perception that performance and weight are interwoven, sport personnel may also be less than supportive of athletes needing treatment, especially initially, due to their focus on the immediate moment and success (Reel & Voelker, 2012). For instance, Michael Phelps indicated that “As an American it’s (seen as) weakness when you ask for help and, in our society, it’s just not what you do. It took me a while to get to that point where it’s OK to ask somebody for help” (Murphy & Wire, 2017). Michael also stated that, “I got down to four-and-a-half percent body fat. I mean, it’s basically like skating on thin ice – any lower than that is unhealthy. Holy hell, four-and-ahalf percent was just ridiculous. I don’t think I’ll ever get back to that again” (Murphy & Wire, 2017). Hence, sport personnel and clinicians involved in treatment plans should be mindful of this potential resistance and may want to consider using mental skills that athletes are familiar with to enhance their treatment receptiveness. In essence, it may be most effective to use a collaborative style of therapy when several co-occurring issues exist or when increased structure of therapy and support is necessary. This dialectical behaviour therapy approach may involve practicing mindfulness and learning specific skills and coping techniques for emotional regulation, interpersonal issues, and distress tolerance related to EDs.

Mindfulness Athletes need to be aware of their biopsychosocial states to achieve and maintain their performance. Using various mental skills (goal setting, imagery, stress and anxiety management, positive self-talk, etc.) can help athletes be aware of their biopsychosocial states to achieve and maintain their performance and can also benefit those struggling with DE (Basile et al., 2021; Brown, 2014; Purcell et al., 2018). Mindfulness, a non-judgmental awareness of biopsychosocial states in the present moment, is a common adjunct therapeutic technique used with other mental skills in sport and performance settings to reduce stress and injury and improve quality of life (e.g., Petterson & Olson, 2017; Röthlin et al., 2016). In addition to enhancing training and competitive experiences, elite athletes can use mindfulness to refocus, facilitate positive thoughts, emotions, and behaviours associated with eating and dieting. Although the use of dispositional mindfulness for eating can benefit individuals who are being treated for EDs, it depends on the level of readiness for such an intervention (Anderson et al., 2015; Godfrey et al., 2015; Rodríguez et al., 2013). That is, the ability to regulate emotional experiences, for instance, not only plays a key role in achieving high performance (Pineau et al., 2014), but also in managing DE. As noted, the severity of DE falls along a continuum (see Figure 7.1). Hence, different treatment needs and goals exist from one end to the other end of the spectrum. For example, AN may present different treatment needs and goals, at least in the early stages of recovery, than BED. Typically, those with BED have less acuity and should be introduced to mindful eating early to help heal the relationship with food and eating pathology (Godfrey et al., 2015), whereas those with AN have physical treatment goals that come before addressing eating pathology (Rodríguez et al., 2013). Mindfulness-based approaches, such as MAC, may positively influence or diminish characteristics associated with DE, such as emotional dysregulation, interceptive awareness, impulsivity, and the drive for thinness (Lattimore et al., 2017). They may also reduce body 112

Disordered Eating and Body Dissatisfaction

image concern and negative affect and improve body appreciation and self-esteem compared to active or dissonance-based programs (Beccia et al., 2018). In serious cases, pharmacologic treatment may be required in addition to therapy, especially when the athlete is presenting significant impairment due to comorbidities such as depression and anxiety. In today’s “selfie and tag-along” culture that promotes judgmental and social media-obsessed interactions, the “no pain, no gain” exercise outcome-oriented focus places tremendous stress on individuals, emotionally and physically. These external and internal pressures reinforce the cycle of turning to food to self-regulate. One aspect of mindfulness for DEBs and EDs is that it helps individuals manage their thoughts and emotions that lead to judgment. Mindfulness is essential because it can diminish negative emotional reactions about the future and events in the past (Brewer et al., 2018). Using mindfulness can heal those with EDs by introducing a healthy relationship with food – meeting needs of autonomy and competency with food. However, using mindful eating exercises in the treatment of EDs is delicate at best. Overtime, the brain and other feedback loops that regulate hunger and fullness (Ely et al., 2017) can automate diets and adaptive eating behaviours. Regardless of why the behaviour started, the body makes adjustments that can override the basics of mindful eating. Thus, physical stabilization is of the highest priority before advocating mindful eating. That is, intervention may be necessary to restore the brain and physical health to a state where mindful eating can be effective, especially for those who are not weight restored or are engaged in active purging behaviours (Brewer et al., 2018). Mindful eating exercises often focus primarily on the food and the process of eating, while attempting to avoid distractions such as reading, talking, watching TV, or exercising. Chewing each bite thoroughly while paying attention to the taste and texture and levels of hunger and fullness without being worried about whether the calories ingested will negatively affect performance can improve the physical and emotional experience of eating and overall health. Mindful eating exercises should also include important thoughts, emotions, and behaviours that occur hours or moments before and after the food intake experience. Positive thoughts and images regarding the activities before and after food intake may be important for altering negative eating behaviours and emotions that regulate hunger and fullness (Brewer et al., 2018; Ely et al., 2017). Therefore, if used correctly as an adjunct therapy, mindfulness, and other positive psychology techniques may help the body make important adjustments to override habitual negative responses that have the potential to enhance social interactions and performance accomplishments, which ultimately aid the overall recovery process.

Support Groups for Eating Disorders The treatment of EDs requires specialised care that may require coaches, athletic trainers, and mental performance consultants to refer athletes to an eating disorder specialist, such as psychologists and registered dietitians. Training in adjunct therapies, such as mindful eating, may benefit ED professionals’ therapeutic interventions. That is, mindfulness is not merely a technique, but requires training and mindful practice to be competent at being non-judgmental, open, and compassionately aware of the athletes’ personal history and health-related issues (Brewer et al., 2018). Prevention of EDs and management of DE in elite athletes is important due to the adverse effects not only on their personal health and performance behaviours, but also on their relationships and financial responsibilities. To help prevent EDs or manage DE, there should be educational programs in place for athletes, parents, coaches, personal managers, athletic trainers, sponsors, and various athletic staff members. Educational programs should: (a) destigmatise DE, (b) highlight populations that are most at risk, (c) indicate barriers to identifying problems, (d) provide the signs and symptoms, (e) describe the effects, and (f) explain the treatment approach and available resources (Bonci et al., 2008). One of the most effective ways to reduce and prevent EDs in athletes is to ensure sport environments are “mind and body-healthy” using the HEALTH Guidelines (see Table 7.2). The educational materials and policies need to emphasise 113

Cami Barnes et al. Table 7.2 Healthy Eating and Actions for Lifetime Happiness (HEALTH) Guidelines 1 2 3 4 5 6 7 8 9 10

Balance energy using mindful eating and weight control action∗ Consider stage of life and ability level related to training and competition schedule Define success on appropriate achievement (incremental stages within control) Be sensitive to psychological and emotional wellbeing Emphasise positive body image as performance challenges increase Emphasise enjoyment of sport and exercise participation Be aware of health-related physical fitness and skill progression Consider personal sources of social support (family and friends in and out of sport) Disregard negative comments of others or inappropriate comparisons to others Consider cultural, ethnicity, sex, and age

Note: ∗Mindful eating and action refer to a present-moment, non-judgmental awareness of the physical and emotional experience of eating and weight control actions.

that athletes’ health comes first. Mind and body healthy environments place emphasis on separating athletes’ weight from their performance, as no ideal body weight exists that leads to superior sport performance (Bonci et al., 2008). Another triggering factor that is often present in sport settings is the use of weigh-ins. Although some sport are weight-based (wrestling, judo, etc.), these weigh-ins should be done privately and kept confidential between athletic staff and the athletes. Coaches need to be aware of how they communicate with their athletes and attempt to avoid attitudes and behaviors that trigger DEBs. Involving athletes and athletic staff members in DE educational and prevention programs such as the Body Projects provide individuals an opportunity to interact in small-groups to discuss ways to strive for healthy athlete specific body ideals (Ciao et al., 2014). Key components of prevention programs should include: (a) identifying differences between the healthy-ideal versus societal and sport-specific thin-ideals; (b) education regarding dietary constraint; (c) relative energy deficiency; (d) nutrition; (e) the importance of balancing caloric input and output, sleep, and exercise; and (f ) self-identifying healthy and unhealthy behaviours, goal setting, and body image exercises. Female athletes participating in the Female Athlete Body Project showed significantly reduced, fewer DE episodes and lower thin-ideal internalization (Stewart et al., 2019), whereas male athletes participating in the Male Adaptation of the Body Project also found decreases in their drive for muscularity and internalization of body ideals (Perelman, 2020). The Bodies in Motion program designed to help athletes focus on fostering supportive relationships, body ideals, mindfulness, environmental situations and triggers, self-compassion, and psychological consequences (Voelker et al., 2019) led to decreases in thinideal internalization, greater satisfaction and appreciation of their bodies, fewer negative feelings, as well as decreased levels of BN symptomatology (Voelker et al., 2019).

Conclusion The purpose of this chapter was to discuss the importance of early recognition of the biopsychosocial factors that influence EDs and body image issues in elite athletes. Understanding common impairments and dysfunctional behaviours that occur in elite athletic settings can help clinicians, sport personnel, and family members address athletes’ cognitive and interpersonal functioning, psychosocial functioning, compulsive exercise, and emphasis placed on weight and performance success (Chaba et al., 2021; de Bruin, 2017; Fewell et al., 2018; Kong & Harris, 2015). Future research should examine the effectiveness of ED prevention and treatment intervention programs for addressing specific risk factors such as gender, athletic status, type of sport, motivations for sport, and sport culture. In addition, determining athletes’, coaches’, and sport medicine professionals’ attitudes and willingness to participate in ED prevention and treatment programs would help advance understanding and possibly reduce future risks. Continued 114

Disordered Eating and Body Dissatisfaction

research needs to determine how participation in high-level sport influences the presentation, treatment, and outcome of individuals with DEBs and EDs (Fewell et al., 2018). The prevention of EDs, the identification and early treatment of mental health problems in elite athletes, is a priority, even after retirement from sport. Thus, it is important to continue to invest in ED screening and nutritional education across athletes’ life span that promote healthy eating habits and positive body image (Martínez-Rodríguez et al., 2021).

References Ahlich, E., Choquette, E.M., & Rancourt, D. (2019). Body talk, athletic identity, and eating disorder symptoms in men. Psychology of Men & Masculinities, 20(3), 347–355. 10.1037/men0000168 Alfano, L., Hildebrandt, T., Bannon, K., Walker, C., & Walton, K.E. (2011). The impact of gender on the assessment of body checking behavior. Body Image, 8(1), 20–25. 10.1016/j.bodyim.2010.09.005 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. Anderson, C., & Petrie, T.A. (2012). Prevalence of disordered eating and pathogenic weight control behaviors among NCAA Division I female collegiate gymnasts and swimmers. Research Quarterly for Exercise and Sport, 83(1), 120–124. 10.1080/02701367.2012.10599833 Anderson L.M., Reilly, E.E., Schaumberg, K., Dmochowski, S., & Anderson, D.A. (2015). Contributions of mindful eating, intuitive eating, and restraint to BMI, disordered eating, and meal consumption in college students. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 21, 83–90. 10.1007/s40519-015-0210-3 Anttila, V., Bulik-Sullivan, B., Finucane, H.K., Walters, R.K., Bras, J., Duncan, L., et al. (2018). Analysis of shared heritability in common disorders of the brain. Science 360, eaa8757. 10.1126/science.aap8757 Arcelus, J., Mitchell, A.J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724–731. 10.1001/archgenpsychiatry. 2011.74 Argas, W.S., & Bohon, C. (2021). Cognitive behavioral therapy for eating disorders. Annual Review of Clinical Psychology, 17, 417–438. 10.1146/annurev-clinpsy-081219-110907 Arthur-Cameselle, J., Sossin, K., & Quatromoni, P. (2017). A qualitative analysis of factors related to eating disorder onset in female collegiate athletes and non-athletes. Eating Disorders, 25(3), 199–215. 10.1080/10640266.2016. 1258940 Badenes-Ribera, L., Rubio-Aparicio, M., Sánchez-Meca, J., Fabris, M.A., & Longobardi, C. (2019). The association between muscle dysmorphia and eating disorder symptomatology: A systematic review and meta-analysis. Journal of Behavioral Addictions, 8(3), 351–371. 10.1556/2006.8.2019.44 Basile, B., Novello, C., Calugi, S., Grave, R.D., & Mancini, F. (2021). Childhood memories in eating disorders: An explorative study using diagnostic imagery. Frontiers in Psychology, 12, 2890. 10.3389/fpsyg.2021.685194 Beccia, A.L., Dunlap, C., Hanes, D.A., Courneene, B.J., & Zwickey, H.L. (2018). Mindfulness-based eating disorder prevention programs: A systematic review and meta-analysis. Mental Health & Prevention, 9, 1–12. 10.1016/j.mhp. 2017.11.001 Bert, F., Gualano, M.R., Voglino, G., Rossello, P., Perret, J.P., & Siliquini, R. (2019). Orthorexia Nervosa: A crosssectional study among athletes competing in endurance sports in Northern Italy. PloS One, 14(8), e0221399. 10.1371/ journal.pone.0221399 Blodgett Salafia, E.H., Jones, M.E., Haugen, E.C., & Schaefer, M.K. (2015). Perceptions of the causes of eating disorders: A comparison of individuals with and without eating disorders. Journal of Eating Disorders, 3, 32. 10.1186/s40337-0150069-8 Bonci, C.M., Bonci, L.J., Granger, L.R., Johnson, C.L., Malina, R.M., Milne, L.W., & Vanderbunt, E.M. (2008). National Athletic Trainers’ Association position statement: Preventing, detecting, and managing disordered eating in athletes. Journal of Athletic Training, 43(1), 80–108. 10.4085/1062-6050-43.1.80 Boudreault, V., Gagnon-Girouard, M-P., Carbonneau, N., Labossiere, S., Begin, C., & Parent, S. (2021). Extreme weight control behaviors among adolescent athletes: Links with weight-related maltreatment from parents and coaches and sport ethic norms. International Review for Sociology of Sport, 57(3), 421–439. 10.1177/10126902211 018672 Bratland-Sanda, S., & Sundgot-Borgen, J. (2013). Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science, 13(5), 499–508. 10.1080/17461391. 2012.740504

115

Cami Barnes et al. Brewer, J.A., Ruf, A., Beccia, A.L., Essien, G.I., Finn, L.M., van Lutterveld, R., & Mason, A.E. (2018). Can mindfulness address maladaptive eating behaviors? Why traditional diet plans fail and how new mechanistic insights may lead to novel interventions. Frontiers in Psychology, 9, 1418. 10.3389/fpsyg.2018.01418 Brown, G.T. (Ed.). (2014). Mind, body and sport: Understanding and supporting student-athlete mental wellness. Indianapolis, IN: National Collegiate Athletic Association. http://www.ncaa.org/sport-science-institute/introduction-mindbody-and-sport Buckley, G.L., Hall, L.E., Lassemillante, A.C.M., Ackerman, K.E., & Belski, R. (2019). Retired athletes and the intersection of food and body: A systematic literature review exploring compensatory behaviours and body change. Nutrients, 11, 1395. 10.3390/nu11061395 Cafri, G., Blevins, N., & Thompson, J.K. (2006). The drive for muscle leanness: A complex case with features of muscle dysmorphia and eating disorder not otherwise specified. Eating and Weight Disorders, 11(4): e117–e118. 10.1007/BF03327575 Cafri, G., Thompson, J.K., Ricciardelli, L., McCabe, M., Smolak, L., & Yesalis, C. (2005). Pursuit of the muscular ideal: Physical and psychological consequences and putative risk factors. Clinical Psychology Review, 25, 215–239. 10.1016/j.cpr.2004.09.003 Chaba, L., Scoffier-Mériaux, S., D’Arripe-Longueville, F., & Lentillon-Kaestner, V. (2021). Eating behaviors among male bodybuilders and runners: Application of the trans-contextual model of motivation. Journal of Clinical Sport Psychology, 15(4), 373–394. 10.1123/jcsp.2019-0097 Ciao, A.C., Latner, J.D., Brown, K.E., Ebneter, D.S., & Becker, C.B. (2015). Effectiveness of a peer-delivered dissonance-based program in reducing eating disorder risk factors in high school girls. International Journal of Eating Disorders, 48(6), 779–784. 10.1002/eat.22418 Ciao, A.C., Loth, K., & Neumark-Sztainer, D. (2014). Preventing eating disorder pathology: common and unique features of successful eating disorders prevention programs. Current Psychiatry Reports, 16(7), 453. 10.1007/s11920014-0453-0 Clifford, T., & Blyth, C. (2018). A pilot study comparing the prevalence of orthorexia nervosa in regular students and those in university sports teams. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 24(3), 473–480. 10.1007/s40519-018-0584-0 Coelho, G.M., Gomes, A.I., Ribeiro, B.G., & Soares, E. (2014). Prevention of eating disorders in female athletes. Open Access Journal of Sports Medicine, 5, 105–113. 10.2147/OAJSM.S36528 Coker-Cranney, A., Watson, J.C., Bernstein, M., Voelker, D.K., & Coakley, J. (2018) How far is too far? Understanding identity and overconformity in collegiate wrestlers. Qualitative Research in Sport, Exercise and Health, 10(1), 92–116. 10.1080/2159676X.2017.1372798 Conviser, J.H., Tierney, A.S., & Nickols, R. (2018). Essentials for best practice: Treatment approaches for athletes with eating disorders. Journal of Clinical Sport Psychology, 12(4), 495–507. 10.1123/jcsp.2018-0013 Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., & Mitchell, J.E. (2009). Increased Mortality in Bulimia Nervosa and Other Eating Disorders. American Journal of Psychiatry, 166(12), 1342–1346. https://doi.org/10.1176/appi.ajp.2009.09020247 Currie, A., & Morse, E.D. (2005). Eating Disorders in Athletes: Managing the Risks. Clinics in Sports Medicine, 24(4) , 871–883. 10.1016/J.CSM.2005.05.005 de Bruin, A.K. (2017). Athletes with eating disorder symptomatology, a specific population with specific needs. Current Opinion In Psychology, 16, 148–153. 10.1016/j.copsyc.2017.05.009 de Bruin, A.K., & Oudejans, R.R. (2018). Athletes’ body talk: The role of contextual body image in eating disorders as seen through the eyes of elite women athletes. Journal of Clinical Sport Psychology, 12(4), 675–698. 10.1016/ j.copsyc.2017.05.009 de Bruin, A.P., Oudejans, R.R., Bakker, F.C., & Woertman, L. (2011). Contextual body image and athletes’ disordered eating: The contribution of athletic body image to disordered eating in high performance women athletes. European Eating Disorders Review, 19(3), 201–215. 10.1002/erv.1112 DeFeciani, L. (2016). Eating disorders and body image concerns among male athletes. Clinical Social Work Journal, 44(1), 114–123. 10.1007/s10615-015-0567-9 de Oliveira, G.L., de Oliveira, T.A.P., de Pinho Gonçalves, P.S., Valentim Silva, J.R., Roquetti Fernandes, P., & Fernandes Filho, J. (2017). Body Image and Eating Disorders in Female Athletes of Different Sports. Journal of Exercise Physiology Online, 20(2). Deloitte Access Economics. (2020, June). The social and economic cost of eating disorders in the United States of America: A report for the Strategic Training Initiative for the Prevention of Eating Disorders and the Academy for Eating Disorders. Available at: https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/ Dunn, T.M., & Bratman, S. (2016). On orthorexia Nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11–17. 10.1016/j.eatbeh.2015.12.006

116

Disordered Eating and Body Dissatisfaction Eichstadt, M., Luzier, J., Cho, D., & Weisenmuller, C. (2020). Eating disorders in male athletes. Sports Health, 12(4), 327–333. 10.1177/1941738120928991 Ely, A.V., Wierenga, C.E., Bischoff-Grethe, A., Bailer, U.F., Berner, L.A., Fudge, J.L., Paulus, M.P., & Kaye, W.H. (2017). Response in taste circuitry is not modulated by hunger and satiety in women remitted from bulimia nervosa. Journal of Abnormal Psychology, 126(5), 519–530. 10.1037/abn0000218 Engel, G.L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. 10.1126/science.847460 Estour B., Marouani N., Sigaud T., Lang, F., Fakra, E., Ling, Y., et al. (2017). Differentiating constitutional thinness from anorexia nervosa in DSM 5 era. Psychoneuroendocrinology, 84, 94–100. 10.1016/j.psyneuen.2017.06.015 Fairburn, C.G., & Wilson, G.T. (1993). Binge eating: Nature, assessment and treatment (12th ed.). New York: Guilford Press. 10.5860/choice.31-4640 Fewell, L.K., Nickols, R., Tierney, A.S., & Levinson, C.A. (2018). Eating disorders in sport: Comparing eating disorder symptomatology in athletes and non-athletes during intensive eating disorder treatment. Journal of Clinical Sport Psychology, 12(4), 578–594. 10.1123/jcsp.2018-0046 Flatt, R., Thornton, L., Fitzsimmons‐Craft, E., Balantekin, K., Smolar, L., Mysko, C., Wilfley, D.E., Barr Taylor, C., DeFreese, J.D., Bardone-Cone, A.M., & Bulik, C. (2021). Comparing eating disorder characteristics and treatment in self‐identified competitive athletes and non‐athletes from the National Eating Disorders Association online screening tool. International Journal of Eating Disorders, 54(3), 365–375. 10.1002/eat.23415 Fortier, K., Parent, S., Lessard, G. (2020) Child maltreatment in sport: Smashing the wall of silence: A narrative review of physical, sexual, psychological abuses and neglect. British Journal of Sports Medicine, 54(1), 4–7. 10.1136/ bjsports-2018-100224 Giel, K.E., Hermann‐Werner, A., Mayer, J., Diehl, K., Schneider, S., Thiel, A., & Zipfel, S., & GOAL Study Group. (2016). Eating disorder pathology in elite adolescent athletes. International Journal of Eating Disorders, 49(6), 553–562. 10.1002/eat.22511 Glazer, J. (2008). Eating disorders among male athletes. Current Sports Medicine Reports, 7, 332–337. 10.1249/ JSR.0b013e31818f03c5 Godfrey, K.M., Gallo L.C., & Afari, N. (2015). Mindfulness-based interventions for binge eating: A systematic review and meta-analysis. Journal of Behavior Medicine, 38(2), 348–362. 10.1007/s10865-014-9610-5 Gouttebarge, V., Jonkers, R., Moen, M., Verhagen, E., Wylleman, P., & Kerkhoffs, G. (2017). The prevalence and risk indicators of symptoms of common mental disorders among current and former Dutch elite athletes. Journal of Sports Science, 35, 2148–2156. 10.1080/02640414.2016.1258485 Grieve, F.G. (2007). A conceptual model of factors contributing to the development of muscle dysmorphia. Eating Disorders, 15(1), 63–80. 10.1080/10640260601044535 Grieve, F.G., & Shacklette, M.D. (2012). Brief report on men’s bodies and mood: Correlates between depressive symptoms and muscle dysmorphia symptoms. North American Journal of Psychology, 14, 563. Retrieved from http:// www.freepatentsonline.com/article/North-American-Journal-Psychology/312401777.html Hackert, A.N., Kniskern, M.A., & Beasley, T.M. (2020). Academy of Nutrition and Dietetics: Revised 2020 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in eating disorders. Journal of the Academy of Nutrition and Dietetics, 120(11), 1902–1919 E54. 10.1016/j.jand.2020.07.014 Harrington, B.C., Jimerson, M., Haxton, C., & Jimerson, D.C. (2015). Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician, 91(1), 46–52. Izydorczyk, B., Sitnik-Warchulska, K., Lizińczyk, S., & Lipowska, M. (2020). Socio-cultural standards promoted by the mass media as predictors of restrictive and bulimic behaviors. Frontiers in Psychology, 11, 506. 10.3389/fpsyt.2020. 00506 Joy, E., Kussman, A., & Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. British Journal of Sports Medicine, 50(3), 154–162. 10.1136/bjsports-2015-095735 Kampouri, D., Kotopoulea-Nikolaidi, M., Daskou, S., & Giannopoulou, I. (2019). Prevalence of disordered eating in elite female athletes in team sports in Greece. European Journal of Sport Science, 19(9), 1267–1275. 10.1080/174613 91.2019.1587520 Karazsia, B.T., van Dulmen, M.H., Wong, K., & Crowther, J.H. (2013). Thinking meta-theoretically about the role of internalization in the development of body dissatisfaction and body change behaviors. Body Image, 10(4), 433–441. 10.1016/j.bodyim.2013.06.005 Karrer, Y., Halioua, R., Mötteli, S., Iff, S., Seifritz, E., Jäger, M., & Claussen, M.C. (2020). Disordered eating and eating disorders in male elite athletes: A scoping review. BMJ Open Sport & Exercise Medicine, 6(1), e000801. 10.1136/ bmjsem-2020-000801

117

Cami Barnes et al. Klump, K.L. (2013). Puberty as a critical risk period for eating disorders: A review of human and aminal studies. Human Behavior, 64(2), 399–410. 10.1016/j.yhbeh.2013.02.019 Kong, P., & Harris, L.M. (2015). The sporting body: Body image and eating disorder symptomatology among female athletes from leanness focused and nonleanness focused sports. The Journal of Psychology, 149(2), 141–160. 10.1080/ 00223980.2013.846291 Kontele, I., & Vassilakou, T. (2021). Nutritional risks among adolescent athletes with disordered eating. Children, 8, 715–731. 10.3390/children8080715 Lattimore, P., Mead, B.R., Irwin, L., Grice, L., Carson, R., & Malinowski, P. (2017). ‘I can’t accept that feeling’: Relationships between interoceptive awareness, mindfulness and eating disorder symptoms in females with, and atrisk of an eating disorder. Psychiatry Research, 247, 163–171. 10.1016/j.psychres.2016.11.022 Leavy, P., Gnong, A., & Ross, L.S. (2009). Femininity, masculinity, and body image issues among college-age women: An in-depth and written interview study of the mind-body dichotomy. The Qualitative Report, 14(2), 261. Retrieved from http://www.nova.edu/ssss/QR/QR14-2/leavy.pdf Lonergan, A.R., Bussey, K., Fardouly, J., Griffiths, S., Murray, S.B., Hay, P., Mond, J., Trompeter, N., & Mitchison, D. (2020). Protect me from my selfie: Examining the association between photo-based social media behaviors and self-reported eating disorders in adolescence. International Journal of Eating Disorders, 53(5), 755–766. 10.1002/ eat.23256 Martin, S.B. (2005). High school and college athletes’ attitudes toward sport psychology consulting. Journal of Applied Sport Psychology, 17, 127–139. 10.1080/10413200590932434 Martin, S.J., & Anderson, T. (2019). Help-seeking for eating pathology among college athletes: Examining stigma and perfectionism as moderating and mediating mechanisms. Journal of Clinical Sport Psychology, 14(3), 1–30. 10.1123/ jcsp.2018-0098 Martinsen, M., & Sundgot-Borgen, J. (2013). Higher prevalence of eating disorders among adolescent elite athletes than controls. Medicine and Science in Sports and Exercise, 45(6), 1188–1197. 10.1249/MSS.0b013ce318281a939 Martínez-Rodríguez, A., Vicente-Martínez, M., Sánchez-Sánchez, J., Miralles-Amorós, L., Martínez-Olcina, M., & Sánchez-Sáez, J.A. (2021). Eating disorders in top elite beach handball players: Cross sectional study. Children, 8(3), 245. 10.3390/children8030245 McGannon, K.R., & McMahon, J. (2019). Understanding female athlete disordered eating and recovery through narrative turning points in autobiographies. Psychology of Sport and Exercise, 40, 42–50. 10.1016/j.psychsport.2018. 09.003 Murphy, C., & Klosok, A. (2017). Simone Biles: Body image issue was biggest personal challenge. Retrieved from https://www.cnn.com/2017/07/03/sport/simone-biles-olympics-rio-2016-body-image/index.html Murphy, C., & Wire, C. (July 7, 2017). Michael Phelps: ’I locked myself in my room f or four days’. Retrived from: https://www.cnn.com/2017/07/03/sport/olympics-michael-phelps-swimming-mental-health/in dex.html Nemeth, M.C., Park, H., & Mendle, J. (2020). Collegiate female athletes’ body image and clothing behaviors. Fashion and Textiles, 7(1), 1–17. 10.1186/s40691-020-0207-z Olivardia, R., Pope, H.G., Jr., Borowiecki, J.J. III, & Cohane, G.H. (2004). Biceps and body image: The relationship between muscularity and self-esteem, depression, and eating disorder symptoms. Psychology of Men & Masculinity, 5(2), 112–120. 10.1037/1524-9220.5.2.112 Pater, J.A. , Reining, L.E. , Miller, A.D. , Toscos, T. , & Mynatt, E.D. (2019). Exploring male‐related eating disordered content across social media platforms.In Proceedings of the 2019 CHI Conference on Human Factors in Computing Systems (CHI ’19). Association for Computing Machinery, New York, NY, USA, Paper 651, 1–13. https://doi.org/10.1145/3290605.3300881 Perelman, H. (2020). Decreasing body dissatisfaction in male college athletes: A pilot study of the male athlete body project (Doctoral dissertation, Illinois Institute of Technology). Petisco-Rodríguez, C., Sánchez-Sánchez, L.C., Fernández-García, R., Sánchez-Sánchez, J., & García-Montes, J.M. (2020). Disordered eating attitudes, anxiety, self-esteem and perfectionism in young athletes and non-athletes. International Journal of Environmental Research and Public Health, 17(18), 6754. 10.3390/ijerph17186754 Petterson, H. & Olson, B.L. (2017). Effects of mindfulness-based interventions in high school and college athletes for reducing stress and injury, and improving quality of life. Journal of Sport Rehabilitation, 26(6), 578–587. 10.1123/ jsr.2016-0047 Piacentino, D., Kotzalidis, G.D., Longo, L., Pavan, A., Stivali, L., Stivali, G., Ferracuti, S., Brugnoli, R., Frati, P., Fineschi, V., Girardi, P., & Sani, G. (2017). Body Image and Eating Disorders are Common among Professional and Amateur Athletes Using Performance and Image Enhancing Drugs: A Cross-Sectional Study. Journal of Psychoactive Drugs, 49(5), 373–384. 10.1080/02791072.2017.1359708 Pineau, T.R., Glass, C.R., & Kaufman, K.A. (2014). Mindfulness in sport performance. In A. Ie, C.T. Ngnoumen, & E.J. Langer (Eds.), Handbook of mindfulness (pp. 1004–1033). Wiley-Blackwell. 10.1002/9781118294895.ch52

118

Disordered Eating and Body Dissatisfaction Power, K., Kovacs, S., Butcher-Poffley, L., Wu, J., & Sarwer, D. (2020, February 14). Disordered eating and compulsive exercise in collegiate athletes: Applications for sport and research. The Sport Journal, 24, Retrieved from: https://thesportjournal.org/article/disordered‐eating‐and‐compulsive‐exercise‐in‐collegiate‐athletes‐applications‐ for‐sport‐and‐research/ Prnjak, K., Jukic, I., & Tufano, J.J. (2019). Perfectionism, body satisfaction and dieting in athletes: The role of gender and sport type. Sports, 7, 181. 10.3390/sports7080181 Purcell, J.B., Winter, S.R., Breslin, C.M., White, N.C., Lowe, M.R., & Branch Coslett, H. (2018). Implicit Mental Motor Imagery Task demonstrates a distortion of the body schema in patients with eating disorders. Journal of the International Neuropsychological Society 24(7), 715–723. 10.1017/S1355617718000371 Quinn, M.A., & Robinson, S. (2020). College athletes under pressure: Eating disorders among female track and field athletes. The American Economist, 65(2), 232–243. 10.1177/0569434520938709 Rantala, M.J., Luoto, S., Krama, T., & Krams, I. (2019). Eating disorders: An evolutionary psychoneuroimmunological approach. Frontiers in Psychology, 10, 2200. 10.3389/fpsyg.2019.02200 Reel, J.J., & Voelker, D. (2012). Sculpted to perfection: Addressing and managing body image concerns and disordered eating among athletes. In R. Schinke (Ed.), Athletic Insight’s Writings in Sport Psychology (pp. 301–316). Nova Science Publishers, Inc. Rodríguez, I., Cowdrey F., & Park, R. (2013). Is there a place for mindfulness in the treatment of anorexia nervosa? Advances in Eating Disorders, 2(1), 1–11. 10.1080/21662630.2013.795755 Röthlin, P., Birrer, D., Horvath, S., & Holtforth, M.G. (2016). Psychological skills training and a mindfulness-based intervention to enhance functional athletic performance: Design of a randomized controlled trial using ambulatory assessment. BMC Psychology, 4, 39. doi.org/10.1186/s40359-016-0147-y Rudd, N.A., & Carter, J.E. (2006). Building positive body image among college athletes: A socially responsible approach. Clothing and Textiles Research Journal, 24, 363–380. 10.1177/0887302X06293073 Santarossa, S., & Woodruff, S.J. (2017). #SocialMedia: Exploring the relationship of social networking sites on body image, self-esteem, and eating disorders. Social Media+ Society, 3(2), 1–10. 10.1177/2056305117704407 Silverii, G.A., Benvenuti, F., Morandin, G., Ricca, V., Monami, M., Mannucci, E., & Rotella, F. (2021). Eating psychopathology in ballet dancers: A meta-analysis of observational studies. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 27, 1–10. 10.1007/s40519-021-01213-5 Steinfeldt, J.A., Zakrajsek, R., Carter, H., & Steinfeldt, M.C. (2011). Conformity to gender norms among female student-athletes: Implications for body image. Psychology of Men & Masculinity, 12, 401–416. http://dx.doi.org/1 0.1037/a0023634 Stewart, T.M., Pollard, T., Hildebrandt, T., Wesley, N.Y., Kilpela, L.S., & Becker, C.B. (2019). The Female Athlete Body Project study: 18‐month outcomes in eating disorder symptoms and risk factors. International Journal of Eating Disorders, 52(11), 1291–1300. 10.1002/eat.23145 Stirling, A.E., Cruz, L.C., & Kerr, G.A. (2012). Influence of retirement on body satisfaction and weight control behaviors: Perceptions of elite rhythmic gymnasts. Journal of Applied Sport Psychology, 24(2), 129–143. 10.1080/ 10413200.2011.603718 Sundgot-Borgen, J., Meyer, N.L., Lohman, T.G., Ackland, T.R., Maughan, R.J., Stewart, A.D., & Müller, W. (2013). How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the ad hoc research working group on body composition, health and performance, under the auspices of the IOC medical commission. British Journal of Sports Medicine, 47(16), 1012–1022. 10.1136/bjsports-2013-092966 Sundgot-Borgen, J., & Torstveit, M.K. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. Clinical Journal of Sport Medicine, 14, 25–32. 10.1097/00042752-200401000-00005 Swami, V., Frederick, D.A., Aavik, T., Alcalay, L., Allik, J., Anderson, D., et al., (2010). The attractive female body weight and female body dissatisfaction in 26 countries across 10 world regions: Results of the international body project I. Personality in Social Psychology Bulletin, 36, 309–325. 10.1177/0146167209359702 Tamminen, K.A., Holt, N.L., & Crocker, P.R. (2012). Adolescent athletes: Psychosocial challenges and clinical concerns. Current Opinion in Psychiatry, 25(4), 293–300. 10.1097/YCO.0b013e3283541248 Thompson, A., Petrie, T., Balcom, K., Tackett, B., & Edward Watkins, C. (2021). Psychosocial predictors of eating classification in female athletes: From collegiate sport to retirement. International Journal of Eating Disorders, 54(4), 646–651. 10.1002/eat.23456 Uriegas, N.A., Winkelmann, Z.K., Pritchett, K., & Torres-McGehee, T.M. (2021). Examining eating attitudes and behaviors in collegiate athletes, the association between orthorexia Nervosa and eating disorders. Frontier Nutrition, 11(8), 763–838. 10.3389/fnut.2021.763838 van den Berg, P., Thompson, J.K., Obremski-Brandon, K., & Coovert, M. (2002). The Tripartite Influence model of body image and eating disturbance: A covariance structure modeling investigation testing the mediational role of appearance comparison. Journal of Psychosomatic Research, 53(5), 1007–1020. 10.1016/s0022-3999(02)00499-3

119

Cami Barnes et al. Veljković, A.A., Đurović, D., Biro, F., Stojanović, K., & Ilić, P. (2020). Eating attitudes and body image concerns among female athletes from aesthetic sports. Annales Kinesiologiae, 11(1), 3–16. 10.35469/ak.2020.242 Voelker, D.K., Petrie, T.A., Reel, J.J., & Gould, D. (2018). Frequency and psychosocial correlates of eating disorder symptomatology in male figure skaters. Journal of Applied Sport Psychology, 30(1), 119–126. 10.1080/10413200.2017. 1325416 Voelker, D.K., Petrie, T.A., Huang, Q., & Chandran, A. (2019). Bodies in motion: An empirical evaluation of a program to support positive body image in female collegiate athletes. Body Image, 28, 149–158. 10.1016/ j.bodyim.2019.01.008 Wasserfurth, P., Palmowski, J., Hahn, A., & Krüger, K. (2020). Reasons for and consequences of low energy availability in female and male athletes: Social environment, adaptations, and prevention. Sports Medicine-Open, 6(1), 1–14. 10.1186/ s40798-020-00275-6 Werner, A., Thiel, A., Schneider, S., Mayer, J., Giel, K.E., & Zipfel, S. (2013). Weight-control behaviour and weight-concerns in young elite athletes–A systematic review. Journal of Eating Disorders, 1(1), 1–13. 10.1186/20502974-1-18 Wells, K.R., Jeacocke, N.A., Appaneal, R., Smith, H.D., Vlahovich, N., Burke, L.M., & Hughes, D. (2020). The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport. British Journal of Sports Medicine, 54(21), 1247–1258. 10.1136/ bjsports-2019-101813 Zayas, L.V., Wang, S.B., Coniglio, K., Becker, K., Murray, H.B., Klosterman, E., Kay, B., Bean, P., Weltzin, T., Franko, D.L., Eddy, K.T., & Thomas, J.J. (2018). Gender differences in eating disorder psychopathology across DSM-5 severity categories of anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 51(9), 1098–1102. 10.1002/eat.22941

120

8 ADDICTION (DRUGS AND GAMBLING) DISORDERS IN ATHLETES Claudia L. Reardon and Ryan Benoy

Introduction Athletes are not immune from mental health symptoms and disorders. Addiction disorders, specifically including substance use and gambling disorders, represent important examples of this. Athletes are, in some respects, disproportionately affected by addiction disorders relative to the general population. There have been several high-profile examples of this among elite athletes in recent years, and simultaneously, many athletes suffer in silence. This chapter focuses on these disorders. Specifically, substance use disorders covered in this chapter relate to recreational drugs; for ergogenic substance use, see Chapter 19.

Definitions and Reasons for Use/Participation in Addictive Behaviours It is important to distinguish substance use from substance misuse and substance use disorders. Substance use is defined as occasional social, recreational, or episodic experimentation without associated problems (United States Department of Health and Human Services, 2016). Substance misuse is defined as heavy, risky, harmful, hazardous, illicit, improper, or problem use and typically involves progression to a more regular and/or serious level of use (United States Department of Health and Human Services, 2016). Finally, substance use disorders are defined as those that involve clinically significant distress or impairment including at least some of the following: excessive use; excessive time spent using or recovering from use; unsuccessful efforts to cut down; cravings; failure to meet important obligations because of use; continued use despite negative consequences; reduced time spent on important activities because of use; physically hazardous use; and tolerance and/or withdrawal if stopping use (American Psychiatric Association, 2013). Gambling disorder is a “non-substance-related disorder” within the “substance-related and addictive disorders” section of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013). It is defined as a persistent and recurrent gambling behaviour leading to clinically significant distress or impairment (American Psychiatric Association, 2013). The behaviour cannot be better explained by a manic episode (which can cause excessive spending). It includes at least some of the following: need to gamble with increasing amounts of money in order to achieve the desired level of excitement; restlessness or irritability when attempting to cut down or stop gambling; repeated unsuccessful efforts to control, cut back, or stop gambling; preoccupation with gambling (including persistent thoughts of reliving past gambling experiences, handicapping, or planning the next gambling venture, and/or thinking of ways with which to gamble); often gambling when feeling distress (e.g., helpless, guilty, anxious, depressed); DOI: 10.4324/9781003099345-12

121

Claudia L. Reardon and Ryan Benoy

after losing money gambling, often returns another day to get even (chase one’s losses); lies to conceal the extent of involvement with gambling; jeopardizing or losing a significant relationship, job, or educational or career opportunity because of gambling; and reliance on others to provide money to relieve desperate financial situations caused by gambling (American Psychiatric Association, 2013). There are varied reasons why athletes start to and/or continue to use recreational substances. Many of these overlap with reasons for use by non-athletes and include: experimentation; pleasure; socialization; boost confidence; increase alertness and energy; relieve stress and negative emotions; and relieve pain (McDuff et al., 2019). As use increases, reasons for continued use also may include cravings and relief of withdrawal (McDuff et al., 2019). Similarly, there are several reasons why athletes might gamble. These include winning money; enjoyment/fun; social reasons; excitement; and thrill of competition (Barry et al., 2014). Elite athletes might be particularly likely to gamble given the availability and accessibility of gambling venues to them, the social acceptability and glamorization of gambling, their access to money through loans, credit cards, and scholarships, their general risk-taking, their perceived knowledge of sport that might inform sport wagering, and their self-perceived invulnerability (Derevensky et al., 2019).

General Prevalence In most sport, athletes use substances at lower rates than the general population, especially during the competitive season (McDuff et al., 2019). For example, U.S. collegiate athletes across all sport report lower annual use of alcohol, cigarettes, marijuana, stimulants (amphetamines and cocaine), ecstasy, and lysergic acid diethylamide than non-athlete college students (National Collegiate Athletic Association, 2018; Schulenberg et al., 2017; SIUC/Core Institute, 2013). However, athletes in some sport and across genders use and misuse some substances at higher rates than non-athletes (McDuff et al., 2019). Studies of prevalence rates of problem gambling among collegiate athletes suggest that the rates of disordered gambling are significant, ranging from 2.9% to 15%, with men much more likely to be afflicted than women (Ellenbogen et al., 2008). Elite athletes may be particularly susceptible to gambling problems relative to the general population (Shead et al., 2010). For example, rates of gambling during the previous year by European professional athletes have been reported at 56.6%, with problem gambling at 8.2% (Grall-Bronnec et al., 2016).

Specific Substances Alcohol While overall rates of alcohol use are reportedly lower among many cohorts of athletes, binge drinking rates are often higher. U.S. elite male athletes in lacrosse, ice hockey, rugby, wrestling, and swimming have reported disproportionately high binge drinking rates (Du Preez et al., 2017; National Collegiate Athletic Association, 2018;). Professional European male football (soccer) players (Gouttebarge et al., 2015) and professional male rugby players, the latter spanning four continents in one study, have reported relatively high rates of recent adverse alcohol behaviours (e.g., regular, heavy drinking and/or binge drinking; Zanotti et al., 2017). Alcohol may be used by athletes for many reasons, including before competition to reduce performance anxiety or tremor, and after competition, to reduce stress, increase social connectedness, and improve team cohesion (McDuff et al., 2019). The latter factors are particularly relevant in sport with strong cultural connections to alcohol, e.g., football (soccer), U.S. football, rugby, and lacrosse (McDuff et al., 2019). Despite the motivations for use, alcohol has detrimental effects on sport performance. These include dehydration, insomnia/poor sleep quality, injury, slower injury healing, impaired psychomotor 122

Addiction Disorders in Athletes

performance, lateness, missing obligations due to use or recovering from use, reduced glycogen resynthesis, weight gain, and academic difficulties that can threaten sport eligibility in student-athletes (McDuff & Baron, 2005). Heavy alcohol use is also associated with negative mental health outcomes, including depression and suicidality (Dvorak et al., 2013).

Cannabinoids Cannabis is the most widely used illicit substance in the general population and in most cohorts of elite athletes (McDuff et al., 2019). However, athletes overall use cannabis less than the general population (McDuff et al., 2019). Use has increased among athletes living in locations where medical or recreational cannabis is now legal—an increasingly common situation (National Collegiate Athletic Association, 2018). Among collegiate athletes, more Division III athletes (i.e., those at smaller colleges/universities) use cannabis than do Division I athletes (those at the larger colleges/universities; National Collegiate Athletic Association, 2018). Cannabidiol (CBD) is a natural compound found in cannabis plants that does not contain tetraydrocannabinol (THC—the psychoactive component of marijuana that gives the high). CBD products are increasingly available (McDuff et al., 2019) and of interest to many athletes. However, 25% of CBD products may be contaminated with meaningful amounts of THC (Lachenmeier et al., 2020) that could result in positive drug tests (Bonn-Miller et al., 2017). Similarly, synthetic cannabinoids are increasingly popular, and their use by athletes has been increasingly detected (Möller et al., 2010). These synthetic formulations may be neurotoxic and appear to share psychoactive effects with THC (Castaneto et al., 2014). While athletes report use of cannabinoids for pain control, insomnia, stress, anxiety, anger, depression, and management of concussion, there is little evidence to support their effectiveness for these purposes (McDuff et al., 2019). In fact, heavy cannabinoid use is associated with negative mental health outcomes including psychosis, mania, and suicide (Sideli et al., 2019). Moreover, several performance-limiting effects have been reported, including increased heart rate, slowed reaction time, impaired coordination, reduced motivation, anxiety, psychosis, and confusion (LaBrie et al., 2009).

Nicotine Nicotine is consumed in many forms, including via smoking (e.g., via cigarettes or cigars), orally (e.g., via snuff), or vaping. It is commonly used by athletes, especially in certain sport. For example, U.S. data show particularly common use by male lacrosse, baseball, and ice hockey athletes (National Collegiate Athletic Association, 2018). Data are sparser for female athletes, but for U.S. collegiate athletes, the highest use rate is for ice hockey (National Collegiate Athletic Association, 2018). Vaping of nicotine is increasingly common, with 8% of U.S. collegiate student athletes reporting use in this form in the past year (National Collegiate Athletic Association, 2018). Athletes report use of nicotine for reasons that include improvements in alertness and concentration, energy, muscular strength and power, endurance, relaxation, weight control, and relief of boredom (McDuff et al., 2019). However, these effects are not well substantiated by research (McDuff et al., 2019). On the converse, performance decrement might ensue due to anxiety, insomnia, and respiratory infections (McDuff & Baron, 2005).

Stimulants Stimulants include caffeine, nicotine (covered above), prescription medications (e.g., methylphenidate or amphetamine salts most commonly prescribed for attention-deficit/hyperactivity disorder), methamphetamine, and cocaine. It is easy for athletes, with conscious intention or not, to consume large amounts 123

Claudia L. Reardon and Ryan Benoy

of caffeine via dietary supplements with or without other caffeinated products. Stimulants may be used by athletes for recreational purposes or performance-enhancing ones. Thus, they may be used to improve reaction time and concentration, increase arousal, improve memory, boost energy, trigger relaxation and confidence, and increase energy when fatigued (McDuff et al., 2019). While these substances potentially have performance-enhancing effects, side effects that might impair performance may manifest at high doses or when combined (“stacked”) (McDuff & Baron, 2005). These detrimental effects include anxiety, jitteriness/tremor, insomnia, gastrointestinal upset, and tachycardia.

Prescription Drugs Prescription medication misuse occurs most often with stimulants (typically prescribed for attentiondeficit/hyperactivity disorder; described above) or opioids (typically prescribed for pain). Nonprescription use of opioids is higher for athletes who are injured than for those who are neither athletes nor injured (Ford et al., 2017). Athletes may thus begin using prescription opioids for purposes of pain management and treatment of injuries, but physical and psychological dependence on them may eventually take over as the main reason for use. Effects of opioids that can negatively impact sport performance include sedation, impaired cognition and psychomotor function, and slowed reaction time (which can also increase injury risk) (Heuberger et al., 2018; Hainline et al., 2017). Though it’s been postulated that the analgesic effect of opioids might improve athletic performance, this hasn’t been well established (Holgado et al., 2017). One study investigating the hypoalgesia effect found athletes who used opioids just prior to exercise experienced profound peripheral muscle weakness and delayed muscle recovery, secondary to hypoventilation and respiratory and metabolic acidosis (Amann et al., 2009). Opioids may additionally negative impact mental health via association of misuse with depression, anxiety, and suicide (Ashrafioun et al., 2017).

Sport-Related Gambling Sport wagering is particularly of interest to athletes and consists of betting on individual sporting events or contests, through fantasy sport (seasonal or daily), or on individual players or events. It may occur among peers, through a bookmaker, or through online sites. This type of gambling—especially through online venues—has been increasing in popularity (Derevensky et al., 2019). Fantasy sport wagering is one form of sport wagering wherein participants assemble virtual teams (usually online) of real players. These teams then compete against other teams based on the statistical performance of the players (Derevensky et al., 2019). Originally based on a season, fantasy sport wagering has evolved into daily fantasy sport, with the apparent intention of online gambling operators being to increase the frequency of betting (Derevensky et al., 2019). While there is still debate concerning whether fantasy sport wagering should be considered “gambling” or “skill”, participants have been characterised by high gambling frequency and gambling-related problems (Nower et al., 2018). One of the more “innovative” and popular forms of online sport is inplay/prop sport bets, where individuals can wager on specific events (e.g., which team or player will have the most points in a given time frame) or players (e.g., who will score first) within a sport event. Inplay betting has significant implications for the integrity of sporting events given that athletes can bet against themselves in a relatively anonymous manner using different online accounts (Derevensky et al., 2019).

Mental Health Symptoms and Disorders Associated with Problem Gambling Problem gambling commonly results in multiple negative outcomes, including risky behaviours, underperformance in roles, and mental health disorders (Lorains et al., 2011). Problem gamblers often experience decreased academic and athletic performance, engage in socially isolating behaviours, and 124

Addiction Disorders in Athletes

experience difficulties in relationships (Shead et al., 2010). On average, relative to the general population, they are more likely to suffer from anxiety, depression, suicide attempts, and substance use disorders (Derevensky et al., 2019).

Prevention Drugs Drug testing of athletes is intended to serve many purposes. While deterring use of performanceenhancing substances so as to ensure fairness is one purpose, it also serves to promote health among athletes. Thus, even substances that are primarily recreational and have little evidence demonstrating performance-enhancing effects may be part of drug testing panels in collegiate, professional, and international/Olympic sport. The hope is that such testing prevents use out of athlete fear of testing positive and being sanctioned. However, testing and detection are challenges, as athletes may use many strategies to avoid detection, including use of substances not yet identified by testing agencies and masking agents (Alquraini & Auchus, 2018). Competition-day urine drug testing is a common way of determining use/ misuse, but it presumably underestimates prevalence (Dunn et al., 2011). More reliable methods include team urine surveillance and post-game testing; repeat testing; hair testing; early out-of-season testing; and more frequent testing in general. For team physicians and other healthcare providers looking to get the truth from athletes so treatment can commence when needed, strategies can include doping attitude scale administration (assesses perspectives on use, with riskier views associated with increased likelihood of use), indirect questioning techniques (e.g., “Would you think about using cannabis if there were no drug testing?”), and interviews not only with athletes but also with teammates, parents, and/or coaches (Druckman et al., 2014).

Gambling Unlike many other mental health disorders, including some other addiction disorders, gambling disorder can go undetected for some time, and thus is often referred to as a “hidden addiction” (Derevensky, 2012). Gambling begins early in most cultures, but few educational or athletic institutions have gambling prevention programs (Derevensky et al., 2019). As a preventive strategy, inservice and other educational training related to gambling disorders is warranted (Derevensky et al., 2019).

Management Drugs Healthcare service delivery models can be set up in ways that appear to increase the likelihood of early detection of and appropriate management of addiction disorders in athletes (McDuff et al., 2019). For example, substance screenings and brief interventions can be integrated with other health screenings and interventions (McDuff & Garvin, 2016). Pre-participation physical examinations for high school, collegiate, and professional athletes can incorporate such approaches as delivered by the primary care/sport medicine team physicians, with appropriate referrals for more comprehensive management as needed. Alternatively, licensed mental health/substance use professionals can be the ones to conduct these preseason screenings, and they then can proceed with follow-up evaluations and treatment for those who screen positive (McDuff & Baron, 2005). Motivational interviewing strategies, delivered in either individual or group settings and delivered by licensed professionals, may successfully prevent or decrease substance misuse by athletes (Donohue et al., 125

Claudia L. Reardon and Ryan Benoy

2020). Key family members or other members of the athletes’ entourage might attend such sessions as appropriate (McDuff et al., 2019). Group therapies using a variety of therapeutic approaches might help athletes with substance misuse as well (Brisola-Santos et al., 2016). However, there has been no research on the use of self-help groups in the form of Alcoholics Anonymous and related entities for athletes, and concerns about confidentiality might limit participation particularly by high-level athletes (McDuff et al., 2019). Finally, research has shown that athletic trainers and academic advisors can screen for and deliver brief motivational interviewing messages that lead to decreased rates of binge drinking (Agley et al., 2012). Psychosocial interventions such as individual and group therapies are typically the cornerstone of management of substance misuse and use disorders, including in athletes. However, there may be a place for medication to manage withdrawal, cravings, and comorbid mental health symptoms and disorders such as mood disturbance (e.g., depression), anxiety, and insomnia (McDuff et al., 2019). There are several options available to manage alcohol use disorder when cravings are strong or the athletes otherwise cannot stop drinking despite consequences. These options include naltrexone, acamprosate, and disulfiram, all of which are approved in some countries for alcohol use disorder, as well as non-approved options for which evidence exists for their efficacy in this setting (McDuff et al., 2019). The latter options include gabapentin (potential side effects of relevance to athletes include dizziness and sedation; Mason et al., 2014), topiramate (potential side effects of relevance include concentration difficulties; Johnson et al., 2007), and ondansetron (Johnson et al., 2003). There are also medications available for management of opioid use disorder, specifically methadone and buprenorphine. However, opioids (including methadone and buprenorphine) are prohibited by the National Collegiate Athletic Association, some professional sport leagues, and in-competition by the World Anti-Doping Agency (McDuff et al., 2019). Thus, treatment with these medications would typically require a break in competition for elite athletes (Gil et al., 2016; McDuff et al., 2019). If an athlete is not open to such a break in sport, providers might consider prescription of an opioid antagonist (oral or extended-release naltrexone; Woody, 2017).

Gambling In light of the potential severity of disordered gambling and its association with serious mental health symptoms and disorders, comprehensive and expanded screening, brief interventions, and referrals for more comprehensive treatment are warranted (Derevensky et al., 2019). Psychotherapy, especially cognitive behavioural therapy, is the mainstay of treatment (Cowlishaw et al., 2012). Brief motivational treatments and self-help groups (e.g., Gamblers Anonymous) may help (Hodgins et al., 2011), though confidentiality concerns may limit participation for elite athletes in Gamblers Anonymous. There are no approved medications for gambling disorder, but multiple controlled trials of various medications (e.g., naltrexone, nalmefene, fluvoxamine) have shown efficacy (Bullock & Potenza, 2012). These medications have not been studied in athletes for this purpose.

Practical Implications A number of practical implications for professionals flow from the information presented. Specifically: •

• •

Members of the athlete entourage should specifically talk to athletes about substance use and gambling. If you are not doing so personally, ensure that someone is screening athletes for participation in these activities. Inform athletes of the detrimental impact of substance use and gambling on sport performance. Remind athletes of any prohibitions (e.g., by professional sport leagues, collegiate sport associations, etc.) against use of certain substances or participation in gambling. 126

Addiction Disorders in Athletes

• •

Investigate the possibility of educational programs for athletes in your jurisdiction on substance use and gambling. Refer athletes of concern to comprehensive screening and/or treatment for substance misuse/use disorders or problem gambling.

Summary Addiction disorders involving substances and gambling in athletes are unfortunately commonplace. While both can go unrecognised for some period of time, this is especially true in disordered gambling. Both have potential significant negative implications for life functioning, impact on sport performance, and development of mental health symptoms or disorders. Several questions remain unanswered, providing directions for future study: •

•

•

• • •

More thorough and reliable mental health epidemiology on substance misuse/use disorders and disordered gambling in athletes is needed, with attention to cross cultural differences in manifestations of symptoms and disorders. More research on and subsequent recommendations for expanded substance use and disordered gambling screening of athletes is needed. Screening is an important step to ensure that more affected athletes ultimately receive the treatment they need. Timing of screening must be carefully considered, given that risks may increase at various times throughout an athlete’s career. Development of athlete-specific screening tools, taking into consideration potential unique manifestations of these conditions in this population, is needed. To be able to develop such tools, we need better understanding of the unique symptom manifestation in athletes, which will require in-depth study across countries and cultures. Additional research is needed on treatments, including psychotherapy and pharmacological treatment, for substance use disorder and gambling disorder in athletes. Additional prevention strategies for substance misuse/use disorders and gambling disorder in athletes are needed. Researchers need to better understand the impact of sport sponsorship by companies that promote alcohol, tobacco, other substances, and gambling outlets associated with adverse mental health outcomes in athletes.

References Agley, J., Walker, B.B., & Gassman, R.A. (2012). Adaptation of alcohol and drug screening, brief intervention and referral to treatment (SBIRT) to a department of intercollegiate athletics: The COMPASS project. Health Education Journal, 72(6), 647–659. 10.1177/0017896912456337 Alquraini, H., & Auchus, R.J. (2018). Strategies that athletes use to avoid detection of androgenic-anabolic steroid doping and sanctions. Molecular and Cellular Endocrinology, 464, 28–33. 10.1016/j.mce.2017.01.028 Amann, M., Proctor, L.T., Sebranek, J.J., Pegelow, D.F., & Dempsey, J.A. (2009). Opioid-mediated muscle afferents inhibit central motor drive and limit peripheral muscle fatigue development in humans. The Journal of Physiology, 587(1), 271–283. 10.1113/jphysiol.2008.163303 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. Ashrafioun, L., Bishop, T.M., Conner, K.R., & Pigeon, W.R. (2017). Frequency of prescription opioid misuse and suicidal ideation, planning, and attempts. Journal of Psychiatric Research, 92, 1–7. 10.1016/j.jpsychires.2017.03.011 Barry, A.E., Howell, S.M., Riplinger, A., & Piazza-Gardner, A.K. (2014). Alcohol use among college athletes: Do intercollegiate, club, or intramural student athletes drink differently? Substance Use & Misuse, 50(3), 302–307. 10.3109/ 10826084.2014.977398

127

Claudia L. Reardon and Ryan Benoy Bonn-Miller, M.O., Loflin, M.J.E., Thomas, B.F., Marcu, J.P., Hyke, T., & Vandrey, R. (2017). Labeling accuracy of cannabidiol extracts sold online. JAMA, 318(17), 1708. 10.1001/jama.2017.11909 Brisola-Santos, M.B., Gallinaro, J.G.d.M.e., Gil, F., Sampaio-Junior, B., Marin, M.C.D., de Andrade, A.G., Richter, K.P., Glick, I.D., Baltieri, D.A., & Castaldelli-Maia, J.M. (2016). Prevalence and correlates of cannabis use among athletes-A systematic review. The American Journal on Addictions, 25(7), 518–528. https://doi.org/10.1111/ajad.12425 Bullock, S.A., & Potenza, M.N. (2012). Pathological gambling: Neuropsychopharmacology and treatment. Current Psychopharmacology, 1(1), 67–85. 10.2174/2211556011201010067 Castaneto, M.S., Gorelick, D.A., Desrosiers, N.A., Hartman, R.L., Pirard, S., & Huestis, M.A. (2014). Synthetic cannabinoids: Epidemiology, pharmacodynamics, and clinical implications. Drug and Alcohol Dependence, 144, 12–41. 10.1016/j.drugalcdep.2014.08.005 Cowlishaw, S., Merkouris, S., Dowling, N., Anderson, C., Jackson, A., & Thomas, S. (2012). Psychological therapies for pathological and problem gambling. Cochrane Database of Systematic Reviews, 11. 10.1002/14651858.cd008937. pub2 Derevensky, J.L. (2012). Teen gambling: Understanding a growing epidemic. Rowman & Littlefield. Derevensky, J.L., Mcduff, D., Reardon, C.L., Hainline, B., Hitchcock, M.E., & Richard, J. (2019). Problem gambling and associated mental health concerns in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 761–766. 10.1136/bjsports-2019-100668 Donohue, B., Gavrilova, Y., Galante, M., Burnstein, B., Aubertin, P., Gavrilova, E., … Benning, S.D. (2020). Empirical development of a screening method for mental, social, and physical wellness in amateur and professional circus artists. Psychology of Aesthetics, Creativity, and the Arts, 14(3), 313–324. 10.1037/aca0000199 Druckman, J.N., Gilli, M., Klar, S., & Robison, J. (2014). Measuring drug and alcohol use among college. Social Science Quarterly, 96(2), 369–380. 10.1111/ssqu.12135 Du Preez, E.J., Graham, K.S., Gan, T.Y., Moses, B., Ball, C., & Kuah, D.E. (2017). Depression, Anxiety, and Alcohol Use in Elite Rugby League Players Over a Competitive Season. Clinical Journal of Sport Medicine, 27(6), 530–535. 10.1097/jsm.0000000000000411 Dunn, M., Thomas, J.O., Swift, W., & Burns, L. (2011). Elite athletes’ estimates of the prevalence of illicit drug use: Evidence for the false consensus effect. Drug and Alcohol Review, 31(1), 27–32. 10.1111/j.1465-3362.2011.00307.x Dvorak, R.D., Lamis, D.A., & Malone, P.S. (2013). Alcohol use, depressive symptoms, and impulsivity as risk factors for suicide proneness among college students. Journal of Affective Disorders, 149(1-3), 326–334. 10.1016/j.jad.2013. 01.046 Ellenbogen, S., Jacobs, D., Derevensky, J., Gupta, R., & Paskus, T. (2008). Gambling behavior among college student-athletes. Journal of Applied Sport Psychology, 20(3), 349–362. 10.1080/10413200802056685 Ford, J.A., Pomykacz, C., Veliz, P., Mccabe, S.E., & Boyd, C.J. (2017). Sports involvement, injury history, and nonmedical use of prescription opioids among college students: An analysis with a national sample. The American Journal on Addictions, 27(1), 15–22. 10.1111/ajad.12657 Gil, F., Andrade, A.G.D., & Castaldelli-Maia, J.M. (2016). Discussing prevalence, impacts, and treatment of substance use disorders in athletes. International Review of Psychiatry, 28(6), 572–578. 10.1080/09540261.2016.1212821 Gouttebarge, V., Backx, F.J., Aoki, H., & Kerkhoffs, G.M. (2015). Symptoms of common mental disorders in professional football (soccer) across five European countries. Journal of Sports Science & Medicine, 14(4), 811–818. Grall-Bronnec, M., Caillon, J., Humeau, E., Perrot, B., Remaud, M., Guilleux, A., … Bouju, G. (2016). Gambling among European professional athletes. Prevalence and associated factors. Journal of Addictive Diseases, 35(4), 278–290. 10.1080/10550887.2016.1177807 Hainline, B., Derman, W., Vernec, A., Budgett, R., Deie, M., Dvořák, J., … Engebretsen, L. (2017). International Olympic Committee consensus statement on pain management in elite athletes. British Journal of Sports Medicine, 51(17), 1245–1258. 10.1136/bjsports-2017-097884 Heuberger, J.A.A.C., & Cohen, A.F. (2018). Review of WADA prohibited substances: Limited evidence for performance-enhancing effects. Sports Medicine, 49(4), 525–539. 10.1007/s40279-018-1014-1 Hodgins, D.C., Stea, J.N., & Grant, J.E. (2011). Gambling disorders. The Lancet, 378(9806), 1874–1884. 10.1016/ s0140-6736(10)62185-x Holgado, D., Hopker, J., Sanabria, D., & Zabala, M. (2017). Analgesics and sport performance: Beyond the painmodulating effects. PM&R, 10(1), 72–82. 10.1016/j.pmrj.2017.07.068 Johnson, B.A. (2007). Topiramate for treating alcohol dependence: A randomized controlled trial. JAMA, 298(14), 1641. 10.1001/jama.298.14.1641 Johnson, B.A., Ait-Daoud, N., Bowden, C.L., Diclemente, C.C., Roache, J.D., Lawson, K., … Ma, J.Z. (2003). Oral topiramate for treatment of alcohol dependence: A randomised controlled trial. The Lancet, 361(9370), 1677–1685. 10.1016/s0140-6736(03)13370-3

128

Addiction Disorders in Athletes Labrie, J.W., Grossbard, J.R., & Hummer, J.F. (2009). Normative misperceptions and marijuana use among male and female college athletes. Journal of Applied Sport Psychology, 21(sup1), S77–S85. 10.1080/10413200802582839 Lachenmeier, D.W., Habel, S., Fischer, B., Herbi, F., Zerbe, Y., Bock, V., … Sproll, C. (2020). Are side effects of cannabidiol (CBD) products caused by tetrahydrocannabinol (THC) contamination? F1000Research, 8, 1394. 10.12688/f1000research.19931.3 Lorains, F.K., Cowlishaw, S., & Thomas, S.A. (2011). Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction, 106(3), 490–498. 10.1111/j.13600443.2010.03300.x Mason, B.J., Quello, S., Goodell, V., Shadan, F., Kyle, M., & Begovic, A. (2014). Gabapentin treatment for alcohol dependence: A randomized clinical trial. JAMA Internal Medicine, 174(1), 70. 10.1001/jamainternmed.2013.11950 Mcduff, D.R., & Baron, D. (2005). Substance use in athletics: A sports psychiatry perspective. Clinics in Sports Medicine, 24(4), 885–897. 10.1016/j.csm.2005.06.004 Mcduff, D.R., & Garvin, M. (2016). Working with sports organizations and teams. International Review of Psychiatry, 28(6), 595–605. 10.1080/09540261.2016.1212820 Mcduff, D., Stull, T., Castaldelli-Maia, J.M., Hitchcock, M.E., Hainline, B., & Reardon, C.L. (2019). Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review. British Journal of Sports Medicine, 53(12), 754–760. 10.1136/bjsports-2019-100669 Möller, I., Wintermeyer, A., Bender, K., Jübner, M., Thomas, A., Krug, O., … Thevis, M. (2010). Screening for the synthetic cannabinoid JWH-018 and its major metabolites in human doping controls. Drug Testing and Analysis, 3(9), 609–620. 10.1002/dta.158 National Collegiate Athletic Association. (2018). National Study on Substance Use Habits of College Student-Athletes. Received from http://www.ncaa.org/sites/default/files/2018RES_Substance_Use_Final_Report_FINAL_ 20180611.pdf Nower, L., Caler, K.R., Pickering, D., & Blaszczynski, A. (2018). Daily fantasy sports players: gambling, addiction, and mental health problems. Journal of Gambling Studies, 34(3), 727–737. 10.1007/s10899-018-9744-4 Schulenberg, J.E., Johnston, L.D., O’Malley, P.M., Bachman, J.G., Miech, R.A., & Patrick, M.E. (2017). Monitoring the Future national survey results on drug use, 1975-2016: Volume II, college students and adults ages 19–55. The University of Michigan Institute for Social Research. Shead, N.W., Derevensky, J.L., & Gupta, R. (2010). Risk and protective factors associated with youth problem gambling. International Journal of Adolescent Medicine and Health, 22(1), 39–58. Sideli, L., Quigley, H., Cascia, C.L., & Murray, R.M. (2019). Cannabis use and the risk for psychosis and affective disorders. Journal of Dual Diagnosis, 16(1), 22–42. 10.1080/15504263.2019.1674991 SIUC/Core Institute. (2013). Annual Data. Core Alcohol and Drug Survey Long Form – Form 194. Executive Summary. Carbondale, IL: SIUC/Core Institute 2013;2013 https://core.siu. edu/_common/ documents/ 2013. pdf United States Department of Health and Human Services Office of the Surgeon General. (2016). (rep.). Facing addiction in America: The surgeon general’s report on alcohol, drugs, and health. United States Department of Human Health Services Woody, G.E. (2017). Advances in the treatment of opioid use disorders. F1000Research, 6, 87. 10.12688/f1000research. 10184.1 Zanotti, D., Kaier, E., & Strunk, K. (2017). Prevalence of mental health symptoms in college athletes. American Psychological Association.

129

9 THE ROLE OF EXECUTIVE FUNCTIONS IN ELITE ATHLETES’ MENTAL HEALTH Robert S. Vaughan, Jack Brimmell, and Bjoern Krenn

Introduction This chapter reviews the relationship between executive function and mental health in athletes. However, before readers are introduced to this topic several important caveats should be presented. Research has a longstanding interest in the cognitive ability of elite athletes (Scharfen & Memmert, 2019). Current literature suggests that elite athletes tend to score better on tasks of cognitive ability, conceptualised as executive functions, which may contribute to better sport performance (Vaughan & Edwards, 2020) and other health benefits (e.g., improved motor performance in disabled athletes; Di Russo et al., 2010). Nonetheless, some accounts suggest that executive functions alone are insufficient in explaining why elite athletes score better on executive function task performance compared to their less elite counterparts or non-athletes (Beavan et al., 2020; Vaughan et al., 2021). Similar to other domains such as education (Kassai et al., 2019), it is likely that the executive function and performance link is best captured in interaction terms showing some dependence on other individual differences factors (e.g., positive and negative affect; Vaughan & McConville, 2021). This is a salient analytical point to note as the literature base continues to grow. Likewise, readers should note that the evidence base is heterogeneous with a range of methodological designs that rarely control for important executive function covariates such as physical activity (Vaughan et al., 2021) and uncritically adopt varied definitions of the main independent variable – athletic expertise (see Brimmell et al., 2022; Swann et al., 2016, for a review). This oversight makes consensus difficult, and readers should maintain caution when evaluating the executive function in elite athlete literature. Finally, empirical work examining the relationship between executive function and mental health is scarce with much of the research focusing on concussion experience. Whilst reasons for this research gap may be speculated on, it is likely in part due to the lack of accepted sport specific measures of mental health (e.g., such as the DASS-21; Vaughan et al., 2020). Nonetheless, given the neuropsychological links between executive function and disorders such as depression in the general population (Cotrena et al., 2016) understanding executive functions will be important for researchers and practitioners when considering elite athlete mental health. The following text will provide an overview of what executive functions are, how executive functions are measured, review the executive function of elite athlete’s research to date, and summarise the executive function and mental health relationship. Readers are provided with guidelines for working with elite athletes and a summary of the research regarding the relationship between executive function and mental health in elite athletes. 130

DOI: 10.4324/9781003099345-13

The Role of Executive Functions

Definition Executive function has become a common term within the domain of sport and exercise psychology and refers to a group of cognitive processes that influence and control behaviour (Diamond, 2013). Prior to the turn of the century, executive functions were rarely examined in cognitive psychology, and even less in sport and exercise psychology (Miyake et al., 2000). Although this is not surprising given the typical experimental information processing approach previously utilised in psychology which meant that psychologists had to reduce complex problems of human cognition into small, isolated aspects of cognition (Furley & Wood, 2016; Mandler, 2007). In doing so, each research area became more specialised and targeted in focus, losing sight of the wider application of these executive processes (i.e., application in fields outside of cognitive psychology; Styles, 2005). As it became clear that more than physical prowess was required for exceptional sport performance the focus switched and researchers became more interested in the underlying executive processes involved in sport and exercise performance (Ducrocq et al., 2017). In the 20 years that have passed the role of executive processes including attentional control, perceptual-cognition, and anticipation, decision making has increased dramatically (see Mann et al., 2007; Scharfen & Memmert, 2019, for reviews). Specific functions such as working memory (i.e., updating), inhibitory control (i.e., inhibition), cognitive flexibility (i.e., shifting), decision making, and anticipation have become widely researched in sport and exercise psychology. Working memory, inhibitory control, and cognitive flexibility comprise lower-order executive functions, meaning their relatively less complex and easier to measure in isolation (Miyake et al., 2000). Working memory is concerned with maintaining small pieces of information in an active state until no longer relevant (Baddeley, 2007), while shifting involves shifting attentional focus between multiple tasks, sets, or operations (Miyake et al., 2000); and inhibition involves withholding no longer appropriate responses (Miyake et al., 2000). Decision making and anticipation comprise higher-order executive functions as their functionality often depends upon multiple lower-order constructs (e.g., optimal decisions require inhibition of suboptimal choices and updating of opponent and teammate spatial location; Williams & Jackson, 2019). Decision making refers to an individual’s capability to select an appropriate action within a specific task from numerous possible actions (Hastie, 2001). Anticipation pertains the ability to infer action from others based on the personal perception of cues from said individual and/or from within the environment (Williams & Jackson, 2019). Sport and exercise provide researchers with an excellent opportunity for observing and measuring these cognitive/executive processes given the prevalence of situations that require fast, accurate, and situationspecific decisions based on perceived contextual signals (Stratton et al., 2004). Consider a game of soccer, for example, whereby any individual must monitor and update the location of teammates and opponents throughout the game (e.g., working memory). When in possession of the ball an individual must decide whether to pass the ball, of which multiple options are possible including long, short, high, low, forward, backward passes, or dribble to maintain possession (e.g., cognitive flexibility). An individual must also be ready to suppress pre-planned, or indeed in-motion, motor actions when they are no longer appropriate (e.g., when an opposing player blocks the passing line; inhibitory control; Huijgen et al. 2015). The above hypothetical scenarios rely upon lower-order executive functions (i.e., working memory, cognitive flexibility, and inhibitory control) to ensure that the outcome is optimal (e.g., decision making), expressing the importance of these functions for sport and exercise performers. Given that numerous executive functions are required, and often work in conjunction with other functions, during sport and exercise activity creating targeted models can be difficult. Despite this difficulty, various models do exist that include and explain relationships between numerous cognitive processes (e.g., Diamond, 2013; Miyake et al., 2000). One of the earliest and most seminal efforts in the area of executive function, specifically focused on working memory, is Baddeley and Hitch’s (1974) model. 131

Robert S. Vaughan et al.

Baddeley and Hitch (1974) offered one of the first theoretical abandonments of a singular working memory store in favour of the three-component model of the phonological loop, the visuo-spatial sketchpad, and the central executive. While the phonological loop and visuo-spatial sketchpad are mainly concerned with speech and visual-spatial information, respectively, the central executive was considered responsible for cognitive process known as executive function (Miyake et al., 2000). Despite the model from Baddeley and Hitch (1974), research remained “embarrassingly ignorant” (Monsell, 1996) of how specific cognitive processes controlled and coordinated performance during complex tasks (Miyake et al., 2000). That is until two of the most utilised executive function models in cognitive and sport and exercise psychology today further explored the central executive, and also examined it beyond just the notion of working memory, offering the first agreed-upon approach to theorising about these cognitive processes. First, the lower-order model of executive function that comprised shifting, updating, and inhibition (Miyake et al., 2000); and the second similar model comprised of the lower-order functions that include cognitive flexibility, inhibitory control, and working memory (Diamond, 2013). These three functions were initially selected based on concerns that previously used “all-encompassing” measures (e.g., Wisconsin Card Sorting Task) may not allow for specific comments on precise functions (i.e., the Wisconsin Card Sorting Task may require multiple lower-order executive functions whose roles are difficult to differentiate in a singular task; Miyake et al., 2000). These three lower-order functions were found to be interrelated, yet distinct from one another. That is, when performing more complex executive tasks all three functions are utilised, but to varying degrees (Miyake et al., 2000). As well as focussing on similar executive functions, the models of Miyake et al. (2000) and Diamond (2013) both posit that these functions are fundamental in more complex, higher-order, functions (e.g., decision making, planning, and problem solving; Diamond, 2013). Though the proposed executive functions are believed to be distinct, yet interrelated, both models reject the idea of a “general” system, comparable to something like Spearman’s g (Spearman, 1927), which has been reported as an over-arching component of executive functions (e.g., Luria, 1966). Both models agree with the unity-diversity proposition, but differ on the exact relationship between these three executive functions. First, Miyake et al. (2000) reported moderate correlations between all possible combinations of the three executive functions (correlations ranged from .42 to .63), suggesting similar relationships between the three. However, the model from Diamond (2013) suggests that working memory and inhibitory control may underpin cognitive flexibility. Also, Diamond’s (2013) model may be noted as more comprehensive, albeit less parsimonious. Inhibitory control involves cognitive inhibition (similar to that outlined in Miyake et al., 2000), response inhibition (linked to self-control; Diamond, 2013), selective attention, and self-regulation (where emotions are often the focus over cognitive processes). Working memory reflects the early model of Baddeley and Hitch (1974) in that both verbal (phonological loop) and visuo-spatial (the visuo-spatial sketchpad) are proposed. Finally, creativity is specifically mentioned in relation to cognitive flexibility in Diamond’s (2013) model. Despite these differences support for their underlying structure comprising as shifting/cognitive flexibility, working memory/updating, and inhibition/inhibitory control have been supported in elite athlete samples (Vaughan & Edwards, 2020; Vaughan & McConville, 2021). These models have been commonly used within the literature supporting their strength and applicability. Breaking higher-order processes (e.g., decision making) into more precise functions (e.g., inhibition, working memory, and cognitive flexibility) allows researchers to reduce the task impurity problem (Miyake et al., 2000) and to target specific underlying processes within interventions (e.g., Ducrocq et al., 2017). Though these models cover the generally accepted trio of executive function (inhibition, shifting, and updating) they still may contain commonalities as outlined by Diamond (2013). For example, inhibitory control comprises response inhibition and interference control, which is further divided into cognitive inhibition and selective attention, and is underpinned by self-regulation (Diamond, 2013). Meaning caution must be taken when concluding upon the outcome of seemingly “precise” tasks 132

The Role of Executive Functions

and more reliable results may stem from using multiple measures of each executive function where possible (e.g., tasks that appear different on the surface but capture the same underlying function; Miyake & Friedman, 2012). To date, no research has examined the measurement quality of the lower-order model in athlete samples and remains an avenue for future work.

Measurement Tasks used to measure executive function in elite athletes have developed substantially alongside the growth of this research area. Some of the earliest tasks utilised paper and pen methods (e.g., the trail making task; Reitan & Wolfson, 1985) while technological advancements have allowed for specific and adaptive tasks to be produced (e.g., the Stop Signal Task for inhibition; Verbruggen et al., 2019). It is important to note that these paper and pen methods are not rendered useless and can still be seen today where applicable (e.g., Finkenzeller et al., 2021). Given the wide range of higher (e.g., decision making) and lower-order (e.g., inhibition) executive functions that are now examined, it is no surprise that tasks to measure these functions are at the forefront of research where the goal is to provide researchers with accurate, sensitive, and specific measures to capture these executive functions (Chan et al., 2008). Common measures of higher- and lower-order executive functions are often grounded within classic theoretical models. Though typically clinical in origin, measures of executive function are readily applied in sport (e.g., the Wisconsin Card Sorting Task; Han et al. 2014). Norman and Shallice (1986) proposed the supervisory attentional system (SAS) as a model for programming, regulating, and verifying human thoughts and actions. Several popular measures were derived to test the SAS model including the Stroop task, the Wisconsin Card Sorting Task, Trail Making Task, and sustained attention tasks (see Chan et al., 2008 for detailed definitions) – many of which are still used today (e.g., the Trail Making Task; Scharfen & Memmert, 2021). Stuss and Benson (1986) expanded research on the SAS by examining its relationship with other attentional components and developed a battery of tests including tasks of mental conflict, mental switching, and higher cortical control (Chan et al., 2008). These tasks are and helped form some of the most popular measures of executive function used today and include choice reaction time tasks, count/span tasks, switch tasks, go/no-go tasks, and suppression tasks (Stuss et al., 2005). Many of these tasks are offered in the form of test batteries, which have received support in the literature for their reliability and validity (e.g., Cambridge Neuropsychological Test Automated Battery; Syvaoja et al., 2015). Modern advances in computerised technology have allowed measures of executive function to move online and become easily editable and shareable by researchers. For example, software such as Millisecond by Inquisit, Gorilla, and E-Prime provide researchers with an online interactive platform to build and edit measures and tasks. Regarding the model of three lower-order executive functions, a number of primary measures have been utilised and can be accessed or built on the above software (as well as other software). Popular measures of inhibition include the go/no-go task and stop signal task. Both measures involve physical motor responses on certain trials and response suppression on other trials. While seemingly similar these tasks measure different forms of inhibition, go/no-go tasks assess automatic inhibition while stop signal tasks are focussed on controlled inhibition (Verbruggen & Logan., 2008). Typically, applied updating tasks involve stimuli presentation and recall. For example, two prevalent measures, the N-Back task and the digit span task, both require individuals to attend to a presented stimulus and recall information about that stimulus based on task rules. Shifting tasks tend to focus on individual differences in the ability to flexibly switch between rules mid-task. Common measures such as the colour-shape task and the local-global task (Friedman et al., 2008; Miyake et al., 2000) require individuals to categorise stimuli based on a certain characteristic. However, on certain trials the categorisation criteria are altered and the speed and accuracy in which individuals can adapt to the rule change is often the outcome measure. 133

Robert S. Vaughan et al.

Higher-order executive functions (e.g., decision making) are sometimes measured via sport-specific videos in which in-situ scenarios are re-created and recorded. Videos are then occluded before a critical moment at which point participants must provide their optimal decision-making outcome. Large scale projectors can also be used to enhance video size and allow for a more realistic feel. Enhancing on this, virtual reality offers an exciting avenue for measuring decision making with improved task validity (given the creation of a virtual sport environment) and has been applied within the literature (see Romeas et al., 2019, for an example with a 3D motion object tracking task). Caution must be taken with this method though as issues around adequate creation of depth perception and haptic feedback have been raised meaning measurement may not be as accurate (e.g., reliance on visual acuity or specific lower order functions; Harris et al., 2018). Outlined above are several measures and tasks used to understand higher- and lower-order executive functions. While these measures may be designed to assess particular executive functions, it is not always possible to ensure measures are process-pure (i.e., measure only a prespecified process) or that measures are applied appropriately. A lot of commonly used and seminal tasks contain overlap of functions, some of which is unavoidable. For example, the Wisconsin Card Sorting Task may assess set-shifting, working memory, and inhibition meaning the specific roles of each process within the task, and drawing conclusion, are very difficult (Konishi et al., 2003). In addition, single task measures of these functions may lead to misrepresentation of results. Miyake et al. (2000) suggest that using one task to obtain an overall executive function (e.g., inhibition) score may be suboptimal and instead result in task-specific outcome measures. Another issue concerns a general lack of consideration for important covariates when examining executive function in elite athletes. Research has suggested that age and physical activity have a large impact upon executive function and should be considered in analyses. For instance, through adolescence parts of the brain associated with executive function (e.g., pre-frontal cortex) are undergoing structural and functional development (Crone & Dahl, 2012). As elite status can be obtained at a wide variety of ages it is important to control for this variable when examining executive function in elite athletes to ensure that analyses, and thus conclusions, are accurate. A similar case can be made for physical activity. Huijgen et al. (2015) found that elite soccer players had more physical training hours and performed better on measures of inhibition, shifting, and updating. Again, caution is important as it has also been proposed that simple aerobic exercise that places no demands upon the executive functions (e.g., running) may not enhance executive function in the same way that more cognitively demanding physical activity (e.g., soccer) might (Diamond & Ling, 2016).

Elite Athletes By taking a closer look at the cognitive demands of several sports the significance of executive functions in elite athletes is clear. Thus, executive functions might contribute to the understanding of why some athletes are able to perform better and more successfully than others. Exemplarity in team sport, like football or basketball, players constantly have to scan the positions of their team members and their opponents, inhibit responses and distractors (e.g., crowd noise, negative thoughts), recall tactical information and strategies, and adapt to continuously changing situations (cf. Verburgh et al., 2014). These demands seem to be in line with the understanding of core executive functions (Diamond, 2013; Miyake et al., 2000). In addition, higher-level executive functions are required when players have to solve upcoming tactical and strategical problems on the playing field, generate new options, and repeatedly modify their action plans. Consequently, empirical research has started to shed a light on executive functions role in elite athletes and questioned differences in executive functions between differing expertise levels and its interaction with performance measures. Vestberg and colleagues (2012) revealed higher executive functions in football players from the first division compared to football players from the second and third division in Sweden. Most notably, all 134

The Role of Executive Functions

sampled football players outperformed the population norm. These findings were surprising as past research disclaimed significant differences between sport experts and novices in basic cognitive abilities (Ericsson et al., 2018; Furley & Memmert, 2010; Memmert et al., 2009). In addition, Vestberg et al. (2012) revealed a significant partial correlation between executive function scores and players’ scored goals and assists across two successive seasons when controlling for field position, league, and age, which was partially corroborated some years later (Vestberg et al., 2020; Vestberg et al., 2017). This line of research inspired numerous studies contributing to the clarity of the role of executive functions in elite athletes. A number of studies was able to replicate the reported findings signifying differences in executive functions between sport experts and novices or population norms – such benefits were reported in football (Vestberg et al., 2020; Vestberg et al., 2017), ice-hockey (Lundgren et al., 2016), table tennis (Elferink-Gemser et al., 2018), and volleyball (Alves et al., 2013; Finkenzeller et al., 2021; Meng et al., 2019). In addition, research also detected benefits in executive functions for athletes with higher expertise levels in comparison to athletes with lower expertise levels in youth football (Huijgen et al., 2015; Sakamoto et al., 2018; Verburgh et al., 2014) and ultra-marathons (Cona et al., 2015). However, these findings on differences between athletes of differing levels of expertise revealed some inconsistencies. Some studies refuted this benefit for athletes with higher expertise (Finkenzeller et al., 2021; Lundgren et al., 2016) or rather concluded the benefit on selected EF-subdimensions only (Huijgen et al., 2015; Verburgh et al., 2014; Vestberg et al., 2017). These results caused a broad discussion about the underlying mechanism causing the interaction between executive functions and athletes’ expertise. So far, it still seems undetermined whether athletes’ benefit in executive functions is a consequence of their collective experiences in handling the cognitive demands over years of training in their sport, or rather if their elite status is a consequence of their beneficial executive functions. On the one hand, it seems possible that higher executive functions of elite athletes are developed by chronic participation in their sport and by continuously handling these demands, whereas on the other hand a high level of executive function might also represent an essential selection criterion to reach elite status in one’s sport (Hagyard et al., 2021; Koch & Krenn, 2021; Vaughan & McConville, 2021). Research comparing the cognitive demands of several sports brought some insights into the origin of these higher executive functions in elite athletes. For example, Jacobson and Matthaeus (2014) suggested a correlation between sport type and executive function performance, finding differences in executive function measures between athletes of open-skill and closed-skill sport. These findings were corroborated by showing benefits on executive function measures for elite athletes of more cognitively challenging sport types (e.g., open-skill sport) than rather less cognitively challenging sport types (e.g., closed-skill sport; Krenn et al., 2018; Meng et al., 2019; Yu, Chan, Chau, & Fu, 2017). In addition, the benefit for closed-skill sport elite athletes in executive functions was detected in the case of a higher involvement in open-skill sport in their youth, representing the developmental important of sport and exercise for elite athletes executive functions (Koch & Krenn, 2021). Thus, the more experience elite closed-skill athletes collected in cognitively challenging sport, the better their executive functions scores were in later life regardless of specialisation. However, results have varied between the executive function subdimensions of inhibition, working memory and cognitive flexibility. Whilst the benefit of more cognitively challenging sport was observed fairly consistently for inhibition (Brevers et al., 2018; Chan et al., 2011; Hagyard et al., 2021; Heppe & Zentgraf, 2019; Nakamoto & Mori, 2008; Wang et al., 2013), the benefit for working memory (Furley & Memmert, 2010; Meng et al., 2019; Vaughan & Laborde, 2021), cognitive flexibility, and higher-level executive functions was less consistently reported (Elferink-Gemser et al., 2018; Jacobson & Matthaeus, 2014; Meng et al., 2019). In addition, methodological limitations restrict the generalisability of the reported findings and are noted briefly next. First, the measurement of executive functions varied across the studies, which confines their comparability and emphasises the question of the psychometric quality of each test. Several studies assessed the 135

Robert S. Vaughan et al.

Design Fluency Test (Delis et al., 2001), which was developed for clinical populations and its evidence of reliability and validity in athletes seems questionable (Finkenzeller et al., 2021; Suchy et al., 2010). Second, the theoretical assignment of each task within the theoretical concept of executive functions is pending. Here the assessment of inhibition and working memory seems more common and standardised, whereas for cognitive flexibility or higher-level executive functions the assessment seems rather vague and the evidence on reliability and validity is scarce (Chaytor et al., 2006; Ericsson et al., 2018; Suchy et al., 2010; Suchy et al., 2017). Third, research dealing with executive functions in elite athletes revealed high inconsistencies in defining elite status of athletes. This problem is augmented by the fact that studies were conducted with differing age groups, for which a consistent definition of expertise status is even more challenging (cf. Vaughan & McConville, 2021). Finally, several studies utilised only small samples of one sport which also restricts results’ generalisability. However, the current state of research suggests an important role of executive functions in elite sport. The results revealed benefits of elite athletes in comparison to novices, whereas more profound results were found for elite athletes of open-skilled sport than closed-skilled sport. It seems that higher cognitive demands in several sport go along with higher executive functions in elite athletes of these sport. It remains unknown whether these higher executive functions scores are the origin of their elite level or rather the consequence of athletes experienced cognitive challenges within their sport type. Understanding the developmental aspects of sport participation in relation to executive function development will be key for understanding the executive function and mental health relationship in elite athletes.

Impact on Mental Health Outside of sport, lower executive function performance (or executive dysfunction) is associated with greater mental health symptomology (e.g., higher depression, anxiety, and stress; Bettis et al., 2017). For example, depressed adults typically report greater executive dysfunction (Snyder, 2013). Likewise, deficits in execute function are linked with higher levels of anxiety, related stress, and poorer quality of life (Snyder et al., 2013). Researchers have provided mostly biological explanations for this relationship, such as alterations in frontolimbic areas (e.g., such as the prefrontal dorsolateral and ventromedial cortices; Snyder, 2013). However, as mentioned, little available data directly assesses the relationship between executive functions and mental health in elite athletes. The lack of empirical work examining the relationship between executive function and mental health may be attributable to lack of a sport-specific measure of mental health symptomology. In a recent effort Vaughan and colleagues (2021) assessed the psychometric properties of the DASS-21 (Lovibond & Lovibond, 1995), a 21-item self-report survey that measures depression, anxiety, and stress with results indicating that this scale can be reliably and validly applied with athlete samples. Alternatively, until research emerges assessing this relationship, readers can draw parallels from other individual differences in variables that may directly impact mental health. One such example examined the relationship between positive and negative affect with the lowerorder model of executive function (i.e., inhibition, shifting, and updating) in a sample of 256 athletes with differing levels of athletic expertise (Vaughan & McConville, 2021). Concentrating on negative affect, which is linked with depression and anxiety in athletes (Vancini et al., 2019), results showed a positive relationship between negative affect and executive function effectiveness (i.e., correct hits) scores but not efficiency scores (i.e., correct hits over time), and that these effects were larger in those with higher athletic expertise. It is possible that the presence of affect activates cognitive networks that improve executive function performance in elite level athletes regardless of valence. Similarly, elite level athletes may have better emotional coping, represented by higher dispositions in traits such as emotional intelligence, which may offset disorders such as depression, anxiety, and stress in athletes (Laborde et al., 2016). This notion was supported by Vaughan et al. (2021) in a sample of 437 participations, finding that trait emotional intelligence was associated with better working memory and that this effect was larger for 136

The Role of Executive Functions

those who reported greater athletic expertise. These authors proposed that elite level athletes may be better equipped to balance their emotional and cognitive abilities in turn helping them to achieve their goals. Additionally, and of high relevance to elite-level athletes, is the role of physical activity with both executive function and mental health impacted by cardiovascular fitness. For example, whilst mental health symptoms and injuries are common in athletes (Rice et al., 2016), research notes that physical activity can sometimes offset the negative experiences of depression and anxiety. Also, Mitchell and Phillips (2007) note that arousal and executive function activate similar areas of the prefrontal cortex suggesting they share a similar neurological basis and can be somewhat enhanced by physical activity. It is therefore important that research moving forward controls for physical activity in executive function data with elite athletes (see Brimmell et al., 2021, for an example). Whilst executive function and mental health is under-researched, the link between executive function and injury, in the form of concussion, has attracted considerable attention (Cunningham et al., 2020; Lax et al., 2015; Manley et al., 2017; Tapper et al., 2017; Willer et al., 2018). Previous research points towards a negative relationship between concussion experience and later executive function performance. For example, a systematic review by Manley et al. (2017) reported that sport-related concussion experience was related to a range of long-term illness and injury in retired athletes (e.g., depression and cognitive deficits). However, detangling the known reciprocal influence of these disorders on the prevalence of cognitive impairment and depression was not possible and more research was needed. In another more recent systematic review, Cunningham et al. (2020) reported that sport-related concussions had an adverse effect on retired professional athletes’ executive function albeit Cunningham et al. (2020) also noted that the research area lacked methodological rigour. In a three-year examination of youth hockey players Lax et al. (2015) found that concussion experience negatively impacted shifting and psychomotor speed. Tapper et al. (2017) also found a negative relationship between concussion experience and working memory but only when cognitive resources were stressed in a dual-task paradigm that required simultaneously processing of visual and auditory information. Finally, Willer et al. (2018) found that retired National Football League and National Hockey League athletes reported significantly higher self-report depression and anxiety in comparison to non-contact sport athlete controls, but no significant differences were found on a test battery of executive function. It should be noted that these latter findings appear against the trend in the literature and is perhaps attributable to the small sample size.

Implications for Practitioners According to the fit between the cognitive demands of various sports, and the role of executive functions, a high degree of interest arose in the trainability of these processes. This attempt was driven by the empirical findings suggesting differences in executive functions between different levels of expertise and correlations of executive functions with athletic performances and mental health (Cona et al., 2015; Diamond & Ling, 2016; Vestberg et al., 2012). Most notably, the findings of Vestberg and colleagues (2012; 2020) suggested a causally determined interaction between executive functions and athletic performance, at which higher executive functions are causing better performances in football. However, other empirical evidence for such a causal impact is scarce and therefore findings should be interpreted with caution. Several studies have challenged the question surrounding the trainability of executive functions and its effectiveness concerning the transfer to other cognitive skills or behavioural measures, like athletic performance (Harris et al., 2018). So far, empirical evidence shows the trainability of executive functions at any age through different methods, like computerised cognitive training or cognitively demanding physical activity (Diamond & Ling, 2016). However, most of these studies only detected improvements on the skills participants practiced (near transfer), whereas a broad transfer – to skills, which were not directly trained during the intervention – was mostly not detected (Diamond & Ling, 2016; Harris et al., 2018; Simons et al., 2016). In sport, only a few studies questioned the transfer of executive functions 137

Robert S. Vaughan et al.

training interventions on athletic performance. Most notably, Ducrocq and colleagues (2016,; 2017) revealed transfer effects of a ten-day computer-based intervention focused on working memory (adaptive dual N-Back task; Ducrocq et al., 2017) as well as a six-day intervention focusing on inhibition (Ducrocq et al., 2016) in tennis players. The authors argued that their interventions enhanced working memory capacity and inhibition, which facilitates player’s attentional control. Consequently, the negative impact of the perceived pressure of competition in athletes should decline, which might help the players to perform better in high-pressure situations (cf. Attentional Control Theory of Anxiety; Eysenck et al., 2007). Indeed, the authors found this expected benefit in athletes’ working memory capacity, inhibition measures (near transfer), but most notably also in a tennis volleying task under a high-pressure situation (broad transfer). However, taking the small number of empirical studies and methodological limitations into consideration, these promising findings about a broad transfer of executive functions training interventions on athletic performance again should be interpreted with caution (Romeas et al., 2016). Many studies focusing executive-function interventions beyond the scope of sport did not corroborate a broad transfer to untrained skills or behavioural outcome measures (Diamond & Ling, 2016; Harris et al., 2018; Simons et al., 2016). From a practitioner’s perspective the significance of executive functions seems great due to its interactions with athletic expertise, cognitive skills, mental health, and to some extent athletic performance. Thus, the assessment of executive functions for understanding and predicting athlete’s behaviour appears essential and might present a benefit for athletes, coaches, and sport psychologists in the field. In this regard, practitioners should rely on reliable and valid executive function measurement. Whereas sufficient proofs of reliability and validity seem to exist for tests measuring aspects of inhibition (e.g., Flanker Tasks, Eriksen & Eriksen, 1974; or Stop Signal Tasks, Verbruggen et al., 2008) and working memory (e.g., Corsi Block test, Leznak, 1983), the operationalisation and measurement of cognitive flexibility as well as higher-level executive functions is less definitive in athletes (Diamond, 2013; Finkenzeller et al., 2021; Ionescu, 2012; Suchy et al., 2010). Therefore, practitioners must interpret results with caution and be careful in generalising executive functions assessments (cf. Toplak et al., 2013). In this regard, future research is challenged to gain more insights into a reliable and valid assessment of executive functions and especially higher-level processes in elite athletes.

Conclusion Interest in elite athletes’ executive functions has increased recently and shows some important findings and highlights some methodological (e.g., definition of elite athletes) and theoretical (e.g., utility executive function training) gaps in the literature. The preceding text underscores the role of executive functions for elite athlete mental health. Like many of the chapters within this book, there is a call for more research to better understand the specific relations between mental health symptomology and injury (e.g., see Chapter 14 on concussion). This is an important line of enquiry given that training executive functions may have the potential to offset later cognitive impairment and even neurodegenerative disorders (Cunningham et al., 2020; Manley et al., 2017). There are also some potential lines of enquiry to help address these gaps in the literature. For example, research on athlete executive functions relies mostly on tasks that were developed for non-sport specific samples. No work to date has investigated whether task performance differs for sport specific tasks/tasks using sport stimuli from the validated tasks with the general population. It is possible that elite athletes executive function performance may differ from non-athletes on an N-Back task indexing updating that uses sport specific stimuli rather than numbers or letters. Indeed, video paradigms to assess sport specific decision making suggest that this may be the case (Harris et al., 2018). Also, little research exists that assess the relationship between sport specific mental health symptomologies, such as athlete burnout and executive function. To date, only one study examines these variables concurrently, indicating that athletes 138

The Role of Executive Functions

reporting higher burnout symptomology report lower Stroop Colour and Word Test accuracy (Ryu et al., 2015). Given the cognitive impairments associated with burnout in the general population, understanding this association is important for identifying how executive functions may be impacted by training and competition stressors (Bayes et al., 2021). Finally, lessons can be learned from other areas of psychology regarding the study of executive functions in elite athletes and researchers should aim to examine these hypotheses. For example, researchers should look to test more sophisticated models such as those offered via moderation and mediation whilst controlling for important covariates. Likewise, an assessment of the lower-order model of executive function in sport, despite its widespread adoption, has still not occurred with a sport-specific sample. It is likely that addressing these concerns will require larger samples and greater transparency such as those advocated in the open science movement (e.g., efforts to replicate findings). It is a shift to designs that offer more control, such as more longitudinal work and research clinical trials, that will better help researchers and practitioners better understand the role of executive functions for elite athlete mental health.

References Alves, H., Voss, M., Boot, W., Deslandes, A., Cossich, V., Inacio Salles, J., & Kramer, A. (2013). Perceptualcognitive expertise in elite volleyball players. Frontiers in Psychology, 4(36). 10.3389/fpsyg.2013.00036 Bayes, A., Tavella, G., & Parker, G. (2021). The biology of burnout: Causes and consequences. The World Journal of Biological Psychiatry, 22(9)686–689. 10.1080/15622975.2021.1907713 Baddeley, A. (2007). Working memory, thought, and action. Oxford University Press. https://doi.org/10.1093/ acprof:oso/9780198528012.001.0001 Baddeley, A.D., & Hitch, G. (1974). Working memory. Psychology of Learning and Motivation, Elsevier (pp. 47–89). 10.1016/S0079-7421(08)60452-1 Beavan, A., Spielmann, J., Mayer, J., Skorski, S., Meyer, T., & Fransen, J. (2020). The rise and fall of executive functions in high-level football players. Psychology of Sport and Exercise, 49, 101677. 10.1016/j.psychsport.2020.101677 Bettis, A.H., Coiro, M.J., England, J., Murphy, L.K., Zelkowitz, R.L., Dejardins, L., … & Compas, B.E. (2017). Comparison of two approaches to prevention of mental health problems in college students: Enhancing coping and executive function skills. Journal of American College Health, 65(5), 313–322. doi: 10.1080/07448481.2017.1312411 Brevers, D., Dubuisson, E., Dejonghe, F., Dutrieux, J., Petieau, M., Cheron, G., … Foucart, J. (2018). Proactive and reactive motor inhibition in top athletes versus nonathletes. Perceptual and Motor Skills, 125(2), 289–312. doi: 10.1177/0031512517751751 Brimmell, J., Edwards, E.J., Smith, M., & Vaughan, R.S. (2021). Think, see, do: Executive function, visual attention, and soccer penalty performance. Sport, Exercise, and Performance Psychology, 10(2), 290–309. 10.1037/spy0000265 Brimmell, J., Edwards, E.J., & Vaughan, R.S. (2022). Executive function and visual attention in sport: A systematic review. International Review of Sport and Exercise Psychology. 10.1080/1750984X.2022.2145574 Chan, R.C., Shum, D., Toulopoulou, T., & Chen, E.Y. (2008). Assessment of executive functions: Review of instruments and identification of critical issues. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of Neuropsychologists, 23(2), 201–216. https://doi.org/10.1016/j.acn.2007.08.010 Chan, J.S.Y., Wong, A.C.N., Liu, Y., Yu, J., & Yan, J.H. (2011). Fencing expertise and physical fitness enhance action inhibition. Psychology of Sport and Exercise, 12(5), 509–514. doi: 10.1016/j.psychsport.2011.04.006 Chaytor, N., Schmitter-Edgecombe, M., & Burr, R. (2006). Improving the ecological validity of executive functioning assessment. Archives of Clinical Neuropsychology, 21(3), 217–227. doi: 10.1016/j.acn.2005.12.002 Cona, G., Cavazzana, A., Paoli, A., Marcolin, G., Grainer, A., & Bisiacchi, P.S. (2015). It’s a matter of mind! Cognitive functioning predicts the athletic performance in ultra-marathon runners. PLOS ONE, 10(7), e0132943. doi: 10.1371/journal.pone.0132943 Cotrena, C., Branco, L.D., Shansis, F.M., & Fonseca, R.P. (2016). Executive function impairments in depression and bipolar disorder: association with functional impairment and quality of life. Journal of Affective Disorders, 190, 744–753. 10.1016/j.jad.2015.11.007 Crone, E.A., & Dahl, R.E. (2012). Understanding adolescence as a period of social-affective engagement and goal flexibility. Nature Reviews Neuroscience, 13(9), 636–650. doi.org/10.1038/nrn3313 Cunningham, J., Broglio, S.P., O’Grady, M., & Wilson, F. (2020). History of sport-related concussion and long-term clinical cognitive health outcomes in retired athletes: A systematic review. Journal of Athletic Training, 55(2), 132–158. 10.4085%2F1062-6050-297-18

139

Robert S. Vaughan et al. Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis–Kaplan executive function system—Technical manual. San Antonio, TX: NCS Pearson. Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135–168. 10.1146/annurev-psych-113 011-143750 Diamond, A., & Ling, D.S. (2016). Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. Developmental Cognitive Neuroscience, 18, 34–48. doi: 10.1016/j.dcn.2015.11.005 Di Russo, F., Bultrini, A., Brunelli, S., Delussu, A.S., Polidori, L., Taddei, F., … & Spinelli, D. (2010). Benefits of sports participation for executive function in disabled athletes. Journal of Neurotrauma, 27(12), 2309–2319. 10.1089/neu. 2010.1501 Ducrocq, E., Wilson, M., Vine, S., & Derakshan, N. (2016). Training attentional control improves cognitive and motor task performance. Journal of Sport and Exercise Psychology, 38(5), 521–533. doi: 10.1123/jsep.2016-0052 Ducrocq, E., Wilson, M., Smith, T.J., & Derakshan, N. (2017). Adaptive working memory training reduces the negative impact of anxiety on competitive motor performance. Journal of Sport and Exercise Psychology, 39(6), 412–422. doi: 10.1123/jsep.2017-0217 Elferink-Gemser, M.T., Faber, I.R., Visscher, C., Hung, T.-M., de Vries, S.J., & Nijhuis-Van der Sanden, M.W.G. (2018). Higher-level cognitive functions in Dutch elite and sub-elite table tennis players. PLOS ONE, 13(11), e0206151. doi: 10.1371/journal.pone.0206151 Ericsson, K.A., Hoffman, R.R., Kozbelt, A., & Williams, A.M. (Eds.). (2018). The Cambridge handbook of expertise and expert performance. Cambridge, UK: Cambridge University Press. Eriksen, B.A., & Eriksen, C.W. (1974). Effects of noise letters upon the identification of a target letter in a nonsearch task. Perception and Psychophysics, 16(1), 143–149. doi: 10.3758/bf03203267 Eysenck, M.W., Derakshan, N., Santos, R., & Calvo, M.G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336–353. doi: 10.1037/1528-3542.7.2.336 Finkenzeller, T., Krenn, B., Würth, S., & Amesberger, G. (2021). The design fluency test: a reliable and valid instrument for the assessment of game intelligence? 51, German Journal of Exercise and Sport Research. doi: 10.1007/s12662020-00697-0 Friedman, N.P., Miyake, A., Young, S.E., DeFries, J.C., Corley, R.P., & Hewitt, J.K. (2008). Individual differences in executive functions are almost entirely genetic in origin. Journal of Experimental Psychology. General, 137(2), 201–225. https://doi.org/10.1037/0096‐3445.137.2.201 Furley, P., & Memmert, D. (2010). Differences in spatial working memory as a function of team sports expertise: The Corsi Block-tapping Task in sport psychological assessment. Perceptual and Motor Skills, 110(3), 801–808. doi: 10.2466/pms.110.3.801-808 Furley, P., & Wood, G. (2016). Working memory, attentional control, and expertise in sports: A review of current literature and directions for future research. Journal of Applied Research in Memory and Cognition, 5(4), 415–425. https://doi.org/10.1016/j.jarmac.2016.05.001 Hagyard, J., Brimmell, J., Edwards, E.J., & Vaughan, R.S. (2021). Inhibitory control across athletic expertise and its relationship with sport performance. Journal of Sport and Exercise Psychology, 43(1), 14–27. doi: 10.1123/jsep. 2020-0043 Han, G., Helm, J., Iucha, C., Zahn‐Waxler, C., Hastings, P.D., & Klimes‐Dougan, B. (2016). Are executive functioning deficits concurrently and predictively associated with depressive and anxiety symptoms in adolescents? Journal of Clinical Child & Adolescent Psychology, 45(1), 44–58. 10.1080/15374416.2015.1041592 Harris, D.J., Wilson, M.R., & Vine, S.J. (2018). A systematic review of commercial cognitive training devices: Implications for use in sport. Frontiers in Psychology, 9(709). doi: 10.3389/fpsyg.2018.00709 Hastie R. (2001). Problems for judgment and decision making. Annual review of psychology, 52, 653–683. https://doi. org/10.1146/annurev.psych.52.1.653 Heppe, H., & Zentgraf, K. (2019). Team handball experts outperform recreational athletes in hand and foot response inhibition: A behavioral study. Frontiers in Psychology, 10(971). doi: 10.3389/fpsyg.2019.00971 Huijgen, B.C.H., Leemhuis, S., Kok, N.M., Verburgh, L., Oosterlaan, J., Elferink-Gemser, M.T., & Visscher, C. (2015). Cognitive functions in elite and sub-elite youth soccer players aged 13 to 17 years. PLOS ONE, 10(12), e0144580. doi: 10.1371/journal.pone.0144580 Ionescu, T. (2012). Exploring the nature of cognitive flexibility. New Ideas in Psychology, 30(2), 190–200. 10.1016/ j.newideapsych.2011.11.001 Jacobson, J., & Matthaeus, L. (2014). Athletics and executive functioning: How athletic participation and sport type correlate with cognitive performance. Psychology of Sport and Exercise, 15(5), 521–527. 10.1016/j.psychsport. 2014.05.005

140

The Role of Executive Functions Kassai, R., Futo, J., Demetrovics, Z., & Takacs, Z. K. (2019). A meta‐analysis of the experimental evidence on the near‐ and far‐transfer effects among children’s executive function skills. Psychological Bulletin, 145(2), 165–188. https://doi.org/10.1037/bul0000180 Koch, P., & Krenn, B. (2021). Executive functions in elite athletes – Comparing open-skill and closed-skill sports and considering the role of athletes’ past involvement in both sport categories. Psychology of Sport and Exercise, 55, 101925. doi: 10.1016/j.psychsport.2021.101925 Konishi, S., Jimura, K., Asari, T., & Miyashita, Y. (2003). Transient activation of superior prefrontal cortex during inhibition of cognitive set. Journal of Neuroscience, 23(21), 7776–7782. 10.1523/JNEUROSCI.23-21-07776.2003 Krenn, B., Finkenzeller, T., Würth, S., & Amesberger, G. (2018). Sport type determines differences in executive functions in elite athletes. Psychology of Sport and Exercise, 38, 72–79. 10.1016/j.psychsport.2018.06.002 Laborde, S., Dosseville, F., & Allen, M. (2016). Emotional intelligence in sport and exercise: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 26(8), 862–874. 10.1111/sms.12510 Lax, I.D., Paniccia, M., Agnihotri, S., Reed, N., Garmaise, E., Azadbakhsh, M., … & Keightley, M. (2015). Developmental and gender influences on executive function following concussion in youth hockey players. Brain Injury, 29(12), 1409–1419. 10.3109/02699052.2015.1043344 Leznak, M. (1983). Neuropsychological assessment. New York: Oxford Univ. Press. Lovibond, P.F., & Lovibond, S.H. (1995). The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behaviour Research and Therapy, 33(3), 335–343. 10.1016/0005-7967(94)00075-U Lundgren, T., Högman, L., Näslund, M., & Parling, T. (2016). Preliminary investigation of executive functions in elite ice hockey players. Journal of Clinical Sport Psychology, 10(4), 324–335. doi: 10.1123/jcsp.2015-0030 Luria, A.R. (1966). Higher cortical functions in man. New York: Basic Books. Mandler, G. (2007). Involuntary memories: Variations on the unexpected. In J. H. Mace (Ed.), Involuntary memory (pp. 208–223). Blackwell Publishing. https://doi.org/10.1002/9780470774069.ch10 Manley, G., Gardner, A.J., Schneider, K.J., Guskiewicz, K.M., Bailes, J., Cantu, R.C., … & Iverson, G.L. (2017). A systematic review of potential long-term effects of sport-related concussion. British Journal of Sports Medicine, 51(12), 969–977. 10.1136/bjsports-2017-097791 Mann, D. T., Williams, A. M., Ward, P., & Janelle, C. M. (2007). Perceptual‐cognitive expertise in sport: a meta‐analysis. Journal of Sport & Exercise Psychology, 29(4), 457–478. https://doi.org/10.1123/jsep.29.4.457 Query Memmert, D., Simons, D.J., & Grimme, T. (2009). The relationship between visual attention and expertise in sports. Psychology of Sport and Exercise, 10, 146–151. doi: 10.1016/j.psychsport.2008.06.002 Meng, F.-W., Yao, Z.-F., Chang, E.C., & Chen, Y.-L. (2019). Team sport expertise shows superior stimulus-driven visual attention and motor inhibition. PLOS ONE, 14(5), e0217056. doi: 10.1371/journal.pone.0217056 Mitchell, R.L., & Phillips, L.H. (2007). The psychological, neurochemical and functional neuroanatomical mediators of the effects of positive and negative mood on executive functions. Neuropsychologia, 45(4), 617–629. doi: 10. 1016/j.neuropsychologia.2006.06.030 Miyake, A., & Friedman, N. P. (2012). The nature and organization of individual differences in executive functions: Four general conclusions. Current Directions in Psychological Science, 21(1), 8–14. https://doi.org/10.1177/ 0963721411429458 Miyake, A., Friedman, N.P., Emerson, M.J., Witzki, A.H., Howerter, A., & Wager, T.D. (2000). The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis. Cognitive Psychology, 41(1), 49–100. doi: 10.1006/cogp.1999.0734 Monsell, S. (1996). Control of mental processes. In V. Bruce (Ed.), Unsolved mysteries of the mind: Tutorial essays in cognition (pp. 93–148). Erlbaum (Uk) Taylor & Francis, Publ. Nakamoto, H., & Mori, S. (2008). Effects of stimulus–response compatibility in mediating expert performance in baseball players. Brain Research, 1189, 179–188. 10.1016/j.brainres.2007.10.096 Norman, D.A., Shallice, T. (1986). Attention to Action. In Davidson, R.J., Schwartz, G.E., Shapiro, D. (Eds.), Consciousness and self‐regulation. Springer, Boston, MA. https://doi.org/10.1007/978-1-4757-0629-1_1 Reitan, R.M., & Wolfson, D. (1985). The Halstead–Reitan neuropsycholgical test battery: Therapy and clinical interpretation. Neuropsychological Press. Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Romeas, T., Chaumillon, R., Labbé, D., & Faubert, J. (2019). Combining 3D‐MOT with sport decision‐making for perceptual‐cognitive training in virtual reality. Perceptual and Motor Skills, 126(5), 922–948. https://doi.org/10. 1177/0031512519860286 Romeas, T., Guldner, A., & Faubert, J. (2016). 3D-multiple object tracking training task improves passing decisionmaking accuracy in soccer players. Psychology of Sport and Exercise, 22, 1–9. doi: 10.1016/j.psychsport.2015.06.002

141

Robert S. Vaughan et al. Ryu, K., Kim, J., Ali, A., Choi, S., Kim, H., & Radlo, S.J. (2015). Comparison of athletes with and without burnout using the stroop color and word test. Perceptual and Motor Skills, 121(2), 413–430. 10.2466%2F22.PMS.121c16x7 Sakamoto, S., Takeuchi, H., Ihara, N., Ligao, B., & Suzukawa, K. (2018). Possible requirement of executive functions for high performance in soccer. PLOS ONE, 13(8), e0201871. doi: 10.1371/journal.pone.0201871 Scharfen, H.E., & Memmert, D. (2019). Measurement of cognitive functions in experts and elite athletes: A meta‐analytic review. Applied Cognitive Psychology, 33(5), 843–860. 10.1002/acp.3526 Scharfen, H.E., & Memmert, D. (2021). Fundamental relationships of executive functions and physiological abilities with game intelligence, game time and injuries in elite soccer players. Applied Cognitive Psychology, 35(6), 1535‐1546. https://doi.org/10.1002/acp.3886 Simons, D.J., Boot, W.R., Charness, N., Gathercole, S.E., Chabris, C.F., Hambrick, D.Z., & Stine-Morrow, E.A.L. (2016). Do “Brain-Training” programs work? Psychological Science in the Public Interest, 17(3), 103–186. doi: 10.1177/1529100616661983 Snyder, H.R. (2013). Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: A meta-analysis and review. Psychological Bulletin, 139(1), 81–132. 10.1037/a0028727 Snyder, H.R., Kaiser, R.H., Whisman, M.A., Turner, A.E.J., Guild, R.M., & Munakata, Y. (2014). Opposite effects of anxiety and depressive symptoms on executive function: The case of selecting among competing options. Cognition and Emotion, 28(5), 893–902. 10.1080/02699931.2013.859568 Spearman, C. (1927). The measurement of intelligence. Nature, 120, 577–578. https://doi.org/10.1038 Stuss, D.T., Alexander, M.P., Shallice, T., Picton, T.W., Binns, M.A., Macdonald, R., Borowiec, A., & Katz, D.I. (2005). Multiple frontal systems controlling response speed. Neuropsychologia, 43(3), 396–417. https://doi.org/10. 1016/j.neuropsychologia.2004.06.010 Suchy, Y., Kraybill, M.L., & Gidley Larson, J.C. (2010). Understanding design fluency: Motor and executive contributions. Journal of International Neuropsychological Society, 16(1), 26–37. doi: 10.1017/s1355617709990804 Suchy, Y., Ziemnik, R.E., & Niermeyer, M.A. (2017). Assessment of Executive Functions in Clinical Settings. In E. Goldberg (Ed.), Executive functions in health and disease (pp. 551–569). San Diego: Academic Press. Swann, C., Moran, A., & Piggott, D. (2016). Defining elite athletes: Issues in the study of expert performance in sport psychology. Psychology of Sport and Exercise, 16(1), 3–14. 10.1016/j.psychsport.2014.07.004 Syvaoja, H.J., Tammelin, T.H., Ahonen, T., Rasanen, P., Tolvanen, A., Kankaanpaa, A., & Kantomaa, M.T. (2015). Internal consistency and stability of the CANTAB neuropsychological test battery in children. Psychological Assessment, 27(2), 698–709. 10.1037/a0038485 Tapper, A., Gonzalez, D., Roy, E., & Niechwiej-Szwedo, E. (2017). Executive function deficits in team sport athletes with a history of concussion revealed by a visual-auditory dual task paradigm. Journal of Sports Sciences, 35(3), 231–240. 10.1080/02640414.2016.1161214 Toplak, M.E., West, R.F., & Stanovich, K.E. (2013). Practitioner review: Do performance‐based measures and ratings of executive function assess the same construct? Journal of Child Psychology and Psychiatry, 54(2), 131–143. doi: 10.1111/jcpp.12001. Vancini, R.L., Gomes, A.A., de Paula-Oliveira, H., de Lira, C., Rufo-Tavares, W., Andrade, M.S., … & Knechtle, B. (2019). Quality of life, depression, anxiety symptoms and mood state of wheelchair athletes and non-athletes: A preliminary study. Frontiers in Psychology, 10, 1848. 10.3389/fpsyg.2019.01848 Vaughan, R.S., & Edwards, E.J. (2020). Executive function and personality: The moderating role of athletic expertise. Personality and Individual Differences, 161, 109973. 10.1016/j.paid.2020.109973 Vaughan, R.S., Edwards, E.J., & MacIntyre, T.E. (2020). Mental health measurement in a post Covid-19 world: Psychometric properties and invariance of the DASS-21 in athletes and non-athletes. Frontiers in Psychology, 11, 590559. 10.3389/fpsyg.2020.590559 Vaughan, R.S., Hagyard, J.D., Edwards, E.J., & Jackson, R.C. (2021). Reflection-impulsivity in athletes: A crosssectional and longitudinal investigation. European Journal of Sport Science, 21(10), 1436–1447. 10.1080/17461391. 2020.1861106 Vaughan, R.S., & McConville, C. (2021). Executive function and mood: The moderating role of athletic expertise. Perceptual and Motor Skills, 128(2), 672–691. 10.1177%2F0031512520987364 Verbruggen F., Aron A.R., Band G.P., Beste C., Bissett P.G., Brockett A.T., et al. (2019). A consensus guide to capturing the ability to inhibit actions and impulsive behaviors in the stop‐signal task. eLife, 8. https://doi:10. 7554/elife.46323 Verbruggen, F., Logan, G.D., & Stevens, M.A. (2008). STOP-IT: Windows executable software for the stop-signal paradigm. Behavior Research Methods, 40(2), 479–483. doi: 10.3758/BRM.40.2.479 Verburgh, L., Scherder, E.J.A., van Lange, P.A.M., & Oosterlaan, J. (2014). Executive functioning in highly talented soccer players. PLOS ONE, 9(3), e91254. doi: 10.1371/journal.pone.0091254

142

The Role of Executive Functions Vestberg, T., Gustafson, R., Maurex, L., Ingvar, M., & Petrovic, P. (2012). Executive functions predict the success of top-soccer players. PLoS ONE, 7(4), e34731. 10.1371/journal.pone.0034731 Vestberg, T., Jafari, R., Almeida, R., Maurex, L., Ingvar, M., & Petrovic, P. (2020). Level of play and coach-rated game intelligence are related to performance on design fluency in elite soccer players. Scientific Reports, 10(1), 9852. doi: 10.1038/s41598-020-66180-w Vestberg, T., Reinebo, G., Maurex, L., Ingvar, M., & Petrovic, P. (2017). Core executive functions are associated with success in young elite soccer players. PLoS ONE, 12(2), e0170845. 10.1371/journal.pone.0170845 Wang, C.-H., Chang, C.-C., Liang, Y.-M., Shih, C.-M., Chiu, W.-S., Tseng, P., … Juan, C.-H. (2013). Open vs. closed skill sports and the modulation of inhibitory control. PLOS ONE, 8(2), e55773. doi: 10.1371/ journal.pone.0055773 Willer, B.S., Tiso, M., Haider, M.N., Hinds, A.L., Baker, J.G., Miecznikowski, J.C., & Leddy, J.J. (2018). Evaluation of executive function and mental health in retired contact sport athletes. The Journal of Head Trauma Rehabilitation, 33(5), E9. doi: 10.1097/HTR.0000000000000423 Williams, A.M., & Jackson, R.C. (2019). Anticipation in sport: Fifty years on, what have we learned and what research still needs to be undertaken? Psychology of Sport and Exercise, 42, 16–24. https://doi.org/10.1016/ j.psychsport.2018.11.014 Yu, Q., Chan, C.C.H., Chau, B., & Fu, A.S.N. (2017). Motor skill experience modulates executive control for task switching. Acta Psychologica, 180, 88–97. 10.1016/j.actpsy.2017.08.013

143

10 PERSONALITY DISORDERS IN ELITE ATHLETES Christopher M. Bader and LaTisha L. Bader

Introduction Finding balance within mental, emotional, physical, and spiritual aspects of self is imperative to an athlete’s success in sport and life. When those aspects become unbalanced or unmanageable, they can result in suffering and impact the athlete’s outlook and performance (Brown, 2014). Many factors determine a person’s health at any juncture. While some individuals can objectively assess and evaluate these factors when it comes to the average person, they may minimise or rationalise an athlete’s functioning which can cause a skewed perception. Myths suggest that athletes are mentally tough and do not suffer with mental health disorders or “weakness” (Markser, 2011). Reality and research suggest that athletes struggle with mental illness at similar rates as their non-athlete peers. Studies have found that elite athletes report equal amounts of anxiety, depression, posttraumatic stress, and sleep disorders (Gouttebarge et al., 2019; Rice et al., 2019). Ferraro (2004) helped normalise the mental health concerns of athletes suggesting, “they are just like you and me,” (p. 15) having struggles with anxiety, depression, and personality problems. We can theorise a biopsychosocial approach to understanding an athlete’s mental health that encompasses a holistic understanding. And, when an athlete experiences changes in their biological, psychological, or social environment we can start to identify the impact those changes have on their lives, either acutely or chronically. Research suggests the most common concerns in athletes are anxiety disorders, mood disorders, personality disorders, attention deficit hyperactivity disorder, eating disorders, body dysmorphic disorder, adjustment disorders, substance use disorders, impulse control disorders, and psychosomatic illnesses (Brown, 2014). Many of these concerns are more state based – versus trait based – and have clear routes of treatment. The exception in that list is personality disorders. Regarding personality and personality disorders, they can be thought of as a longer developmental journey which can affect an individual’s ability to connect with others, and their overall perspective. The effect of personality and personality disorders on an athlete can impact their team, coaches, and overall athletic environment. Tracking athletes’ thinking, functioning, and behaviours allows insight into their mental health. As these thoughts, functions, and behaviours develop into patterns, they can become an individual’s personality. Personality types develop at a young age but become patterned and consistent usually within the teen years or young adult years, often when athletes are steeped in sport culture. The facets of, and the responses to, the environment develop into the personality of an elite athlete. Personality traits have been found to correlate with performance (Hendawy & Awad, 2013). Personality 144

DOI: 10.4324/9781003099345-14

Personality Disorders in Elite Athletes

represents the patterns of thinking, behaving and beliefs of a person, and within normal limits, allows for individual expression and can be a hallmark of an athlete. If an athlete’s personality patterns become rigid and unhealthy, they can cause strain, interpersonal conflict, or tension, and/or become a predictable pattern of problematic behaviours. If this happens, they could be considered to have a personality disorder.

Theoretical Approaches History of Personality Theories of personality are first documented within Greek medicine. Early physicians defined four temperaments, described as: phlegmatic, sanguine, melancholic, and choleric; which depicts predictable response patterns based on the imbalance of elements (humours) in the body (Haslam et al., 2017). Ancient Chinese medicine began to explain unusual temperaments within people. Confucius suggested that a person’s temperament could vary during their life. This psychological energy “qi” is represented in traditional Chinese philosophy. When out of balance it could lead to undesirable characteristics (Morella Medical Clinic, 2018). Early philosophers identified 30 character-types, considering them fixed responses to life circumstances. As the descriptions continued, the explanation of personality types continues to be clarified and synthesised. Interestingly, many depictions were similar throughout cultures and over the years. Although the methods of discernment have changed, from humours, blood, energy, phrenology, and neural development to interpersonal interactions we continue to agree that personality can range from adaptive to dysfunctional, to pathological. Within the field of psychiatry, early pioneers included Pinel, Esquirol, and Prichard (Crocq, 2013). They provided descriptions of patients and frequent patterns of dysfunction that were observed. This documentation in the field of medicine and psychiatry began to collect and synthesise diagnostic information and interpretation. Through the influence of Kraepelin, Freud, Abraham, Reich, and many others (as well as the desire for objective measurement from Cattle) we can classify behaviours and temperaments in types and characteristics using objective criteria. Starting with the Diagnostic and Statistical Manual (DSM) in the 1950s, character disorders became formally recognised. They were not considered a mental illness, but more of a deficit of character (Hoermann et al., 2021). These form the personality types we know today. When referring to personality we are suggesting that certain traits can be observed on a recurrent basis that contributes to a person’s overall disposition. The most recent diagnostic manual, the DSM-5 (American Psychiatric Association, 2013) integrated both dimensional and topical classifications, to elucidate the most accurate depiction of personality. Dimensional systems illustrate the continuum from normal to abnormal, indicating when they cross a dysfunctional threshold (Crocq, 2013).

Personality and Its Disorders Defined Personality Personality is defined as “a characteristic way of thinking, feeling, and behaving. Personality embraces moods, attitudes, and opinions and is most clearly expressed in interactions with other people. It includes behavioural characteristics, both inherent and acquired, that distinguish one person from another and that can be observed in people’s relations to the environment and to the social group” (Holzman, 2021). The concept of personality is a way to describe a person’s presentation that occurs regularly. Understanding someone’s personality can assist the person, the people around them, their response to 145

Christopher M. Bader and LaTisha L. Bader

environment stressors, and emotional reactivity. As mentioned before theorists and researchers have attempted to categorise personality types and describe what falls within expected limits versus behaviours or beliefs that fall outside of these parameters. Research has attempted to understand the comorbidity of personality and mental health disorders, including bivariate models and multivariate models and reframing personality disorders using biological evidence (Livesley & Larstone, 2018). Within the Handbook of Personality Disorders, a classification system that encompasses quantitative, biological, theoretical, and practical information is offered. During a thorough exploration to craft the DSM-5 the authors and editors highlight well known personality models. The most well know personality dimensions are referred to as the Big 5 (Five Factor Model (FFM)) – Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness (Costa & McCrea, 1990). There are also five domains of maladaptive personality (negative affect, detachment, antagonism, disinhibition, and psychoticism) (Livesley & Larstone, 2018). Culture also plays a part in mental health considerations, and personality and the associated disorders are no different. The largest study to date to categorise behaviour traits across societies was Ivanova and colleagues (2007). Taking the Youth Self-Report (YSR; Achenbach & Rescorla, 2001) completed by 30,243 youth in 23 countries they conceived an eight-syndrome taxonomic model. The eight syndromes were labelled anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behaviour, and aggressive behaviour. These categories would suggest that there are some universal personalities that would be present across cultures. Referencing these types of personality traits start to demonstrate the leanings a person might have. It is only when these become disordered, or out of balance would the consideration of a personality disorder be suggested (Livesley & Larstone, 2018). Understanding the personality traits of athletes can help when consulting with them, and it can help predict how they may approach training and competition, as well as how they might respond to stress (Owen, 2016). Often, personalities of athletes are amenable to the culture of sport and serve to enhance not only the athlete but the team and sport. The most common personality traits in athletes are extraversion, perfectionism, and narcissism (Hendawy & Awad, 2013). One could see how these traits would be helpful to an athlete. Being in the public eye would be conducive to extraversion. Perfectionism is highly valued, if not nurtured, in athletes. Setting high standards, striving daily to achieve the highest level of performance would be reinforced. Narcissism is the pursuit of gratification from one’s own self-image and attributes. In its healthy forms, this trait would act as motivation and serve to continuously strive for self-improvement. In excess it would be expressed as a dark triadic trait. It is when personalities become maladaptive that they cease to be well served.

Personality Disorders A personality disorder is a way of thinking, feeling, and behaving that deviate from the expectations of the culture, causes distress or problems functioning, and lasts over time. The main features of a personality disorder include (a) distorted thinking, (b) problems with emotional regulation, (c) problems with impulse regulation, and (d) interpersonal difficulties (Hoermann et al., 2021). Many coaches and teammates will tolerate some variance in personality if it serves the collective goals of the team, but it can produce strain and tension. Acknowledging that some discord is normal and natural, even healthy, and can be utilised to build bonds but when it becomes unmanageable it is helpful to know there are diagnostic criteria that can be used to conceptualise the types of personality disorders. There are relatively basic answers to the questions about the development and definition of personality, and an increasing understanding of the aetiology of personality. Meanwhile, there is continued debate between various agencies and organisations as to the agreed upon constructs used to diagnose and treat personality disorders (Livesley & Larstone, 2018). Gratefully, within the current zeitgeist of psychology, the 146

Personality Disorders in Elite Athletes

field agrees on the use of the DSM-5 to order the understanding of personality and its disorders. Prior to the classification, let us explore the potential factors that can lead to a disordered expression of personality.

Factors Involved in the Development of Personality and Its Disorders Many early theorists debated between the aetiology of personality, beginning with the consideration of nature versus nurture. As knowledge grew, they surmised the origins of these descriptive categories such as: early childhood experience, types of parenting, instincts, impulses, and drives. The American Psychological Association believes the aetiology of personality disorders include genetics, abuse, environment, and relationships (Huff, 2004). Genes have been linked to many disorders, including obsessive-compulsive disorder, aggression, anxiety, and fear. Gene-environment interactions are part of the diathesis-stress models of pathology (Rutter, 2006). When a person experiences adversity they are more likely to be pathogenic if there is a genetic predisposition. One of the largest studies of personality disorders suggests a strong link between childhood trauma and the development of personality disorders (Gunderson et al., 2000). There is some suggestion that individuals who had high rates of childhood sexual trauma may specifically develop borderline personality disorder traits (Livesley & Larstone, 2018). The Handbook of Personality Disorders (Livesley & Larstone, 2018) mentions some typical childhood adversities associated with personality disorders including dysfunctional families because of parental psychopathology, family breakdown, and parenting practices. There is a suggestion that emotional dysregulation runs in families. So, individuals that have parents or close relatives that struggle with personality disorders would have a higher probability to struggle themselves. Whether its impulsivity, schizotypal, or compulsive personality disorders, there is a relationship between heritable and temperamental similarities. Verbal abuse can also have an impact on the development of personality disorders. Children who experienced a parent screaming at them, telling them they did not love them, or threatening to send them away were three times more likely to have borderline, narcissistic, obsessive-compulsive, or paranoid disorders in adulthood (Johnson et al., 2001). High reactivity to light, noise, texture, and other stimuli may play a role as well (Livesley & Larstone, 2018). Development of behaviours described as shy, timid, or anxious personalities may also be correlated to reactivity. Social stressors are also an influence in the development of personality disorders. Negative influences can be offset by positive relationships with a relative, teacher, or friend. Overall, individuals with personality disorders experience interpersonal difficulties, impulse control problems, misperception of comments or situations, and affective instability. Individuals with personality disorders have maladaptive coping skills (Brown, 2014; Hendawy & Awad, 2013). One can start to extrapolate the factors that build a personality and discern where certain factors begin to influence maladaptive patterns. As noted in the DSM-5 (American Psychiatric Association, 2013), there are noted gender differences in diagnosis of some personality disorders (Antisocial is diagnosed more in males, whereas borderline, histrionic, and dependent are diagnosed more often in females). Given the necessity of a “pervasive pattern” for the diagnosis of a personality disorder, they are rarely diagnosed in children and in individuals younger than 18, the pattern of concern must be present for at least one year (American Psychiatric Association, 2013). In elite athletes, there are common factors that shape personality disorders observed within the sport world. Athletes may never leave the high-pressure environment of sport during their years of formation; this environment may influence the development or revelation of personality characteristics. As alluded to previously, one factor that may contribute to the development of a disorder is verbal abuse. Athletes are exposed to copious amounts of verbal instruction through coaching, feedback from administrators and crowds, critique from teammates and parents, as well as media. This may constitute a level of verbal interaction that registers as 147

Christopher M. Bader and LaTisha L. Bader

verbal abuse to athletes. Previous styles of coaching that have come from a shame-based style, “gentle ribbing”, teasing, or bullying have been used within coach–player relationships. These approaches of “getting on to” a player to get a performance may impact personality (Johnson et al., 2001; Sagar et al., 2011). Athletes also experience significant amounts of somatic, social, and interpersonal stress (Markser, 2011) which can also shape a person’s behaviours, beliefs, and eventually personality. External demands along with internal responses may contribute to a personality style that appears disordered (Livesley & Larstone, 2018) within or outside of the sport arena (Andersen et al., 1994). As we start to notice deviations in personality, we can organise them into types. As suggested previously, the DSM describes ten primary types of personality disorders and organises them into clusters. It is important to note that if a person does not “cleanly” fit into a type, meaning that they do not fit the allotted number of criteria they can be described using a cluster type. This means that they share characteristics of multiple types that all fit under the umbrella of one cluster.

Characterisation of Personality Disorders The DSM-5 (American Psychiatric Association, 2013) suggests personality disorders have individualised criteria and believe they are long-term patterns of behaviour. Although there can be some disagreement in the aetiology of disordered personality, there is consensus that characteristics will begin to develop in late adolescence or early adulthood and begin to cause distress or difficulties in functioning. The DSM-5 offers both the traditional model of characterising personality disorders and an alternative model for personality disorders. Table 10.1 outlines the traditional model of these disorders. The alternative model is mentioned here and as an acknowledgement that the traditional model has its shortcomings and has opened research into alternative characterisations of personality disorders. Widiger (2018) offers a historical review of the characterisation and classification of personality disorders and reviews multiple classification systems within personality disorders. The alternative model suggests personality disorders be considered regarding problems in personality functioning and disordered personality traits (American Psychiatric Association, 2013). This model attempts to address some diagnostic concerns around the current/traditional model that will be mentioned further later in this chapter. All personality disorders are characterised by a pattern of behaviour which is outlined in Table 10.1 next to the name of each personality disorder. The ten personality disorders are organised into three clusters (A, B, and C) based on overlap of traits amongst the disorders in that cluster. Cluster A is labelled the “Odd, Eccentric” cluster. The disorders within have common features of social awkwardness and social withdrawal. Disorders included in Cluster A are paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster B is labelled the “Dramatic, Emotional, Erratic” cluster. The disorders within have common features of dramatic, overly emotional, or unpredictable thinking or behaviour. Disorders included in Cluster B are antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Cluster C is labelled the “Anxious, Fearful” cluster. The disorders within have common features of anxious, fearful thinking or behaviour. Disorders included in Cluster C are avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. In addition to the DSM-5 (American Psychiatric Association, 2013) clustering system for personality disorders, there is some research on common traits that lend themselves to certain personality disorders or personality types. Paulhus and Williams (2002) defined three personality traits as the dark triad. “Individuals with these traits shared a tendency to be callous, selfish, and malevolent in their interpersonal dealings” (p. 100). These dark triad traits (narcissism, Machiavellianism, and psychopathy) are associated with misbehaviour, revenge, excessive and exaggerated self-admiration, hostility, and insensitivity. These words have 148

Personality Disorders in Elite Athletes Table 10.1 Names and Characteristics of the Personality Disorders (PD) CLUSTER A (Odd, Eccentric) Paranoid PD • Suspicious of others and seeing them as mean or spiteful • Often assume people will harm or deceive them • Do not confide in others or become close to them Schizoid PD • Detached from social relationships and expressing little emotion • Typically does not seek close relationships • Chooses to be alone • Seems to not care about praise or criticism from others Schizotypal PD • Very uncomfortable in close relationships • Having distorted thinking and eccentric behavior • May have odd beliefs or odd or peculiar behavior or speech • May have excessive social anxiety CLUSTER B (Dramatic, Emotional, Erratic) Antisocial PD • Tends to disregard or violate the rights of others • May not conform to social norms • May repeatedly lie or deceive others • May act impulsively Borderline PD • Instability in personal relationships • Intense emotions • Poor self-image and impulsivity • May go to great lengths to avoid being abandoned • May have repeated suicide attempts, • May display inappropriate intense anger • May have ongoing feelings of emptiness Histrionic PD • Excessive emotion and attention seeking • May be uncomfortable when they are not the center of attention • May use their physical appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions Narcissistic PD • High need for admiration • Lack of empathy for others • May have a grandiose sense of self-importance • May have a sense of entitlement • May take advantage of others CLUSTER C (Anxious, Fearful) Avoidant PD • Extreme shyness • Feelings of inadequacy and extreme sensitivity to criticism • May view themselves as not being good enough • May view themselves as socially inept (Continued)

149

Christopher M. Bader and LaTisha L. Bader Table 10.1 (Continued) • •

May be unwilling or get involved with people unless they are certain of being like May be preoccupied with being criticised or rejected

Dependent PD • Has a need to be taken care of and submissive and clingy behavior • May have difficulty making daily decisions without reassurance from others • May feel uncomfortable or helpless when alone because of fear of inability to take care of themselves Obsessive-Compulsive PD (this is not the same as obsessive-compulsive disorder) • Preoccupation with orderliness, perfection, and control • May be overly focused on details or schedules • May work excessively not allowing time or leisure or friends • May be inflexible in their morality and values Note: The diagnostic criteria for each of these disorders are much more complex than the characteristics below. Making a diagnosis requires numerous symptoms and should only be made by a qualified clinician.

been used to describe athletes especially in certain sport or positions. Interestingly, those traits may be valued or trained. One article reported that athletes who participate in competitive sport have higher scores in the dark triad (González-Hernández et al., 2020). Results showed that competitiveness is strongly related to this dark personality triad. Narcissism is related to the desire to win and fear of losing, Machiavellian tendencies are when athletes feel like losers. Psychopathy is related to inferiority and fear of failure. The study suggested that the traits are part of the athlete’s psychology as well as the competitive environment. Hendawy and Awad (2013) provides information that points to personality traits correlating with athletic performance. Additionally, Sagar and colleagues (2011) suggested that fear of failure and sport experience positively predicted antisocial behaviour. The characterisation of personality disorders is important to consider when exploring diagnostic concerns for a particular individual. Other important factors include the diagnostic criteria and the timing of the diagnosis. It is imperative that before making a diagnosis the individual in question be evaluated in multiple environments, be evaluated with numerous points of data, be sober, and be out of any acute emotional states. It is helpful to both conceptualise and treat within a collaborative treatment team with multiple perspectives before settling on a diagnosis.

Biopsychosocial Model (BPS) The Biopsychosocial Model (BPS) integrates the connections between biological, psychological, and social-environmental factors. This model is utilised to examine and explain various concerns ranging from health and disease to development. The BPS approach was developed by doctors George Engel and John Romano in the late 1970s to improve the medical model of biomedicine (Engel, 1980). When considering personality disorder aetiology, it can be helpful to use a similar approach. The BPS model suggests that there is not a single factor that can explain the development of personality disorders. Thus, when conceptualising personality disorders, it is suggested that diagnosticians consider BPS as a starting point.

Diagnosing Personality Disorders The process of diagnosing a personality disorder, is just that, a process. Diagnosing a personality disorder can serve as a framework to provide a greater understanding of the individual. That increased 150

Personality Disorders in Elite Athletes

understanding can provide information for interventions and maladaptive behaviours that can be addressed. Addressing fears, instability of relationships, unclear or shifting self-image, as well as impulsivity, self-harm, or extreme mood swings can provide avenues to improve the person’s life experience. The diagnostic process may include a specifically designed interview and assessment tools to evaluate a person. This interview is often a response to observed behavioural data over time. In any setting, it is best to utilise information from multiple sources. Within athletic settings, those sources may include, but not be limited to coaches, teammates, trainers, (sport) psychologists, friends, family, and others in the individuals’ life to ascertain patterns of behaviours. Utilising diagnostic criteria found in the DSM-5 (American Psychiatric Association, 2013), it can be helpful to begin with one of the “Clusters” of personality and then delineate the specific disorder by using the diagnostic criteria for each disorder. It is cautioned to use a diagnosis as a label that “traps” the individual with a myopic understanding of themselves. Diagnosing a personality disorder usually occurs after the age of 18, and often people need to be sober and out of chaotic environments to ascertain a clear diagnostic picture. The diagnostic approach for athletes is no different than that of non-athletes, and findings from Hendawy et al., (2012) suggest that many competitive athletes qualify for at least one personality disorder with the most common being obsessive-compulsive, borderline, narcissistic, and mixed personality disorders. While mixed personality disorder is not an official diagnosis, it points to what many clinicians realise, most pathological personality profiles do not fit neatly into one diagnostic personality disorder. Individuals may show traits of certain disorders but may not qualify for a full diagnosis. With the above information in mind, considering the prevalence rates of the various personality disorders is important. It is interesting to note that the DSM-5 (American Psychiatric Association, 2013) published prevalence rates on the clusters themselves as well as noting data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The prevalence rates from Cluster A are 5.7%, those from Cluster B are 1.5%, and from Cluster C are 6.0%, and the prevalence rate for any personality disorder is 9.1%. The NESARC data points to as many as 15% of U.S. adults having at least one personality disorder. In breaking down those numbers into the specific disorders, the following brief descriptions and prevalence rates are offered. In someone with paranoid personality disorder (PPD) there is a lack of trust and presence of suspicion such that the individual with PPD interprets others’ motives as malevolent. Estimated prevalence rates are from two different surveys and range from 2.3% and 4.4% in those survey populations (American Psychiatric Association, 2013). Schizoid personality disorder is uncommon in clinical settings and is seen in approximately 3.1% to 4.9% of individuals. Individuals with this pattern of behaviour display a detachment from social relationships, and a restricted range of emotional expression (American Psychiatric Association, 2013). Schizotypal personality disorder presents with acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. Based on cross-cultural data, prevalence rates range from 0.6% (Norway) to 4.6% (in the United States). It is seen infrequently in clinical settings (0%–1.9%), and the NESARC data indicated an overall prevalence rate of 3.9% (American Psychiatric Association, 2013). Antisocial personality disorder (ASPD) has a lifetime prevalence of approximately 1–4% of the general population (American Psychiatric Association, 2013). Werner et al. (2015) suggests that most of the research conducted on individuals with ASPD is within the criminal population. ASPD is a described as “a pervasive pattern of disregard for, and violation of, the rights of others, occurring since age 15” (American Psychiatric Association, 2013, p. 659). Borderline personality disorder (BPD) has hallmarks of conflict and opposing fears of abandonment and dependency (Beeney et al 2018) and is described as “a pattern of instability in interpersonal relationships, selfimage, and affects, and marked impulsivity” (American Psychiatric Association, 2013, p. 645). Clinicians sometimes refer to this pattern by using the Kreisman and Straus (2010) book title, I Hate You – Don’t Leave Me. 151

Christopher M. Bader and LaTisha L. Bader

This illustrates the sometimes severe shifts in mood that can bring panic to the individual and often causing strife in their world. It is estimated that there are more than 18 million people that suffer from BPD in the United States today (Kreisman & Straus, 2010). There are known connections between BPD and substance abuse, sexual abuse, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, and eating disorders. The prevalence rates of BPD vary by setting with median population estimates between 1.6% and 5.9% (American Psychiatric Association, 2013). The DSM-5 (American Psychiatric Association, 2013) also estimates that BPD is seen in about 6% of patients in primary care settings, 10% of individuals seen in outpatient mental health clinics, and 20% among psychiatric inpatients. Excessive emotionality and attention seeking behaviours are the hallmarks of histrionic personality disorder (HPD), and data from NESARC suggest that HPD occurs in about 1.84% of individuals (American Psychiatric Association, 2013). Narcissistic personality disorder (NPD) prevalence estimates range somewhat widely from 0% to 6.2% in community-based samples. As the name would suggest, grandiosity, need for admiration, and lack of empathy are tell-tale indicators of the possibility of this personality disorder (American Psychiatric Association, 2013). NESARC data for avoidant personality disorder indicates that it occurs in 2.4% of people. Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation are seen in the individuals who meet criteria for this personality disorder (American Psychiatric Association, 2013). Dependent personality disorder (DPD) seems to be one of the personality disorders with the lowest prevalence rates (0.49% to 0.6%). Individuals with DPD are characterised by submissive and clinging behavior related to an excessive need to be taken care of or protected (American Psychiatric Association, 2013). As opposed to DPD, obsessive-compulsive personality disorder (OCPD) is considered one of the most prevalent personality disorders in the general population with prevalence estimates ranging from 2.1% to 7.9%. Individuals diagnosed with OCPD have a preoccupation with orderliness, perfectionism, and control (American Psychiatric Association, 2013). It is important to note here that OCPD is distinct and diagnostically separate from obsessive-compulsive disorder (OCD). When considering making a diagnosis, it is suggested that the diagnosing professional (preferably, a licensed mental health practitioner with experience in diagnosing personality disorders) consider the following points: observable behaviors (first-hand observation is preferred), additional points of data from stakeholders within the individuals’ life, assess any personal biases in the previous two points, review the diagnostic criteria and the characterisation system of preference, and move ahead with the diagnostic framework.

Impact on Social-Emotional Functioning Personality disorders can disrupt the person, their environment, and the people who care about them. Causing disruption in relationships, work, or school, or sport and can lead to isolation, risk taking behaviors, and substance use/abuse. Ideal social and emotional functioning would include displaying self-control, expressing feelings with words, listening, paying attention, pride in accomplishments, positive self-image, asking for help when needed, showing affection to familiar people, and being aware of other people’s feelings. One’s ability to achieve these things is crucial to health human development (National Scientific Council on the Developing Child, 2004). When genetics, abuse, and negative environmental factors delay or block this development maladaptive responses can be seen. Skodol et al. (2005) indicated that individuals with mood disorders and co-occurring personality disorders have significantly more impairment and role limitations. Emotional problems, social functioning, and general health can also be impacted. It was concluded that a co-occurring personality disorder contributed significantly to impairment in social and emotional functioning and reduced well-being for 152

Personality Disorders in Elite Athletes

individuals with depression. Additionally, individuals with BPD report poorer social support, more conflict in their social network, and less connection to important people (Beeney et al., 2018). In essence, they are at a social disadvantage.

Impact on Elite Athletes The need to understand mental health disorders (specifically personality disorders) is imperative for the universal understanding of athletes. Arnold and Fletcher (2012) identified 640 distinct stressors in the life of a professional or elite athlete with mental health and its disorders being two of those stressors. It is well known that involvement in sport provides protective factors and increases the emotional wellbeing of individuals. Literature suggests ten psychological and social benefits of athletic participation: camaraderie, learning to lose, respecting authority, controlling emotions, self-esteem, patience, dedication, working together, less selfish, and resilience (Nikolic, 2015). Playing on teams can help individuals develop social skills, including cooperation, being less selfish, listening, and creating a sense of belonging. It helps build new friends and social circles. Sport provide a place people can see social, emotional, and cognitive skills be expressed by coaches, parents, and other players. With the positive effects of sport participation mentioned above, it is understandable that participation in competitive sport may impact the development of personality and thus those potentially maladaptive patterns that can emerge. Due to the high demands of sport and insulation of the sport environment athletes may need additional time to develop aspects of personality and emotional maturity. Additionally, in the Long-Term Athletic Development Model (Balyi et al., 2014), the sixth stage of the model is “training to win.” In this stage, many athletes begin to shape their behaviors to achieve success with intensity of schedule, rigor of training methods, and seeking out top-rated equipment and facilities. Those are traits that could support the maladaptive patterns seen in personality disorders. It is important to consider these factors and influences throughout the diagnostic process. Markser (2011), when educating about sport psychiatry, shares how athletes are engaging in rigorous training demands during a pivotal time of psychological development and sometimes this psychological development is unable to keep up with the physical environment. With most of the attention placed on physical development it is difficult to surmise when young athletes have reached their emotional or mental limit. Athletes may find the physical and psychological balance difficult, and may refuse to accept limitations. We might begin to see this expressed as traits of one or more of the personality disorders described in this chapter. While research into personality disorders in athletes is lacking, there are some studies that report general mental health disorders/problems in athlete populations. Prevalence rates of mental health disorders in currently competing elite athletes range from 19% (alcohol misuse) to 34% (anxiety/depression). For former athletes, prevalence rates range from 16% (“distress”) to 26% (anxiety/depression; Gouttebarge et al., 2019). Åkesdotter and colleagues (2020) reported the lifetime prevalence of mental health problems in elite athletes to be 51.7%, noting that the symptoms usually began at an early age and that recurrent occurrences of those mental health problems were common. The most common disorders found were a depressive disorder, an eating disorder, or a trauma or stress-related disorder (burnout). The impact of a personality disorder on an athlete may significantly impact their ability to be successful in achieving mental resilience, affect regulation, impulse control, and interpersonal effectiveness (Owen, 2016). This ability to self-regulate translates to an athlete’s capacity to function within their team/organisation and participate in the daily rigor of sport. Athletes may not recognise their own patterns of behaviour as disordered because those patterns have seemed natural and have often served a greater purpose. Demonstrating traits of extraversion, perfectionism, and narcissism appeals to the culture of sport and may garner favour with coaches and/or teams. It is when this strength, taken to extremes, can become a liability that it needs to be identified and addressed. 153

Christopher M. Bader and LaTisha L. Bader

It would only take a few moments to invoke names of athletes that have strong, memorable personalities. With the appropriate diagnostic criteria in hand, many of these individuals might fit criteria for a personality disorder. What may be less clear is differentiating whether that person is playing for the crowd or media, keeping up a certain persona, or if they are displaying behaviors that would lend themselves to a personality disorder diagnosis. Differentiating the presenting concerns can help inform both diagnostic and treatment options.

Treatment of Personality Disorders There are no medications specifically used to treat personality disorders (American Psychiatric Association, 2018), and limited information exists on the effectiveness of drug therapies (Nelson, 2018). Some medications that provide mood stabilisation have been used to help with personality disorders; and, because people with personality disorders experience maladaptive behaviours and abnormal thoughts, those can be addressed in therapy. Overall, personality disorders are difficult to treat, but research suggests that the following types of therapy have been effective: psychoanalytic/psychodynamic therapy, dialectical behaviour therapy, cognitive behavioural therapy, group therapy, and psychoeducation (teaching the individual and family members about the illness, its treatments, and ways of coping). Within those different therapies, it is important for the clinical staff to gauge whether the maladaptive behaviours are state-based or trait-based. That differentiation can help with diagnostic information as well as how best to approach discussing the diagnosis with the individual patient.

Practical Applications and Guidelines Currently there is no comprehensive framework or model to care for the needs of elite athletes (Purcell et al., 2019). The challenge is to become aware of issues and have personnel in place trained to recognise them. Most mental health concerns or psychiatric disorders improve and resolve with proper intervention. Regarding personality disorders, they may not resolve but with accurate diagnostic discernment and targeted interventions, personality disorders can be managed. That management can lead to increased support and improved interpersonal relationships. Early detection and intervention are the best predictors of improving mental wellbeing minimising negative impact on the athlete (Purcell et al., 2019). That early detection may take the form of a preperformance behavioural health survey wherein disorders are screened for with the goal being early intervention prior to performance disruption. Within a screening, one may consider assessing for the nonpersonality disorders mentioned earlier in this chapter (i.e., anxiety). The addition of non-clinical measures (e.g., the Athletic Identity Measurement Scale, a short interview, a review of information from former coaches/teammates) can assist the evaluator in gauging possible maladaptive patterns within the individual’s personality. It is best to be aware of the conceptualisation of personality and personality disorders. Basic knowledge of DSM/ICD-10 codes as well as taxonomies are important and can help guide practitioners. With this understanding, a provider will be able to recognise when behaviours are falling within normal limits or those expected within the sport world. Recognition can lead to confirmation whether those patterns of behaviour are disrupting the individual’s environment. It is often helpful to conceptualise an individual using the understanding of personality disorders and proceed with this as a framework for understanding the perception of self or the world around them. For example, if an individual were demonstrating labile interpersonal interactions such as one week idealising a coach, then vilifying them and had done this for three years of their career. It would be fitting to move forward with an understanding they might have a personality disorder, thus a better treatment approach might be applying a more specific modality (e.g., cognitive behavioural therapy or dialectical behaviour therapy). 154

Personality Disorders in Elite Athletes

However, providers should take caution in potentially labelling an individual with a personality disorder and then believing in a limited ability to change. It is always best to proceed with a conceptualisation that the athlete is demonstrating personality traits versus a diagnosable disorder, and continue to gather additional collateral information, perspectives from others that interact with them or utilising objective personality inventories. Starting with a framework is often a helpful place to ascertain which interventions or treatment will be most effective. Refer to diagnostic criteria, keeping in mind the age and need for long term behaviour patterns that cannot be better explained by mental health, trauma, substance, or environment. If an athlete you are treating continues to demonstrate behaviours consistent with a personality disorder, it would be helpful to tailor treatment efforts and interventions for the specific disorder. If you do not feel comfortable or qualified to tailor treatment efforts and interventions, please make an appropriate referral to a qualified practitioner. It is best to identify this pattern of functioning early and make the referral earlier in the relationship. It is also recommended that, if you find yourself in the above situation, you discuss your concerns with the other practitioners on your multidisciplinary care team when possible.

Summary This chapter addressed numerous facets of personality and personality disorders as well as those within the context of elite athletes. Personality disorders are generally less disruptive than some other severe and pervasive mental illnesses; however, they can be particularly disruptive within the elite athlete settings. These disruptions can be felt within a small group (performance group or position group), a larger team, and/or within the sport organisation itself (collegiate athletic department, national governing body, and/ or professional sport organisation). Many questions remain when it comes to personality disorders in general – for example, how best to classify or characterise those disorders. The classification is important to explain things to patients, supporters, and treatment teams. The future for personality disorders, especially within elite athletes, is bright in that there are plenty of opportunities to contribute to the research literature. There are good examples of initial research in this area, however, more specified research is needed to better understand personality disorders and their impact. This research could ultimately help individuals diagnosed with personality disorders understand why their interpersonal relationships may be strained at times and how to move more smoothly through life.

Case Presentation Note: This case presentation is a compilation of numerous cases the authors have either worked or collaborated on over the course of their careers. Many times, personality disorders are slow to emerge in a clinical/sport setting. This case tries to illustrate that and to show the importance of a multidisciplinary team for psychological care. While the case is set up in an athletic department setting, the multidisciplinary team approach can be arranged in any number of settings. You are a licensed mental health practitioner and have been approached by a student-athlete to start therapy for support around life and sport. As you get to know the student-athlete and you feel for them – it seems they have struggled in relationships and have gotten the “raw end of the deal” at times. This student-athlete is likable, shows up on time, and is generally personable. You are getting a sense of them in relationships and noticing some patterns to their behavior that could be the focus of counseling. One of those patterns you notice, is the extreme sensitivity to feedback – when feedback is given there seems to be a disproportionate reactivity given the circumstances. A few weeks after your initial appointment, you are approached by a sport administrator with concerns about a 19-year-old collegiate student-athlete (your client, unbeknownst to the administrator). The administrator reports that this student-athlete was highly recruited with no known areas of concern. You 155

Christopher M. Bader and LaTisha L. Bader

also find out that this person attended three high schools and was part of two different club teams for their sport during high school, when asked about this the student-athlete and parents are quick to blame the administration of the schools and teams for “problem behaviors” reported about the student-athlete. When you hear from others (academics, sport medicine, and other support staff) about the studentathlete, a pattern begins to emerge – the student-athlete has limited insight regarding their behaviours and reactivity when those behaviours are addressed. Additionally, you have consulted with this studentathlete’s roommates as they have concerns about the student-athlete’s behaviour, especially on the weekends and when alone. The roommates report that the student-athlete will make veiled threats of selfharm and has tried to pit the roommates against one another by telling them half-truths. The pattern you begin to see is again one of blaming others and an inability to see any fault of their own – across all areas of functioning (athletics, academics, social). You hear from other student-athletes that your client has been going to the coaching staff under the guise of “not wanting to start drama” and reporting half-truths about teammates. When you hear from staff and coaches, they all start off wanting to help this student-athletes given the student-athletes’ “tough set of circumstances” yet eventually all grow tired of the constant stories and “woe is me” dialogue. One weekend the student-athlete calls the after-hours number. They report feeling “off” and not sure they “want to go on”, and then provides information about other student-athletes and suggesting how they “hate me” and “no one likes me, not even the coaches who recruited me”. When asked about suicidality, the student-athlete is elusive and will not admit to thoughts of harming self and is avoidant in their answers to the clinically relevant questions asked. They commit to staying safe this weekend and agree to see you next week. They no-show that appointment, you follow up to no avail, and the following weekend the student athlete calls the afterhours line again with a similar story to the previous weekend. The on-call counselor reports that the student-athlete said they are looking for a counselor and the student-athlete would like to start seeing one of your colleagues. How might you handle this situation at various points? What are your diagnostic impressions? What would be your treatment recommendations?

References Achenbach, T.M., & Rescorla, L.A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Åkesdotter, C., Kenttä, G., Eloranta, S., & Franck, J. (2020). The prevalence of mental health problems in elite athletes. Journal of Science and Medicine in Sport, 23(4), 329–335. doi: 10.1016/j.jsams.2019.10.022 Andersen, M.B., Denson, E.L., Brewer, B.W., & van Raalte, J.L. (1994). Disorders of personality and mood in athletes: Recognition and referral. Journal of Applied Sport Psychology, 6(2), 168–184. 10.1080/10413209408406292 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. 10.1176/appi.books.9780890425596 American Psychiatric Association. (2018). What are personality disorders? Retrieved from https://www.psychiatry. org/patients-families/personality-disorders/what-are-personality-disorders Arnold, R., & Fletcher, D. (2012). A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. Journal of Sport and Exercise Psychology, 34(3), 397–429. doi: 10.1123/jsep.34.3.397 Balyi, I., Way, R., & Higgs, C. (2014). Long-term athlete development. Human Kinetics. Illinois. Beeney, J.E., Hallquist, M.N., Clifton, A.D., Lazarus, S.A., & Pilkonis, P.A. (2018). Social disadvantage and borderline personality disorder: A study of social networks. Personality Disorders, 9(1), 62–72. doi: 10.1037/per0000234 Brown, G.T. (2014). Mind, body and sport: Understanding and supporting student-athlete mental wellness. Indianapolis, Indiana: National Collegiate Athletic Association. Costa, P., & McCrea, R. (1990). Personality disordered and the five-factor model of personality. Journal of Personality Disorders, 8(2), 149–167. Crocq, M.A. (2013). Milestones in the history of personality disorders. Dialogues in Clinical Neuroscience, 15(2), 147–153. doi: 10.31887/DCNS.2013.15.2/macrocq

156

Personality Disorders in Elite Athletes Engel, G.L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535–544. Ferraro, T. (2004). Is sport psychology failing the athlete? Athletic Insight: The Online Journal of Sport Psychology, 6(2), 10–16. González-Hernández, J., Cuevas-Campos, R., Tovar-Gálvez, M.I., & Melguizo-Rodríguez, L. (2020). Why negative or positive, if it makes me win? Dark personality in Spanish competitive athletes. International Journal of Environmental Research and Public Health, 17(10), 3504. 10.3390/ijerph17103504 Gouttebarge, V., Castaldelli-Maia, J.M., Gorczynski, P., Hainline, B., Hitchcock, M.E., Kerkhoofs, G.M. (2019). Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. British Journal of Sport medicine. 53(11), 700–706. doi: 10.1136/bjsports-2019-100671 Gunderson, J.G., Shea, M.T., Skodol, A.E., McGlashan, T.H., Morey, L.C., Stout, R.L. Zanarini, M.C., Grilo, C.M., Oldham, J.M., & Keller, M.B. (2000) The collaborative longitudinal personality disorders study: Development, aims, design, and sample characteristics. Journal of Personality Disorders, 14(4), 300–315. doi: 10.1521/pedi.2000.14.4.300 Haslam, N., Smillie, L., & Song, J. (2017). An introduction to personality, individual differences, and intelligence (2nd ed.). Sage: London. Hendawy, H.M.F.M., & Awad, E.A.A. (2013). Personality and personality disorders in athletes. In D.A. Baron, C.L. Reardon, & S.H. Baron (Eds.) Clinical Sports Psychiatry: An International Perspective. Wiley. Hendawy, H.M., Baron, D.A., & Sei-Eldawla, A., et al. (2012). Prevalence of psychiatric disorders and coping processes in a sample of Egyptian competitive athletes. In D.A. Baron (Ed.) Clinical Sports Psychiatry: An International Perspective. (p. 53–64). John Wiley & Sons: Oxford, UK. Hoermann, S., Zupanick, C.E., & Dombeck, M. (2021). The history of the psychiatric diagnostic system continued. Retrieved from https://www.gulfbend.org/poc/view_doc.php?type=doc&id=560 Holzman, P.S. (2021). Personality. Britannica. https://www.britannica.com/topic/personality Huff, C. (2004). Where personality goes awry. American Psychological Association Monitor on Psychology, 35(3), 42. Ivanova, M.Y., Achenbach, T.M., Rescorla, L.A., Dumenci, L., Almqvist, F., Bilenberg, N. … et al. (2007). The generalizability of the Youth Self-Report Syndrome structure in 23 societies. Journal of Consulting and Clinical Psychology, 75(5), 729–738. doi: 10.1037/0022-006X.75.5.729 Johnson, J.G., Cohen, P., Smailes, E.M., Skodol, A.E., Brown, J., & Oldham, J.M. (2001). Childhood verbal abuse and risk for personality disorders during adolescence and early adulthood. Comprehensive Psychiatry, 42(1), 16–23. doi: 10.1053/comp.2001.19755 Kreisman, J.J., & Straus, H. (2010). I hate you - don’t leave me: Understanding the borderline personality. Penguin Random House LLC. Livesley, W.J., & Larstone, R. (2018). Handbook of personality disorders: Theory, research and treatment (2nd ed.). The Guildford Press. New York. Markser, V.Z. (2011). Sport psychiatry and psychotherapy. Mental strains and disorders in professional sports. Challenge and answer to societal changes. European Archives of Psychiatry and Clinical Neuroscience, 261(Suppl 2), S182–S185. doi: 10.1007/s00406-011-0239-x Morella Medical Clinic. (2018, May 21). QI deficiency explained in traditional Chinese medicine. Retrieved from https://moreliaclinic.com/qi-deficiency-explained-in-traditional-chinese-medicine/ National Scientific Council on the Developing Child. (2004). Children’s emotional development is built into the architecture of their brains. Working paper #2. Cambridge, MA: Harvard. Retrieved from www.developingchild.harvard.edu Nelson, K.J. (2018). Pharmacotherapy for personality disorders. Retrieved from https://www.uptodate.com/contents/ pharmacotherapy-for-personality-disorders Nikolic, I. (2015). 10 psychological and social benefits of sport for kids. Retrieved from https://uqsport.com.au/10psychological-and-social-benefits-of-sport-for-kids/ Owen, B. (2016). The athletic personality and personality disorders. In A. Currie & B. Owen (Eds.), Sports psychiatry. Oxford University Press. Paulhus, D.L., & Williams, K.M. (2002). The dark triad of personality: Narcissism, machiavellianism, and psychopathy. Journal of Research in Personality, 36, 556–563. 10.1016/S0092-6566(02)00505-6 Purcell, R., Gwyther, K., & Rice, S.M. (2019). Mental health in elite athletes: Increased awareness requires an early intervention framework to respond to athlete needs. Sports Med – Open, 5(46). 10.1186/s40798-019-0220-1 Rice, S.M., Gwyther, K., Santesteban-Echarri, O., Baron, D., Gorczynski, P., & Gouttebarge, V. … et al. (2019). Determinants of anxiety in elite athletes: A systematic review and meta-analysis. British Journal of Sports Medicine, 53(110), 722–730. 10.1136/bjsports-2019-100620 Rutter, M. (2006). Genes and behavior: Nature-nurture interplay explained. London: Blackwell. Sagar, S.S., Boardley, I.D., & Kavussanu, M. (2011). Fear of failure and student athletes’ interpersonal antisocial behaviour in education and sport. British Journal of Educational Psychology, 81(3), 391–408. doi: 10.1348/2044-82 79.002001

157

Christopher M. Bader and LaTisha L. Bader Skodol, A.E., Gunderson, J.G., Shea, M.T., McGlashan, T.H., Morey, L.C., Sanislow, C.A., … et al. (2005). The collaborative longitudinal personality disorders study (CLPS): Overview and implications. Journal of Personality Disorders, 19(5), 487–504. doi: 10.1521/pedi.2005.19.5.487 Werner, K.B., Few, L.R., & Bucholz, K.K. (2015). Epidemiology, comorbidity, and behavioral genetics of antisocial personality disorder and psychopathy. Psychiatric Annals, 45(4), 195–199. doi: 10.3928/00485713-20150401-08 Widiger, T.A. (2018). Official classification systems. In W.J. Livesley, & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., pp. 47–71). The Guilford Press.

158

11 ANXIETY DISORDERS AMONG ELITE ATHLETES Courtney C. Walton, Simon Rice, Lisa Olive, Claudia L. Reardon, and Rosemary Purcell

The Spectrum of Anxiety in Elite Sport As discussed throughout the chapters of this book, the mental health of elite athletes has become of increasing concern to, and an increasing focus of, practitioners and researchers alike (Poucher et al., 2019; Reardon et al., 2019; Rice et al., 2016; Vella et al., 2021). Within the scope of athlete mental health, a range of experiences from subclinical symptomology to clinical disorders can occur. Of particular focus in this chapter, anxiety is common in athletes (Reardon et al., 2021; Rice et al., 2019), despite the known anxiolytic effects of exercise more generally (Bradley et al., 2008; Stubbs et al., 2017). Most research into anxiety within elite sport has focussed on performative – rather than mental health – concerns (Rice et al., 2016). At appropriate levels, anxiety can be fundamental to peak performance by increasing cognitive and physiological preparedness for action (Mellalieu et al., 2006). Competition induced arousal and performance anxiety can, however, become debilitating for some athletes, impairing performance and disrupting other aspects of life including sleep, social engagement, and well-being. This form of competition anxiety is discussed at length in Chapter 15, Competition Anxiety, and is therefore not the focus of this chapter. Further to the detrimental effects of competition anxiety, many athletes may experience an anxiety disorder. Clinically defined anxiety disorders include Specific Phobias, Social Anxiety Disorder, Generalised Anxiety Disorder (GAD), Panic Disorder, Agoraphobia, and Separation Anxiety and Selective Mutism (occurring primarily in childhood) (American Psychiatric Association, 2013). In this chapter, we will primarily focus on GAD, with some reference to Social Anxiety Disorder and Panic Disorder, owing to the limited scope of available research. We discuss how these disorders may manifest in elite sport as well as approaches to assessment, treatment, and prevention.

Anxiety Disorders: An Overview Anxiety disorders are the earliest seen mental disorders in children and together represent the most common forms of mental illness (Penninx et al., 2021). They are described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) as being fundamentally characterised by excessive fear and worry, with related behavioural disturbances or functional impairment. An important distinction between these aspects is that while fear relates to an immediate or currently present threat, anxiety is primarily a response to a perceived – real or DOI: 10.4324/9781003099345-15

159

Courtney C. Walton et al.

unlikely – future threat. Commonly, individuals experiencing clinical anxiety present with a range of symptoms across cognitive and emotional (e.g., rumination, excessive worry), behavioural (e.g., avoidance, compensatory methods such as substance use), and physiological (e.g., increased heart rate, sweating, nausea) domains. Panic attacks (discrete episodes of intense fear, accompanied by physical and cognitive symptoms) may also be present alongside many of the anxiety disorders. This can be particularly troubling given the association between panic attacks and increased suicidal behaviour (Bentley et al., 2016). While a comprehensive overview of all disorders is beyond the scope of this chapter, some context regarding the manifestation of key anxiety disorders is important. Generally, the anxiety disorders are differentiated by the types of objects or situations which induce fear, anxiety, and associated cognitive and behavioural consequences (American Psychiatric Association, 2013). Further, they are differentiated from developmentally normative fear and anxiety, as well as transient state-like anxiety (as in competition anxiety) due to their typically persistent duration and level of functional impairment (American Psychiatric Association, 2013). A brief summary of the key disorders is provided in Table 11.1, though interested readers are referred to the DSM-5 (American Psychiatric Association, 2013) or the Tenth Edition of the International Classification of Diseases (ICD-10; World Health, 1988), noting that differences exist between these two leading resources (Bandelow, 2017). Table 11.1 Overview of Key Anxiety Disorders Anxiety Disorder a Key Diagnostic Features

Recommended Assessment Tool

Lifetime Prevalence Lifetime (General Prevalence Population)b (Elite Athletes)c

Generalised Anxiety Disorder

GAD-7

3.7%

8%

LSAS

4.0%

1.3%

BAI

1.7%

2.8%

FQ

7.4%

Unknown

Social Anxiety Disorder

Panic Disorder

Specific Phobia

Excessive anxiety and worry about a range of events or activities, which is out of proportion to the actual likelihood or impact of the occurrence. Fear, anxiety, or avoidance of social interactions or situations that involve the perceived possibility of scrutiny. Fear being negatively evaluated, embarrassed, humiliated, rejected, or offending others. Recurrent panic attacks,d with subsequent persistent concern and maladaptive behaviour change due to the fear of further attacks occurring. Panic attacks are abrupt surges of intense fear or intense discomfort accompanied by physical and/or cognitive symptoms Excessive fear or anxiety that is specific to an object or situation (e.g., flying, heights, animals)

Notes: aOther disorders listed but not described due to a lack of meaningful research available here include Separation Anxiety Disorder, Selective Mutism, Agoraphobia, Substance/Medication Induced Anxiety Disorder, Anxiety Disorder Due to Another Medical Condition, Other Specified Anxiety Disorder, and Unspecified Anxiety Disorder; bLifetime prevalence rates are taken from the World Mental Health Survey Initiative; cLifetime prevalence rates are taken from Schaal et al. (2011); dPanic attacks are fundamental to a diagnosis of Panic Disorder but may also be used as a descriptive specifier for a range of other disorders; GAD-7 ( Spitzer et al., 2006), LSAS = Liebowitz Social Anxiety Scale ( Liebowitz, 1987), BAI = Beck Anxiety Inventory ( Beck et al., 1988), FQ = The Fear Questionnaire ( Van Zuuren, 1988).

160

Anxiety Disorders Among Elite Athletes

In the general population, the one-year and lifetime prevalence estimates across all anxiety disorders has been projected to be 10.6% and 16.6%, respectively (Somers et al., 2006), with no evidence of increased prevalence over the past two decades since this seminal research (Penninx et al., 2021). Globally, data from the World Mental Health Survey Initiative (De Jonge et al., 2016; Ruscio et al., 2017; Stein et al., 2017; Wardenaar et al., 2017) suggest that the most common diagnoses among adults, as determined by lifetime prevalence, are Specific Phobia (7.4%), Social Anxiety Disorder (4.0%), GAD (3.7%), and Panic Disorder (1.7%), though reliability of these estimates is affected significantly by major heterogeneity across age, sex, location, and study methodology (Baxter et al., 2013; Penninx et al., 2021; Remes et al., 2016). In particular, sex and age are significant risk factors for anxiety in the general population, with females roughly twice as likely to be diagnosed with an anxiety disorder as compared to males (Baxter et al., 2013; Remes et al., 2016). The average age of onset for anxiety disorders is around 12 years old (Lijster et al., 2017), and these disorders are thought to be most common among 18–25 year olds (the cumulative prevalence of all anxiety disorders in this age group is betwen 20–30%; Penninx et al., 2021). Among the different anxiety disorders, the average age of onset is lowest for Separation Anxiety Disorder (10.6 years), Specific Phobia (11.0 years), and Social Anxiety Disorder (14.3 years), while Panic Disorder (30.3 years) and GAD tend to develop later in life (34.9 years) (Lijster et al., 2017). These rates can all be considered to overlap with key periods of athlete development, professionalisation, and career transitions. The aetiology of anxiety disorders stems from a range of biopsychosocial factors such as childhood adversity or trauma, as well as an array of neurobiological and neuropsychological dysfunctions subsequent to a genetic predisposition (Bandelow et al., 2017; Penninx et al., 2021). Patterns of psychological functioning and temperament can also play an important role in the expression of anxiety. Anxiety is more likely to persist in individuals who display enduring and severe avoidance behaviour, rumination, lower extraversion, higher sensitivity to anxiety, neuroticism, negative affectivity, and increased behavioural inhibition, in addition to clinical predictors such as panic attacks and the occurrence of comorbid personality disorders (Fox & Pine, 2012; Hovenkamp-Hermelink et al., 2021). Generally, comorbidity is extremely common among the anxiety disorders, with individuals more likely to concurrently meet criteria for multiple anxiety disorders, as well as other mood-, somatic-, substance use-, and personality disorders (Kessler et al., 2005; Saha et al., 2021).

Prevalence Rates of Anxiety Among Athletes Despite anxiety being a major mental health concern, likely impacting large numbers of elite athletes, there remains a paucity of accurate data on prevalence rates of precisely diagnosed anxiety disorders in elite sport. The majority of studies rely on brief and generalised self-report measures, as reviewed elsewhere (Reardon et al., 2021; Rice et al., 2019). Further, many studies use imprecise measures that report scores for combined symptoms of anxiety with other symptom domains like depression or sleep problems (e.g., Foskett & Longstaff, 2018; Gouttebarge et al., 2018; Walton et al., 2021), which are unable to provide specific detail regarding unique anxiety symptomatology. Such studies are, therefore, not generally discussed here. One of the few studies that has used clinical criteria based on direct athlete consultation (with either a psychologist or physician) to assess common mental health disorder rates was conducted by Schaal et al. (2011). Their sample included over 2,000 elite French athletes, aged 18.5 ± 4.9 years old (range: 12–35 years). A lifetime prevalence of 12.1% for any anxiety disorder (women: 15.8%, men: 10.1%) was reported. More specifically, prevalence rates were 8% for GAD (women: 10.3%, men: 6.8%), 2.8% for Panic Disorder (women: 4.4%, men: 1.9%), and 1.3% for Social Phobia (both women and men: 1.2%). The authors suggest that it is likely these rates may be an underestimation given lower diagnostic rates when assessment was completed by physicians as compared to psychologists (Schaal et al., 2011). 161

Courtney C. Walton et al.

The overall prevalence rates reported by Schaal and colleagues (2011) appear relatively similar to that seen in the general population, though disorder-specific rates varied more notably. Further, recent metaanalytic evidence has suggested that there are no statistically significant differences in rates of broadly defined anxiety symptomatology between elite athletes and the general population (d = −.11, p = .28; Rice et al., 2019). The fact that athletes appear to report anxiety at similar rates to the general population is important as many individuals assume that elite athletes may be exempt from experiencing anxiety disorders due to the demands of elite sport potentially “filtering out” athletes with clinically relevant anxiety from performing at a high level. Instead, best current evidence suggests that those in sport settings, including parents, coaches, and medical or support staff, should aim to be well equipped to recognise the key signs and symptoms of clinical anxiety that extend beyond performance, to facilitate better support for mental health and well-being in elite athletes.

Generalised Anxiety Disorder GAD is the most extensively researched of the anxiety disorders in elite sport. Given that past researchers used clinician-rated assessment, the aforementioned work by Schaal et al. (2011) represents some of the more reliable estimates regarding the prevalence of GAD in elite athletes. Schaal et al. (2011) reported current (within 6 months) rates of GAD at 6% (women: 7.5%; men: 5.2%), with lifetime rates of 8% (women: 10.3%; men: 6.8%). In addition, they found that GAD was significantly more common among athletes competing in aesthetic sport, while high risk sport had the lowest prevalence. Using self-report – predominantly via the cut-off score of >10 on the Generalised Anxiety Scale (GAD-7) – a range of other athlete populations have been assessed for generalised anxiety symptomology, with caseness rates typically varying between 5–15%. In a large study of Australian elite athletes, Gulliver et al. (2015) reported current caseness rates of 7.1% (women: 10.2%; men: 3.8%), with injured athletes likely to report worse symptomatology. In a mixed-sport sample of current or previous British elite athletes, 5% of participants were characterised as currently meeting potential caseness for GAD (McLoughlin et al., 2020). McLoughlin et al. (2020) further identified a range of stressors that were associated with increased anxiety symptomatology over and above the contributions of age and sex. These included stress around housing, marital/partner, other relationships, life-threatening situations, interpersonal loss, humiliation, physical danger, entrapment, and role change/disruption. Other studies focused on specific sport have provided similar results, with 8.3% of female German football players meeting the cut-off for GAD (Junge & Prinz, 2019). Younger athletes and those who belonged to a second league squad experienced higher rates of anxiety. Akesdotter et al. (2020) reported 12.6% of their sample of elite Swedish athletes meeting the cut-off for moderate generalised anxiety. By sex, 16.8% and 5.6% of females, and 6.6% and 2.2% of males, met the cut off for moderate and severe anxiety, respectively. In Canada, findings from Poucher et al. (2021) suggested that 18.8% of their elite athlete sample met criteria for GAD. Correlations suggested that higher anxiety symptomatology was associated with younger age, as well as higher stress and training load. Reduced rates of emotional and esteem support, along with low self-esteem and coping skills were also related. GAD symptomatology was also highly correlated with symptoms of depression. Indeed 9.1% of the sample met criteria for both GAD and depression. Exceptions in either direction are apparent, however. In a study of football players in Switzerland, only 1.1% of female and 1% of male first league players scored above the cut-off for GAD (Junge & Feddermann-Demont, 2016). This prevalence rate is comparatively low and may reflect potential differences across studies in assessment methods, response rates (e.g., selection bias), or athlete characteristics. Further, time of assessment during an athlete’s competitive season may significantly affect these figures. In a study of elite Chinese collegiate athletes, 22% met the cut off for generalised anxiety, with no effect of sex or sport-type and achievement. The authors found that previous sport injury, symptoms of ADHD, and fear of failure were significant risk factors for GAD (Li et al., 2021). 162

Anxiety Disorders Among Elite Athletes

For currently unclear reasons, particularly high rates have been found in rugby league, an immensely physical team sport. Ten percent of professional male rugby league players in Australia met the cut-off for clinically relevant GAD symptomatology in-season and 14.6% during pre-season (Du Preez et al., 2017), while 13.7% were categorised using the Hospital Anxiety Depression Scale as experiencing moderate to severe anxiety in a sample of 233 professional Super League players in the United Kingdom (Nicholls et al., 2020). These rates appear notably high for all-male samples in a high-risk sport. Further, two studies of professional jockeys have provided even higher rates, with 21% (Losty et al., 2019) and 27% (King et al., 2020) meeting the GAD cut-off. One rationale for these higher rates relate to the strict weightbased requirements and potential for severe injury/death. However, given high-risk sport have previously been associated with lower rates of anxiety (Schaal et al., 2011), these highlight some of the inconsistencies within the literature. Further research providing high level evidence for sport specific factors which contribute towards the expression of GAD are needed.

Social Anxiety Disorder There is scant research examining the presence of social anxiety disorder in elite athletes, though a larger literature on children’s involvement in school sport exists. Lifetime prevalence for social phobia was reported by Schaal et al. (2011) as 1.3% (similar across sex), with 0.8% experiencing distress currently. These are significantly lower than other studies, again potentially reflecting Schaal and colleagues’ stricter assessment methodology. Gulliver et al. (2015) reported 14.7% of participants meeting caseness for social anxiety disorder, also with similar rates across sex. This could be considered unusually high, particularly when considering the 12-month prevalence in the relative (Australian) general population around this measurement period was 4.7% (Slade et al., 2009). Another study with high rates included a sample of Division 1 intercollegiate athletes in the USA (Storch et al., 2005). Using the Social Anxiety Scale for Adolescents, 37.3% of female athletes (compared to 28.1% of female non-athletes) and 22.2% of male athletes (compared to 21.5% of male non-athletes) recorded clinically significant symptomatology consistent with social anxiety disorder. In a study of elite footballers in Demark and Sweden, caseness was not reported, with mean scores on the Social Phobia Inventory at 11.53 (SD = 9.61; established cut-off is ≥19) (Jensen et al., 2018). This study suggested symptoms were significantly higher in junior athletes as compared to professional players. There appears to be some preliminary evidence for higher rates of social anxiety disorder in athletes than in the general population. However, differences between studies investigating the occurrence of clinically relevant social anxiety, again, highlight the variability in the field and the need for further work to establish more accurate rates and predictors. It is important not to misclassify general competition anxiety as social anxiety disorder. Individuals with competition anxiety may show particularly heightened fear and anxiety of negative evaluation from others, however, whether this is environmentally specific to sport performance, or reflective of a broader concern in other social settings is crucial to understand (Reardon et al., 2021). There is the possibility that misclassification via general measurement approaches have occurred in the literature, and this points to the need for athlete-specific measurement tools, or the consideration of sport-specific factors during assessment (Gouttebarge et al., 2020).

Panic Disorder Extremely limited research exists regarding the remaining anxiety disorders in elite athletes, with two of the aforementioned studies that examined mental health broadly providing the most reliable estimates (Gulliver et al., 2015; Schaal et al., 2011). Schaal et al. (2011) reported a lifetime and current prevalence for panic disorder of 2.8% (women: 4.4%, men: 1.9%) and 1.2% (women: 1.1%, men: 1.5%), respectively. Gulliver et al. (2015) reported a current prevalence rate of 4.5% (women: 5.9%, men: 2.8%) in their sample, and to our knowledge no further studies have investigated this diagnosis in elite athletes. There is 163

Courtney C. Walton et al.

some rationale to believe individuals with panic disorder may be less likely to engage with intensive competitive exercise in the first place, given participation often results in the same physiological features of a panic attack (Reardon et al., 2021).

Related Disorders Post-traumatic stress disorder and obsessive-compulsive disorder are sometimes included within the literature under the umbrella of anxiety disorders, due to their previous listing in the anxiety disorder subsection of DSM-IV (American Psychiatric Association, 1994) and relevant symptomatic overlap. Posttraumatic stress disorder and obsessive-compulsive disorder are now categorised as diagnostically separate in the DSM-5 (American Psychiatric Association, 2013), and included respectively under separate categories as “Trauma- and Stressor-Related Disorders” and “Obsessive-Compulsive and Related Disorders”. We note that symptomatology of post-traumatic stress disorder is seen at potentially greater rates in athletes than the general population; often a result of experiencing or witnessing serious injury or abuse within sport settings, as reviewed by Aron et al. (2019). Somewhat surprisingly, obsessive-compulsive disorder has not been extensively explored in athletes. In a study of U.S. collegiate athletes, 5.2% met full criteria for diagnosis, doubling the rate seen in the general population (Cromer et al., 2017). It is extremely important not to misdiagnose obsessive-compulsive disorder in athletes who may exhibit superstitious rituals and mannerisms, or purposeful performance routines, which are common and often beneficial in athletes (Cotterill, 2010; Dömötör et al., 2016). Rather, for a diagnosis of obsessivecompulsive disorder, functional impairment must be associated with the behaviours.

Contributing Factors to Athlete Anxiety Limited information exists regarding contributors to clinical anxiety disorders, and most information regarding contributors to anxiety come from more broad measures. Including studies such as these, a recent meta-analysis conducted by Rice et al. (2019) investigated the determinants of anxiety using predominantly self-report measurement of generalised symptoms in elite athletes (including mixed scales like depression/ anxiety). Results suggested that, female sex, younger age, and the experience of adverse life events were associated with higher reporting of anxiety symptoms. The results relating to age and sex are unsurprising and mirror that seen in the general population as well as the studies thus far discussed in sport. Relating more specifically to sport, adverse life events like concussion or musculoskeletal injury and career dissatisfaction were specifically associated with increased anxiety symptomatology (Rice et al., 2019). Indeed, a review of psychosocial outcomes following sport injury identified increased anxiety as a common and key outcome, commonly stemming from performance anxiety, fear of re-injury, or isolation and alienation (Forsdyke et al., 2016). Evidence for the role of adverse life events primarily comes from a set of studies that used anxiety/depression as the outcome (Gouttebarge et al., 2016; Gouttebarge et al., 2015; Gouttebarge et al., 2017; Gouttebarge & Kerkhoffs, 2017). However, a meta-analysis by subgroup suggested that this effect was only significant in former athletes, potentially pointing to the role of retirement. Retirement from sport plays a role in the development of anxiety in athletes, including nonprofessional transitions out of youth or college sport. For example, over-identification with the athletic role is associated with increased anxiety symptomatology following the retirement of collegiate athletes (Giannone et al., 2017). Type of sport may confer some specific risk on the presence of anxiety; however, conflicting results hinder drawing a consensus on this risk factor. Those athletes engaged in individual sport may be at an increased risk than those in team sport, though this evidence is inconsistent (Rice et al., 2019). Sport-specific anxiety has been shown to be higher in individual sport athletes (Correia & Rosado, 2019), potentially reflecting an increased likelihood of these athletes to internalise failure after loss, set overbearing personal 164

Anxiety Disorders Among Elite Athletes

goals, demonstrate higher levels of perfectionism, and receive less social support (Nixdorf et al., 2013; Nixdorf et al., 2016). In youth athletes, physician-diagnosed depression/anxiety was reported in 13% of individual sport athletes, compared to 8% of those involved in team sport, though further multivariate analysis accounting for sex did not provide statistically significant support for this relationship (Pluhar et al., 2019). These authors highlight that as female athletes are more likely to engage with individual sport, this may be the more important factor. Levit et al. (2018) also found no difference between team and individual sport using the State-Trait Anxiety Inventory. Theoretical assumptions supporting the assumption that team sport are a protective factor for anxiety come from the finding that athletes engaged in individual sport report doing so more for goal-oriented reasons and less for fun than team-sport athletes (Pluhar et al., 2019). Individual sport athletes are also far more likely to be involved in just one sport, potentially accentuating the high standards and demands they are thought to place on themselves (Pluhar et al., 2019). Further to these environmental predictors of anxiety, it may be that a focus on aesthetics – far more commonly seen in individual sport – is the major driver of differences seen. Other stressors have been suggested to be linked with symptoms of anxiety, though limitations persist. In a non-specific study of mental health symptoms, scores on the anxiety/insomnia subscale of the GHQ were significantly associated with increased alcohol use, lower self-esteem, and lower social support in women athletes, but more body dissatisfaction lower self-esteem, being abused on social media, and financial hardship in men athletes (Walton et al., 2021). Unfortunately, it is difficult to make clear conclusions based on the available scientific literature on sport-based antecedents for clinical – rather than competitive – anxiety among elite athletes (Figure 11.1). Anxiety can be experienced broadly by athletes within elite sport. Competition anxiety can range from facilitative through to debilitative, while many athletes may also experience a diagnosable anxiety disorder. This does not mean to imply that such a process is linear, but rather that anxiety can manifest in a range of more or less disabling ways potentially concurrently. In addition, there are range of factors that have been linked to an increased likelihood of athletes experiencing anxiety, though the majority of these have shown inconsistent evidence. (Figure 11.2), however, given inconsistent findings, it is likely that the expression of anxiety is much more dependent on the complex interplay between the individual and their environment, than specific sportbased risk factors. Therefore, practitioners, parents, and coaches would benefit from being mindful of the

Figure 11.1

Manifestations of Anxiety as Experienced by Elite Athletes

165

Courtney C. Walton et al.

Figure 11.2 Factors Influencing Anxiety among Elite Athletes. (Adapted from Reported Findings of Reardon et al. 2021 and Rice et al. 2019.)

warning signs among individual athletes with regards to anxiety, and employ a more tailored lens with which to understand an athlete’s concerns. In the following sections, we will overview approaches to assessment and treatment of clinical anxiety disorders.

Assessment of Anxiety Disorders There are only limited options for sport-specific measurement of mental health concerns in athletes. The recently developed Athlete Psychological Strain Questionnaire (Rice et al., 2020; Rice et al., 2019) provides an effective screening tool for psychological distress. However, currently there are no established athlete-specific clinical anxiety measures, with sport-specific anxiety tools such as the Sport-Anxiety Scale-2 (Smith et al., 2006) focused on competitive anxiety instead. Therefore, common approaches to assessment following clinical protocols and guidelines should be completed (Andrews et al., 2018; Bandelow et al., 2017). The foremost of these is the Structured Clinical Interview for DSM-5 (SCID-5); a semi-structured interview guide for diagnosing major DSM-5 disorders (American Psychiatric Association, 2013; First, 2015). The interview should be administered by a trained interviewer familiar with the DSM-5 classification and diagnostic criteria. In terms of less time-intensive screening measures, which can be used by professionals not suitably qualified to administer the SCID-5 reliably, the GAD-7 (Spitzer et al., 2006) is recommended by the recently established Sport Mental Health Assessment Tool 1 (SMHAT-1; Gouttebarge et al., 2020), and is appropriate as an initial brief assessment. The GAD-7 measures generalised anxiety symptoms and can function as an effective initial screening tool for GAD or other anxiety disorders (Plummer et al., 2016). More specific symptomatic measures (e.g., for social anxiety) from other appropriate sources can subsequently be administered as required. Table 11.1 provides examples of common measures relevant to each of the primary anxiety presentations.

Treatment of Anxiety Disorders While many sport specific approaches to managing competitive anxiety are found throughout the field of applied sport psychology, treatment of anxiety disorders should predominantly follow recommendations 166

Anxiety Disorders Among Elite Athletes

for the general population, with extensive guidelines outlined elsewhere (Andrews et al., 2018; Baldwin et al., 2014; Bandelow et al., 2017; Bandelow et al., 2015). Psychotherapy should be considered the firstline approach to treatment for athletes with mild to moderate symptoms, particularly given potentially problematic side effects (e.g., sedation, weight gain) of some psychiatric medications in athletes (Reardon, 2016).

Non-Pharmacological Treatment For more detail on implementing psychotherapy in athletes, readers are directed to a recent review by Stillman et al. (2019) and Chapter 21, Psychotherapeutic Applications in Elite Sport - Evidence Informed Interventions, within this book. Cognitive behavioural therapy (CBT) stands as the most extensively researched psychotherapeutic treatment option for most anxiety disorders (Andrews et al., 2018; Bandelow et al., 2017; Carpenter et al., 2018). Specifically, meta-analytic evidence from randomised placebo-controlled trials suggests that anxiety disorders are well treated through CBT methods (Carpenter et al., 2018; Hofmann & Smits, 2008). The most recent of these illustrated moderate effects of CBT on the specific anxiety disorder symptoms (Hedges’ g = 0.56), with small to moderate effects on other anxiety symptoms (Hedges’ g = 0.38). Large effect sizes were found for GAD, with small to moderate effect sizes across social anxiety disorder and panic disorder (Carpenter et al., 2018). It has been proposed that athletes may be particularly well suited to CBT, given their familiarity with receiving instruction, following rules, and completing “homework” (Reardon et al., 2021). Another approach which is often well received by athletes is Acceptance and Commitment Therapy (ACT), which has been proposed as an alternative ‘Third Wave” approach to treating anxiety disorders and includes a range of mindfulness-based approaches. While the base of evidence is not yet as extensive as that of CBT, ACT has demonstrated favourable improvements across a range of anxiety disorders, and often displaying equivalence with more traditional CBT methods (A-Tjak et al., 2015; Gloster et al., 2020; Ruiz, 2012; Swain et al., 2013). While not adequately explored in sporting populations for clinical disorders, ACT is well received by athletes in performance contexts (Henriksen et al., 2019), and may sit as a beneficial approach to treatment. Self-compassionate approaches can also be considered viable, with implementation in both performance and mental health, and an emerging area in elite sport (Mosewich et al., 2019; Walton et al., 2022). Indeed, in the broader population, meta-analytic evidence has suggested a beneficial role for compassion focused psychotherapies for anxiety reduction (Ferrari et al., 2019; Kirby et al., 2017; Wilson et al., 2019). Transdiagnostic approaches to treatment which focus on core commonalities present between different (often comorbid) disorders and symptoms are also well evidenced (Barlow et al., 2017; Leonardo et al., 2021) and may be well suited to athletes, though intervention evidence is currently lacking. Dropout rates for psychotherapy for GAD are high, estimated at 17% for adults engaged in individual sessions (Gersh et al., 2017). There is reason to believe these rates may be even higher in athlete populations who are often time-limited, facing additional challenges to confidentiality and stigma, and travelling frequently, making regular face-to-face therapy more difficult. Therefore, delivery of these treatments via telehealth and online platforms may be a particularly useful variation to accommodate for the highly transient nature of elite sort. It is likely that many athletes have become increasingly familiar with telehealth and other virtual approaches to psychotherapy in the wake of delivery changes enforced by COVID-19 (Reardon, Bindra et al., 2021). There is evidence that online psychotherapies, in particular eCBT, show efficacy for treating anxiety (Deady et al., 2017; Olthuis et al., 2016). Specific to sport, a focus of treatment should at least in part relate to prevention or early environmental intervention. For example, many of the risk factors for increased anxiety should first be addressed within sport organisations. For example, protocols should be in place for ongoing management of injured (see Chapter 23, Injury Prevention and Rehabilitation) or transitioning athletes 167

Courtney C. Walton et al.

(see Chapter 18, Career Transitions), as well as ensuring preventative strategies are in place along with swift and meaningful processes for dealing with any potential harassment or abuse of athletes (Mountjoy et al., 2016). Coaches, parents, and support staff who work with athletes in individual sport or those for which aesthetic evaluations are fundamental are advised to be particularly vigilant in looking for signs of symptoms of anxiety disorders so that any athlete who may require treatment can be referred early. Early intervention is also indicated where performance anxiety has escalated notably, in order to prevent transition to a broader, more debilitating anxiety disorder (Reardon et al., 2021). Anecdotally, many athletes and sport organisations have made use of yoga as an anxietyreducing intervention and preventative technique, with early evidence suggesting potential benefits on performance anxiety (Cadieux et al., 2021). In the broader clinical literature, yoga appears beneficial for moderately elevated levels of anxiety, though there is inconclusive evidence individuals with a diagnosed anxiety disorder (Cramer et al., 2018).

Pharmacological Treatment In terms of pharmacological treatment of athlete anxiety, a number of specific factors should be considered (Glick et al., 2012; Reardon, 2016). While psychotherapy is regarded as first-line treatment for mild to moderate anxiety symptoms, medications may be needed in moderate to severe cases (Reardon et al., 2021). Side effects, safety issues, and potential impact on performance must be considered in choosing a specific medication for a high-level athlete (Reardon et al., 2019). While research is limited, selectiveserotonin reuptake inhibitors (SSRIs) – specifically escitalopram, sertraline, and fluoxetine – are often regarded as medications of choice for athletes with anxiety (Reardon & Creado, 2016). Among these, fluoxetine has undergone preliminary study with small samples of male athletes and not been found to inhibit physical performance (Meeusen et al., 2001; Parise et al., 2001). While escitalopram and sertraline have not specifically been studied in athletes, they are nonetheless anecdotally used by clinicians working with athletes without substantial concern (Reardon & Creado, 2016). Other medications sometimes considered and used for anxiety include buspirone (Reardon et al., 2021). It has received very little study in athletes, with the only known study assessing the non-real-world prescribing parameter of a single 45-mg dose (Marvin et al., 1997). While that study noted performance impairment after taking the medication, it would be difficult to extrapolate those findings to typical prescribing patterns. Tricyclic antidepressants such as amitriptyline or nortriptyline may also be considered in non-athlete populations as they are known to have anxiolytic in addition to antidepressant properties (much as the SSRIs do). However, side effects including weight gain, sedation, and orthostatic dizziness, along with theoretical cardiac concerns in intensely exercising athletes and potential blood level toxicity if athletes become dehydrated during endurance exercise, limit their utility in this population (Reardon et al., 2019). Quick-acting, as-needed medications are sometimes used in non-athletes for performance anxiety such as before public speaking, academic examinations, or musical performances. However, medications are not indicated for performance anxiety in athletes (Reardon et al., 2019). Typically, these types of medications cause side effects that would be expected to detrimentally impact sport performance. For example, benzodiazepines cause muscle relaxation and sedation and may slow reaction time (Johnston & McAllister-Williams, 2016). Beta-blockers such as propranolol may diminish cardiopulmonary capacity and lower blood pressure and thus cause dizziness in athletes, who often have relatively low blood pressure at baseline (Charles et al., 1987). Conversely, beta-blockers may enhance performance in some sport, e.g., by improving fine motor control (Reardon et al., 2019). The World Anti-Doping Agency prohibits betablockers at all times (out-of-competition and in-competition) for athletes in archery and shooting, and incompetition for athletes in automobile, billiards, darts, golf, some skiing/snowboarding, and some underwater sport (World Anti-Doping Agency, 2021). 168

Anxiety Disorders Among Elite Athletes

Future Directions Knowledge as to how clinical anxiety disorders manifest in elite athletes – as opposed to performancebased anxiety – is only in its infancy. Future work is needed to identify and understand a range of factors relating to anxiety in elite athletes. Specifically, there is a need to identify accurate prevalence rates of anxiety disorders, with replication of potential correlates and predictors needed for consensus to be established. For example, while women and younger athletes experiencing higher rates of anxiety is a relatively reliable finding and corresponds to findings in the general community, there are inconsistencies in the literature regarding almost all other factors, particularly when sport-based. Factors such as selection pressures, abuse on social media platforms, repetitive negative media attention, and performance slumps have all frequently been anecdotally linked to persistence of anxiety and other clinical disorders; however, reliable evidence regarding these relationships remains elusive. Studies which employ strict guidelines regarding clinical measurement tools are needed, with the Structured Clinical Interview for DSM-5 (SCID-5) the gold standard (First, 2015). Second, there is a major need for more sport-informed treatment approaches, with evidence for psychotherapeutic interventions extremely limited (Stillman et al., 2019). Sport-specific approaches like that described by Donohue et al. (2018) are vital for facilitating better engagement and outcomes for the novel presentations of elite and youth athletes.

Summary Anxiety disorders persist in elite athletes, with best available evidence suggesting this is at relatively similar rates to the general population. However, significantly more research is needed to fully understand the complex interplay between elite sport settings and anxiety, particularly with respect to causative and protective factors. Considerable attention and expertise is required in order to identify and treat these disorders, and individuals working within psychology and mental health care in elite sport should be alert to key warning signs. Psychotherapy, particularly CBT and ACT, may be best placed as treatment approaches, though carefully considered pharmacological management may be required in more severe cases.

References A-Tjak, J.G.L., Davis, M.L., Morina, N., Powers, M.B., Smits, J.A.J., & Emmelkamp, P.M.G. (2015). A metaanalysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. doi: 10.1159/000365764 Akesdotter, C., Kentta, G., Eloranta, S., & Franck, J. (2020). The prevalence of mental health problems in elite athletes. Journal of Science and Medicine in Sport, 23(4), 329–335. doi: 10.1016/j.jsams.2019.10.022 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV) (Vol. 886). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Association. Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109–1172. doi: 10.1177/0004 867418799453 Aron, C.M., Harvey, S., Hainline, B., Hitchcock, M.E., & Reardon, C.L. (2019). Post-traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 779. doi: 10.1136/bjsports-2019-100695 Baldwin, D.S., Anderson, I.M., Nutt, D.J., Allgulander, C., Bandelow, B., den Boer, J.A., … Wittchen, H.U. (2014). Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessivecompulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. Journal of Psychopharmacology, 28(5), 403–439. doi: 10.1177/0269881114525674 Bandelow, B. (2017). Comparison of the DSM–5 and ICD–10: Panic and other anxiety disorders. CNS Spectrums, 22(5), 404–406. doi: 10.1017/S1092852917000116

169

Courtney C. Walton et al. Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues Clinical Neuroscience, 19(2), 93–107. doi: 10.31887/DCNS.2017.19.2/bbandelow Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: A meta-analysis. International Clinical Psychopharmacology, 30(4), 183–192. doi: 10.1097/ YIC.0000000000000078 Barlow, D.H., Farchione, T.J., Bullis, J.R., Gallagher, M.W., Murray-Latin, H., Sauer-Zavala, S., … Boswell, J.F. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74(9), 875–884. doi: 10.1001/ jamapsychiatry.2017.2164 Baxter, A.J., Scott, K.M., Vos, T., & Whiteford, H.A. (2013). Global prevalence of anxiety disorders: A systematic review and meta-regression. Psychological Medicine, 43(5), 897–910. doi: 10.1017/S003329171200147X Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893–897. doi: 10.1037//0022-006x.56.6.893 Bentley, K.H., Franklin, J.C., Ribeiro, J.D., Kleiman, E.M., Fox, K.R., & Nock, M.K. (2016). Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review. Clinical Psychology Review, 43, 30–46. doi: 10.1016/j.cpr.2015.11.008 Bradley, M.W., Chad, D.R., & Daniel, M.L. (2008). The anxiolytic effects of exercise: A meta-analysis of randomized trials and dose–response analysis. Journal of Sport and Exercise Psychology, 30(4), 392–410. doi: 10.1123/jsep.30.4.392 Cadieux, E.G., Gemme, C., & Dupuis, G. (2021). Effects of yoga interventions on psychological health and performance of competitive athletes: A Systematic Review. Journal of Science in Sport and Exercise, 3(2), 158–166. doi: 10.1007/ S42978-020-00104-Y Carpenter, J.K., Andrews, L.A., Witcraft, S.M., Powers, M.B., Smits, J.A.J., & Hofmann, S.G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514. doi: 10.1002/da.22728 Charles, R.B., Kirkham, A.J., Guyatt, A.R., & Parker, S.P. (1987). Psychomotor, pulmonary and exercise responses to sleep medication. British Journal of Clinical Pharmacology, 24(2), 191–197. doi: 10.1111/j.1365-2125.1987.tb03161.x Correia, M., & Rosado, A. (2019). Anxiety in athletes: gender and type of sport differences. International Journal of Psychological Research, 12(1), 9–17. Cotterill, S. (2010). Pre-performance routines in sport: Current understanding and future directions. International Review of Sport and Exercise Psychology, 3(2), 132–153. doi: 10.1080/1750984X.2010.488269 Cramer, H., Lauche, R., Anheyer, D., Pilkington, K., de Manincor, M., Dobos, G., & Ward, L. (2018). Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 35(9), 830–843. doi: 10.1002/da.22762 Cromer, L., Kaier, E., Davis, J., Stunk, K., & Stewart, S.E. (2017). OCD in college athletes. American Journal of Psychiatry, 174(6), 595–597. doi: 10.1176/appi.ajp.2017.16101124 De Jonge, P., Roest, A.M., Lim, C.C.W., Florescu, S.E., Bromet, E.J., Stein, D.J., … Levinson, D. (2016). Cross‐national epidemiology of panic disorder and panic attacks in the world mental health surveys. Depression and Anxiety, 33(12), 1155–1177. doi: 10.1002/da.22572 Deady, M., Choi, I., Calvo, R.A., Glozier, N., Christensen, H., & Harvey, S.B. (2017). eHealth interventions for the prevention of depression and anxiety in the general population: A systematic review and meta-analysis. BMC Psychiatry, 17(1), 310. doi: 10.1186/s12888-017-1473-1 Dömötör, Z., Ruíz-Barquín, R., & Szabo, A. (2016). Superstitious behavior in sport: A literature review. Scandinavian Journal of Psychology, 57(4), 368–382. doi: 10.1111/sjop.12301 Donohue, B., Gavrilova, Y., Galante, M., Gavrilova, E., Loughran, T., Scott, J., … Allen, D.N. (2018). Controlled evaluation of an optimization approach to mental health and sport performance. Journal of Clinical Sport Psychology, 12(2), 234–267. doi: 10.1123/jcsp.2017-0054 Du Preez, E.J., Graham, K.S., Gan, T.Y., Moses, B., Ball, C., & Kuah, D.E. (2017). Depression, anxiety, and alcohol use in elite rugby league players over a competitive season. Clinical Journal of Sport Medicine, 27(6), 530–535. doi: 10.1097/ JSM.0000000000000411 Ferrari, M., Hunt, C., Harrysunker, A., Abbott, M.J., Beath, A.P., & Einstein, D.A. (2019). Self-compassion interventions and psychosocial outcomes: a meta-analysis of RCTs. Mindfulness, 10(8), 1455–1473. doi: 10.1007/s12 671-019-01134-6 First, M.B. (2015). Structured clinical interview for the DSM (SCID). The Encyclopedia of Clinical Psychology, 1(6), 530–535. doi: 10.1002/9781118625392.wbecp351 Forsdyke, D., Smith, A., Jones, M., & Gledhill, A. (2016). Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: A mixed studies systematic review. British Journal of Sports Medicine, 50(9), 537. doi: 10.1136/bjsports-2015-094850

170

Anxiety Disorders Among Elite Athletes Foskett, R.L., & Longstaff, F. (2018). The mental health of elite athletes in the United Kingdom. Journal of Science and Medicine in Sport, 21(8), 765–770. doi: 10.1016/j.jsams.2017.11.016 Fox, N.A., & Pine, D.S. (2012). Temperament and the emergence of anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 51(2), 125. doi: 10.1016/j.jaac.2011.10.006 Gersh, E., Hallford, D.J., Rice, S.M., Kazantzis, N., Gersh, H., Gersh, B., & McCarty, C.A. (2017). Systematic review and meta-analysis of dropout rates in individual psychotherapy for generalized anxiety disorder. Journal of Anxiety Disorders, 52, 25–33. doi: 10.1016/j.janxdis.2017.10.001 Giannone, Z.A., Haney, C.J., Kealy, D., & Ogrodniczuk, J.S. (2017). Athletic identity and psychiatric symptoms following retirement from varsity sports. International Journal of Social Psychiatry, 63(7), 598–601. Glick, I.D., Stillman, M.A., Reardon, C.L., & Ritvo, E.C. (2012). Managing psychiatric issues in elite athletes. The Journal of Clinical Psychiatry, 73(5), 640–644. Gloster, A.T., Walder, N., Levin, M.E., Twohig, M.P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181–192. doi: 10.1016/ j.jcbs.2020.09.009 Gouttebarge, V., Aoki, H., & Kerkhoffs, G.M. (2016). Prevalence and determinants of symptoms related to mental disorders in retired male professional footballers. Journal of Sports Medicine and Physical Fitness, 56(5), 648–654. Gouttebarge, V., Backx, F.J., Aoki, H., & Kerkhoffs, G.M. (2015). Symptoms of common mental disorders in professional football (soccer) across five European countries. Journal of Sports Science and Medicine, 14(4), 811–818. Gouttebarge, V., Bindra, A., Blauwet, C., Campriani, N., Currie, A., Engebretsen, L., … Budgett, R. (2020). International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health. British Journal of Sports Medicine, 55(1), 30–37. doi: 10.1136/bjsports-2020-102411 Gouttebarge, V., Hopley, P., Kerkhoffs, G., Verhagen, E., Viljoen, W., Wylleman, P., & Lambert, M. (2018). A 12-month prospective cohort study of symptoms of common mental disorders among professional rugby players. European Journal of Sport Science, 18(7), 1004–1012. doi: 10.1080/17461391.2018.1466914 Gouttebarge, V., Jonkers, R., Moen, M., Verhagen, E., Wylleman, P., & Kerkhoffs, G. (2017). The prevalence and risk indicators of symptoms of common mental disorders among current and former Dutch elite athletes. Journal of Sports Sciences, 35(21), 2148–2156. doi: 10.1080/02640414.2016.1258485 Gouttebarge, V., & Kerkhoffs, G. (2017). A prospective cohort study on symptoms of common mental disorders among current and retired professional ice hockey players. The Physician and Sportsmedicine, 45(3), 252–258. doi: 10.1080/00913847.2017.1338497 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. doi: 10.1016/j.jsams.2014.04.006 Henriksen, K., Hansen, J., & Larsen, C.H. (2019). Mindfulness and acceptance in sport: How to help athletes perform and thrive under pressure. Routledge. doi: 10.4324/9780429435232 Hofmann, S.G., & Smits, J.A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621–632. doi: 10.4088/jcp.v69n0415 Hovenkamp-Hermelink, J.H.M., Jeronimus, B.F., Myroniuk, S., Riese, H., & Schoevers, R.A. (2021). Predictors of persistence of anxiety disorders across the lifespan: A systematic review. The Lancet Psychiatry, 8(5), 428–443. doi: 10.1016/S2215-0366(20)30433-8 Jensen, S.N., Ivarsson, A., Fallby, J., Dankers, S., & Elbe, A.-M. (2018). Depression in Danish and Swedish elite football players and its relation to perfectionism and anxiety. Psychology of Sport and Exercise, 36, 147–155. doi: 10.1016/ j.psychsport.2018.02.008 Johnston, A., & McAllister-Williams, R.H. (2016). Psychotropic drug prescribing. Sports Psychiatry (pp. 133–143). Oxford: Oxford University Press. Junge, A., & Feddermann-Demont, N. (2016). Prevalence of depression and anxiety in top-level male and female football players. BMJ Open Sport & Exercise Medicine, 2(1), e000087. 10.1136/bmjsem-2015-000087 Junge, A., & Prinz, B. (2019). Depression and anxiety symptoms in 17 teams of female football players including 10 German first league teams. British Journal of Sports Medicine, 53(8), 471. doi: 10.1136/bjsports-2017-098033 Kessler, R.C., Chiu, W.T., Demler, O., & Walters, E.E. (2005). Prevalence, severity, and comorbidity of 12-Month DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 617–627. doi: 10.1001/archpsyc.62.6.617 King, L., Cullen, S.J., O’Connor, S., McGoldrick, A., Pugh, J., Warrington, G., … Losty, C. (2020). Common mental disorders among Irish jockeys: Prevalence and risk factors. The Physician and Sportsmedicine, 49(2), 207–213. doi: 10.1080/00913847.2020.1808435 Kirby, J.N., Tellegen, C.L., & Steindl, S.R. (2017). A meta-Analysis of compassion-based interventions: Current state of knowledge and future directions. Behavior Therapy, 48(6), 778–792. doi: 10.1016/j.beth.2017.06.003

171

Courtney C. Walton et al. Leonardo, C., Aristide, S., & Michela, B. (2021). On the efficacy of the Barlow unified protocol for transdiagnostic treatment of emotional disorders: A systematic review and meta-analysis. Clinical Psychology Review, 87, 101999. Levit, M., Weinstein, A., Weinstein, Y., Tzur-Bitan, D., & Weinstein, A. (2018). A study on the relationship between exercise addiction, abnormal eating attitudes, anxiety and depression among athletes in Israel. Journal of Behavioral Addictions, 7(3), 800–805. Li, C., Fan, R., Sun, J., & Li, G. (2021). Risk and protective factors of generalized anxiety disorder of elite collegiate athletes: A cross-sectional study. Frontiers in Public Health, 9, 11. doi: 10.3389/fpubh.2021.607800 Liebowitz, M.R. (1987). Social phobia. Modern problems of pharmacopsychiatry, 22, 141–173. doi: 10.1159/000414022 Lijster, J. M. d., Dierckx, B., Utens, E.M.W.J., Verhulst, F.C., Zieldorff, C., Dieleman, G.C., & Legerstee, J.S. (2017). The age of onset of anxiety disorders. Canadian Journal of Psychiatry. Canadian Journal of Psychiatry, 62(4), 237–246. doi: 10.1177/0706743716640757 Losty, C., Warrington, G.D., McGoldrick, A., Murphy, C., Burrows, E., & Cullen, S. (2019). Mental health and wellbeing of jockeys. Journal of Human Sport and Exercise, 14(1), 147–158. doi: 10.14198/jhse.2019.141.12 Marvin, G., Sharma, A., Aston, W., Field, C., Kendall, M.J., & Jones, D.A. (1997). The effects of buspirone on perceived exertion and time to fatigue in man. Experimental Physiology, 82(6), 1057–1060. doi: 10.1113/ expphysiol.1997.sp004080 McLoughlin, E., Fletcher, D., Slavich, G.M., Arnold, R., & Moore, L.J. (2020). Cumulative lifetime stress exposure, depression, anxiety, and well-being in elite athletes: A mixed-method study. Psychology of Sport and Exercise, 52, 101823. doi: 10.1016/j.psychsport.2020.101823 Meeusen, R., Piacentini, M.F., Van Den Eynde, S., Magnus, L., & De Meirleir, K. (2001). Exercise performance is not influenced by a 5-HT reuptake inhibitor. International Journal of Sports Medicine, 22(05), 329–336. Mellalieu, S.D., Hanton, S., & Fletcher, D. (2006). A competitive anxiety review: Recent directions in sport psychology research. Literature Reviews in Sport Psychology (pp. 1–45). Hauppage, NY: Nova Science. Mosewich, A.D., Ferguson, L.J., McHugh, T.-L. F., & Kowalski, K.C. (2019). Enhancing capacity: Integrating selfcompassion in sport. Journal of Sport Psychology in Action, 10(4), 235–243. doi: 10.1080/21520704.2018.1557774 Mountjoy, M., Brackenridge, C., Arrington, M., Blauwet, C., Carska-Sheppard, A., Fasting, K., … Budgett, R. (2016). International Olympic Committee consensus statement: Harassment and abuse (non-accidental violence) in sport. British Journal of Sports Medicine, 50(17), 1019. doi: 10.1136/bjsports-2016-096121 Nicholls, A.R., Madigan, D.J., Fairs, L.R.W., & Bailey, R. (2020). Mental health and psychological well-being among professional rugby league players from the UK. BMJ Open Sport & Exercise Medicine, 6(1), e000711. doi: 10.1136/ bmjsem-2019-000711 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among german elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. doi: 10.1123/jcsp.7.4.313 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. doi: 10.3389/fpsyg.2016.00893 Olthuis, J.V., Watt, M.C., Bailey, K., Hayden, J.A., & Stewart, S.H. (2016). Therapist‐supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews, 3(3), CD011565. doi: 10.1002/14651858.CD011565.pub2 Parise, G., Bosman, M.J., Boecker, D.R., Barry, M.J., & Tarnopolsky, M.A. (2001). Selective serotonin reuptake inhibitors: Their effect on high-intensity exercise performance. Archives of Physical Medicine and Rehabilitation, 82(7), 867–871. Penninx, B.W.J.H., Pine, D.S., Holmes, E.A., & Reif, A. (2021). Anxiety disorders. Lancet, 397(10277), 914–927. doi: 10.1016/S0140-6736(21)00359-7 Pluhar, E., McCracken, C., Griffith, K.L., Christino, M.A., Sugimoto, D., & Meehan, W.P., 3rd. (2019). Team sport athletes may be less likely to suffer anxiety or depression than individual sport athletes. Journal of Sports Science & Medicine, 18(3), 490–496. Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 24–31. doi: 10.1016/ j.genhosppsych.2015.11.005 Poucher, Z.A., Tamminen, K.A., Sabiston, C.M., Cairney, J., & Kerr, G. (2021). Prevalence of symptoms of common mental disorders among elite Canadian athletes. Psychology of Sport and Exercise, 57, 102018. doi: 10.1016/ j.psychsport.2021.102018 Poucher, Z.A., Tamminen, K.A., Kerr, G., & Cairney, J. (2019). A commentary on mental health research in elite sport. Journal of Applied Sport Psychology, 33(1), 60–82. doi: 10.1080/10413200.2019.1668496 Reardon, C.L. (2016). The sports psychiatrist and psychiatric medication. International Review of Psychiatry, 28(6), 606–613. doi: 10.1080/09540261.2016.1190691

172

Anxiety Disorders Among Elite Athletes Reardon, C.L., Bindra, A., Blauwet, C., Budgett, R., Campriani, N., Currie, A., … Purcell, R. (2021). Mental health management of elite athletes during COVID-19: A narrative review and recommendations. British Journal of Sports Medicine, 55(11), 608–615. Reardon, C.L., & Creado, S. (2016). Psychiatric medication preferences of sports psychiatrists. Physician and Sportsmedicine, 44(4), 397–402. doi: 10.1080/00913847.2016.1216719 Reardon, C.L., Gorczynski, P., Hainline, B., Hitchcock, M.E., Purcell, R., Rice, S., & Walton, C.C. (2021). Anxiety disorders in athletes: A clinical review. Advances in Psychiatry, 1(1), 149–160. doi: 10.1016/j.ypsc.2021.05.010 Reardon, C.L., Hainline, B., Aron, C.M., Baron, D., Baum, A.L., Bindra, A., … Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement. British Journal of Sports Medicine, 53(11), 667–699. doi: 10.1136/bjsports-2019-100715 Remes, O., Brayne, C., Van Der Linde, R., & Lafortune, L. (2016). A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain and Behavior, 6(7), e00497. doi: 10.1002/brb3.497 Rice, S., Olive, L., Gouttebarge, V., Parker, A.G., Clifton, P., Harcourt, P., … Purcell, R. (2020). Mental health screening: Severity and cut-off point sensitivity of the Athlete Psychological Strain Questionnaire in male and female elite athletes. BMJ Open Sport & Exercise Medicine, 6(1), e000712. doi: 10.1136/bmjsem-2019-000712 Rice, S.M., Gwyther, K., Santesteban-Echarri, O., Baron, D., Gorczynski, P., Gouttebarge, V., … Purcell, R. (2019). Determinants of anxiety in elite athletes: A systematic review and meta-analysis. British Journal of Sports Medicine, 53(11), 722–730. doi: 10.1136/bjsports-2019-100620 Rice, S.M., Parker, A.G., Mawren, D., Clifton, P., Harcourt, P., Lloyd, M., … Purcell, R. (2019). Preliminary psychometric validation of a brief screening tool for athlete mental health among male elite athletes: The Athlete Psychological Strain Questionnaire. International Journal of Sport and Exercise Psychology, 18(6), 850–865. doi: 10.1080/ 1612197X.2019.1611900 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. doi: 10.1007/s40279-016-0492-2 Ruiz, F.J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta-analysis of current empirical evidence. International Journal of Psychology & Psychological Therapy, 12(3), 333–357. Ruscio, A.M., Hallion, L.S., Lim, C.C.W., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., … Bunting, B. (2017). Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiatry, 74(5), 465–475. doi: 10.1001/jamapsychiatry.2017.0056 Saha, S., Lim, C.C.W., Cannon, D.L., Burton, L., Bremner, M., Cosgrove, P., … McGrath, J.J. (2021). Comorbidity between mood and anxiety disorders: A systematic review and meta-analysis. Depression and Anxiety, 38(3), 286–306. doi: 10.1002/da.23113 Schaal, K., Tafflet, M., Nassif, H., Thibault, V., Pichard, C., Alcotte, M., … Toussaint, J.-F. (2011). Psychological balance in high level athletes: Gender-based differences and sport-specific patterns. PLOS ONE, 6(5), e19007. doi: 10.1371/journal.pone.0019007 Slade, T., Johnston, A., Oakley Browne, M.A., Andrews, G., & Whiteford, H. (2009). 2007 National survey of mental health and wellbeing: Methods and key findings. Australian and New Zealand Journal of Psychiatry, 43(7), 594–605. doi: 10.1080/00048670902970882 Smith, R.E., Smoll, F.L., Cumming, S.P., & Grossbard, J.R. (2006). Measurement of multidimensional sport performance anxiety in children and adults: The Sport Anxiety Scale-2. Journal of Sport and Exercise Psychology, 28(4), 479–501. doi.org/10.1123/jsep.28.4.479 Somers, J.M., Goldner, E.M., Waraich, P., & Hsu, L. (2006). Prevalence and incidence studies of anxiety disorders: A systematic review of the literature. Canadian Journal of Psychiatry, 51(2), 100–113. doi: 10.1177/070674370605100206 Spitzer, R.L., Kroenke, K., Williams, J.B.W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. doi: 10.1001/archinte.166.10.1092 Stein, D.J., Lim, C.C.W., Roest, A.M., De Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., … Bruffaerts, R. (2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative. BMC Medicine, 15(143), 1–21. 10.1186/s12916-017-0889-2 Stillman, M.A., Glick, I.D., McDuff, D., Reardon, C.L., Hitchcock, M.E., Fitch, V.M., & Hainline, B. (2019). Psychotherapy for mental health symptoms and disorders in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 767–771. doi: 10.1136/bjsports-2019-100654 Storch, E.A., Storch, J.B., Killiany, E.M., & Roberti, J.W. (2005). Self-reported psychopathology in athletes: A comparison of intercollegiate student-athletes and non-athletes. Journal of Sport Behavior, 28(1), 86–98. Stubbs, B., Vancampfort, D., Rosenbaum, S., Firth, J., Cosco, T., Veronese, N., … Schuch, F.B. (2017). An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Research, 249, 102–108. doi: 10.1016/j.psychres.2016.12.020

173

Courtney C. Walton et al. Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and commitment therapy in the treatment of anxiety: A systematic review. Clinical Psychology Review, 33(8), 965–978. doi: 10.1016/j.cpr.2013.07.002 Van Zuuren, F.J. (1988). The fear questionnaire: Some data on validity, reliability and layout. The British Journal of Psychiatry, 153(5), 659–662. Vella, S.A., Schweickle, M.J., Sutcliffe, J.T., & Swann, C. (2021). A systematic review and meta-synthesis of mental health position statements in sport: Scope, quality and future directions. Psychology of Sport and Exercise, 55, 101946. doi: 10.1016/j.psychsport.2021.101946 Walton, C.C., Rice, S., Gao, C.X., Butterworth, M., Clements, M., & Purcell, R. (2021). Gender differences in mental health symptoms and risk factors in Australian elite athletes. BMJ Open Sport & Exercise Medicine, 7(1), e000984. doi: 10.1136/bmjsem-2020-000984 Walton, C.C., Osborne, M.S., Gilbert, P., & Kirby, J. (2022). Nurturing self-compassionate performers. Australian Psychologist, 57(2), 77–85. 10.1080/00050067.2022.2033952 Wardenaar, K.J., Lim, C.C.W., Al-Hamzawi, A.O., Alonso, J., Andrade, L.H., Benjet, C., … Florescu, S.E. (2017). The cross-national epidemiology of specific phobia in the World Mental Health Surveys. Psychological Medicine, 47(10), 1744–1760. doi: 10.1017/S0033291717000174 Wilson, A.C., Mackintosh, K., Power, K., & Chan, S.W.Y. (2019). Effectiveness of self-compassion related therapies: A systematic review and meta-analysis. Mindfulness, 10(6), 979–995. 10.1007/s12671-018-1037-6 World Anti-Doping Agency. (2021). World anti-doping agency prohibited list. World Health Organization. Division of Mental Health. (1988). Tenth revision of the International Classification of Diseases chapter V (F: mental, behavioural and developmental disorders, clinical descriptions and diagnostic guidelines), Rev. 2 draft. World Health Organization. https://apps.who.int/iris/handle/10665/61362

174

SECTION C

Subclinical and Related Challenges

INTRODUCTION TO THE SECTION Insa Nixdorf and Raphael Nixdorf

In this section, the authors address the various challenges and problems in the context of mental health in elite sport. Besides mental disorders, there are various syndromes with clear negative impacts. Although its clinical recognition is sometimes at debate, athlete burnout is a syndrome with high importance and exemplifies a major challenge for mental health in elite sport. Further, its overlap and somewhat unclear separation to depression and the overtraining syndrome is another challenge for practitioners and researchers alike. Often, the high physical demands and impacts interact with mental health and illness. This is reflected in the overtraining syndrome and just as well by the problem of concussion in elite athletes. Besides physical demands, the psychological demands that go along with competing at the highest sporting level challenge mental health aspects. Anxiety and fear of competitions can intensify stress in athletes and possibly affect performance as well as mental health issues. Understanding stress within the context of elite sport is therefore vital. Stigmatisation of athletes with mental issues can hinder help-seeking behaviour. Taking into consideration athletes’ careers from an integral perspective, different phases, and especially the transition between those phases are important for building mental health and resilience to adversities and negative behaviour such as illegal performance enhancement and drug misuse. The following section will give a thorough overview of all the mentioned topics and their importance considering mental health and illness. The authors provide empirical data, such as prevalence rates where available, offer theoretical models explaining connections and processes, and conclude with recommendations for athletes and their support teams in navigating and handling these subclinical, related challenges.

176

DOI: 10.4324/9781003099345-17

12 REDUCING BURNOUT IN ATHLETES Daniel J. Madigan, Henrik Gustafsson, and Luke F. Olsson

Introduction Burnout has never been more relevant. This is especially the case for athletes, who train and compete under extreme and, it would appear, increasing levels of stress (e.g., Lopes Dos Santos et al., 2020). For example, the significant challenges and disruption caused by the COVID-19 pandemic, such as training in quarantine, restricted access to facilities, and the uncertainty of rescheduled competitive seasons, may have drastically accelerated the risk that athletes will develop burnout (e.g., Spagnoli et al., 2021). Unsurprisingly, these issues pose a significant challenge for those working with athletes (e.g., Schinke et al., 2020). As noted previously (e.g., Madigan et al., 2021), however, there is a limited evidence base in sport from which to make applied recommendations. Consequently, in this chapter, given the much larger body of evidence, we provide a review of research that has examined the efficacy of interventions in reducing burnout outside of sport. Based on the findings of this review, we provide suggestions for how practitioners might reduce burnout in athletes. But first we introduce athlete burnout. This includes providing a definition and description of burnout, details of how to measure burnout, models outlining the development of burnout, and an overview of the consequences of burnout for athletes, before moving on to our review.

What Is Burnout? Burnout has its scientific roots in occupational psychology. In this regard, at around the same time, in the 1970s, two psychologists – Christina Maslach and Herbert Freudenberger – observed a phenomenon of gradual exhaustion and loss of commitment in those working in caring and care-giving professions (e.g., Freudenberger, 1974; Maslach & Pines, 1977). This phenomenon became known as burnout. Shortly after this initial recognition, Maslach provided the first formal conceptualisation of burnout in which she defined burnout as a multidimensional syndrome that theoretically arose as a consequence of chronic work stress. This definition posits that there are three main symptoms (or dimensions) of burnout: (1) emotional exhaustion (feelings of being emotionally overextended and exhausted at one’s work), (2) cynicism (an unfeeling and impersonal response toward recipients of one’s service, care, treatment, or instruction), and (3) reduced professional efficacy (feelings of reduced competence and achievement in one’s work with people; Maslach et al., 1986). Since its conceptualisation, a vast body of work has explored the antecedents, correlates, and consequences of burnout and has done so in many occupations (e.g., teaching, health care, sport). DOI: 10.4324/9781003099345-18

177

Daniel J. Madigan et al.

It was not until the early 2000s that a systematic examination of burnout in athletes occurred. This shift was spurred by the recontextualization of burnout to the sport domain. Specifically, Raedeke and Smith (2001) recontextualized the occupational symptoms to better suit the experience of athletes. By doing so, athlete burnout was, and still is, viewed as an extreme form of sport disillusionment that is comprised of three symptoms that mirror those in the work domain: (1) physical and emotional exhaustion, (2) devaluation or cynicism directed at sport, and (3) a reduced sense of athletic accomplishment (Raedeke & Smith, 2001). Physical and emotional exhaustion is characterised by the perceived depletion of emotional and physical resources resulting from training and/or competition. Sport devaluation is the development of a cynical attitude towards sport participation. Finally, reduced sense of athletic accomplishment is characterised by a negative evaluation of one’s sporting abilities and achievements. In providing their recontextualization, Raedeke and Smith (2001) also developed a tool to quantify burnout in athletes – the Athlete Burnout Questionnaire (ABQ). The ABQ consists of 15 items, with five items reflecting physical and emotional exhaustion, five items reflecting sport devaluation, and five items reflecting a reduced sense of accomplishment. This self-report instrument asks athletes to reflect on the frequency with which they are experiencing these symptoms (almost never to almost always). Recent work has suggested that quantifying the intensity (very mild to very strong) and duration (no time to a very long time) of symptoms may also be beneficial (Madigan, 2021). This instrument is the most commonly used tool to determine whether athletes are experiencing burnout and has been used with athletes of many ages, competitive levels, and across a large range of individual and team sport (Eklund & DeFreese, 2020). In doing so, the psychometric properties of the instrument have held up under scrutiny (e.g., Gerber et al., 2018), leading burnout researchers to denote the ABQ as the current “gold standard” for athlete burnout assessment (Eklund & DeFreese, 2020).

How Does Burnout Develop? Many models have been used to understand the development of burnout in athletes. This includes models adapted from the broader organisational literature (e.g., commitment; Schmidt & Stein, 1991), models of optimal functioning (e.g., Self-Determination Theory; Deci & Ryan, 2002), and also sport-specific models (e.g., Smith, 1986). The models differ in regard to the main antecedents, but are similar in that they posit that both personal and organisational/environmental factors are causally linked to burnout. We discuss the three main models of athlete burnout below.

Smith’s (1986) Cognitive-Affective Model This model postulates that burnout develops because of chronic stress. When athletes appraise an imbalance between the demands of a situation (e.g., training) and their resources to cope with these demands, they will experience stress. If this imbalance between perceived demands and resources to cope becomes chronic, athletes will experience a range of emotions (e.g., anxiety) and rigid behavioural responses (e.g., withdrawal) that comprise their attempt to relieve the negative experiences associated with chronic stress. This model argues that one such behavioural response is burnout development.

Raedeke’s (1997) Commitment Model Commitment has also been proposed as an important factor in the development of burnout (Raedeke, 1997). In this regard, commitment represents the desire and resolve to continue sport participation (Scanlan et al., 1993). There are three factors affecting commitment. First, how attractive or enjoyable the activity is perceived. Second, which alternatives to the activity are viewed as in a greater or lesser degree as attractive. Finally, the restrictions the athlete perceives to withdraw from sport such as personal 178

Reducing Burnout in Athletes

investments and social constraints. How the athletes interpret these categories determine whether the commitment is based on enjoyment or entrapment. The athlete whose sport commitment is based on entrapment can be described as participating in sport “because I have to” in contrast to “because I want to.” According to this perspective, athletes who burn out do so because they are committed solely for entrapment reasons.

Deci and Ryan’s (2002) Self-Determination Theory (SDT) This theory contends that social-environmental conditions underlie the progression or attenuation of selfmotivated behaviour and health via the satisfaction or thwarting of three basic psychological needs (autonomy, relatedness, and competence; Ryan & Deci, 2017). SDT assumes that characteristics of the social environment are critical to the level of need satisfaction that individuals experience (Ryan & Deci, 2000). Athletes therefore who are exposed to especially controlling environments (e.g., working with an authoritative coach) will have their needs thwarted, develop more extrinsic motives for participation, and, over time, one wellbeing outcome is burnout development. Many studies have sought to determine the usefulness of these models in understanding burnout development. This includes a large number of studies linking stress to athlete burnout (e.g., DeFreese & Smith, 2014). In fact, a recent meta-analysis of 48 studies has confirmed a strong relationship between the two (considered large-sized; Lin et al., 2021). Similarly, there is meta-analytic evidence to support the role of perfectionism (a stress-related personality trait) in burnout development (Hill & Curran, 2016; see also Madigan et al., 2015). To a lesser extent, research has also shown commitment to play an important role (e.g., Woods, et al., 2020). Finally, through the lens of SDT, Li et al. (2013) provided a meta-analysis of 18 studies examining motivation, psychological needs, and burnout. Burnout was consistently associated with need thwarting and maladaptive forms of motivation (e.g., controlled). These models therefore provide a useful base from which to consider which factors may be most important in the development of burnout in sport.

Why Is Burnout Important? It is commonly assumed that because the behaviours and activities that athletes engage in are generally considered to be healthy (e.g., physical activity, restricted diet), that they are less susceptible to mental health and well-being problems. There is, however, a growing body of literature that suggests this is far from the truth (e.g., Henriksen et al., 2020). Burnout in athletes serves to illustrate and reinforce this point. While samples generally present low-to-moderate average levels of burnout, a significant percentage are susceptible to moderate and severe levels (Gustafsson et al., 2007). Levels appear to increase as the competitive season progresses, with athletes gradually developing more extreme and frequent symptoms (Cresswell & Eklund, 2006), and suffering from more extreme repercussions as a consequence. Burnout is very likely, therefore, more relevant to greater numbers of athletes than we may first assume. A small, but growing literature has attested to the consequences of burnout for athletes. In this regard, there is evidence that burnout is a significant mental health and well-being issue. This is because of its strong direct links to depression (Frank et al., 2017, also see Chapter 6), worry (Moen et al., 2017), and anxiety (Isoard-Gautheur et al., 2010). It will also affect athletes more broadly, and their well-being indirectly. For example, it is widely assumed that burnout will result in performance impairment (Gustafsson et al., 2011), and disengagement from sport activities (e.g., Gould & Whitley, 2009). Given its prevalence, then, a significant proportion of athletes are likely to suffer from burnout-related mental health, well-being, and performance problems. Predictably, this issue has given those working to support athletes serious pause for concern. 179

Daniel J. Madigan et al.

Reducing Burnout in Athletes Many researchers have called for interventions in sport to prevent and reduce burnout (e.g., DeFreese & Smith, 2014; De Francisco et al., 2016; Isoard-Gautheur et al., 2016). In this regard, at their broadest, interventions can target factors at the individual level (e.g., delivering stress management training) as well as at the organisational level (e.g., changing working hours; Maslach et al., 2012). Madigan (2021) recently reviewed interventions aimed at reducing burnout in athletes. This review, however, included only three studies that have sought to test the effectiveness of interventions for athletes (Dubuc-Charbonneau & Durand-Bush, 2015; Gabana et al., 2019; Langan et al., 2015). These studies employed interventions based on self-regulation, gratitude, and self-determination theory. Overall, all three studies reported beneficial effects on athlete burnout, to some degree. As highlighted by Madigan (2021), however, only one of these studies adopted a randomised controlled design. This is important because without a control group and random group allocation, our ability to draw causal conclusions is significantly impaired. For this reason, randomised controlled trials (RCTs) are the preferred evidence from which to inform practice. It is clear, then, that we currently have a very limited base in sport from which to derive recommendations to help athletes (i.e., one study). To the contrary, there is an abundance of interventions in contexts outside of sport. This work has examined many interventions in many different populations. As such, given the dearth of evidence in sport, it may be worthwhile to explore what interventions have been conducted elsewhere, and more importantly which, if any, are effective at reducing burnout. Such a review could help inform decisions in sport, and guide much-needed research in this area for the coming years. Because so many studies have been conducted outside of sport, meta-analyses have proliferated the literature. Meta-analyses provide a quantitative summary of research. To do so, all studies examining a particular relationship or testing a particular intervention or set of interventions are collated. Statistical analyses that aggregate the effects are performed. Such analyses weight effects sizes as a function of each study’s sample size – this way those studies with larger samples, and therefore more accurate estimates of population effect sizes, contribute more to the overall meta-analytic effect. In this way, meta-analyses can be considered the gold standard way in which to summarise and provide the best understanding of a relationship or intervention. It is for this reason that we provide a review of meta-analyses of burnout interventions, and because of their strength in testing causal inferences and informing practice, we focus on meta-analyses of randomised controlled trials.

The Current Review The current review was based on an electronic literature search. This search aimed to identify metaanalyses of intervention studies to reduce burnout, which adopted randomised controlled designs. This search was based on several databases (PsycINFO, PsycARTICLES, SPORTDiscus) using the terms “burnout”, “intervention”, and “meta-analysis”. The search was conducted in April 2021 and focused on peer-reviewed meta-analyses published in English. Our search identified 13 meta-analyses, which are summarised in Table 12.1. We now provide a discussion of the meta-analyses in general, and then an examination of interventions grouped by type (individual, organisational, combined).

Overview of Meta-Analyses The 13 meta-analyses included 151 studies and 45 effect sizes (across total burnout and its symptoms). They were all conducted in the last seven years. The meta-analyses focused on a variety of contexts and participants; this included physicians (N = 4), professionals (N = 3), nurses (N = 2), teachers (N = 1), 180

181 Individual Organisational

12 8

Physicians

Individual

Individual

5 4

Individual

4

Professionals

Individual

6

Ochentel et al. (2018) Panagioti et al. (2017)

Individual

12

Individual

Individual

Maricutoiu et al. Professionals (2014)

23

Individual and organisational

7

Teachers

Iancu et al. (2018)

13

Lee et al. (2016) Nurses

Mental health providers

Individual

13

Dreison et al. (2018)

Organisational

7

Physicians

Organisational

9

Physicians

Busireddy et al. (2017) De Simone et al. (2021)

Number of Intervention studies

Context

Study

MBSR, self-confidence, communication, exercise Workload, teamwork, leadership

Exercise

Role-related

Interpersonal

Relaxation

CBT

Workload, Communication, Teamwork, Discussion Groups MBSR, ACT Mindfulness, Communication, Stress Management, Exercise Job training and education, Stress management workshop, REBT, Team communication, Clinical supervision CBT, Mindfulness, professional development, Psychoeducational, Social Support, Socio-emotional skills, other Stress management, CBT

Work hour limits

Details

–

−2.70 [−3.98, −1.41] –

Exhaustion

–

−0.16 [−0.41, 0.09] –

–

–

–

–

–

−0.18 [−0.07, −0.29]

−0.18 [−0.32, −0.03] −0.45 [−0.62, −0.28]

−2.43 [−1.33, −3.54] −0.15 [.0.01, −0.31] −0.51 [−0.11, −0.91] 0.01 [0.22, −0.20] −0.39 [0.01, −0.79] –

−0.18 [−0.06, −0.30]

−0.20 −.021 [−0.02, −0.38] 1 [−0.04, −0.39]

−0.45 [−0.62, −0.27] −0.18 [−0.33, −0.04]

–

Total

Table 12.1 Meta-Analyses Examining Randomised Controlled Interventions to Reduce Burnout

–

–

−0.96 [−0.39, −1.53] 0.01 [0.23, −0.21] −0.08 [0.13, −0.30] 0.08 [0.27, −0.12] −0.55 [0.60, −1.70] –

−0.03 [0.08, −0.14]

−0.36 [−0.13, −0.59]

−1.43 [−2.54, −0.31] −0.34 [−0.66, −0.02] −0.17 [−0.34, 0.01]

Cynicism

–

–

(Continued)

−1.86 [−0.74, −2.98] 0.08 [0.44, −0.28] −0.17 [0.16, −0.51] −0.27 [−0.07, −0.47] 0.22 [1.10, −0.66] –

−0.14 [−0.03, −0.25]

−0.03 [0.26, −0.31]

0.99 [-.004, 2.02] −0.32 [−0.06, −0.59] −0.29 [−0.10, −0.48]

Reduced efficacy

Reducing Burnout in Athletes

Individual

4 2 15

Nurses

Physicians

Stress management, communication skills training, MBSR, work conditions

Mindfulness

ACT

CBT, Qigong

Details

−6.00% [−19.00, 7.00] 3

−0.26 [0.14, −0.65] –

–

Total

−1.91 [−4.50, 0.68]

–

–

Cynicism

−2.06 −0.92 [−3.86, −0.27] 2 [−1.90, 0.05] 2

−1.32 [−9.41, 6.78] 2

0.01 [−0.37, 0.38] –

Exhaustion

–

2.12 [−9.91, 14.14]

–

–

Reduced efficacy

Note: Effect sizes are Standardised Mean Differences (95% confidence intervals) unless otherwise stated. Negative effect sizes favour the experimental group (i.e., the intervention reduced burnout; all effects are reported in this manner). Effect sizes are based on the most complete data (i.e., pre- to-post-intervention). Efficacy scores are reversed to reflect reduced efficacy. Bold = statistically significant (p < .05). CBT = cognitive behavioural therapy. ACT = acceptance commitment therapy. MBSR = mindfulness based stress reduction. REBT = rational emotive behavioural therapy. 1 Effect sizes are Hedge’s g. 2 Effects sizes are absolute mean differences. 3 Effect sizes are mean differences in percent.

Individual and organisational

Individual

Individual

3

Perski et al. (2017) Reeve et al. (2018) SuleimanMartos et al. (2020) West et al. (2016)

Number of Intervention studies

Patients (stress disorders) Direct care staff

Context

Study

Table 12.1 (Continued)

Daniel J. Madigan et al.

182

Reducing Burnout in Athletes

patients (stress disorders; N = 1), mental health providers (N = 1), and direct care staff (N = 1). They employed an extensive range of individual and organisational interventions, which are examined in more detail below.

Individual Interventions Ten meta-analyses were focused on individual-level interventions. Across the burnout symptoms, there were 31 tests of intervention effectiveness. Interventions resulted in statistically significant reductions in burnout in 11 instances (35.48%). As such, interventions aimed at the individual level appear to work sometimes, but more often than not are ineffective. To determine which instances, and interventions, are effective, we discuss the specific intervention types next. In terms of those interventions that were effective, the majority were cognitive-based therapies aimed at relieving stress. This included those using traditional Cognitive Behavioural Therapy (CBT) techniques, stress management, and relaxation, and also techniques from the third wave of cognitive behavioural therapies such as Mindfulness-Based Stress Reduction (MBSR). The former techniques are based around changing underlying cognitive processes and patterns which in turn lead to more adaptive behaviours (e.g., Shafran et al., 2009), while the latter relates to the ability to stay attuned to the present in a nonjudgmental manner, rather than ruminating about the past or worrying about the future (Kabat-Zinn, 2003). These approaches seemed most effective in teachers, nurses, and physicians. However, they did not appear effective in professionals (i.e., in the general workforce). This last issue highlights the possibility that the population, and therefore context, are relevant when considering individual-level burnout interventions.

Organisational Interventions Three meta-analyses were focused on organisational-level interventions. Across the burnout symptoms, there were seven tests of intervention effectiveness. Interventions resulted in statistically significant reductions in burnout in six instances (85.71%). As such, although there are fewer interventions tested at this level when compared to individual level ones, it would appear that they have the potential to be more effective. To explore these further, we now discuss the specific intervention types. In terms of the interventions that were effective, there appeared to be three main approaches responsible for the reduction in burnout. This includes those interventions based around altering workload, and those aimed at enhancing teamwork and communication. The former involved reducing the total number of hours worked or reducing the duration of individual shifts, the latter involved enhancing both interpersonal and hierarchical communication (e.g., from management to staff). Notably, all organisational interventions were tested among physicians. Although there is strong evidence these interventions are effective, it is unclear whether these findings would generalise to other contexts, especially to sport.

Individual and Organisational Interventions In two instances, meta-analyses combined individual and organisational interventions (i.e., they did not run separate analyses for each type). In these instances, there were seven tests of intervention effectiveness. Interventions resulted in statistically significant reductions in burnout in four instances (57.14%). As such, the interventions summarised were effective to a similar degree as they were ineffective. It is difficult to identify which interventions specifically were responsible for these findings. However, we have elaborated on each type below. A range of interventions were included. This included individual level interventions as already discussed (e.g., stress management), but also Rational Emotive Behaviour Therapy (where the emphasis is on 183

Daniel J. Madigan et al.

identifying and changing irrational beliefs; Ellis & Dryden, 2007), and also organisational interventions already mentioned (e.g., communication). These analyses suggested the interventions were most effective in mental health providers, but that they were less effective in physicians, it is unclear unfortunately whether this pattern reflects a predominance of individual or organisational interventions.

Key Findings, Critical Considerations, and Recommendations So as to help inform possible recommendations in sport, we now spend some time summarising the main findings of our review. The most important point that we note is that burnout interventions can work. That is, several different approaches were effective in reducing burnout symptoms, and did so across a range of different contexts. This is obviously promising in terms of our potential to help athletes when they develop similar symptoms in sport. Another notable fact to arise from the present review is that there appears to be differences in terms of effectiveness between individual and organisational interventions. On the whole, organisational interventions were more effective than individual ones. However, there are two important caveats. First, many more individual intervention types have been tested; thus, the interpretation of what particular mechanisms and aspects are responsible for the effectiveness is difficult to interpret. Second, organisational interventions have primarily been implemented and tested in physicians. In addition, individual level interventions were found to be effective in multiple contexts. In relation to sport, then, there is evidence that both approaches could be applicable, but these findings also highlight the potential need for athletespecific interventions to be developed. We now use these findings to make some critical comments, and provide some recommendations for both practice and research. Can these findings be directly translated and used to make recommendations for intervening with athletes? The evidence in relation to individual level interventions would suggest they are both feasible and relevant. According to the findings, the most effective guise would come in the form of cognitive behavioural therapies – providing athletes with the means to reduce stress (reappraise situations as less stressful) is likely to provide some protection against burnout. This point has also been made elsewhere (e.g., Gustafsson, DeFreese, & Madigan, 2017), and this recommendation aligns well with sport-specific theories of the development of burnout (Smith, 1986). Consequently, building on the relatively large literature in sport that adopts cognitive approaches in relation to performance and other well-being issues could be an excellent place to start intervening in practice and empirically testing their effectiveness. Do the findings speak to any means to intervene with sport more broadly? The studies in physicians we reviewed have shown clearly that interventions at the organisational level are effective. In this regard, given the differences between the context of hospital surgery and sport, some intervention types may not be feasible or relevant (e.g., reductions in duty hours). Instead, it may be more appropriate for organisational based interventions in sport to consider SDT as a promising place to start as it provides the means to understand the role of the social environment in terms of well- and ill-being. This idea is reflected in the one randomised controlled trial in sport (Langan et al., 2015). We therefore need more tests of SDTbased interventions in athletes, but also the development of new theoretically driven organisational interventions that seek to account for the unique aspects of sport. Addressing both the individual and organisational levels simultaneously may have the most potential in sport, as has been suggested elsewhere (West et al., 2016). Here, sport-specific interventions aimed at both the athlete and those that heavily influence their experiences (e.g., the coach) could be particularly impactful. A good place to start would be enhancing each individual’s awareness and knowledge of burnout in sport. This would at least provide the means for athletes to recognise burnout symptoms in themselves, and coaches to recognise them in others. This is especially important as prevention based on early detection is preferable due to the potentially long way back from severe burnout (Gustafsson et al., 2017). 184

Reducing Burnout in Athletes

Finally, in this chapter, we have focused on randomised controlled trials. These are the strongest designs available to determine causal effects. For future work in sport, then, testing interventions with randomised controlled designs is essential. We have a long way to go, but through concerted efforts within the academic community, we can build an evidence base from which to protect athletes.

Summary Athletes have never been more at risk of burnout. At the same time, we still have a limited understanding of how to intervene when athletes do experience frequent burnout symptoms. In this chapter, we have summarised the best evidence from outside of sport in order to inform what should be done in sport. We conclude that cognitive-based individual interventions and SDT-based organisational interventions would be the best place to start. It is hoped these recommendations will act as a foundation from which to build a sport-specific intervention evidence base and, in doing so, provide those working in sport with a means to help recognise, prevent, and reduce burnout in their athletes.

References References marked with an asterisk indicate studies included in the review. ∗ Ahola, K., Toppinen-Tanner, S., & Seppänen, J. (2017). Interventions to alleviate burnout symptoms and to support return to work among employees with burnout: Systematic review and meta-analysis. Burnout Research, 4, 1–11. 10.1016/j.burn.2017.02.001 ∗ Busireddy, K.R., Miller, J.A., Ellison, K., Ren, V., Qayyum, R., & Panda, M. (2017). Efficacy of interventions to reduce resident physician burnout: A systematic review. Journal of Graduate Medical Education, 9(3), 294–301. 10.43 00/JGME-D-16-00372.1 Cresswell, S.L., & Eklund, R.C. (2006). Changes in athlete burnout over a thirty-week “rugby year”. Journal of Science and Medicine in Sport, 9, 125–134. 10.1016/j.jsams.2006.03.017 De Francisco, C., Arce, C., del Pilar Vílchez, M., & Vales, Á. (2016). Antecedents and consequences of burnout in athletes: Perceived stress and depression. International Journal of Clinical and Health Psychology, 16(3), 239–246. 10.1 016/j.ijchp.2016.04.001 ∗ De Simone, S., Vargas, M., & Servillo, G. (2021). Organizational strategies to reduce physician burnout: A systematic review and meta-analysis. Aging Clinical and Experimental Research, 33(4), 883–894. 10.1007/s40520-019-01368-3 Deci, E.L., & Ryan, R.M. (2002). Overview of self-determination theory: An organismic dialectical perspective. Handbook of self-determination research, University of Rochester Press. DeFreese, J.D., & Smith, A.L. (2014). Athlete social support, negative social interactions, and psychological health across a competitive sport season. Journal of Sport and Exercise Psychology, 36, 619–630. 10.1123/jsep.2014-0040 ∗ Dharmawardene, M., Given, J., Wachholtz, A., Makowski, S. & Tjia, J. (2016). A system review and meta-analysis of meditative interventions for informal caregivers and health professionals. BMJ Support Palliate Care, 6(2), 160–169. 10.1136/bmjspcare-2014-000819.A ∗ Dreison, K.C., Luther, L., Bonfils, K.A., Sliter, M.T., McGrew, J.H., & Salyers, M.P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18–30. 10.1037/ocp0000047 Dubuc-Charbonneau, N., & Durand-Bush, N. (2015). Moving to action: The effects of a self-regulation intervention on the stress, burnout, well-being, and self-regulation capacity levels of university student-athletes. Journal of Clinical Sport Psychology, 9(2), 173–192. 10.1123/jcsp.2014-0036 Eklund, R.C., & DeFreese, J.D. (2020). Athlete burnout. In G. Tenenbaum, & R.C. Eklund (Eds.), Handbook of sport psychology (pp. 1220–1240). New York: John Wiley & Sons. 10.1002/9781119568124.ch60 Ellis, A., & Dryden, W. (2007). The practice of rational emotive behavior therapy. Springer Publishing Company. 10.1891/ 9780826122179 Frank, R., Nixdorf, I., & Beckmann, J. (2017). Analyzing the relationship between burnout and depression in junior elite athletes. Journal of Clinical Sport Psychology, 11, 287–303. 10.1123/JCSP.2017-0008 Freudenberger, H.J. (1974). Staff burn‐out. Journal of Social Issues, 30, 159–165. Gabana, N.T., Steinfeldt, J., Wong, Y.J., Chung, Y.B., & Svetina, D. (2019). Attitude of gratitude: Exploring the implementation of a gratitude intervention with college athletes. Journal of Applied Sport Psychology, 31(3), 273–284. 10.1080/10413200.2018.1498956

185

Daniel J. Madigan et al. Gerber, M., Gustafsson, H., Seelig, H., Kellmann, M., Ludyga, S., Colledge, F., … & Bianchi, R. (2018). Usefulness of the Athlete Burnout Questionnaire (ABQ) as a screening tool for the detection of clinically relevant burnout symptoms among young elite athletes. Psychology of Sport and Exercise, 39, 104–113. 10.1016/j.psychsport.201 8.08.005 Goodger, K., Gorely, T., Lavallee, D., & Harwood, C. (2007). Burnout in sport: A systematic review. The Sport Psychologist, 21, 127–151. 10.1123/tsp.21.2.127 Gould, D., & Whitley, M.A. (2009). Sources and consequences of athletic burnout among college athletes. Journal of Intercollegiate Sport, 2, 16–30. 10.1123/jis.2.1.16 Gustafsson, H., DeFreese, J.D., & Madigan, D.J. (2017). Athlete burnout: Review and recommendations. Current Opinion in Psychology, 16, 109–113. 10.1016/j.copsyc.2017.05.002 Gustafsson, H., Kenttä, G., & Hassmén, P. (2011). Athlete burnout: An integrated model and future research directions. International Review of Sport and Exercise Psychology, 4(1), 3–24. 10.1080/1750984X.2010.541927 Gustafsson, H., Kenttä, G., Hassmén, P., & Lundqvist, C. (2007). Prevalence of burnout in competitive adolescent athletes. The Sport Psychologist, 21, 21–37. 10.1123/tsp.21.1.21 Henriksen, K., Schinke, R., Moesch, K., McCann, S., Parham, W.D., Larsen, C.H., & Terry, P. (2020). Consensus statement on improving the mental health of high performance athletes. International Journal of Sport and Exercise Psychology, 18, 553–560. 10.1080/1612197X.2019.1570473 Hill, A.P., & Curran, T. (2016). Multidimensional perfectionism and burnout: A meta-analysis. Personality and Social Psychology Review, 20, 269–288. 10.1177/1088868315596286 ∗ Iancu, A.E., Rusu, A., Măroiu, C., Păcurar, R., & Maricuoiu, L.P. (2018). The effectiveness of interventions aimed at reducing teacher burnout: A meta-analysis. Educational Psychology Review, 30(2), 373–396. 10.1007/s10648-0179420-8 Isoard-Gautheur, S., Guillet-Descas, E., & Gustafsson, H. (2016). Athlete burnout and the risk of dropout among young elite handball players. The Sport Psychologist, 30(2), 123–130. 10.1123/tsp.2014-0140 Isoard-Gautheur, S., Oger, M., Guillet, E., & Martin-Krumm, C. (2010). Validation of a French version of the Athlete Burnout Questionnaire (ABQ). European Journal of Psychological Assessment, 26, 203–211. 10.1027/1015-5 759/a000027 Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8, 73. Langan, E., Toner, J., Blake, C., & Lonsdale, C. (2015). Testing the effects of a self-determination theory-based intervention with youth Gaelic football coaches on athlete motivation and burnout. The Sport Psychologist, 29(4), 293–301. 10.1123/tsp.2013-0107 ∗ Lee, H.F., Kuo, C.C., Chien, T.W., & Wang, Y.R. (2016). A meta-analysis of the effects of coping strategies on reducing nurse burnout. Applied Nursing Research, 31(2016), 100–110. 10.1016/j.apnr.2016.01.001 Li, C., Wang, C.J., & Kee, Y.H. (2013). Burnout and its relations with basic psychological needs and motivation among athletes: A systematic review and meta-analysis. Psychology of Sport and Exercise, 14, 692–700. 10.1016/ j.psychsport.2013.04.009 Lin, C.H., Lu, F.J.H., Chen, T.W., & Hsu, Y. (2022). Relationship between athlete stress and burnout: A systematic review and meta-analysis. International Journal of Sport and Exercise Psychology, 20(5),1295–1315. 10.1080/16121 97X.2021.1987503 Lopes Dos Santos, M., Uftring, M., Stahl, C.A., Lockie, R.G., Alvar, B., Mann, J.B., & Dawes, J.J. (2020). Stress in academic and athletic performance in collegiate athletes: A narrative review of sources and monitoring strategies. Frontiers in Sports and Active Living, 2, 42. 10.3389/fspor.2020.00042 Madigan, D.J. (2021). Diagnosing problems, prescribing solutions, and advancing athlete burnout research. In Z. Zenko & L. Jones (Eds.), Essentials of exercise and sport psychology: An open access textbook (pp. 664–682). Society for Transparency, Openness, and Replication in Kinesiology: United Kingdom. 10.51224/B1028 Madigan, D.J., Gustafsson, H., Hill, A.P., Mellano, K.T., Pacewicz, C.E., Raedeke, T.D., & Smith, A.L. (2021). Perspectives on the future of burnout in sport. Journal of Clinical Sport Psychology, 16(1), 75–88. 10.1123/jcsp.20210045 Madigan, D.J., Gustafsson, H., Smith, A., Raedeke, T., & Hill, A.P. (2019). The BASES expert statement on burnout in sport. The Sport and Exercise Scientist, 61, 6–7. Madigan, D.J., Stoeber, J., & Passfield, L. (2015). Perfectionism and burnout in junior athletes: A three-month longitudinal study. Journal of Sport and Exercise Psychology, 37, 305–315. 10.1123/jsep.2014-0266 ∗ Maricuţoiu, L.P., Sava, F.A., & Butta, O. (2016). The effectiveness of controlled interventions on employees’ burnout: A meta-analysis. Journal of Occupational and Organizational Psychology, 89(1), 1–27. 10.1111/joop.12099 Maslach, C., & Jackson, S.E. (1981). The measurement of experienced burnout. Journal of organizational behavior, 2(2), 99–113. 10.1002/job.4030020205

186

Reducing Burnout in Athletes Maslach, C., Jackson, S.E., Leiter, M.P., Schaufeli, W.B., & Schwab, R.L. (1986). Maslach burnout inventory (Vol. 21, pp. 3463–3464). Palo Alto, CA: Consulting psychologists press. Maslach, C., Leiter, M.P., & Jackson, S.E. (2012). Making a significant difference with burnout interventions: Researcher and practitioner collaboration. Journal of Organizational Behavior, 33(2), 296–300. 10.1002/job.784 Maslach, C., & Pines, A. (1977). The burn-out syndrome in the day care setting. Child Care Quarterly, 6, 100–113. Moen, F., Myhre, K., Klöckner, C.A., Gausen, K., & Sandbakk, O. (2017). Physical, affective and psychological determinants of athlete burnout. Sport Journal, 1, 1–14. ∗ Ochentel, O., Humphrey, C., & Pfeifer, K. (2018). Efficacy of exercise therapy in persons with burnout. A systematic review and meta-analysis. Journal of Sports Science and Medicine, 17(3), 475–484. ∗ Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., … & Esmail, A. (2017). Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Internal Medicine, 177(2), 195–205. 10.1001/jamainternmed.2016.7674 ∗ Perski, O., Grossi, G., Perski, A., & Niemi, M. (2017). A systematic review and meta-analysis of tertiary interventions in clinical burnout. Scandinavian Journal of Psychology, 58(6), 551–561. 10.1111/sjop.12398 Raedeke, T.D. (1997). Is athlete burnout more than just stress? A sport commitment perspective. Journal of Sport and Exercise Psychology, 19(4), 396–417. 10.1123/jsep.19.4.396 Raedeke, T.D., & Smith, A.L. (2001). Development and preliminary validation of an athlete burnout measure. Journal of Sport and Exercise Psychology, 23, 281–306. 10.1123/jsep.23.4.281 ∗ Reeve, A., Tickle, A., & Moghaddam, N. (2018). Are acceptance and commitment therapy-based interventions effective for reducing burnout in direct-care staff? A systematic review and meta-analysis. Mental Health Review Journal, 23(3), 131–155. 10.1108/MHRJ-11-2017-0052 Ryan, R.M., & Deci, E.L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68. 10.1037/0003-066X.55.1.68 Ryan, R.M., & Deci, E.L. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. Guilford Publications. 10.1521/978.14625/28806 Scanlan, T.K., Carpenter, P.J., Schmidt, G.W., Simons, J.P., & Keeler, B. (1993). The sport commitment model: An introduction and empirical test. Journal of Sport and Exercise Psychology, 15, 1–15. 10.1123/jsep.15.1.1 Schinke, R., Papaioannou, A., Henriksen, K., Si, G., Zhang, L., & Haberl, P. (2020). Sport psychology services to high performance athletes during COVID-19. International Journal of Sport and Exercise Psychology, 18, 269–272. 10.1080/1612197X.2020.1754616 Schmidt, G.W., & Stein, G.L. (1991). Sport commitment: A model integrating enjoyment, dropout, and burnout. Journal of Sport and Exercise Psychology, 13, 254–265. 10.1123/jsep.13.3.254 Shafran, R., Clark, D.M., Fairburn, C.G., Arntz, A., Barlow, D.H., Ehlers, A., … & Wilson, G.T. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47, 902–909. 10.1016/j.brat.2 009.07.003 Smith, R.E. (1986). Toward a cognitive-affective model of athletic burnout. Journal of Sport Psychology, 8(1), 36–50. 10.1123/jsp.8.1.36 Spagnoli, P., Buono, C., Kovalchuk, L.S., Cordasco, G., & Esposito, A. (2021). Perfectionism and burnout during the COVID-19 crisis: A two-wave cross-lagged study. Frontiers in Psychology, 11, 4087. 10.3389/fpsyg.2020.631994 ∗ Suleiman-Martos, N., Gomez-Urquiza, J.L., Aguayo-Estremera, R., Cañadas-De La Fuente, G.A., De La FuenteSolana, E.I., & Albendín-García, L. (2020). The effect of mindfulness training on burnout syndrome in nursing: A systematic review and meta-analysis. Journal of Advanced Nursing, 76(5), 1124–1140. 10.1111/jan.14318 ∗ West, C.P., Dyrbye, L.N., Erwin, P.J., & Shanafelt, T.D. (2016). Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. The Lancet, 388(10057), 2272–2281. 10.1016/S0140-6736(16) 31279-X Woods, S., Dunne, S., McArdle, S., & Gallagher, P. (2020). Committed to burnout: An investigation into the relationship between sport commitment and athlete burnout in Gaelic games players. International Journal of Sport Psychology, 51(3), 247–270.

187

13 DEPRESSION, ATHLETE BURNOUT, AND OVERTRAINING: A REVIEW OF SIMILARITIES AND DIFFERENCES Raphael Nixdorf, Daniel J. Madigan, Göran Kenttä, and Peter Hassmén

Introduction Sport psychology is a rather young research discipline. Indeed, the unique emotional challenges that athletes face in relation to psychological distress and mental health have only been recognised over the last few decades (Moesch et al., 2018). For example, in the 1980s, Morgan and colleagues’ pioneering research showed clear connections between increased exercise loads and negative or depressed mood (Morgan et al., 1987; Morgan et al., 1988; O’Connor et al., 1989; Raglin et al., 1991). This research presented a clear connection between physiological training load and mood responses in athletes as expressed by a dose-response relationship. This resulted in the integration of emotional and mood responses in the syndrome of overtraining in addition to the development of monitoring and screening systems including some measurement of mood and emotional responses (Kenttä et al., 2001; Meeusen et al., 2013). Moreover, symptoms such as fatigue, loss of weight and appetite, sleep disturbances, emotional instability, anxiety, depressive mood, heavy transpiration, heavy muscles, and frequent minor infections have also been investigated (Budgett et al., 2000). Many of these symptoms can be related to symptoms during a depressive disorder and articles pointed out that both syndromes are closely related and have overlaps in their symptomatology (Armstrong & Van Heest, 2002; Puffer & McShane, 1992). However, only later studies in U.S. college athletes (Yang et al., 2007) and European elite athletes (Nixdorf et al., 2013) investigated depression as a severe challenge for elite athletes. In addition, burnout became recognised as an emotional challenge in the general population (Freudenberger, 1974) and was later adapted and investigated in athletes (Raedeke, 1997). Because athlete burnout addressed many parts of overtraining (state of fatigue in response to stress) with additional emotional and motivational responses, research within sport psychology has focused primarily on athlete burnout in the last three decades (Eklund & DeFreese, 2015). Only over the last few years have depression and burnout been investigated simultaneously (De Francisco et al., 2016) and research aimed to analyse mechanisms between these closely related syndromes (Frank et al., 2017). As a function of these complexities, a clear understanding of the connection and relation between all three syndromes is currently missing. In this chapter, we aim to highlight and integrate findings on all three syndromes and therefore provide a summary picture for research and applied sport psychology. To this aim, we begin by introducing each syndrome and highlighting their importance to athletes, and then proceed to distinguish similarities and differences before making recommendations for practice based on a novel integrative model. 188

DOI: 10.4324/9781003099345-19

Depression, Athlete Burnout, and Overtraining

Depression Depression is a psychological disorder and the concept of depression is deeply rooted in medical history. Several types of depression are included in the current fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V, American Psychiatric Association, 2013). Broadly, depressive syndromes are characterised by symptoms of depressed mood, anhedonia, fatigue, feelings of guilt, and suicidal ideation. Furthermore, depression can be regarded as a multisystem disorder with affective, cognitive, and physiological manifestations (Insel & Charney, 2003; Lee et al., 2010). In addition to its symptoms and consequent increased risk of suicidal behaviour (Hawton et al., 2013), depression is a severe psychological disorder that can manifest itself in a long-lasting chronic problem associated with other comorbidities (Holzel et al., 2011). In the context of sport, and its unique influences, depressive syndromes can often be overlooked or even increased in severity. Examples of high-level athletes who suffer from depressive syndromes to a point where they “outed” themselves as depressive, anecdotally reveal that clinical depression can be found in the highest echelons of sport. At the same time, the stressful nature of sport including intensive training, inadequate recovery, pressures to perform, media attention and financial challenges can put athletes at risk for this disorder (see Nixdorf et al., 2015; see Chapter 6). For practitioners, the clinical picture can sometimes be difficult to unravel, as other similar constructs such as burnout and overtraining can also be present. In addition, terms are often handled imprecisely, causing further confusion and increasing complexity.

Burnout In contrast to depression, the conceptualisation of burnout continues to evolve. However, there is a generally accepted definition of burnout as a psychosocial syndrome of exhaustion, cynicism, and reduced efficacy (Maslach et al., 1993). In terms of clinically recognised diagnostic systems, such as the DSM V (American Psychiatric Association, 2013) or the International Classification of Diseases (ICD 11; World Health Organisation, 2020), burnout is not represented as a formal diagnosis, but instead defined as an occupational phenomenon comprising these three symptoms. Importantly, as an occupational syndrome, burnout is clearly differentiated from pervasive mood disorders such as depression. While burnout more broadly is conceptualised in relation to work with others, the context of sport provides different challenges and unique circumstances that make the broad definition problematic (e.g., inclusion of physical training load, lack of a recipient of care). As such, much of the early work sought to understand how burnout may manifest in athletes. In this regard, the work of Raedeke and Smith (2001) is highly influential in that they provided a formal definition, and measurement tool, that accounts for what makes sport unique. This definition sees athlete burnout as an extreme form of sport disillusionment that comprises three symptoms, that mirror, but modify, those from the broad definition of burnout: physical and emotional exhaustion, sport devaluation, and reduced sense of athletic accomplishment. Using this model and associated measure, many researchers have sought to examine both the antecedents and consequences of burnout for athletes (e.g., Madigan et al., 2019). In this regard, burnout has many significant and notably negative consequences. These include reduced volume and quality of motivation, decreased well-being, and likely worse performance (see Chapter 12 for a review). Given these implications, much work has sought to elucidate further the causes of burnout itself as well as to wrestle with various conceptual and measurement issues.

Increased Complexity in Sport: The Overtraining Syndrome A key question in competitive sport is: how should training programmes look like that optimise gains in performance and at the same time minimise the risk for negative consequences from overtraining? It is 189

Raphael Nixdorf et al.

common practice that elite athletes devote many hours each year to regular and rigorous training with the aim to optimise performance development and to be successful in competitions. Recently, Nils van der Poel (2022), a Swedish speed skater published his training manifesto, “How to skate a 10k”, that resulted in two Olympic gold medals in 2022. He published 2,903 hours of training in detail that covered 33 months. That is 1,056 hours per year on average. Of course, there are many different approaches to training that to a large degree depend on what physical capacity is required for each sport (i.e., more endurance or strength and sprint oriented). Regardless of the type of training programme and the mix of training frequency, duration and intensity, the major challenge is to find the optimal balance between training and adequate recovery (Meeusen et al., 2013) – this has typically been described in practise as “balancing on a sharp knife-edge”. Too much training and insufficient recovery can lead to maladaptive responses, both physiological and psychological; too little can prevent desirable positive adaptations such as improved performance (Carfagno & Hendrix, 2014). Or in other words, as van der Poel noted in his epilogue: “Be courageous. Do not overtrain, but stick to the limit” (van der Poel, 2022).

Definition and Models Many terms exist in the scientific literature for what nowadays is widely used and accepted: overtraining syndrome (OTS). Some similar terms are often used as synonyms and interchangeably: training stress syndrome, failure adaptation, muscle failure adaptation, under-recovery syndrome, unexplained underperformance syndrome, maladjustment syndrome in athletes, overreaching, chronic fatigue, staleness, and burnout (Meeusen et al., 2013). This multitude of terms have confused both researchers and end users; to use one term is preferable – provided it is well defined. The joint consensus statement by the European College of Sport Science and the American College of Sport Medicine (Meeusen et al., 2013) is therefore welcome. Meeusen and his colleagues describes OTS as occurring on a continuum, see Table 13.1. Here, intensified training is further differentiated with functional overreaching, non-functional overreaching and the actual OTS as the severest case of intensified training loads. Noteworthy for this chapter, the statement on OTS does not at all discuss overlap or similarities with burnout. More recently, Armstrong and colleagues (2021) extended the work of Meeusen et al. (2013) and stressed the relevance of integrating undertraining and detraining into the model. The reason for also including undertraining is that some athletes may – knowingly or probably often unknowingly – underload themselves. Whereas overload is more common, too little, or inadequate training load will result in unchanged or even decreased performance. Athletes balancing on an imaginary knife-edge can indeed go both ways. Neither too little nor too much is desirable. It has been suggested that increased attention to the risk of developing OTS may encourage both athletes and coaches to err on the side of caution – taking an extra rest-day and/or reducing the load, intensity, and duration (Kellmann et al., 2022). Interestingly, it seems to be less concern and discussion “on fear of rest and recovery” as the core belief still is, more is

Table 13.1 The Different Stages Described by Meeusen et al. (2013) Regular Training (overload)

Functional Overreaching

Normal training with acute Intensified trainings with a fatigue, increased temporary performance performance after day(s) decrement. of recovery Recovery takes days to weeks.

Non-functional Overreaching

Overtraining Syndrome OTS

Intensified training with a stagnation and possible decrease in performance. Recovery takes weeks to months.

Intensified training with a decrease in performance. Recovery takes months.

190

Depression, Athlete Burnout, and Overtraining

Figure 13.1

A Model of Overtraining and Possible Consequences. (Adapted from Kenttä, 2001.)

always better. Nevertheless, the balance between long term overload training combined with insufficient recovery can have serious consequences. For whatever reason, if OTS is ignored, or occur frequently, an athlete may develop burnout, pointing out the connection and one possible pathway from one syndrome to the other. Consequently, several different stages can be associated to various levels of training stress as discussed in the model of overtraining (Kenttä, 2001) (Figure 13.1). Progressive overload is necessary for performance improvements to occur. Athletes will experience acute fatigue, but with sufficient rest – one to three days – homoeostasis will return in line with the supercompensation principle (e.g., Bompa & Buzzichelli, 2018). This is the preferred and most common aim with training and involves training periodisation. During some periods of the training year, athletes may increase their training load to a level when restorative recovery and rest may be intentionally insufficient – at least short-term and carefully scheduled. This type of training when performance is temporary decreased has been referred to as functional overreaching (Meeusen et al., 2013). Fatigue remains a bit longer and mood can be affected. Nevertheless, homoeostasis is achievable within days or at the most a couple of weeks. If carefully monitored, athletes will benefit from this temporary unbalanced training, often performed at training-camps or when preparing for an important competition. A more serious and undesirable state is non-functional overreaching when training and recovery is unbalanced during a longer period. In addition to more severe and prolonged fatigue and exhaustion, athletes may experience depressed mood and reduced performance over a longer period. Rest and recovery can still restore performance capacity, but it may require weeks or even months. Obviously, this is not something that athletes strive for, yet many athletes even continue to push through with their unbalanced training and develop OTS. Research reports that 1/3 to 2/3 of competitive athletes will develop OTS at some point during their careers (Kenttä et al, 2001; Matos et al., 2011).

191

Raphael Nixdorf et al.

Athletes suffering from OTS will experience prolonged underperformance and may suffer from chronic fatigue and maladaptive outcomes such as long-term illness. Psychological distress and mood disturbances are common; athletes have reported clinical symptoms such as anxiety disorders and major depression (Meeusen et al., 2013). Other symptoms may include decreased motivation, loss of pleasure, restlessness, impaired concentration, disruptive behaviour such as anger or irritability, even suicidal ideation (Birrer, 2019). Recovery – if at all possible – can take several months to years.

Similarities and Differences Between Depression, Burnout, and Overtraining Depression, burnout and overtraining in athletes can manifest in very similar ways. However, there are important differences, and this section is dedicated to highlighting and discussing these differences. To do so, we first provide an overview of their conceptual and empirical overlap and then point out their differences. We use this information to help further work in this area by providing an integrative model that can be used as the basis for applied recommendations. The overlap between depression and burnout has been a topic of interest in context of the general population for many years. Although their definitions offer some points for differentiation (e.g., the strict relation of burnout to the occupational setting), some researchers argue that the two syndromes share more than they differ (e.g., that burnout is a sub-dimension or facet of depression; Bianchi et al., 2015), and, if so, they argue that it is not possible to disentangle the two (Schonfeld & Bianchi, 2016). The introduction of new definitions of burnout over the recent years has been a major part of this critique (Bianchi et al., 2015). This is because new definitions focus on the exhaustion component almost exclusively and therefore remove some of the key facets that are theoretically distinct from depression. Even when this is done, however, there is still evidence from factor analytic studies that two separate factors emerge, representing burnout and depression separately (Bakker et al., 2000; De Francisco et al., 2016; Toker & Biron, 2012). Sport is something of an anomaly when trying to differentiate between burnout and depression. This is because there is strong support for the distinction between the two constructs, and only relatively small amounts of empirical overlap (Cresswell & Eklund, 2005). These findings are noteworthy for several reasons. First, it tells us something about the bracketed nature of burnout – that is, burnout is best conceptualised and measured in relation to the specific context under examination – in this case, sport. Burnout is something athletes experience in relation to their sport. Its consequences are therefore strongly related to outcomes in and around their sporting endeavours. Depression, on the other hand, is not bracketed. Its consequences are pervasive and will impact sport and non-sport activities alike. Second, when athletes experience burnout, they do not necessarily experience depression simultaneously (and vice versa). This is perhaps the strongest evidence that the two phenomena can, and should be, examined, measured, and prevented separately. Sport is unique to a greater extent than general contexts in terms of its physical and psychological demands. For these reasons, researchers and practitioners also must consider the possibility of overtraining. As highlighted, aspects of overtraining – such as exhaustion and performance impairment – are quite similar to those of depression and burnout. Thus, some have argued that depression exclusively occurs in the context of overtraining (Puffer & McShane, 1992). However, we argue that this perspective falls short of considering important aspects and elements, which distinguish these three syndromes. We now expand on ways in which these factors are similar and different and focus on definitional and aetiological similarities and differences.

Definitional Similarities and Differences By their common definitions, depression, athlete burnout and overtraining have some overlapping symptoms (Table 13.2). Physical and emotional exhaustion or fatigue is a core symptom for all the three 192

Depression, Athlete Burnout, and Overtraining Table 13.2 Comparison of Symptoms of Depression, Athlete Burnout and Overtraining Syndrome Depressive symptoms (DSM V; American Psychiatric Association, 2013)

Athlete burnout symptoms ( Raedeke & Smith, 2001)

Overtraining symptoms ( Meeusen et al., 2013)

• • • • • • •

•

Physical and emotional exhaustion

•

Fatigue, physical exhaustion

•

Reduced sense of accomplishment

• •

Reduced level of performance Mood disturbance

•

Sport devaluation

• •

Fatigue or loss of energy Change in weight Insomnia or hypersomnia Psychomotor agitation or retardation Depressed mood Feelings of worthlessness and/or guilt Impaired concentration or decision making Anhedonia (loss of interest and pleasure) Suicidal ideation

Note: Symptoms set in italics represent major criteria for each construct.

constructs. In terms of depression, there are some more detailed descriptions available on the syndrome level. Affected athletes present physical symptoms such as change in weight, sleep disturbances, or psychomotor changes. However, these symptoms can be expected in burnout and overtraining as well, since functions of the hypothalamic–pituitary–adrenal axis (HPA axis) are likely to be affected after chronic stress or fatigue (Lee et al., 2010; Varghese & Brown, 2001). This highlights the common overlap: accumulated enduring fatigue from overwhelming levels of stress. Focusing only on this stress-based reaction, an overlap is obvious, and empirical data supports such overlap for example between burnout and depression in athletes (De Francisco et al., 2016; Frank et al., 2017). However, a closer look at the three syndromes reveals some distinction. Given the research history and knowledge on the syndromes, the description of depression is most detailed. Symptoms such as sleep disturbances, changes in weight and appetite, and psychomotor agitation are part of the criteria for a depressive disorder (American Psychiatric Association, 2013). In terms of burnout and overtraining, such symptoms might occur, but are not a general part of the syndrome. Consequently, those symptoms are beyond the core features of the performance decrease, as seen in overtraining, or the fatigue in burnout and might point to a depressive episode. In turn, decreased sport performance is something, which is not (necessarily) connected with depression in athletes. It is noteworthy, that decreased level of functioning is a general feature of mental disorders which can affect athletes as well. However, many examples of athletes competing at the highest levels while suffering from depressive disorders indicate that this feature should not be regarded as a principal symptom in depressed athletes. Moreover, a careful assessment of different aspects of functioning such as athletic performance, functioning in daily life, social integration or cognitive functioning might be useful. In addition, the differentiation between aspects of mental health and mental illness (Keyes 2002, 2005; see Chapter 1) could enhance the understanding of this circumstance and possibly categorise performance on a different dimension (health) than the actual depressive symptoms (illness). With regards to burnout, there is a sense of reduced accomplishment, but this does not (necessarily) involve an objectively measurable decrease in performance. Here, athletes evaluate themselves negatively, rather than underperform. Often, this negative evaluation comes from high personal expectations and perfectionistic attitudes which are hard and sometimes impossible to meet (Appleton et al., 2009; Madigan et al., 2015). Other shared features are the motivational and emotional response to this stress-based reaction. In all three syndromes, there are changes in mood and motivation involved. But again, there are important differences with regards to the scope of these responses. In overtraining, high motivation is often a problem as it might 193

Raphael Nixdorf et al.

lead to a lack of recovery. Athletes are driven to quickly get back to their normal performance ability. Changes in motivation can occur later in the process – when athletes realise their performance has diminished. Such processes may then lead to the development of burnout, and motivational changes are useful in distinguishing staleness from an evolving burnout syndrome (Kenttä et al., 2001). Motivational changes are a vital feature of burnout. In fact, many studies show the impact that motivation has on the syndrome of burnout (e.g., Cresswell & Eklund, 2005; Jowett et al., 2013). Although changes in motivation may be present in depressive syndromes as well, there are some qualitative differences. For burnout, changes in motivation are related to the occupation and therefore its source of the syndrome. Athletes with burnout syndrome devaluate their performance and their sport itself, which is often followed by withdrawal and possibly drop-out from sport (Isoard-Gautheur et al., 2016; Sarrazin et al., 2002). With regards to depression, global changes in motivation occur instead. Depressed athletes lose their joy of life in general and lack in motivation for many things including aspects besides their sport (such as leisure activities, relationship, social engagement). In the most severe cases, associated suicidal ideation even leads withdrawal from life itself. This pattern shows itself in changes in mood, too. Depressed mood is a core feature of depression (World Health Organisation, 2020). Although potentially part of the other syndromes as well, this is a main symptom for highlighting a depressive episode. Negative affect from depression is showcased in many facets of an athlete’s life. With regards to burnout and overtraining syndrome, negative mood in general can also be seen, but negative thinking and opinions are more closely related to their individual sport.

Aetiological Similarities and Differences There are different models of the aetiology of depression, burnout, and overtraining. However, some models provide possible mechanisms for relations between two constructs. Kenttä et al. (2001), for example, conceptualised possible processes from overtraining to burnout, highlighting differences between athletes in adapting to training stress. The integrated model of athlete burnout provides a conceptual understanding of burnout involving stress-based antecedents such as excessive training or performance demands and possible negative consequences such as withdrawal or chronic inflammation due to individual maladaptation (Gustafsson et al., 2011). We argue therefore, that depression, burnout, and overtraining can be integrated into a stress-based model, which highlights their shared features and similarities while at the same time will point out differences and assumptions on their relationship. In the following, we present such an integrative model (Figure 13.2).

An Integrative Model of Depression, Burnout, and Overtraining All three syndromes can be viewed from a stress-based perspective and might be linked in this regard. Taking a closer look at their conceptual definition regarding stress, burnout is defined as being connected to occupational stress (Maslach et al., 2001), which is also highlighted in the core dimensions for athletes (Raedeke & Smith, 2001). According to more strict terms of overtraining, the location is even more specific: extensive training load, which are vital differences between depression, burnout, and overtraining. However, more recent overtraining research conceptualise and consider training and non-training stressors, but still with a strong emphasis on stress driven by the training load (Figure 13.2). The difference in the location of a stressor can bear useful information for discriminating the three constructs from one another. However, the actual consecutive symptomatology is still dependent on individual factors and shifts from one syndrome to another are possible (Frank et al., 2017). Athletes whose main source of stress is their training load can still develop a depressive disorder whereas stressors in an 194

Depression, Athlete Burnout, and Overtraining

Figure 13.2

An Integrative Model of Depression, Burnout, and Overtraining Syndrome. (Figure available from Nixdorf & Nixdorf, 2022, under a CC-BY4.0 license at https://osf.io/426rc.)

athlete’s life also have the potential to lead to overtraining. Thus, such differentiation between the sources of stress is limited to a certain degree. Often, athletes may not only suffer from one stressor, but present multiple stressors and most likely indicate stressors within sport as this is certainly an important aspect of their life. For example, depression has been linked to sport-related factors such as injuries (Kerr et al., 2012; Mainwaring et al., 2010), overtraining (Armstrong & Van Heest, 2002), failure during competition (Hammond et al., 2013), or effects of the sport discipline (Nixdorf et al., 2016; Schaal et al., 2011; Wolanin et al., 2016). Nixdorf et al. (2015) analysed major stressors and revealed higher depression scores for athletes, with stressors mainly related to their sport and the demands within. Thus, trying to isolate one stressor’s location may be artificial, but still may help understanding why athletes suffer. The impact and dispersion of the various possible stressors is dependent on the individual resources and adaptation, which involves biological, psychological, and social variables. These variables include genetic predispositions as well as the current ability to recover from stress, which can change over time (Kellmann, 2010). Recovery is a vital element in any stress-related process and especially with regards to exercise and training in elite sport. Therefore, recovery is a central element for adaption to necessary and unwanted stress with the potential to determine positive outcomes such as performance enhancement or negative outcomes such as OTS, burnout, or depression (Nixdorf et al., 2020). Besides recovery, important psychological variables for the three constructs are perfectionistic and dysfunctional attitudes (Hill et al., 2008; Nixdorf et al., 2020), coping strategies (Raedeke & Smith, 2004), and motivational differences (Madigan et al., 2016). Social variables involve level of social support (DeFreese & Smith, 2013) or lack of autonomy (Jowett et al., 2013). We argue that the process of adaption, involving those important variables, interacts interdependently with the stressors and the syndromic outcome in both directions. Thus, for example, a sport specific 195

Raphael Nixdorf et al.

stressor can expand to other areas in life due to maladaptation and affect a broader range of stressors, too. Also, a certain symptomatology, which can be viewed as characteristic to one construct, can function as a stressor itself and affect the other constructs. For example, depressive symptoms with apparent negative self-worth and pessimistic thinking of life could lead to an athlete ignoring signs of exhaustion (maladaptation) and thus affect the athlete’s performance. Research on the inter-relation between all three constructs is, however, limited. Longitudinal data on burnout and depression show relative stability for both constructs with a small effect for a bidirectional link between them (Frank et al., 2017). Other studies investigating the interplay between constructs point as well to small effects from one construct to the other, with variables such as perfectionism as a possible linking factor (Smith et al., 2018). Further data suggests as well, to assume interactions between important variables such as mental toughness (Gerber et al., 2018). These data provide preliminary support for our framework. However, due to the limited nature of this research, specific interacting and mediating variables are unclear and, as such more, research is needed. With our framework, however, we aim to provide a basic understanding and promote further research on these questions.

Future Research We have provided a theoretical model to help elucidate antecedents and outcomes for depression, burnout, and overtraining. However, there are still many challenges and unresolved issues that need to be addressed to progress our understanding in this area. In this section, we highlight a few of the key points. First, we need to consider the role of diagnoses in context of these syndromes. So far, depression is the only factor that has clear and reproducible diagnostic criteria, which are applied in practice. This issue, however, is worthy of further thought and discussion. This is because burnout for example is measured in a continuous manner – that is, athletes score themselves on a continuum of increasingly more frequent symptomology (e.g., Madigan, 2021). Second, to unravel the processes underpinning the development of the three syndromes in the context of competitive sport with athletes, advanced research designs are required. This should include both longitudinal studies spanning months, if not years, but also so-called shortitudinal studies that seek to examine changes over a narrower time period (e.g., Dormann & Griffin, 2015). Daily diary or ecological momentary assessment may be useful in this regard. Finally, measurement and measurement reliability and validity are an ongoing process. Consequently, research should continue to develop, refine, and test instruments used to measure these constructs. Burnout instruments have been tested in many countries, across many different sport, and across a range of athletes. Instruments to measure overtraining are less rigorously tested, partly due to the complexity of its definition and consequences, and therefore would benefit from further work especially based on advances in factor analysis (e.g., exploratory structural equation modelling). Last, whether instruments for measuring depression in athletes require any element of contextualisation to capture both broad and sportspecific experiences of athletes is worthy of further research.

Practical Recommendations We end with a series of practical recommendations to help those working in this area. First, in Table 13.3, we have included a summary of the key symptoms to be aware of when working with athletes. These symptoms are based on the current understanding of the syndromes and highlight their shared features (e.g., fatigue) but also provide information on the differences which can help directing the understanding of a present case with symptoms in this field. Moreover, the table also provides a basic conceptual system, which can improve the understanding of a practitioner and in turn improve the understanding of an individual athlete. 196

Depression, Athlete Burnout, and Overtraining Table 13.3 Summary of Symptom and Conceptual Similarities and Differences Between Depression, Burnout, and Overtraining in Athletes

Symptomatology Symptoms resulting from chronic stress Exhaustion and fatigue Impact on cognition, attitudes and self-worth

Overtraining

Burnout

Depression

✔

✔

✔

✔ –(overrating of decreased performance possible)

✔ ✔ Negative thinking on athletic aspects (performance, striving, value) ✔ Sport devaluation

✔Per definition

(✔)mostly subjective (reduced sense of accomplishment)

✔ ✔ Negative thinking; multiple aspects affected including self-worth ✔ In general including suicidal ideation –(symptoms may affect performance)

✔ Physical; training stress –(possible associations)

✔ In sport; mental and physical stress (✔) (with adaptive and maladaptive side)

Withdrawal behaviour

Performance impairment

Conceptual aspects Stress relation Location of stressor Dysfunctional attitudes; perfectionism

✔ Stress of all kinds (also Sportunrelated) ✔ Dysfunctional vulnerability

Second, systematic monitoring for symptoms of ill-being (and well-being) together with performance is likely to be an important part of sport science support provided to athletes. There are many ways to incorporate these aspects into practice, this includes within training load monitoring practices. This information is likely to be useful for athletes and coaches alike. Engaging athletes in open and honest discussions will have positive implications beyond the reporting of illness. Such sport environments will be conducive to shared decision making and optimal care. Finally, it is perhaps pertinent to briefly discuss the process of referral to multidisciplinary professional support for when an athlete is at risk or suspected of experiencing one or more of these syndromes. Sport science support staff, including sport and exercise psychologists, have a broad array of expertise; however, should athletes show symptoms of clinical disorders it is essential that referral processes are not only in place but are followed. These are country dependent but will likely involve either clinical staff associated with the club or activity or national health services that provide both physical and mental healthcare services.

Conclusion In this chapter, we have sought to define depression, burnout, and overtraining. We have also provided some thoughts regarding what are the key similarities and differences between these three syndromes. Further, we introduced an integrated model and hope it enhances the overall understanding of the three syndromes. We also hope that with the model-associated practical recommendations will help in the support and identification of athletes who may be at risk of these highly problematic syndromes, and in doing so, help to enhance the well-being of athletes more generally. 197

Raphael Nixdorf et al.

References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA. Appleton, P.R., Hall, H.K., & Hill, A.P. (2009). Relations between multidimensional perfectionism and burnout in junior-elite male athletes. Psychology of Sport and Exercise, 10(4), 457–465. 10.1016/j.psychsport.2008.12.006 Armstrong, L.E., Bergeron, M.F., Lee, E.C., Mershon, J.E., & Armstrong, E.M. (2021). Overtraining syndrome as a complex systems phenomenon. Frontiers in Network Physiology, 1. 10.3389/fnetp.2021.794392 Armstrong, L.E., & Van Heest, J.L. (2002). The unknown mechanism of the overtraining syndrome: Clues from depression and psychoneuroimmunology. Sports Medicine, 32(3), 185–209. Bakker, A.B., Schaufeli, W.B., Demerouti, E., Janssen, P.P.M., Van der Hulst, R., & Brouwer, J. ( 2000). Using equity theory to examine the difference between burnout and depression. Anxiety, Stress and Coping, 13(3), 247–268. 10.1080/10615800008549265 Bianchi, R., Schonfeld, I.S., & Laurent, E. (2015). Burnout-depression overlap: A review. Clinical Psychology Review, 36, 28–41. 10.1016/j.cpr.2015.01.004 Birrer, D. (2019). Rowing over the edge: Nonfunctional overreaching and overtraining syndrome as maladjustment— Diagnosis and treatment from a psychological perspective. Case Studies in Sport and Exercise Psychology, 3(1), 50–60. 10.1123/cssep.2019-0006 Bompa, T.O., & Buzzichelli, C.A. (2018). Periodization: Theory and methodology of training, 6th ed. Human kinetics. Budgett, R., Newsholme, E., Lehmann, M., Sharp, C., Jones, D., Peto, T., Collins, D., Nerurkar, R., & White, P. (2000). Redefining the overtraining syndrome as the unexplained underperformance syndrome. British Journal of Sports Medicine, 34(1), 67–68. https://www.ncbi.nlm.nih.gov/pubmed/10690455 Carfagno, D.G. & Hendrix, J.C. (2014). Overtraining syndrome in the athlete: Current clinical practice. Current Sports Medicine Reports, 13(1), 45–51. 10.1249/JSR.0000000000000027 Cresswell, S.L., & Eklund, R.C. (2005). Changes in athlete burnout and motivation over a 12-week league tournament. Medicine and Science in Sports and Exercise, 37(11), 1957–1966. 10.1249/01.mss.0000176304.14675.32 De Francisco, C., Arce, C., Vílchez, M. d. P., & Vales, Á. (2016). Antecedents and consequences of burnout in athletes: Perceived stress and depression. International Journal of Clinical and Health Psychology, 16(3), 239–246. 10.1016/j.ijchp. 2016.04.001 DeFreese, J.D., & Smith, A.L. (2013). Teammate social support, burnout, and self-determined motivation in collegiate athletes. Psychology of Sport and Exercise, 14(2), 258–265. 10.1016/j.psychsport.2012.10.009 Dormann, C., & Griffin, M.A. (2015). Optimal time lags in panel studies. Psychological Methods, 20(4), 489. 10.1037/ met0000041 Eklund, R.C., & DeFreese, J. (2015). Athlete burnout: What we know, what we could know, and how we can find out more. International Journal of Applied Sports Sciences, 27(2), 63–75. 10.24985/ijass.2015.27.2.63 Frank, R., Nixdorf, I., & Beckmann, J. (2017). Analyzing the relationship between burnout and depression in junior elite athletes. Journal of Clinical Sport Psychology, 11(4), 287–303. 10.1123/jcsp.2017-0008 Freudenberger, H.J. (1974). Staff burn‐out. Journal of Social Issues, 30(1), 159–165. Gerber, M., Best, S., Meerstetter, F., Walter, M., Ludyga, S., Brand, S., Bianchi, R., Madigan, D.J., Isoard-Gautheur, S., & Gustafsson, H. (2018). Effects of stress and mental toughness on burnout and depressive symptoms: A prospective study with young elite athletes. Journal of Science and Medicine in Sport, 21(12), 1200–1205. 10.1016/j.jsams.2018.05.018 Gustafsson, H., Kenttä, G., & Hassmén, P. (2011). Athlete burnout: An integrated model and future research directions. International Review of Sport and Exercise Psychology, 4(1), 3–24. 10.1080/1750984X.2010.541927 Hammond, T., Gialloreto, C., Kubas, H., & Davis, H. (2013). The prevalence of failure-based depression among elite athletes. Clinical Journal of Sport Medicine, 23(4), 273–277. 10.1097/JSM.0b013e318287b870 Hawton, K., Casanas, I.C.C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147(1–3), 17–28. 10.1016/j.jad.2013.01.004 Hill, A.P., Hall, H.K., Appleton, P.R., & Kozub, S.A. (2008). Perfectionism and burnout in junior elite soccer players: The mediating influence of unconditional self-acceptance. Psychology of Sport and Exercise, 9(5), 630–644. 10.1016/j.psychsport.2007.09.004 Holzel, L., Harter, M., Reese, C., & Kriston, L. (2011). Risk factors for chronic depression--a systematic review. Journal of Affective Disorders, 129(1-3), 1–13. 10.1016/j.jad.2010.03.025 Insel, T.R., & Charney, D.S. (2003). Research on major depression: Strategies and priorities. JAMA, 289(23), 3167–3168. Isoard-Gautheur, S., Guillet-Descas, E., & Gustafsson, H. (2016). Athlete burnout and the risk of dropout among young elite handball players. Sport Psychologist, 30(2), 123–130. Jowett, G.E., Hill, A.P., Hall, H.K., & Curran, T. (2013). Perfectionism and junior athlete burnout: The mediating role of autonomous and controlled motivation. Sport Exercise and Performance Psychology, 2(1), 48–61. 10.1037/ a0029770

198

Depression, Athlete Burnout, and Overtraining Kellmann, M. (2010). Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scandinavian Journal of Medicine and Science in Sports, 20, 95–102. 10.1111/j.1600-0838.2010.01192.x Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A.J., Duffield, R., Erlacher, D., Halson, S.L., Hecksteden, A., Heidari, J., Kallus, K.W., Meeusen, R., Mujika, I., Robazza, C., Skorski, S., Venter, R., & Beckmann, J. (2022). Recovery and performance in sport: Consensus statement. International Journal of Sports Physiology and Performance, 13(2), 240–245. 10.1123/ijspp.2017-0759 Kenttä, G., Hassmén, P., & Raglin, J.S. (2001). Training practices and overtraining syndrome in Swedish age-group athletes. International Journal of Sports Medicine, 22(6), 460–465. 10.1055/s-2001-16250 Kerr, Z.Y., Marshall, S.W., Harding, H.P., Jr., & Guskiewicz, K.M. (2012). Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. American Journal of Sports Medicine, 40(10), 2206–2212. 10.1177/0363546512456193 Keyes, C.L. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43(2), 207–222. https://www.ncbi.nlm.nih.gov/pubmed/12096700 Keyes, C.L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology, 73(3), 539–548. 10.1037/0022-006X.73.3.539 Lee, S., Jeong, J., Kwak, Y., & Park, S.K. (2010). Depression research: Where are we now? Molecular Brain, 3, 8. 10.1186/ 1756-6606-3-8 Madigan, D.J. (2021). Diagnosing problems, prescribing solutions, and advancing athlete burnout research. In Z. Zenko & L. Jones (Eds.), Essentials of exercise and sport psychology: An open access textbook (pp. 664–682). Society for Transparency, Openness, and Replication in Kinesiology. Madigan, D.J., Gustafsson, H., Smith, A., Raedeke, T., & Hill, A.P. (2019). The BASES expert statement on burnout in sport. Sport and Exercise Scientist, 61, 6–7. Madigan, D.J., Stoeber, J., & Passfield, L. (2015). Perfectionism and burnout in junior athletes: A three-month longitudinal study. Journal of Sport & Exercise Psychology, 37(3), 305–315. 10.1123/jsep.2014-0266 Madigan, D.J., Stoeber, J., & Passfield, L. (2016). Motivation mediates the perfectionism-burnout relationship: A three-wave longitudinal study with junior athletes. Journal of Sport & Exercise Psychology, 1–39. 10.1123/jsep.20150238 Mainwaring, L.M., Hutchison, M., Bisschop, S.M., Comper, P., & Richards, D.W. (2010). Emotional response to sport concussion compared to ACL injury. Brain Injury, 24(4), 589–597. 10.3109/02699051003610508 Maslach, C., & Schaufeli, W.B. (1993). Historical and conceptual development of burnout. In W.B. Schaufeli, C. Maslach, & T. Marek (Eds.). Professional Burnout: Recent Developments in Theory and Research (1 st ed.) (pp. 1–16). CRC Press. https://doi.org/10.1201/9780203741825 Maslach, C., Schaufeli, W.B., & Leiter, M.P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. Matos, N.F., Winsley, R.J., & William, C.A. (2011). Prevalence of nonfunctional overreaching/overtraining in young English athletes. Medicine & Science in Sports & Exercise, 43(7), 1287–1294. 10.1249/MSS.0b013e318207f87b Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., Raglin, J., Rietjens, G., Steinacker, J., Urhausen, A., European College of Sport, S., & American College of Sports, M. (2013). Prevention, diagnosis, and treatment of the overtraining syndrome: Joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Medicine and Science in Sports and Exercise, 45(1), 186–205. 10.1249/ MSS.0b013e318279a10a Moesch, K., Kenttä, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Morgan, W.P., Brown, D.R., Raglin, J.S., O’Connor, P.J., & Ellickson, K.A. (1987). Psychological monitoring of overtraining and staleness. British Journal of Sports Medicine, 21(3), 107–114. https://www.ncbi.nlm.nih.gov/ pubmed/3676635 Morgan, W.P., Costill, D.L., Flynn, M.G., Raglin, J.S., & O’Connor, P.J. (1988). Mood disturbance following increased training in swimmers. Medicine and Science in Sports and Exercise, 20(4), 408–414. https://www.ncbi.nlm. nih.gov/pubmed/3173050 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. 10.1123/jcsp.7.4.313 Nixdorf, I., Frank, R., & Beckmann, J. (2015). An explorative study on major stressors and its connection to depression and chronic stress among German elite athletes. Advances in Physical Education, 5(04), 255–262. 10.4236/ ape.2015.54030 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893

199

Raphael Nixdorf et al. Nixdorf, I., Beckmann, J., & Nixdorf, R. (2020). Psychological predictors for depression and burnout among German junior elite athletes. Frontiers in Psychology, 11, 601. 10.3389/fpsyg.2020.00601 Nixdorf, R., & Nixdorf, I. (2022). Mental health in elite athletes. https://osf.io/qwu9a/ O’Connor, P.J., Morgan, W.P., Raglin, J.S., Barksdale, C.M., & Kalin, N.H. (1989). Mood state and salivary cortisol levels following overtraining in female swimmers. Psychoneuroendocrinology, 14(4), 303–310. https://www.ncbi. nlm.nih.gov/pubmed/2813655 Puffer, J.C., & McShane, J.M. (1992). Depression and chronic fatigue in athletes. Clinics in Sports Medicine, 11(2), 327–338. http://www.ncbi.nlm.nih.gov/pubmed/1591789 Raedeke, T.D. (1997). Is athlete burnout more than just stress? A sport commitment perspective. Journal of Sport & Exercise Psychology, 19(4), 396–417. Raedeke, T.D., & Smith, A.L. (2001). Development and preliminary validation of an athlete burnout measure. Journal of Sport & Exercise Psychology, 23(4), 281–306. Raedeke, T.D., & Smith, A.L. (2004). Coping resources and athlete burnout: A examination of stress mediated and moderation hypotheses. Journal of Sport & Exercise Psychology, 26(4), 525–541. Raglin, J.S., Morgan, W.P., & O’Connor, P.J. (1991). Changes in mood states during training in female and male college swimmers. International Journal of Sports Medicine, 12(6), 585–589. 10.1055/s-2007-1024739 Sarrazin, P., Vallerand, R., Guillet, E., Pelletier, L., & Cury, F. (2002). Motivation and dropout in female handballers: A 21-month prospective study. European Journal of Social Psychology, 32(3), 395–418. 10.1002/ejsp.98 Schaal, K., Tafflet, M., Nassif, H., Thibault, V., Pichard, C., Alcotte, M., Guillet, T., El Helou, N., Berthelot, G., Simon, S., & Toussaint, J.F. (2011). Psychological balance in high level athletes: Gender-based differences and sport-specific patterns. PloS One, 6(5), e19007. 10.1371/journal.pone.0019007 Schonfeld, I.S., & Bianchi, R. (2016). Burnout and depression: Two entities or one? Journal of Clinical Psychology, 72(1), 22–37. 10.1002/jclp.22229 Smith, E.P., Hill, A.P., & Hall, H.K. (2018). Perfectionism, burnout and depressive symptoms in youth soccer players: A longitudinal study. Journal of Clinical Sport Psychology, 12(2), 1–34. 10.1123/jcsp.2017-0015 Toker, S., & Biron, M. (2012). Job burnout and depression: Unraveling their temporal relationship and considering the role of physical activity. Journal of Applied Psychology, 97(3), 699–710. 10.1037/a0026914 Van der Poel, N. (2022). How to skate a 10k … and also half a 10k. https://www.howtoskate.se/_files/ugd/e11bfe_ b783631375f543248e271f440bcd45c5.pdf Varghese, F.P., & Brown, E.S. (2001). The hypothalamic-pituitary-adrenal axis in major depressive disorder: A brief primer for primary care physicians. Primary Care Companion to the Journal of Clinical Psychiatry, 3(4), 151–155. https://www.ncbi.nlm.nih.gov/pubmed/15014598 Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50(3), 167–171. 10.1136/bjsports-2015-095756 World Health Organization (2020). International classification of diseases - 11th revision. https://icd.who.int/en Yang, J., Peek-Asa, C., Corlette, J.D., Cheng, G., Foster, D.T., & Albright, J. (2007). Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sport Medicine, 17(6), 481–487. 10.1097/JSM.0b013e31815aed6b

200

14 CONCUSSIONS IN ATHLETES Jingzhen Yang, Robyn Recker, and Lindsay Sullivan

Definition of Concussion A concussion is a type of traumatic brain injury (TBI) induced by a direct or indirect blow to the head, neck, face, or other part of the body that results in forces to the brain. Concussions are considered a functional injury rather than a gross structural injury as the acute signs and symptoms of concussion often represent abnormal functioning of networks in the brain (McCrory, Feddermann-Demont, et al., 2017; McCrory, Meeuwisse, et al., 2017). Concussions can result in a variety of symptoms, clinical presentations, and recovery trajectories, as well as altered mental function (Lumba-Brown et al., 2020; McCrea et al., 2017). The definition of concussion has evolved over the past 50 years, with various definitions proposed by individual authors, research groups, and international bodies (Aubry et al., 2002; Broglio et al., 2014; Harmon et al., 2013; Lefevre-Dognin et al., 2020; McCrory, Feddermann-Demont, et al., 2017). Although these definitions are distinct and do not necessarily concur with one another, they share a common element: the rapid onset of impairment to neurologic functioning that typically resolves spontaneously over a short time frame (McCrory, Feddermann-Demont, et al., 2017; McCrory et al., 2013). Currently, the most commonly used operational definition of sport-related concussion is the “Berlin definition” provided by the 2017 Berlin Concussion in Sport Group Consensus Statement (McCrory, Meeuwisse, et al., 2017). According to the Berlin definition, concussion is a TBI induced by biomechanical forces. Box 14.1 describes several features commonly used clinically to define the nature of a concussive injury (McCrory, Meeuwisse, et al., 2017). In the published literature, the term concussion is often used interchangeably with mild TBI. One key unresolved issue is whether concussion falls on the less severe side of the brain injury spectrum or is the result of reversible physiological changes (McCrory, Feddermann-Demont, et al., 2017; Sussman et al., 2018). Historically, mild TBI is defined based on the Glasgow Coma Score and is an acute, objective diagnosis made within minutes to hours of an inciting traumatic event resulting in some disruption of consciousness, memory, mental clarity, or other normal neurologic function (Carroll, Cassidy, Holm, et al., 2004; Teasdale & Jennett, 1974). Concussion, on the other hand, is often used to describe a constellation of clinical signs and symptoms following a TBI, with symptoms overlapping with mild, moderate, or severe TBI (Kamins & Giza, 2016; Sussman et al., 2018). However, not all individuals with a mild TBI have signs or symptoms beyond the acute period (e.g., past 72 hours of injury), and not all individuals with concussion symptoms are diagnosed with a mild TBI (Carney et al., 2014). This discrepancy may be partially explained by the subtle or subclinical nature of neurologic dysfunction that accompanies TBI, which current screening and diagnostic tools cannot detect (Lefevre-Dognin et al., 2020). DOI: 10.4324/9781003099345-20

201

Jingzhen Yang et al.

Box 14.1 Concussion in Sport Group Definition of Sport-Related Concussion adapted from McCrory, Meeuwisse, et al. (2017)

• •

•

•

Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours. Concussion may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. Concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases, symptoms may be prolonged.

The clinical signs and symptoms of concussion cannot be explained by drug, alcohol, medication use, other injuries (e.g., cervical injuries, peripheral vestibular dysfunction) or other comorbidities (e.g., psychological factors, coexisting medical conditions).

While there are no underlying pathophysiologic differences between sport-related and non-sport-related concussions, the literature often distinguishes between the two due to differences in study populations, injury circumstances, and activities engaged in at the time of injury (McCrory, Feddermann-Demont, et al., 2017). The Berlin definition of concussion provides critical insights into the underlying pathophysiology of sportrelated concussion and serves as a foundation for the definition of both sport- and non-sport-related concussions (McCrory, Meeuwisse, et al., 2017). It is vital to recognise that inconsistencies in the definition of concussion make it challenging to truly understand the epidemiology of concussive injury. Given that this book focuses on elite sport athletes, the rest of this chapter will focus specifically on sport-related concussions.

Causes of Concussions A direct or indirect blow to the head, face, neck, or elsewhere on the body can cause the brain to bounce back and forth quickly or twist in the skull resulting in injury (McCrory, Meeuwisse, et al., 2017). Impacts to the head can cause a combined linear and angular acceleration of the skull, which, in turn, may result in a concussion when pressures or strains exceed the brain tissue’s tolerable limits (i.e., concussion threshold) (O’Connor et al., 2017; O’Connor et al., 2017; Rowson & Duma, 2013). The first attempt in the modern era to define the concussion threshold was completed by using laboratory reconstructions (re-enactments) of game impacts in which instrumented test dummies were used to simulate helmeted National Football League (NFL) players, closely matching situations on the field (Pellman et al., 2003). Since this study, several other attempts have followed in the hopes of using impact biomechanics to define the impact threshold that causes concussion (Greenwald et al., 2008; O’Connor et al., 2017; Romeu-Mejia et al., 2019). A variety of head impact sensors such as helmeted devices (e.g., the Riddell Head Impact Telemetry System–HIT System, BRG Sport, Rosemont, IL) and non-helmeted devices [e.g., X2 devices 202

Concussion in Athletes

worn behind the ear (X2 X-Patch, X2 Biosystems Inc., Seattle, WA), custom-formed mouthguards (X2 X-Guard, X2 Biosystems Inc., Seattle, WA)] have also been developed and deployed (Broglio et al., 2017). Although these impact sensors have allowed researchers to investigate the biomechanics of head impacts in vivo, the biomechanical threshold for concussion remains elusive (Guskiewicz & Mihalik, 2011; Rowson & Duma, 2013). It is likely that concussion risk is not determined by a single impact itself but by a host of predisposing factors (Barkhoudarian et al., 2011).

Prevalence of Concussion in Elite Sport Although concussion in elite sport has been a topic of interest for over three decades, recent empirical data on this topic are limited (Casson et al., 2011; Langlois et al., 2006; Yengo-Kahn, Johnson, et al., 2016). Reported sport-related concussions have been on the rise in elite sport, likely due to a combination of increased awareness about concussion signs and symptoms and the increased power and strength of elite athletes (Kerr et al., 2018; Yang et al., 2017). This section will take a closer look at concussions in both professional and collegiate sport.

Concussion in Professional Sport Many studies have explored concussions in professional sport, especially among NFL players. An early study using the NFL Injury Surveillance System to analyse concussions recorded by athletic trainers and team physicians found 0.38 documented concussions occurred per game during the 2002–2007 NFL seasons (Casson et al., 2010). The same study found that the highest concussion incidence rates in NFL players were among tight ends, quarterbacks, defensive secondaries, and wide receivers with 1.45, 1.20, 0.93, and 0.91 concussions per 100 game positions, respectively. Over half (56.5%) of concussions occurred during tackling, and almost one-third (32.2%) occurred while blocking. Rates were highest during kickoffs (8.7/1,000 plays) and punts (2.9/1,000 plays) (Casson et al., 2010). Another study of NFL players analysed concussions during the first 16 weeks of the 2012 and 2013 regular seasons using data obtained from publicly available web-based sources, such as PBS Frontline Concussion Watch and ESPN NFL schedule grid (Myer et al., 2014; Yengo-Kahn, Johnson, et al., 2016). The results of this study revealed a concussion incidence rate of 64.3 per 10,000 game exposures over the two seasons. Incident rates in NFL players may be even higher than reported as over half (50.3%; n = 417) of former NFL players reported that they sustained at least one concussion during their professional playing career that they did not disclose to medical staff (Kerr et al., 2018). Comparatively, during the 2011–2012 season, concussion rates in the National Hockey League (NHL) were estimated to be about 0.05 per game (4.9 concussions/100 games) (Donaldson et al., 2013; Kuhn & Solomon, 2016). Rates varied by position, with forwards (63.3%) sustaining the greatest percentage of concussions followed by defensemen (33.3%) and goalies (3.4%) (Hutchison et al., 2015a, 2015b). In 2010, the NHL introduced Rule 48, which aimed to eliminate illegal checks to the head by increasing the penalty for such behaviour. Before introducing Rule 48, 62.1% of concussions resulted from body checking with head contact, whereas after its introduction, only 28.5% of concussions were due to body checking with head contact (Kuhn & Solomon, 2016). A systematic review and meta-analysis of the incidence of concussion in the Rugby Union revealed that overall incidence rates of concussion in men’s rugby 15s and men’s rugby 7s match-play were 4.7 and 3.0 per 1,000 player match hours, respectively (Gardner, Howell, & Iverson, 2019; Gardner, Iverson, Williams, Baker, & Stanwell, 2014). The forwards and backs positions in men’s rugby 15s had 4.0 and 4.9 concussions per 1,000 player match hours, respectively. In the same systematic review, the incidence rate of concussion in women’s rugby 15s was found to be 0.55 per 1,000 player match hours (Gardner et al., 2014). 203

Jingzhen Yang et al.

A newly published study by Peterson (2020) reported the incidence of concussion among Major League Baseball (MLB) players based on the online transaction pages of MLB (www.mlb.com) and Baseball Prospectus (www.baseballprospectus.com). Results showed that 114 players suffered 142 concussions during the 2001 to 2018 regular seasons, with catchers having the highest frequency of concussion. The most common injury mechanism was a fielding collision (Peterson et al., 2020). In 2018, a study compared concussion incidence rates among NFL, NHL, and Australian Football League (AFL) players during the 2013–2017 seasons utilising the FOX Sport injury tracker (Adams, Lau, et al., 2018; Adams, Li, et al., 2018). The findings indicated that the average concussion rates were 0.58 per game in the NFL, 0.03 per game in the NHL, and 0.24 per game in the AFL. These results suggest that the NFL has relatively higher concussion rates per game as compared to the AFL and NHL.

Concussions in Collegiate Sport The National Collegiate Athletic Association (NCAA) Injury Surveillance Programme has collected national estimates for concussion among collegiate student-athletes in NCAA sport since 1982. During the 2009–2010 to 2013–2014 academic years, a national estimate of 10,560 sport-related concussion was reported annually across 25 NCAA sport, with over two-thirds (68.0%) of these concussions resulting from player contact (Zuckerman et al., 2018b). Men’s American football had the greatest annual estimate of reported sport-related concussion (n = 3,417), followed by women’s soccer (n = 1,113) and women’s basketball (n = 998). The overall concussion incidence rate was 4.5 per 10,000 athlete-exposures (AEs), with concussion rates in games being nearly five times greater than in practices (12.8 concussions per 10,000 AEs in games compared to 2.6 concussions per 10,000 AEs in practices). The highest concussion incidence rates were observed in men’s wrestling (10.9 per 10,000 AEs), followed by men’s ice hockey (7.9 per 10,000 AEs), women’s ice hockey (7.5 per 10,000 AEs), and men’s American football (6.7 per 10,000 AEs) (Zuckerman et al., 2018b). While concussions may be more frequent among male athletes who compete in full-contact/collision sport like wrestling and American football, female athletes may be at greater risk for sport-related concussion than male athletes (Covassin & Elbin, 2011; Covassin et al., 2016; Covassin et al., 2003; Dick, 2009; Hootman et al., 2007). In gender comparable sport (e.g., soccer, basketball) or sport with similar rules (e.g., baseball and softball), female athletes have higher rates of concussions than their male counterparts (Covassin et al., 2016; Kerr et al., 2018; Kerr et al., 2017; Zuckerman et al., 2018b). For example, a study found that in collegiate sport, women’s soccer players had a rate of concussion almost double that of men’s soccer players (0.54 per 1,000 AEs and 0.26 per 1,000 AEs, respectively); women’s basketball players had a higher concussion rate (0.53 per 1,000 AEs) than men’s basketball players (0.38 per 1,000 AEs); and women’s softball players (0.26 per 1,000 AEs) had a higher concussion rate than men’s baseball players (0.09 per 1,000 AEs) (Kerr et al., 2017). Despite differences in body checking rules in men’s and women’s ice hockey (e.g., intentional body-checking is permitted in men’s but not women’s ice hockey), women’s ice hockey players sustain higher rates of concussions (0.78 per 1,000 AEs) relative to men’s ice hockey players (0.74 per 1,000 AEs) (Kerr et al., 2017). Several theories have been proposed to explain these sex-based differences in concussion rates, including hormonal differences, weaker neck muscles, and a higher rate of concussion symptom reporting in female athletes than male athletes (Covassin & Elbin, 2011; Dick, 2009; McGroarty et al., 2020). However, the exact cause of these sex differences in the incidence of concussion is unknown; thus, further research is warranted.

Concussion Symptoms and Symptom Profiles Concussions can result in a range of non-specific symptoms that vary greatly in quantity, severity, and duration from individual to individual (McCrory, Meeuwisse, et al., 2017). Concussed athletes may develop 204

Concussion in Athletes

symptoms over the first several hours post-injury or days after injury. Concussion symptoms are commonly categorised into four domains described in Box 14.2: 1) physical, 2) cognitive, 3) emotional, and 4) sleep. The most common physical symptoms of concussion include headache and dizziness. Other physical symptoms include nausea, vomiting, balance or vision problems, fatigue, sensitivity to light or noise, numbness or tingling, and feeling dazed or stunned (Harmon et al., 2013; McCrory, Meeuwisse, et al., 2017). Cognitive symptoms include feeling mentally “foggy” or slowed down, difficulty concentrating or remembering things, confusion or forgetfulness, answering questions slowly, or repeating questions. Emotional symptoms of concussion include irritability, sadness, feeling more emotional than usual, and nervousness. Sleep symptoms and disturbances include drowsiness, sleeping more or less than normal, and difficulty falling asleep. Emotional and sleep symptoms are often the most concerning symptoms of concussion as they may be overlooked during clinical evaluation, yet they can be debilitating and worrisome for the athlete and may lead to both short- and long-term mental health issues (Randolph et al., 2013). The predominant symptom(s) experienced by athletes may change throughout recovery. Studies suggest that the most common symptoms reported at initial clinical visits for concussions are headache, dizziness, and difficulty concentrating. In contrast, the most predominant symptoms reported at subsequent visits are sleep disturbances, frustration, forgetfulness, and fatigue (McCrory, Meeuwisse, et al., 2017). Symptom severity can also vary widely between concussed athletes. While most individuals recover from a concussion in one to three weeks, a small proportion of individuals may have persistent postconcussive symptoms that last weeks or even months (Casson et al., 2014; Schneider et al., 2017). Multidisciplinary concussion experts have recently proposed classifying concussions by five clinical symptom profiles: 1) cognitive, 2) ocular-motor, 3) headache/migraine, 4) vestibular, and 5) anxiety and mood (described in more detail later in this chapter). Experts have also proposed two concussion-

Box 14.2 (2013)

Common Signs and Symptoms of Concussions, Adapted from Harmon

Physical

Cognitive

Emotional

• • •

Headache Dizziness Nausea

• • •

Feeling mentally foggy • Feeling slowed down • Difficulty • concentrating

• • • •

Vomiting Balance problems Visual problems Fatigue

• • • •

• • • • •

Sensitivity to light Sensitivity to noise Numbness/tingling Dazed Stunned

•

Difficulty remembering • Confusion Forgetfulness Answers questions slowly Repeats questions

205

Irritability Sadness Feeling more emotional than usual Nervousness

Sleep • • •

Drowsiness Sleep more than normal Sleep less than normal

•

Difficulty falling asleep

Jingzhen Yang et al.

associated conditions: 1) sleep disturbances and 2) cervical strain (Howell et al., 2019; Langdon et al., 2020; Lumba-Brown et al., 2020). Subtype classifications, such as those noted above, aim to depict concussive injuries using underlying pathophysiology and symptom constellations. Empirical evidence is needed to confirm the effectiveness and utility of these classifications in concussion management. It is imperative to recognise that the symptoms of concussion can overlap with symptoms of mental health problems. Concussed athletes often report emotional disturbances such as anxiety, depressive symptoms, hypervigilance of somatic complaints, and sleep dysregulation following injury. This symptom overlap is particularly true for athletes who experience persistent post-concussive symptoms as anxiety and mood disturbances often become a major concern during prolonged recovery from injury (Howell et al., 2019; Langdon et al., 2020). Mental health symptoms following injury can negatively influence an athlete’s performance or desire to return to sport once fully recovered from injury.

Diagnosis of Concussions At this time, there is no diagnostic test, clinical biomarker, or imaging tool that can accurately diagnose concussions (McCrea et al., 2017; McCrory, Meeuwisse, et al., 2017). The clinical diagnosis of concussions is primarily based on the self-report of subjective symptoms, clinical history, and signs from physical examination. Due to the nonspecific nature of the signs and symptoms of concussions and the heavy reliance on self-reported measures, differential diagnosis of concussions occurs and can be problematic (Giza et al., 2013).

Clinical History Following concussion, healthcare professionals often document the clinical history of the athlete’s injury, which includes obtaining detailed information about the nature of the initial injury (e.g., date and time of injury, whether the injury resulted in loss of consciousness, whether retrograde or anterograde amnesia were present at time of injury), location and direction of the impact, and mechanism of injury (e.g., contact with another person or with the playing surface) (Harmon et al., 2013). Immediate and delayed symptoms are another critical part of the athlete’s clinical history following concussion. Close attention should be paid to the timing of symptom occurrence and progression, as well as to the variety and severity of symptoms.

Physical Examination The physical examination includes a thorough neurologic examination, starting with the athlete’s mental status (Giza et al., 2013). Additional medical assessments on cognitive functioning, sleep disturbance, ocular function, vestibular function, visual function, gross sensorimotor function, and balance may also be conducted by a medical professional to aid in diagnosing concussion. Several objective tools, including neuropsychological testing, vestibular and balance testing, oculomotor or eye tracking, and autonomic testing, are available and can be used to aid in the clinical diagnosis of a concussion (Collins et al., 2003; Stuart et al., 2020; Sussman et al., 2016). The pre-injury medical (e.g., history of migraines or mood disorders) and developmental (e.g., diagnosed learning or attention disorders) history of athletes is also relevant when evaluating an athlete for concussion as these factors may overlap with post-concussion symptoms (Cunningham, Broglio, O’Grady, & Wilson, 2020; Mansell et al., 2010). Additionally, medical professionals should consider the athlete’s concussion history, including number of prior concussions, severity from each previous concussion, and symptom duration and profile, when evaluating an athlete for a concussion. Such information can be used to inform clinical decision making in concussion diagnosis and management, including whether the athlete should consider retiring from the sport (Guskiewicz et al., 2005; Guskiewicz et al., 2007). 206

Concussion in Athletes

Management of Concussions Following a suspected concussion, an athlete should be immediately removed from play. A sideline evaluation of cognitive function should then be conducted by a trained medical professional to rapidly screen for concussion (Collins et al., 2003). If a concussion is suspected after screening, the athlete should proceed to a diagnostic evaluation in a distraction-free location such as the locker room (McCrory, Meeuwisse, et al., 2017). Follow-up serial evaluation should be considered for athletes who are not diagnosed with concussion during the rapid screening process as they may develop symptoms hours or even days post-injury. Even if a concussion is not suspected after rapid screening, the athlete should not return to play on the same day. Concussed athletes should be seen by a medical provider trained in concussion management within 72 hours of injury to ensure appropriate management, limit symptom exacerbation, and prevent premature return to activities (McCrory, Meeuwisse, et al., 2017). If the athlete delays care-seeking, information should be collected on how their clinical status has changed since time of injury. Acute concussion symptoms are often assessed using The Sport Concussion Assessment Tool, fifth edition (SCAT5) (Echemendia et al., 2017). The SCAT5 includes a list of 22 common concussion symptoms and assesses the severity of each symptom using a Likert-type scale from 0 (none) to 6 (severe), thus capturing both the number and severity of concussion symptoms. Because concussed athletes generally report milder and more heterogeneous symptoms than athletes with more severe TBI, the nuances of diagnosis and assessment are challenging, especially with standard definitions and measures of concussion (McCrea et al., 2013). Current concussion management guidelines focus on managing concussion symptoms, providing recommendations for return to physical and cognitive activities post-injury, and preventing re-injury while the brain is healing (McCrea et al., 2017; McCrory, Meeuwisse, et al., 2017). Traditionally, guidelines for acute concussion management emphasise complete rest until symptom resolution, followed by a gradual return to activities. The rationale is that a brief period of rest post-concussion reduces physical and cognitive demands and, thus, frees up energy for the injured brain’s significantly increased metabolic needs (McCrory et al., 2013). Rest also reduces the risk of recurrent injury during a time of neurometabolic vulnerability. Engaging in high levels of activity prematurely after concussion could lead to greater neurocognitive and functional impairments as well as prolonged recovery (Majerske et al., 2008). Conversely, complete rest for an extended period of time postconcussion can negatively affect athletes due to muscular deconditioning and withdrawal from sport and other activities (Brown et al., 2014). The most up-to-date guidelines call for an initial period of rest post-injury (24 to 48 hours) followed by a gradual, progressive return to activity (McCrory, Meeuwisse, et al., 2017). Both physical and cognitive activities should start at a low intensity, then gradually and progressively increase in intensity and duration as long as the athlete does not experience symptom exacerbation (Schneider et al., 2017). Recent research highlights the benefits of the early introduction of physical activity as a non-pharmacological treatment for concussed athletes who are still experiencing symptoms (Leddy et al., 2019). However, these guidelines are not strongly evidence-based, and the optimal amount and timing of physical activity progression postconcussion have not yet been well defined in the literature. It is crucial that concussed athletes do not return to sport until they receive medical clearance from a trained medical professional. The management of concussion symptoms is often tailored to the individual and their specific symptoms, injury timing, and injury history. In the first ten hours after concussion, mental status-altering medications should be avoided (Harmon et al., 2013). After that time, medications may be used to alleviate symptoms, although those that impact the central nervous system (e.g., stimulants, antidepressants, antinausea medications) should be used with caution. Medications should be avoided when the athlete is being evaluated for return to play, as medication may mask concussion symptoms. Because concussion symptoms vary from person to person and cross multiple domains of medicine, a collaborative, 207

Jingzhen Yang et al.

multifaceted approach to concussion management is essential. The multidisciplinary care team should include physicians, athletic trainers, and sport psychologists (McCrory, Meeuwisse, et al., 2017).

Common Mental Health Symptoms Following a Concussion Common post-concussion symptoms include emotional (e.g., anxiety or depressive symptoms) and sleeprelated symptoms (e.g., insomnia or sleep disturbances), which can influence mental health outcomes. The following sections describe common mental health symptoms following a concussion, focusing on symptoms that are part of the anxiety and mood clinical profile (Figure 14.1). Risk factors for mental health symptoms following a concussion, as well as treatment and prevention strategies for postconcussion mental health problems, will be discussed.

A Model of the Anxiety and Mood Clinical Profile Following a Concussion One of the five concussion clinical symptom profiles outlined earlier in this chapter is anxiety and mood (Howell et al., 2019; Langdon et al., 2020; Lumba-Brown et al., 2020). The anxiety and mood clinical profile consists of depressed mood, anxiety, sleep disruption, ruminative thinking, hypervigilance, panic, or apathy following concussion. Sandel and colleagues (2017) proposed that multiple mechanisms, both physiological and psychosocial, contribute to the anxiety and mood clinical profile following concussion. First, pre-injury characteristics, such as a pre-existing mental health condition(s) and female sex, may increase an athlete’s likelihood of experiencing symptoms within the anxiety and mood clinical profile following concussion. Second, changes in brain function as a result of concussion, including cognitive, neurometabolic, functional, and neurochemical changes, may contribute to the development of symptoms within the anxiety and mood clinical profile, particularly when these changes mimic those observed in psychological disorders. Third, the athlete’s psychological response to concussion, including their coping style, emotional regulation, and response to their specific symptoms, may either increase or decrease their feelings of anxiety or depression post-injury. Lastly, concurrent situational risk factors, such as increased psychosocial stress due to financial strain or an unrelated life event (e.g., breakup, death in the family), can

Figure 14.1 Post-Concussion Anxiety and Mood Mechanisms Model. (Adapted from Sandel et al., 2017.)

208

Concussion in Athletes

also impact anxiety- and mood-related symptoms post-concussion. The extent of influence of each of the physiological and psychosocial mechanisms described above can vary between and within athletes who experience multiple concussions.

Persistent Post-Concussive Symptoms and Post-Concussion Syndrome (PCS) While most concussions resolve within a few weeks, up to one-third of concussed athletes experience persistent post-concussive symptoms (Zemek et al., 2016) or other functional impairments, which may result in missed school or workdays, decreased social activities, and lower quality of life (Rivara et al., 2012; Zuckerman et al., 2018a). To establish a standard definition of persistent post-concussive symptoms in both clinical and research settings, the 2017 Berlin Concussion in Sport Group Consensus Statement defined persistent post-concussive symptoms as symptoms persisting beyond expected time frames following concussion, further described as symptoms lasting longer than 10–14 days in adults and four weeks in children aged ≤ 18 years (McCrory, Meeuwisse, et al., 2017). Concussed athletes with persistent post-concussive symptoms may develop and be diagnosed with post-concussion syndrome (PCS). PCS, a clinical diagnosis, is a more specific subset of persistent postconcussive symptoms. However, universally accepted criteria do not currently exist for the diagnosis of PCS. The two guidelines with standardised criteria used for the diagnosis of PCS are: 1) the Diagnostic and Statistical Manual of Mental Disorders (DSM)-V (American Psychiatric Association, 2013), which states that symptoms must “persist past the acute post-injury period,” although the minimum duration of symptoms post-concussion is not specified (Dwyer & Katz, 2018); and 2) the World Health Organisation’s (WHO) International Classification of Diseases and Related Health Problems, 10th edition (World Health Organisation, 1992), which incorporates nine disparate symptoms measured by self-report (i.e., headaches, dizziness/vertigo, fatigue, difficulty in concentrating, impairment of memory, insomnia, irritability, depression, and anxiety/tension) (Kashluba et al., 2006). Both diagnostic criteria for PCS have been widely criticised as difficult to operationalise due to the ambiguity in the descriptions and a lack of specific diagnostic criteria (Carroll, Cassidy, Peloso, et al., 2004; Dwyer & Katz, 2018). Athletes who experience persistent symptoms or PCS may suffer a multitude of concussion symptoms, including headache, fatigue, sleep disturbance(s), anxiety, depressive symptoms, irritability, apathy, and difficulty concentrating (Dwyer & Katz, 2018; Leddy et al., 2012). These symptoms are non-specific, may be worsened by pre-existing health conditions, and may be influenced by factors other than the concussive injury, such as coping skills or perceived levels of social support (Kashluba et al., 2006; Kutcher & Eckner, 2010; McCrory, Meeuwisse, et al., 2017). Athletes with persistent post-concussive symptoms and PCS often experience mental health challenges, including anxiety, depression/depressive symptoms, and sleep disturbances (Leddy et al., 2016). Being removed from sport (temporarily or permanently) following concussion could lead to reactive depression (i.e., depression brought on by an inability to cope with an event) (Bloom et al., 2004). Reactive depression is of particular concern for elite athletes who are likely to have a strong athletic identity or who rely on their sport for education, employment, or income. It is also important to recognise that concussion may lead to sleep disturbances. Persistent sleep disturbances may result in mental health symptoms or be an indicator of existing mental health issues (Alvaro et al., 2013; Walton et al., 2021); thus, athletes’ sleep patterns should be closely monitored following concussion. Furthermore, studies have shown that some symptoms associated with PCS are common among individuals without a concussion, suggesting that symptoms of PCS may not be specific to concussions (Clarke et al., 2012; Iverson & Lange, 2003; Meares et al., 2011). Thus, multimodal post-concussion assessments and individualised, multidisciplinary treatment plans are needed for athletes with PCS, focusing on changes in symptoms from pre-injury to post-injury (rather than solely post-injury) (Kashluba et al., 2006).

209

Jingzhen Yang et al.

Depression, Depressive Symptoms, and Anxiety Depression and depressive symptoms are the most commonly researched mental health symptoms following concussion. Studies show that concussion can lead to short-term changes in depressive symptoms (Meier et al., 2017; Rice et al., 2018; Singh et al., 2016; Vargas et al., 2015; see Chapter 6). Few studies to date have examined depressive symptoms following concussion in elite athletes. One study found that approximately 20% of elite athletes experience depressive symptoms post-concussion (Vargas et al., 2015). A history of concussion may also be associated with increased depression diagnoses among retired elite athletes (Decq et al., 2016; Didehbani et al., 2013; Guskiewicz et al., 2007; Hart et al., 2013; Kerr et al., 2014; Kerr et al., 2012; Rice et al., 2018; Strain et al., 2013). It is estimated that the prevalence of clinical levels of depressive symptoms or clinical depression diagnoses among retired NFL players with a history of at least one concussion is 20% and 10.2%, respectively, which is similar to the prevalence in the general population (Casson et al., 2014). However, retired NFL players with a history of one or more concussions were between 2.3 to 5.8 times as likely to report a diagnosis of clinical depression than retired NFL players without a history of concussion, with the likelihood of a diagnosis of clinical depression increasing with the number of prior concussions. Despite the documented association of depressive symptoms/depression with suicide, no direct association has been found between history of concussion and suicide (Datoc et al., 2020; Iverson, 2020; McCrory, Meeuwisse, et al., 2017). Prior studies suggest that the rate of suicide is significantly lower among former NFL players than the general population (Iverson, 2020; Lehman et al., 2016), although these studies were limited by not controlling for concussion history. Very few studies to date have examined anxiety symptoms following concussion. Existing studies have observed elevated anxiety symptoms following concussion among elite athletes, but symptoms tend to be short-lived, typically lasting two weeks or less (Meier et al., 2015; Singh et al., 2016). Additionally, anxiety symptoms and depressive symptoms are often co-occurring following a concussion (Yang et al., 2015). While the exact cause of depressive or anxiety symptoms following a concussion is unknown, there are several potential explanations. First, mental health symptoms following a concussion may result from changes in brain function resulting from the concussive injury. Second, concussed athletes may struggle to cope with the injury and time loss from sport due to injury. For example, decreases in an athlete’s performance following a concussion may contribute to depressive symptoms (Datoc et al., 2020). Additional research is needed to further our understanding of the mental health effects of concussions. Towards this aim, a growing body of research has begun to compare anxiety and depressive symptoms in elite athletes following a concussion to other elite sport-related injuries such as musculoskeletal injuries (Covassin et al., 2014; Guo et al., 2020; Hutchison et al., 2009; Mainwaring et al., 2010). The goal of this research is to identify differences in psychological recovery between athletes with a concussion versus those with musculoskeletal injuries and to determine the mechanisms of mental health symptoms following a concussion in elite athletes. However, the complicated pattern of depressive symptoms following both concussive and musculoskeletal injury has led to inconclusive findings (Guo et al., 2020; Hutchison et al., 2009; Mainwaring et al., 2010). For example, one study found that concussed athletes showed smaller, shorter-term increases (lasting less than 1-week) in depressive symptoms than those with an anterior cruciate ligament injury (Mainwaring et al., 2010). Another study observed similar levels of depressive symptoms prior to one month post-injury between athletes with a concussion and athletes with an orthopaedic injury; however, concussed athletes reported more depressive symptoms at one month post-injury compared to athletes with an orthopaedic injury (Guo et al., 2020). Covassin and colleagues (2012) found similar increases in anxiety symptoms in collegiate athletes who experienced a concussion compared to those who experienced an orthopaedic injury. However, others have postulated that concussed athletes may have less fear of returning to play or re-injury than athletes with an orthopaedic injury (Guo et al., 2020). 210

Concussion in Athletes

Other Mental Health Issues Concussions have been shown to influence the mental health status of athletes more broadly. Namely, concussions are associated with other negative consequences, including worse overall mental health/ mood, increased alcohol use, and sleep disturbances. Concussed athletes have reported short-term changes in mood profiles, such as confusion (Mainwaring et al., 2010), fatigue (Hutchison et al., 2009), decreased vigour (Hutchison et al., 2009), and total mood disturbance (Hutchison et al., 2009; Mainwaring et al., 2010). Similar to anxiety symptoms, these effects tend to be short-lived, often lasting less than two weeks post-concussion. However, among retired collegiate athletes, those with a history of concussion experienced worse overall mental health compared to retired collegiate athletes without a history of concussion (Kerr et al., 2014). Athletes with a history of a concussion also reported negative consequences on their affect, sleep, alcohol use, and emotional and behavioural control than athletes with no history of a concussion (Meehan et al., 2016). Finally, former NFL players who experienced undiagnosed or untreated concussions reported higher opioid misuse than the general population (Cottler et al., 2011; Substance Abuse and Mental Health Services Administration, 2009). Future studies should examine the association between a concussion and long-term mental health outcomes in elite athletes using a rigorous study design.

Other Health-Related Problems Following a Concussion A concussion is associated with other health-related problems, including increased risk of orthopaedic injury, cognitive health conditions, and chronic traumatic encephalopathy (CTE). Concussions can also impact an athlete’s career, including negatively impacting their career length, performance, and salary. These factors may directly or indirectly influence an athlete’s mental health status. A history of a concussion may increase one’s risk of sustaining an orthopaedic injury, particularly an injury to the lower extremities such as an ankle or knee injury. A recent systematic review and metaanalysis indicated that collegiate and professional athletes with a history of concussion were 2.11 times as likely to suffer a musculoskeletal injury than athletes without a history of a concussion (McPherson et al., 2019). There are various potential explanations for this observed difference in injury risk. One possible explanation is impaired sensorimotor function following concussion, which can negatively affect an athlete’s motor function and joint stability and, thus, lead to injury (Riemann & Lephart, 2002). Another potential explanation is that concussed athletes may take more physical risks than non-concussed athletes due to dysregulated perception-action coupling (Eagle et al., 2020). It is likely that the increased injury risk in athletes with a history of a concussion results from a convergence of these factors. Furthermore, a concussion has been linked to long-term cognitive health conditions, including mild cognitive impairment (Amen et al., 2011; Guskiewicz et al., 2005; McCrory, Meeuwisse, et al., 2017; Randolph et al., 2013). A recent review of studies examining clinical cognitive function in elite athletes with a history of a concussion found that compared to control participants without a history of a concussion, retired athletes with a history of concussion exhibited worse memory, decreased executive function and psychomotor function, and increased subjective concerns about cognitive function (Cunningham et al., 2020). These potential cognitive impairments following concussion may be particularly detrimental for elite athletes who rely on their memory and executive functioning skills (e.g., decision making, self-control) to excel in their sport. Potential explanations for these impairments hint at possible links to chronic neurocognitive impairment (CNE) and CTE (Harmon et al., 2013). CTE is generally characterised by the accumulation of p-tau in specific brain areas and can only be diagnosed post-mortem (Singla et al., 2019; Zuckerman et al., 2018a). Current research on CTE in elite athletes, like most concussion studies, has centred on male-dominated sport such as American football and boxing (Zuckerman et al., 2018a). A study that analysed the brains of 202 former American football 211

Jingzhen Yang et al.

players whose brains were donated for CTE research found that CTE was present in most of the brains studied, with 91% of college, 64% of semi-professional, 88% of Canadian Football League, and 99% of NFL players’ brains showing signs of CTE (Mez et al., 2017). Given the inability to diagnose CTE antemortem, determining its relationship with concussions and repeated concussions is complicated. Early studies suggest a strong link between repeated concussions and CTE (McKee et al., 2009). However, findings from recent studies are mixed; some studies find no relationship between the number of concussions and CTE (McKee et al., 2013; Mez et al., 2017), while others suggest that repeated concussions may lead to CTE if the brain is not allowed time to fully heal between concussive injuries (Baugh et al., 2012). The latter finding may be particularly concerning for elite athletes in sport such as American football and boxing, where repeated direct and indirect blows to the head are common. Lastly, emerging evidence suggests that CTE is associated with suicide (Iverson, 2014; McKee et al., 2009; Mez et al., 2017; Omalu et al., 2010; Webner & Iverson, 2016). A concussion and repeated concussions may negatively impact an athlete’s athletic career, including decreasing their career length, performance, and salary. Research shows that NFL and NHL players with a history of concussion were released from contracts at higher rates, had shorter career spans postconcussion, and had reductions in their performance and salary following concussion compared to their counterparts with no concussion history (Navarro et al., 2018; Navarro et al., 2017). Performance reductions varied across sport but were particularly evident among offensive American football (e.g., tight ends, running backs, wide receivers, quarterbacks) and ice hockey players (e.g., non-goalie hockey players). Reductions in performance do not seem to be present among NBA players post-concussion (Patel et al., 2019; Yengo-Kahn, Zuckerman, et al., 2016). An athlete’s motivation to continue playing their sport may also change following a concussion. Elite athletes often report external motivations to return to their sport post-injury, such as feeling pressured by their coach or teammates (Podlog & Eklund, 2007), which may lead to premature return to play (Kroshus et al., 2015). However, no studies to date have explored elite athletes’ intrinsic motivations to return to sport following a concussion (Bloom et al., 2020). Future studies that examine both extrinsic and intrinsic motivations to return to sport among elite athletes following a concussion are critically needed.

Major Risk Factors of Concussion-Related Mental Health Symptoms Sex, Race, and Sport While there is substantial evidence for the influence of sex, age, and sport played on concussion incidence, few studies have examined the possible influence of demographic and contextual factors on mental health symptoms following a concussion (Bloom et al., 2020). Of the studies on this topic to date, researchers have investigated the influence of sex, race, and sport on mental health symptoms following a concussion. The findings suggest that female athletes may be more likely to experience mental health symptoms post-concussion than male athletes (André-Morin et al., 2017; Iverson et al., 2015; Kontos et al., 2012). However, it is important to note that females are more likely to report and seek care for mental health symptoms than males; thus, further research is needed to explore sex differences in mental health outcomes post-concussion (Dick, 2009; McGroarty et al., 2020). Additionally, there may be a difference in concussion-related mental health outcomes by race such that non-White athletes may experience poorer mental health outcomes, including increased depressive symptoms, following a concussion than White athletes (Vargas et al., 2015). These racial differences in mental health outcomes post-concussion may be due, in part, to cultural differences in mental health care seeking. Future research should explore this relationship to further our understanding of the potential influence of race on mental health outcomes following a concussion in elite athletes.

212

Concussion in Athletes

Finally, evidence suggests that athletes who participate in high-contact and collision sport, such as American football, are less likely to report and more likely to mask mental health symptoms following a concussion than those in other sport (Delaney et al., 2018). Perhaps, this is due to the stigma associated with mental health and mental health care seeking in traditionally masculine sport or to the mentality of the sport itself, which may encourage athletes to “act tough” and play through pain or injury (Bloom et al., 2004; Bloom et al., 2020; Madrigal et al., 2015). Continued investigation of these factors and their influence on concussion-related mental health symptoms may help team personnel identify athletes at high risk for mental health symptoms following a concussion, which, in turn, could lead to increased recognition and early treatment.

Repeated Concussions Repeated concussions could increase an athlete’s risk of experiencing depressive symptoms following injury (Decq et al., 2016; Didehbani et al., 2013; Kerr et al., 2014). One previous study showed that collegiate athletes who reported two or more concussions were 2.4 times as likely to report moderate or severe depressive symptoms than those who reported no history of concussion (Kerr et al., 2014). This trend persists across athletes from various sport (Decq et al., 2016; Kerr et al., 2014). Existing studies on the influence of repeated concussions on mental health symptoms have focused predominately on male athletes in contact sport (e.g., American football and rugby), providing little evidence among female athletes.

Pre-Existing Mental Health Symptoms Pre-existing mental health conditions, particularly depressive symptoms, may be associated with increased mental health symptoms following concussion. One prior study found that concussed collegiate athletes who reported symptoms of depression before injury were 4.6 times as likely to report depressive symptoms post-concussion and 3.4 times as likely to report anxiety symptoms post-concussion than athletes without baseline (pre-injury) depressive symptoms (Yang et al., 2015). Other studies have found no connection between baseline anxiety and concussion-related mental health symptoms (Hixson et al., 2017). However, anxiety sensitivity (a personality trait where physiological, psychological, and social influences are perceived as threatening to oneself) (Wood et al., 2011) may be a risk factor for other postconcussion symptoms, particularly somatic symptoms (Hixson et al., 2017). Furthermore, athletes with pre-existing mental health conditions may also be more likely to experience persistent post-concussive symptoms, with depression post-concussion being a documented risk factor for persistent post-concussive symptoms, which, in turn, may lead to prolonged recovery (McCrory, Meeuwisse, et al., 2017).

Symptom Overlap Between Mental Health Disorders and Concussions Concussion symptoms may overlap with pre-existing mental health conditions such as depression or anxiety. Distinguishing post-concussion symptoms from the symptoms of a pre-existing mood disorder can be challenging due to overlapping symptoms. The medical team must determine which symptoms first developed after the concussion and which symptoms existed before the injury and worsened following injury (Harmon et al., 2013). Baseline testing is a common method used to help distinguish between pre-existing symptoms and those caused or worsened by the injury. However, baseline testing typically focuses on neuropsychological aspects (e.g., memory tasks, decision-making tasks, etc.) rather than mental health symptoms. Furthermore, mood disorders, as well as learning and attention disorders, can impact neuropsychological testing, which, in turn, can interfere with accurate test interpretation, subsequent diagnosis, and treatment plans (Bailey et al., 2010; Covassin et al., 2012). The addition of mental health screenings to baseline testing and documenting pre-existing mental health conditions could help differentiate between pre-existing, worsened, and new mental health symptoms following 213

Jingzhen Yang et al.

concussion. Such screenings could also identify athletes who may be at higher risk for concussion-related mental health symptoms, which could help ensure that the appropriate support mechanisms are in place if the athlete were to sustain a concussion. It is of paramount importance that the medical care team take all pre-injury mental health conditions into account when assessing post-concussion mental health status and designing an individualised treatment plan for the athlete.

Strategies to Prevent and Mitigate Concussion-Related Mental Health Consequences in Elite Sport Strategies to prevent and mitigate concussion-related mental health consequences in elite sport can be classified into three approaches: 1) primary prevention, strategies that aim to prevent concussion-related mental health consequences from occurring; 2) secondary prevention, strategies used to detect concussion-related mental health consequences early and prevent their worsening; and 3) tertiary prevention, strategies that aim to improve concussion-related mental health consequences and lessen their long-term effects. A combination of primary, secondary, and tertiary prevention strategies should be used to address concussion-related mental health consequences. Each approach involves different strategies and, often, different target populations. In recent years, a growing emphasis has been placed on primary prevention as these strategies have demonstrated the greatest impact.

Primary Prevention Strategies Preventing the occurrence of concussion is one strategy used to prevent concussion-related mental health symptoms. Many elite sport leagues have adapted the rules of the game to increase player safety and reduce the risk for a concussion. For example, in the 2014 season, MLB implemented Rule 7.13, making it illegal for runners to deviate from their direct path to home plate to initiate contact with the catcher (or other player covering the plate) (MLB, 2014). Violation of this rule results in the runner being called out, even if the fielder drops the ball. Additionally, both the NFL and NCAA football have adopted regulations and penalties related to targeting (e.g., hits on a defenceless player or hits leading with the helmet). These regulations and penalties aimed to promote player safety and decrease concussion incidence by discouraging players from making dangerous tackles that are likely to result in head injuries. Since 2013, NCAA football athletes who violate this rule are subject to ejection from the game, in addition to the yardage penalty applied to their team (NCAA Football, 2019). Many elite sport leagues, including the NFL, NHL, and NCAA football, continually evaluate their rules to protect players and discourage players from engaging in dangerous plays that leave themselves and others at risk for injury. Another strategy to prevent concussion-related mental health symptoms is concussion education programmes for coaches and players. The goal of such educational programmes is to increase concussion awareness and promote a culture of concussion safety. Some concussion education programmes incorporate training on safer practices for the sport as well as information on concussion symptom recognition and management. Some programmes also emphasise the emotional and sleep symptoms of a concussion and the potential effects of a concussion on the mental health of athletes (Feiss et al., 2020). The NFL Players Association partnered with the American Academy of Neurology, the American Brain Foundation, and current and former NFL players to create a concussion education video that was widely distributed to players prior to the 2016 season (NFL Player Health & Safety, 2016). Alternatively, primary prevention strategies could focus on reducing the risk for concussion-related mental health symptoms rather than on preventing the occurrence of concussion. First, sport leagues and organisations could utilise sport psychology services to equip athletes with a repertoire of adaptive coping strategies that could help athletes thrive despite adversity, stress, or trauma; these coping strategies could help athletes cope with the stress associated with concussion and concussion recovery. Furthermore, 214

Concussion in Athletes

equipping athletes with healthy and adaptive coping strategies may prevent athletes from using maladaptive coping mechanisms, such as alcohol misuse, which could negatively impact their mental health. Second, building strong, positive relationships with coaches, teammates, and other team staff may help increase feelings of support and relatedness, which may be particularly beneficial during recovery from concussion. These positive relationships, combined with high levels of perceived social support, may be protective against mental health symptoms post-concussion. For athletes who have pre-existing anxiety or depressive disorders, regular visits with a mental health professional before injury may help prevent or minimise the effects of concussion on one’s mental health post-injury.

Secondary Prevention Strategies Elite athletes often have access to high-quality, specialised care, which may result in the early identification of concussion-related mental health consequences and prevent the worsening of symptoms. Ensuring the availability of mental health care services and promoting mental health care seeking behaviours following a concussion can help alleviate concussion-related mental health symptoms (McCrory, Meeuwisse, et al., 2017). Additionally, many elite sport leagues, particularly those with a high risk of concussion, should have established protocols for identifying mental health symptoms following a concussion. These practices aim to increase the recognition of mental symptoms following a concussion and increase early referrals to mental health professionals. Lastly, the use of clinical symptom profiles can help physicians treat concussed athletes by tailoring treatment to the athlete’s specific symptoms, which can help prevent mental health symptoms from worsening (Sandel et al., 2017). For example, if an athlete’s symptoms are classified as the anxiety and mood clinical profile, a treatment plan that focuses on alleviating mental health symptoms and providing necessary mental health support, such as including psychotherapy in the treatment plan, could be prescribed.

Tertiary Prevention Strategies Athletes experiencing persistent post-concussive symptoms or PCS, especially if their symptoms fit the anxiety and mood clinical profile, may benefit from the mental health and sport psychology services available to them. The Berlin Concussion in Sport Group Consensus Statement recommends the use of Cognitive Behavioural Therapy (CBT) as part of a collaborative treatment approach for athletes experiencing persistent post-concussive symptoms (McCrory, Meeuwisse, et al., 2017), further highlighting the importance of having a sport psychologist or other mental health professionals on the multidisciplinary concussion care team. CBT can be used to treat post-concussion mental health symptoms such as depression/depressive symptoms, anxiety, or insomnia (Chen et al., 2020; Cooper et al., 2015). CBT can be delivered in various formats, including virtually via telehealth. Additionally, mental health or sport psychology services may be helpful for athletes who find their mental health symptoms interfering with their ability to return to sport following concussion. For example, working with a sport psychologist could help athletes build adaptive coping and communication skills that may help them deal with psychological and situational factors, including fear of re-injury, negatively impacting their ability to return successfully to sport post-concussion. Unlike primary and secondary prevention, tertiary prevention may involve medical treatment (e.g., medications) for concussion-related mental health consequences.

Implications for Future Research and Practice Implications for Research Although the body of research on sport-related concussion is growing, research on mental health symptoms either as antecedents or consequences of concussion is limited. This section acknowledges 215

Jingzhen Yang et al.

limitations of prior research in the field of concussion, with a particular focus on the limitations of research on post-concussion mental health problems. Recommendations for future studies furthering our understanding of how concussion may affect the mental health of elite sport athletes will be made. Such studies are sorely needed and could help inform the management of concussion among elite athletes, including preventing and reducing mental health symptoms post-concussion. First, most epidemiological studies examining concussion in elite sport have been limited to male athletes, team sport athletes, and sport leagues in North America such as the NFL or NHL. Similarly, studies that have examined mental health symptoms post-concussion in elite sport athletes have focused predominately on male athletes who compete in team sport. More research is needed on concussions and concussion-related mental health problems in elite sport female athletes, individual sport athletes (e.g., skiing, snowboarding, cycling), and in sport leagues in other regions of the world such as the European Rugby League. Furthermore, social support, an effective coping strategy during concussion recovery, is likely different in female and individual sport athletes than in male and team sport athletes, which may impact mental health outcomes post-injury (Kontos et al., 2004). Thus, additional research on mental health symptoms following concussion in female and individual sport athletes is warranted. Second, existing concussion studies are limited by the study design and methods employed, such as a lack of a universal concussion surveillance system, restricted access to the concussion data collected by sport leagues, and differences in the denominator used to measure concussion risk (e.g., number of games, number of athlete exposures) (McCrory, Feddermann-Demont, et al., 2017; McCrory, Meeuwisse, et al., 2017). Documenting the true incidence of a concussion in elite sport or making comparisons across sport becomes challenging. More rigorous research that accurately quantifies concussion incidence rates and risk in elite sport is needed. Additionally, studies on mental health symptoms following a concussion are often limited by self-report data and a retrospective study design. Future studies should utilise prospective, longitudinal study designs with data collected at baseline (pre-injury) and post-injury. Future studies should also utilise standardised mental health measurements to allow for comparisons across different athletic populations and different time points. Such research would advance our understanding of how concussions impact the mental health of elite sport athletes. Third, despite the increased risk of mental health problems following concussion among athletes with pre-existing mental health conditions, few studies account for pre-existing mental health conditions when examining mental health symptoms post-concussion. Future studies examining the joint contributions of pre-existing mental health conditions and post-concussion mental health problems on recovery outcomes are critically needed. Lastly, future studies should examine protective factors against and risk factors for mental health problems following a concussion. The findings of such studies could inform the development of evidencebased interventions that aim to prevent and mitigate mental health problems in elite sport athletes by identifying modifiable determinants of mental health problems post-concussion. For instance, future studies should examine the role of social support and coping skills on mental health symptoms following concussion, including whether social support and adaptive coping skills are protective against mental health symptoms post-concussion, which could inform the development of social support and coping intervention strategies for concussed athletes. It is also critical to highlight the need for interventions and strategies that combine primary, secondary, and tertiary prevention approaches to prevent and reduce mental health problems following a concussion.

Implications for Practice It is crucial to establish a multidisciplinary concussion care team to facilitate concussion recovery and prevent and mitigate mental health symptoms following concussion. The multidisciplinary team 216

Concussion in Athletes

should consist of medical professionals who can help manage athletes’ concussion symptoms and trained mental health providers, such as sport psychologists, who can help athletes cope with new or pre-existing mental health symptoms following concussion. This section highlights practical implications for medical staff, sport psychologists, and the team (e.g., coaching staff and athletes) to help prevent post-concussion mental health symptoms that could negatively impact an athlete’s recovery outcomes. Specific recommendations to help athletes who develop new mental health symptoms following concussion and special considerations for athletes with pre-existing mental health conditions are provided.

Medical Staff Medical staff are an instrumental part of the concussion care team. They are responsible for managing a concussion from the time of injury until the athlete fully recovers from their concussion. Medical staff not only play a critical role in physical recovery post-concussion but also can help prevent and treat mental health symptoms after concussion. It is of paramount importance that the medical team is trained in concussion management and stays up to date with best practices in concussion care. Medical staff should consider incorporating mental health screenings as part of athletes’ pre-participation physical examinations before each athletic season to determine each athletes’ baseline levels of anxiety and depressive symptoms. Moreover, medical staff should develop and implement athlete-centred, individualised treatment plans for concussed athletes with and without pre-existing mental health conditions and for concussed athletes with high versus low levels of post-concussion anxiety or depressive symptoms. The athlete-centred, individualised treatment plan should include support from trained mental health professionals. Medical staff should screen and monitor the mental health symptoms of all concussed athletes during follow-up visits and make appropriate referrals, as needed. Lastly, medical staff should educate sport psychologists, coaches, and athletes about concussions and warning signs that a concussed athlete is suffering from mental health problems post-injury.

Applied Sport Psychologists Sport psychologists should be part of a multidisciplinary concussion care team for elite sport athletes. Sport psychologists can help medical staff treat athletes with persistent post-concussive symptoms and PCS. Sport psychologists must be trained in concussion recognition, management, and recovery, including the potential mental health issues related to concussion (Kontos et al., 2004). Prior to the athletic season, sport psychologists could provide athletes with resilience training to enhance resilience and equip athletes with a repertoire of adaptive coping strategies (Sullivan et al., 2021). Such training may help concussed athletes cope with anxiety or depressive symptoms post-concussion. During recovery from injury, sport psychologists can help concussed athletes cope with feelings of isolation, anxiety, and withdrawal from sport and other activities that often result from concussion (Bloom et al., 2004). Sport psychologists can also help athletes deal with post-concussion issues, including performance difficulties, the pressure to return to play, and the fear of re-injury and returning to sport. Common psychological intervention strategies and techniques such as relaxation, goal setting, positive self-talk, cognitive restructuring, and stress management may promote positive outcomes following concussion. The role of sport psychologists may be particularly imperative for elite athletes who compete in an individual sport and may not have support from teammates post-injury. Moreover, sport psychologists can help athletes who are forced to retire from sport due to a concussion or repeated concussion, assisting these athletes in coping with the loss of athletic identity and sense of belonging to a team, feelings of aimlessness, and other distressful reactions. 217

Jingzhen Yang et al.

Team At the start of each athletic season, coaches and athletes should be formally educated about concussions. Coaches and athletes should be aware of potential mental health issues following a concussion and resources for mental health care. Athletes should be encouraged by their coaches and teammates to seek professional help for mental health difficulties if needed. In addition, coaches and athletes should be trained in mental health first aid to improve their recognition of and response to mental health issues or crises. Moreover, coaches and athletes should provide emotional support to concussed athletes throughout their recovery, as social support may be protective against the potential negative mental health consequences following concussion. Support groups for concussed athletes should be made available, especially for athletes who experience persistent post-concussive symptoms or PCS. Finally, coaches should strive to establish positive relationships with the medical staff and sport psychologists and communicate with them throughout the athlete’s recovery from a concussion.

Conclusions A concussion in elite sport is a common occurrence that may lead to short-term mental health issues, including anxiety and depressive symptoms, sleep disturbances, and other mood disturbances. Postconcussion mental health problems may exacerbate pre-existing mental health conditions. Major risk factors for concussion-related mental health symptoms include female sex, experiencing multiple concussions, and pre-existing mental health conditions. Current research on the mental health of elite athletes following concussion has been limited by four major factors, including the: 1) focus on male athletes who compete in team sport, with few studies on female and individual sport athletes; 2) use of self-report measures, lack of standardised measures, and use of less rigorous study designs; 3) failure to account for pre-existing mental health conditions; and 4) lack of evidence-based interventions that address concussion-related mental health issues. Additional research on the mental health of elite sport athletes following a concussion should be developed to address these limitations. Primary, secondary, and tertiary strategies have been utilised to help prevent, mitigate, and treat concussion-related mental health symptoms. Elite athletes may have increased access to mental health services through medical staff and sport psychologists for concussion-related mental health problems, which could help prevent or alleviate post-concussion mental health symptoms. Establishing a multidisciplinary concussion care team is fundamental to improving an athlete’s concussion recovery outcomes and preventing and mitigating mental health consequences following a concussion. These teams should consist of medical staff, sport psychologists, trained mental health providers, and coaching staff, all of whom should be educated on proper recognition of and response to the potential influence of concussion on mental health. The team approach for concussion care is crucial to prevent and mitigate concussion-related mental health symptoms. Finally, increased research efforts are vital to improve our understanding of the complex relationship between concussion and mental health in elite athletes.

References Adams, R., Lau, G.K., Dai, J.B., Li, A.Y., Cheung, K.P., Haider, S., … Choudhri, T.F. (2018). Evaluation of concussion incidence and modulating factors in the 2013–2017 Australian Football League. Cureus, 10(10), e3465. 10.7759/cureus.3465 Adams, R., Li, A.Y., Dai, J.B., Haider, S., Lau, G.K., Cheung, K.P., … Choudhri, T.F. (2018). Modifying factors for concussion incidence and severity in the 2013–2017 National Hockey League Seasons. Cureus, 10(10), e3530. 10.7759/cureus.3530

218

Concussion in Athletes Alvaro, P.K., Roberts, R.M., & Harris, J.K. (2013). A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep, 36(7), 1059–1068. 10.5665/sleep.2810 Amen, D.G., Wu, J.C., Taylor, D., & Willeumier, K. (2011). Reversing brain damage in former NFL players: Implications for traumatic brain injury and substance abuse rehabilitation. Journal of Psychoactive Drugs, 43(1), 1–5. 10.1080/02791072.2011.566489 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596 André-Morin, D., Caron, J.G., & Bloom, G.A. (2017). Exploring the unique challenges faced by female university athletes experiencing prolonged concussion symptoms. Sport, Exercise, and Performance Psychology, 6(3), 289–303. 10.1037/spy0000106 Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Johnston, K.M., Kelly, J., … Concussion in Sport, G. (2002). Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clinical Journal of Sport Medicine, 12(1), 6–11. 10.1097/00042752-200201000-00005 Bailey, C.M., Samples, H.L., Broshek, D.K., Freeman, J.R., & Barth, J.T. (2010). The relationship between psychological distress and baseline sport-related concussion testing. Clinical Journal of Sport Medicine, 20(4), 272–277. 10.1097/JSM.0b013e3181e8f8d8 Barkhoudarian, G., Hovda, D.A., & Giza, C.C. (2011). The molecular pathophysiology of concussive brain injury. Clinical Journal of Sport Medicine, 30(1), 33–48, vii-iii. 10.1016/j.csm.2010.09.001 Baugh, C.M., Stamm, J.M., Riley, D.O., Gavett, B.E., Shenton, M.E., Lin, A., … Stern, R.A. (2012). Chronic traumatic encephalopathy: Neurodegeneration following repetitive concussive and subconcussive brain trauma. Brain Imaging and Behavior, 6(2), 244–254. 10.1007/s11682-012-9164-5 Bloom, G.A., Horton, A.S., McCrory, P., & Johnston, K.M. (2004). Sport psychology and concussion: New impacts to explore. British Journal of Sports Medicine, 38, 519–521. Bloom, G.A., Trbovich, A.M., Caron, J.G., & Kontos, A.P. (2020). Psychological aspects of sport-related concussion: An evidence-based position paper. Journal of Applied Sport Psychology, 34, 495–513. 10.1080/10413200.2020.1 843200 Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., … National Athletic Trainer’s, A. (2014). National Athletic Trainers’ Association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245–265. 10.4085/1062-6050-49.1.07 Broglio, S.P., Lapointe, A., O’Connor, K.L., & McCrea, M. (2017). Head impact density: A model to explain the elusive concussion threshold. Journal of Neurotrauma, 34(19), 2675–2683. 10.1089/neu.2016.4767 Brown, N.J., Mannix, R.C., O’Brien, M.J., Gostine, D., Collins, M.W., & Meehan, W.P., 3rd. (2014). Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics, 133(2), e299–e304. 10.1542/peds.2 013-2125 Carney, N., Ghajar, J., Jagoda, A., Bedrick, S., Davis-O’Reilly, C., du Coudray, H., … Riggio, S. (2014). Concussion guidelines step 1: Systematic review of prevalent indicators. Neurosurgery, 75(Suppl 1), S3–S15. 10.122 7/NEU.0000000000000433 Carroll, L.J., Cassidy, J.D., Holm, L., Kraus, J., Coronado, V.G., & WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine, 43, 113–125. 10.1080/16501960410023877 Carroll, L.J., Cassidy, J.D., Peloso, P.M., Borg, J., von Holst, H., Holm, L., … Pépin, M. (2004). Prognosis for mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine, 43, 84–105. 10.1080/16501960410023859 Casson, I.R., Viano, D.C., Haacke, E.M., Kou, Z., & LeStrange, D.G. (2014). Is there chronic brain damage in retired NFL players? Neuroradiology, neuropsychology, and neurology examinations of 45 retired players. Sports Health, 6(5), 384–395. 10.1177/1941738114540270 Casson, I.R., Viano, D.C., Powell, J.W., & Pellman, E.J. (2010). Twelve years of national football league concussion data. Sports Health, 2(6), 471–483. 10.1177/1941738110383963 Casson, I.R., Viano, D.C., Powell, J.W., & Pellman, E.J. (2011). Concussions involving 7 or more days out in the national football league. Sports Health, 3(2), 130–144. 10.1177/1941738110397876 Chen, C.L., Lin, M.Y., Huda, M.H., & Tsai, P.S. (2020). Effects of cognitive behavioral therapy for adults with postconcussion syndrome: A systematic review and meta-analysis of randomized controlled trials. Journal of Psychosomatic Research, 136, 110190. 10.1016/j.jpsychores.2020.110190 Clarke, L.A., Genat, R.C., & Anderson, J.F. (2012). Long-term cognitive complaint and post-concussive symptoms following mild traumatic brain injury: The role of cognitive and affective factors. Brain Injury, 26(3), 298–307. 10.3109/02699052.2012.654588

219

Jingzhen Yang et al. Collins, M.W., Iverson, G.L., Lovell, M.R., McKeag, D.B., Norwig, J., & Maroon, J. (2003). On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sport Medicine, 13(4), 222–229. 10.1097/00042752-200307000-00005 Cooper, D.B., Bunner, A.E., Kennedy, J.E., Balldin, V., Tate, D.F., Eapen, B.C., & Jaramillo, C.A. (2015). Treatment of persistent post-concussive symptoms after mild traumatic brain injury: A systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging and Behavior, 9(3), 403–420. 10.1007/s11682-015-9440-2 Cottler, L.B., Ben Abdallah, A., Cummings, S.M., Barr, J., Banks, R., & Forchheimer, R. (2011). Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug and Alcohol Dependence, 116(1-3), 188–194. 10.1016/j.drugalcdep.2010.12.003 Covassin, T., Crutcher, B., Bleecker, A., Heiden, E.O., Dailey, A., & Yang, J. (2014). Postinjury anxiety and social support among collegiate athletes: A comparison between orthopaedic injuries and concussions. Journal of Athletic Training, 49(4), 462–468. 10.4085/1062-6059-49.2.03 Covassin, T., & Elbin, R.J. (2011). The female athlete: The role of gender in the assessment and management of sports-related concussion. Clinical Journal of Sport Medicine, 30(1), 125–131. 10.1016/j.csm.2010.08.001 Covassin, T., Elbin, R.J., 3rd, Larson, E., & Kontos, A.P. (2012). Sex and age differences in depression and baseline sports-related concussion neurocognitive performance and symptoms. Clinical Journal of Sport Medicine, 22(2), 98–104. 10.1097/JSM.0b013e31823403d2 Covassin, T., Moran, R., & Elbin, R.J. (2016). Sex differences in reported concussion injury rates and time loss from participation: An update of the National Collegiate Athletic Association Injury Surveillance Program from 2004–2005 through 2008–2009. Journal of Athletic Training, 51(3), 189–194. 10.4085/1062-6050-51.3.05 Covassin, T., Swanik, C.B., & Sachs, M.L. (2003). Sex differences and the incidence of concussions among collegiate athletes. Journal of Athletic Training, 38(3), 238–244. https://www.ncbi.nlm.nih.gov/pubmed/14608434 Cunningham, J., Broglio, S.P., O’Grady, M., & Wilson, F. (2020). History of sports-related concussion and long-term clinical cognitive health outcomes in retired athletes: A systematic review. Journal of Athletic Training, 55(2), 132–158. 10.4085/1062-6050-297-18 Datoc, A., Horne, K., & Golden, C. (2020). Sport-related concussion and risk for suicide in athletes. Aggression and Violent Behavior, 54. 10.1016/j.avb.2020.101413 Decq, P., Gault, N., Blandeau, M., Kerdraon, T., Berkal, M., ElHelou, A., … Peyrin, J.C. (2016). Long-term consequences of recurrent sports concussion. Acta Neurochirurgica (Wien), 158(2), 289–300. 10.1007/s00701-015-2 681-4 Delaney, J.S., Caron, J.G., Correa, J.A., & Bloom, G.A. (2018). Why professional football players chose not to reveal their concussion symptoms during a practice or game. Clinical Journal of Sport Medicine, 28(1), 1–12. 10.1097/ JSM.0000000000000495 Dick, R.W. (2009). Is there a gender difference in concussion incidence and outcomes? British Journal of Sports Medicine, 43(Suppl 1), i46–i50. 10.1136/bjsm.2009.058172 Didehbani, N., Munro Cullum, C., Mansinghani, S., Conover, H., & Hart, J., Jr. (2013). Depressive symptoms and concussions in aging retired NFL players. Archives of Clinical Neuropsychology, 28(5), 418–424. 10.1093/arclin/ act028 Donaldson, L., Asbridge, M., & Cusimano, M.D. (2013). Bodychecking rules and concussion in elite hockey. PLoS One, 8(7), e69122. 10.1371/journal.pone.0069122 Dwyer, B., & Katz, D.I. (2018). Postconcussion syndrome. Handbook of Clinical Neurology, 158, 163–178. 10.1016/ B978-0-444-63954-7.00017-3 Eagle, S.R., Kontos, A.P., Pepping, G.J., Johnson, C.D., Sinnott, A., LaGoy, A., & Connaboy, C. (2020). Increased risk of musculoskeletal injury following sports-related concussion: A perception-action coupling approach. Sports Medicine, 50(1), 15–23. 10.1007/s40279-019-01144-3 Echemendia, R.J., Meeuwisse, W., McCrory, P., Davis, G.A., Putukian, M., Leddy, J., … Herring, S. (2017). The sport concussion assessment tool 5th edition (SCAT5): Background and rationale. British Journal of Sports Medicine, 51(11), 848–850. 10.1136/bjsports-2017-097506 Feiss, R., Lutz, M., Reiche, E., Moody, J., & Pangelinan, M. (2020). A systematic review of the effectiveness of concussion education programs for coaches and parents of youth athletes. International Journal of Environmental Research and Public Health, 17(8). 10.3390/ijerph17082665 Gardner, A.J., Howell, D.R., & Iverson, G.L. (2019). National Rugby League match scheduling and rate of concussion. Journal of Science and Medicine in Sport, 22(7), 780–783. 10.1016/j.jsams.2019.02.003 Gardner, A.J., Iverson, G.L., Williams, W.H., Baker, S., & Stanwell, P. (2014). A systematic review and meta-analysis of concussion in rugby union. Sports Medicine, 44(12), 1717–1731. 10.1007/s40279-014-0233-3

220

Concussion in Athletes Giza, C.C., Kutcher, J.S., Ashwal, S., Barth, J., Getchius, T.S., Gioia, G.A., … Zafonte, R. (2013). Summary of evidence-based guideline update: evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 80(24), 2250–2257. 10.1212/ WNL.0b013e31828d57dd Greenwald, R.M., Gwin, J.T., Chu, J.J., & Crisco, J.J. (2008). Head impact severity measures for evaluating mild traumatic brain injury risk exposure. Neurosurgery, 62(4), 789–798; discussion 798. 10.1227/01.neu.0000318162 .67472.ad Guo, J., Yang, J., Yi, H., Singichetti, B., Stavrinos, D., & Peek-Asa, C. (2020). Differences in postinjury psychological symptoms between collegiate athletes with concussions and orthopedic injuries. Clinical Journal of Sport Medicine, 30(4), 360–365. 10.1097/JSM.0000000000000621 Guskiewicz, K.M., Marshall, S.W., Bailes, J., McCrea, M., Cantu, R.C., Randolph, C., & Jordan, B.D. (2005). Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery, 57(4), 719–726; discussion 719–726. 10.1093/neurosurgery/57.4.719 Guskiewicz, K.M., Marshall, S.W., Bailes, J., McCrea, M., Harding, H.P., Jr., Matthews, A., … Cantu, R.C. (2007). Recurrent concussion and risk of depression in retired professional football players. Medicine & Science in Sports & Exercise, 39(6), 903–909. 10.1249/mss.0b013e3180383da5 Guskiewicz, K.M., & Mihalik, J.P. (2011). Biomechanics of sport concussion: Quest for the elusive injury threshold. Exercise and Sport Sciences Reviews, 39(1), 4–11. 10.1097/JES.0b013e318201f53e Harmon, K.G., Drezner, J.A., Gammons, M., Guskiewicz, K.M., Halstead, M., Herring, S.A., … Roberts, W.O. (2013). American medical society for sports medicine position statement: Concussion in sport. British Journal of Sports Medicine, 47(1), 15–26. 10.1136/bjsports-2012-091941 Hart, J., Jr., Kraut, M.A., Womack, K.B., Strain, J., Didehbani, N., Bartz, E., … Cullum, C.M. (2013). Neuroimaging of cognitive dysfunction and depression in aging retired National Football League players: A crosssectional study. JAMA Neurology, 70(3), 326–335. 10.1001/2013.jamaneurol.340 Hixson, K.M., Allen, A.N., Williams, A.S., & Valovich McLeod, T.C. (2017). Is state anxiety, trait anxiety, or anxiety sensitivity a clinical predictor of symptoms in those presenting with mild traumatic brain injury or concussion? Journal of Sport Rehabilitation, 26(6), 588–594. Hootman, J.M., Dick, R., & Agel, J. (2007). Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. Journal of Athletic Training, 42(2), 311–319. https://www.ncbi. nlm.nih.gov/pubmed/17710181 Howell, D.R., Kriz, P., Mannix, R.C., Kirchberg, T., Master, C.L., & Meehan, W.P., 3rd. (2019). Concussion symptom profiles among child, adolescent, and young adult athletes. Clinical Journal of Sport Medicine, 29(5), 391–397. 10.1097/JSM.0000000000000629 Hutchison, M., Mainwaring, L.M., Comper, P., Richards, D.W., & Bisschop, S.M. (2009). Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries. Clinical Journal of Sport Medicine, 19, 13–19. Hutchison, M.G., Comper, P., Meeuwisse, W.H., & Echemendia, R.J. (2015a). A systematic video analysis of National Hockey League (NHL) concussions, part I: Who, when, where and what? British Journal of Sports Medicine, 49(8), 547–551. 10.1136/bjsports-2013-092234 Hutchison, M.G., Comper, P., Meeuwisse, W.H., & Echemendia, R.J. (2015b). A systematic video analysis of National Hockey League (NHL) concussions, part II: How concussions occur in the NHL. British Journal of Sports Medicine, 49(8), 552–555. 10.1136/bjsports-2013-092235 Iverson, G.L. (2014). Chronic traumatic encephalopathy and risk of suicide in former athletes. British Journal of Sports Medicine, 48(2), 162–165. 10.1136/bjsports-2013-092935 Iverson, G.L. (2020). Retired national football league players are not at greater risk for suicide. Archives of Clinical Neuropsychology, 35(3), 332–341. 10.1093/arclin/acz023 Iverson, G.L., & Lange, R.T. (2003). Examination of “postconcussion-like” symptoms in a healthy sample. Applied Neuropsychology, 10(3), 137–144. 10.1207/s15324826an1003_02 Iverson, G.L., Silverberg, N.D., Mannix, R., Maxwell, B.A., Atkins, J.E., Zafonte, R., & Berkner, P.D. (2015). Factors associated with concussion-like symptom reporting in high school athletes. JAMA Pediatrics, 169(12), 1132–1140. 10.1001/jamapediatrics.2015.2374 Kamins, J., & Giza, C.C. (2016). Concussion-mild traumatic brain injury: Recoverable injury with potential for serious sequelae. Neurosurgery Clinics of North America, 27(4), 441–452. 10.1016/j.nec.2016.05.005 Kashluba, S., Casey, J.E., & Paniak, C. (2006). Evaluating the utility of ICD-10 diagnostic criteria for postconcussion syndrome following mild traumatic brain injury. Journal of the International Neuropsychological Society, 12(1), 111–118. 10.1017/s1355617706060036 Kerr, Z.Y., Evenson, K.R., Rosamond, W.D., Mihalik, J.P., Guskiewicz, K.M., & Marshall, S.W. (2014). Association between concussion and mental health in former collegiate athletes. Injury Epidemiology, 1(28).

221

Jingzhen Yang et al. Kerr, Z.Y., Marshall, S.W., Harding, H.P., Jr., & Guskiewicz, K.M. (2012). Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. American Journal of Sports Medicine, 40(10), 2206–2212. 10.1177/0363546512456193 Kerr, Z.Y., Register-Mihalik, J.K., Kay, M.C., DeFreese, J.D., Marshall, S.W., & Guskiewicz, K.M. (2018). Concussion nondisclosure during professional career among a cohort of former national football league athletes. American Journal of Sports Medicine, 46(1), 22–29. 10.1177/0363546517728264 Kerr, Z.Y., Roos, K.G., Djoko, A., Dalton, S.L., Broglio, S.P., Marshall, S.W., & Dompier, T.P. (2017). Epidemiologic measures for quantifying the incidence of concussion in National Collegiate Athletic Association Sports. Journal of Athletic Training, 52(3), 167–174. 10.4085/1062-6050-51.6.05 Kontos, A.P., Collins, M., & Russo, S.A. (2004). An introduction to sports concussion for the sport psychology consultant. Journal of Applied Sport Psychology, 16(3), 220–235. 10.1080/10413200490485568 Kontos, A.P., Covassin, T., Elbin, R.J., & Parker, T. (2012). Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Archives of Physical Medicine and Rehabilitation, 93(10), 1751–1756. 10.1016/j.apmr.2012.03.032 Kroshus, E., Garnett, B., Hawrilenko, M., Baugh, C.M., & Calzo, J.P. (2015). Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Social Science & Medicine, 134, 66–75. 10.1016/j.socscimed.2 015.04.011 Kuhn, A.W., & Solomon, G.S. (2016). Concussion in the National Hockey League: A systematic review of the literature. Concussion, 1(1), CNC1. 10.2217/cnc.15.1 Kutcher, J.S., & Eckner, J.T. (2010). At-risk populations in sports-related concussion. Current Sports Medicine Reports, 9(1), 16–20. 10.1249/JSR.0b013e3181caa89d Langdon, S., Konigs, M., Adang, E., Goedhart, E., & Oosterlaan, J. (2020). Subtypes of sports-related concussion: A systematic review and meta-cluster analysis. Sports Medicine, 50(10), 1829–1842. 10.1007/s40279-020-01321-9 Langlois, J.A., Rutland-Brown, W., & Wald, M.M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. Journal of Head Trauma Rehabilitation, 21(5), 375–378. 10.1097/00001199-200609000-00001 Leddy, J.J., Baker, J.G., & Willer, B. (2016). Active rehabilitation of concussion and post-concussion syndrome. Physical Medicine and Rehabilitation Clinics of North America, 27(2), 437–454. 10.1016/j.pmr.2015.12.003 Leddy, J.J., Haider, M.N., Ellis, M.J., Mannix, R., Darling, S.R., Freitas, M.S., … Willer, B. (2019). Early subthreshold aerobic exercise for sports-related concussion: A randomized clinical trial. JAMA Pediatrics, 173(4), 319–325. 10.1001/jamapediatrics.2018.4397 Leddy, J.J., Sandhu, H., Sodhi, V., Baker, J.G., & Willer, B. (2012). Rehabilitation of concussion and post-concussion syndrome. Sports Health, 4(2), 147–154. 10.1177/1941738111433673 Lefevre-Dognin, C., Cogne, M., Perdrieau, V., Granger, A., Heslot, C., & Azouvi, P. (2020). Definition and epidemiology of mild traumatic brain injury, 67(3), 218–221Neurochirurgie. 10.1016/j.neuchi.2020.02.002 Lehman, E.J., Hein, M.J., & Gersic, C.M. (2016). Suicide mortality among retired national football league players who played 5 or more seasons. American Journal of Sports Medicine, 44(10), 2486–2491. 10.1177/036354651 6645093 Lumba-Brown, A., Teramoto, M., Bloom, O.J., Brody, D., Chesnutt, J., Clugston, J.R., … Ghajar, J. (2020). Concussion guidelines step 2: Evidence for subtype classification. Neurosurgery, 86(1), 2–13. 10.1093/neuros/ nyz332 Madrigal, L., Robbins, J., Gill, D.L., & Wurst, K. (2015). A pilot study investigating the reasons for playing through pain and injury: Emerging themes in men’s and women’s collegiate rugby. Sport Psychologist, 29(4), 310–318. 10.1123/tsp.2014-0139 Mainwaring, L.M., Hutchison, M., Bisschop, S.M., Comper, P., & Richards, D.W. (2010). Emotional response to sport concussion compared to ACL injury. Brain Injury, 24(4), 589–597. 10.3109/02699051003610508 Majerske, C.W., Mihalik, J.P., Ren, D., Collins, M.W., Reddy, C.C., Lovell, M.R., & Wagner, A.K. (2008). Concussion in sports: Postconcussive activity levels, symptoms, and neurocognitive performance. Journal of Athletic Training, 43(3), 265–274. 10.4085/1062-6050-43.3.265 Mansell, J.L., Tierney, R.T., Higgins, M., McDevitt, J., Toone, N., & Glutting, J. (2010). Concussive signs and symptoms following head impacts in collegiate athletes. Brain Injury, 24(9), 1070–1074. 10.3109/02699052.2010.4 94589 McCrea, M., Iverson, G.L., Echemendia, R.J., Makdissi, M., & Raftery, M. (2013). Day of injury assessment of sports-related concussion. British Journal of Sports Medicine, 47(5), 272–284. 10.1136/bjsports-2013-092145 McCrea, M.A., Nelson, L.D., & Guskiewicz, K. (2017). Diagnosis and management of acute concussion. Physical Medicine and Rehabilitation Clinics of North America, 28(2), 271–286. 10.1016/j.pmr.2016.12.005

222

Concussion in Athletes McCrory, P., Feddermann-Demont, N., Dvorak, J., Cassidy, J.D., McIntosh, A., Vos, P.E., … Tarnutzer, A.A. (2017). What is the definition of sports-related concussion: A systematic review. British Journal of Sports Medicine, 51(11), 877–887. 10.1136/bjsports-2016-097393 McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., … Vos, P.E. (2017). Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51(11), 838–847. 10.1136/bjsports-2017-097699 McCrory, P., Meeuwisse, W.H., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R.J., … Turner, M. (2013). Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine, 47(5), 250–258. 10.1136/bjsports-2013-092313 McGroarty, N.K., Brown, S.M., & Mulcahey, M.K. (2020). Sport-related concussion in female athletes: A systematic review. Orthopaedic Journal of Sports Medicine, 8(7), 2325967120932306. 10.1177/2325967120932306 McKee, A.C., Cantu, R.C., Nowinski, C.J., Hedley-Whyte, E.T., Gavett, B.E., Budson, A.E., … Stern, R.A. (2009). Chronic traumatic encephalopathy in athletes: Progressive tauopathy after repetitive head injury. Journal of Neuropathology & Experimental Neurology, 68(7), 709–735. 10.1097/NEN.0b013e3181a9d503 McKee, A.C., Stern, R.A., Nowinski, C.J., Stein, T.D., Alvarez, V.E., Daneshvar, D.H., … Cantu, R.C. (2013). The spectrum of disease in chronic traumatic encephalopathy. Brain, 136(Pt 1), 43–64. 10.1093/brain/aws307 McPherson, A.L., Nagai, T., Webster, K.E., & Hewett, T.E. (2019). Musculoskeletal injury risk after sports-related concussion: A systematic review and meta-analysis. American Journal of Sports Medicine, 47(7), 1754–1762. 10.1177/ 0363546518785901 Meares, S., Shores, E.A., Taylor, A.J., Batchelor, J., Bryant, R.A., Baguley, I.J., … Marosszeky, J.E. (2011). The prospective course of postconcussion syndrome: The role of mild traumatic brain injury. Neuropsychology, 25(4), 454–465. 10.1037/a0022580 Meehan, W.P., Taylor, A.M., Berkner, P., Sandstorm, N.J., Peluso, M.W., Kurtz, M.M., … Mannix, R. (2016). Division III collision sports are not associated with neurobehavioral quality of life. Journal of Neurotrauma, 33(2), 254–259. 10.1089/neu.2015.3930 Meier, T.B., Bellgowan, P.S.F., & Mayer, A.R. (2017). Longitudinal assessment of local and global functional connectivity following sports-related concussion. Brain Imaging and Behavior, 11(1), 129–140. 10.1007/s11682-01 6-9520-y Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S. (2015). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, 18(5), 507–511. 10.1016/j.jsams.2014.07.008 Mez, J., Daneshvar, D.H., Kiernan, P.T., Abdolmohammadi, B., Alvarez, V.E., Huber, B.R., … McKee, A.C. (2017). Clinicopathological evaluation of chronic traumatic encephalopathy in players of american football. JAMA, 318(4), 360–370. 10.1001/jama.2017.8334 MLB. (2014). MLB, MLBPA Adopt Experimental Rule 7.13 On Home Plate Collisions. Retrieved May 18 from https:// www.mlb.com/news/mlb-mlbpa-adopt-experimental-rule-713-on-home-plate-collisions/c-68268622 Myer, G.D., Smith, D., Barber Foss, K.D., Dicesare, C.A., Kiefer, A.W., Kushner, A.M., … Khoury, J.C. (2014). Rates of concussion are lower in National Football League games played at higher altitudes. Journal of Orthopaedic & Sports Physical Therapy, 44(3), 164–172. 10.2519/jospt.2014.5298 Navarro, S.M., Pettit, R.W., Haeberle, H.S., Frangiamore, S.J., Rahman, N.M., Farrow, L.D., … Ramkumar, P.N. (2018). Short-term impact of concussion in the NHL: An analysis of player longevity, performance, and financial loss. Journal of Neurotrauma, 35(20), 2391–2399. 10.1089/neu.2017.5611 Navarro, S.M., Sokunbi, O.F., Haeberle, H.S., Schickendantz, M.S., Mont, M.A., Figler, R.A., & Ramkumar, P.N. (2017). Short-term outcomes following concussion in the NFL: A study of player longevity, performance, and financial loss. Orthopaedic Journal of Sports Medicine, 5(11), 2325967117740847. 10.1177/2325967117740847 NCAA Football. (2019). 2019 NCAA Football Rules and Interpretations. In (Sesquicentennial Edition). NFL Player Health & Safety. (2016). NFL Players Association Brain Health and Concussion Education Video. Retrieved May 18 from https://www.nfl.com/playerhealthandsafety/health-and-wellness/player-care/nfl-players-associationbrain-health-and-concussion-education-video O’Connor, K.L., Peeters, T., Szymanski, S., & Broglio, S.P. (2017). Individual impact magnitude vs. cumulative magnitude for estimating concussion odds. Annual Review of Biomedical Engineering, 45(8), 1985–1992. 10.1007/s1 0439-017-1843-3 O’Connor, K.L., Rowson, S., Duma, S.M., & Broglio, S.P. (2017). Head-impact-measurement devices: A systematic review. Journal of Athletic Training, 52(3), 206–227. 10.4085/1062-6050.52.2.05 Omalu, B.I., Hamilton, R.L., Kamboh, M.I., DeKosky, S.T., & Bailes, J. (2010). Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions. Journal of Forensic Nursing, 6(1), 40–46. 10.1111/j.1939-3938.2009.01064.x

223

Jingzhen Yang et al. Patel, B.H., Okoroha, K.R., Jildeh, T.R., Lu, Y., Idarraga, A.J., Nwachukwu, B.U., … Forsythe, B. (2019). Concussions in the National Basketball Association: Analysis of incidence, return to play, and performance from 1999 to 2018. Orthopaedic Journal of Sports Medicine, 7(6), 2325967119854199. 10.1177/2325967119854199 Pellman, E.J., Viano, D.C., Tucker, A.M., Casson, I.R., & Waeckerle, J.F. (2003). Concussion in professional football: Reconstruction of game impacts and injuries. Neurosurgery, 53(4), 799–812; discussion 812–794. 10.1093/ neurosurgery/53.3.799 Peterson, J.G., Tjong, V.K., Terry, M.A., Saltzman, M.D., Gryzlo, S.M., & Sheth, U. (2020). Concussion incidence and impact on player performance in major league baseball players before and after a standardized concussion protocol. Orthopaedic Journal of Sports Medicine, 8(4), 2325967120913020. 10.1177/2325967120913020 Podlog, L., & Eklund, R.C. (2007). The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective. Psychology of Sport and Exercise, 8(4), 535–566. 10.1016/ j.psychsport.2006.07.008 Randolph, C., Karantzoulis, S., & Guskiewicz, K. (2013). Prevalence and characterization of mild cognitive impairment in retired national football league players. Journal of the International Neuropsychological Society, 19(8), 873–880. 10.1017/s1355617713000805 Rice, S.M., Parker, A.G., Rosenbaum, S., Bailey, A., Mawren, D., & Purcell, R. (2018). Sport-related concussion and mental health outcomes in elite athletes: A systematic review. Sports Medicine, 48(2), 447–465. 10.1007/s402 79-017-0810-3 Riemann, B.L., & Lephart, S.M. (2002). The sensorimotor system, part II: The role of proprioception in motor control and functional joint stability. Journal of Athletic Training, 37(1), 80–84. Rivara, F.P., Vavilala, M.S., Durbin, D., Temkin, N., Wang, J., O’Connor, S.S., … Jaffe, K.M. (2012). Persistence of disability 24 to 36 months after pediatric traumatic brain injury: A cohort study. Journal of Neurotrauma, 29(15), 2499–2504. 10.1089/neu.2012.2434 Romeu-Mejia, R., Giza, C.C., & Goldman, J.T. (2019). Concussion pathophysiology and injury biomechanics. Current Reviews in Musculoskeletal Medicine, 12(2), 105–116. 10.1007/s12178-019-09536-8 Rowson, S., & Duma, S.M. (2013). Brain injury prediction: Assessing the combined probability of concussion using linear and rotational head acceleration. Annual Review of Biomedical Engineering, 41(5), 873–882. 10.1007/s10439012-0731-0 Sandel, N., Reynolds, E., Cohen, P.E., Gillie, B.L., & Kontos, A.P. (2017). Anxiety and mood clinical profile following sports-related concussion: From risk factors to treatment. Sport, Exercise, and Performance Psychology, 6(3), 304–323. 10.1037/spy0000098 Schneider, K.J., Leddy, J.J., Guskiewicz, K.M., Seifert, T., McCrea, M., Silverberg, N.D., … Makdissi, M. (2017). Rest and treatment/rehabilitation following sports-related concussion: A systematic review. British Journal of Sports Medicine, 51(12), 930–934. 10.1136/bjsports-2016-097475 Singh, R., Savitz, J., Teague, T.K., Polanski, D.W., Mayer, A.R., Bellgowan, P.S., & Meier, T.B. (2016). Mood symptoms correlate with kynurenine pathway metabolites following sports-related concussion. Journal of Neurology, Neurosurgery, and Psychiatry, 87(6), 670–675. 10.1136/jnnp-2015-311369 Singla, A., Leineweber, B., Monteith, S., Oskouian, R.J., & Tubbs, R.S. (2019). The anatomy of concussion and chronic traumatic encephalopathy: A comprehensive review. Clinical Anatomy, 32(3), 310–318. 10.1002/ca.23313 Strain, J., Didehbani, N., Cullum, C.M., Mansinghani, S., Conover, H., Kraut, M.A., … Womack, K.B. (2013). Depressive symptoms and white matter dysfunction in retired NFL players with concussion history. Neurology, 81(1), 25–32. 10.1212/WNL.0b013e318299ccf8 Stuart, S., Parrington, L., Martini, D., Peterka, R., Chesnutt, J., & King, L. (2020). The Measurement of eye movements in mild traumatic brain injury: A structured review of an emerging area. Frontiers in Sports and Active Living, 2, 5. 10.3389/fspor.2020.00005 Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09–4434). Rockville, MD Retrieved from https://www.datafiles.samhsa.gov/study/national-survey-drug-use-and-healthnsduh-2008-nid13602 Sullivan, L., Carter, J.E., Houle, J., Ding, K., Hautmann, A., & Yang, J. (2021). Evaluation of a resilience training program for college student-athletes: A pilot study. Journal of American College Health, 1–8. 10.1080/07448481 .2021.1891083 Sussman, E.S., Ho, A.L., Pendharkar, A.V., & Ghajar, J. (2016). Clinical evaluation of concussion: The evolving role of oculomotor assessments. Neurosurgical Focus, 40(4), E7. 10.3171/2016.1.FOCUS15610 Sussman, E.S., Pendharkar, A.V., Ho, A.L., & Ghajar, J. (2018). Mild traumatic brain injury and concussion: Terminology and classification. Handbook of Clinical Neurology, 158, 21–24. 10.1016/B978-0-444-639547.00003-3

224

Concussion in Athletes Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2(7872), 81–84. 10.1016/s0140-6736(74)91639-0 Vargas, G., Rabinowitz, A., Meyer, J., & Arnett, P.A. (2015). Predictors and prevalence of postconcussion depression symptoms in collegiate athletes. Journal of Athletic Training, 50(3), 250–255. 10.4085/1062-6050-50.3.02 Walton, S.R., Kerr, Z.Y., Brett, B.L., Chandran, A., DeFreese, J.D., Smith-Ryan, A.E., … Guskiewicz, K.M. (2021). Health-promoting behaviours and concussion history are associated with cognitive function, mood-related symptoms and emotional-behavioural dyscontrol in former NFL players: An NFL-LONG Study. British Journal of Sports Medicine, 55, 683–690. 10.1136/bjsports-2020-103400 Webner, D., & Iverson, G.L. (2016). Suicide in professional American football players in the past 95 years. Brain Injury, 30(13-14), 1718–1721. 10.1080/02699052.2016.1202451 Wood, R.L., McCabe, M., & Dawkins, J. (2011). The role of anxiety sensitivity in symptom perception after minor head injury: An exploratory study. Brain Injury, 25(13-14), 1296–1299. 10.3109/02699052.2011.624569 World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. Yang, J., Comstock, R.D., Yi, H., Harvey, H.H., & Xun, P. (2017). New and recurrent concussions in high-school athletes before and after traumatic brain injury laws, 2005–2016. American Journal of Public Health, 107(12), 1916–1922. 10.2105/AJPH.2017.304056 Yang, J., Peek-Asa, C., Covassin, T., & Torner, J.C. (2015). Post-concussion symptoms of depression and anxiety in division I collegiate athletes. Developmental Neuropsychology, 40(1), 18–23. 10.1080/87565641.2014.973499 Yengo-Kahn, A.M., Johnson, D.J., Zuckerman, S.L., & Solomon, G.S. (2016). Concussions in the National Football League: A current concepts review. American Journal of Sports Medicine, 44(3), 801–811. 10.1177/03635465155 80313 Yengo-Kahn, A.M., Zuckerman, S.L., Stotts, J., Zalneraitis, B.H., Gardner, R.M., Kerr, Z.Y., & Solomon, G.S. (2016). Performance following a first professional concussion among National Basketball Association players. Physician and Sportsmedicine, 44(3), 297–303. 10.1080/00913847.2016.1200956 Zemek, R., Barrowman, N., Freedman, S.B., Gravel, J., Gagnon, I., McGahern, C., … Osmond, M.H. (2016). Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA, 315(10), 1014–1025. 10.1001/jama.2016.1203 Zuckerman, S.L., Brett, B.L., Jeckell, A., Yengo-Kahn, A.M., & Solomon, G.S. (2018a). Chronic traumatic encephalopathy and neurodegeneration in contact sports and american football. Journal of Alzheimer’s Disease, 66(1), 37–55. 10.3233/jad-180218 Zuckerman, S.L., Brett, B.L., Jeckell, A.S., Yengo-Kahn, A.M., & Solomon, G.S. (2018b). Prognostic factors in pediatric sports-related concussion. Current Neurology and Neuroscience Reports, 18(12), 104. 10.1007/s11910-0180909-4

225

15 FEAR AND ANXIETY IN ELITE SPORT Felix Ehrlenspiel, V. Vanessa Wergin, and Jürgen Beckmann

Anxiety in Competitive Sport To the audience, it is suspense, to the athlete, it is pressure; approaching the penalty kick in a World Cup final, running up to the last attempt in the Olympic long-jump. When we think of anxiety in sport, competitive anxiety is most salient. We can see athletes being afraid of missing the goal, of failing the attempt. Sometimes, when they fail, we attribute their failure to the experience of anxiety. But there is more to anxiety in elite sport than just competitive anxiety, and there is more to it than being afraid to fail. A key aspect of elite sport activities is their social nature – athletes compare their performance against others, and their performance is also compared or evaluated by others, such as family and friends, coaches, the audience. But that social evaluation goes beyond an evaluation of performance, it also concerns personal attributes of the athletes, especially their physical attributes such as strength, endurance, or appearance. The physical nature of sport also provides multiple physical threats, potentially leading to pain, at least, or to injury, whether from activities, material, or other athletes. Within the sport psychology literature, accordingly, competitive anxiety is distinguished from social physique anxiety and sport injury anxiety. To date, the major focus of research in sport psychology has been competitive anxiety. In the past, sport psychological research on anxiety in sport mainly addressed the effects of anxiety on performance. Various models exist on the relationship between anxiety and performance. Moderators of this relationship have been identified and attentional mechanisms explaining the relationship have been proposed. But given that athletes usually experience anxiety as unpleasant, the question arises as to how it affects the well-being of athletes. Moreover, because anxiety appears to be a natural part of athletes’ lives (and not only in competitions), the recurrent experience of anxiety must be considered to affect their mental health as more of a long-term outcome. It is then pertinent to understand antecedents and mechanisms of anxiety experience and its effects to develop mental health interventions to help athletes to cope with anxiety.

Defining of Terms When defining anxiety, it is often distinguished from fear, which is somewhat elusive but useful in an applied context (e.g., Beckmann & Elbe, 2015, p. 190 f ). Anxiety is seen as being the response to a more abstract threat in the future where an actual source of danger cannot be identified, whereas fear is considered as response to a more concrete and imminent threat (objective anxiety). Given that there is a 226

DOI: 10.4324/9781003099345-21

Fear and Anxiety in Elite Sport

realistic chance of getting injured or harmed in sport, with the specific odds depending on the type of sport (Sallis et al., 2001), and given that the event of injury is definite, it makes sense to speak of fear of injury, not anxiety. However, still a great ambiguity remains – for example with respect to the type or extent of injury and harm (Kleinert, 2002). Furthermore, following the distinction made by Spielberger (1966) the immediate, more transient response (state anxiety) can be distinguished from the more stable disposition to perceive ambiguous situations as threatening and respond with anxiety (trait anxiety). An athlete high in trait anxiety may more often react to ambiguous situations in competition or practice with a more pronounced and faster response of anxiety (Ehrlenspiel et al., 2011). While research on the relationship between competitive anxiety and performance has often focused on state anxiety (e.g., Woodman & Hardy, 2003), research on fear of failure and social physique anxiety is almost exclusively relying on the assessment of trait anxiety. In fact, trait anxiety in general and social physique anxiety in particular are among the most popular traits assessed in sport and exercise psychology research (Laborde et al., 2020). For the remainder of this chapter, we will also take a trait perspective on the relation between anxiety in sport and mental health in athletes.

Emergence of Anxiety In the sport context, the emergence of anxiety is often explained using a cognitive approach, such as the transactional model of stress (Lazarus, 1999; for a review of stress, see Chapter 16). A person acts within a given situation or condition and there is a “transaction” between the individual with personal characteristics and the environmental demands. These demands are evaluated, resulting in appraisals of threat or of challenge. Subsequent to a threat appraisal, anxiety is experienced as an unpleasant state consisting of feelings of apprehension and worries, physiological activation, and behavioural changes (Meijen et al., 2013). This anxiety, caused by a threat, is a central emotional component in the explanation why athletes fail to perform up to their potential in important competitions (known as “choking under pressure”; Beckmann et al., 2013; Mesagno & Beckmann, 2017, Mesagno & Hill, 2013). The relationship between anxiety and performance may (at least in part) be a vicious circle: because athletes remain anxious, they perform less well, and their poor performance in turn prolongs their anxiety. Underlying the emergence of anxiety in a situation is uncertainty, which has been found to be the key source of anxiety and stress in (elite) sport (Robinson & Freeston, 2015). In competition, this uncertainty pertains first to an uncertainty about the outcome. It is a question of success or failure, about winning or losing, and to some, it is a question of hero or zero. But systematic analyses of sources of stress and anxiety in (elite) sport have identified aspects of uncertainty that go beyond the outcomes (Leary & Kowalski, 1997). Athletes experience uncertainty about how they and their performance will be evaluated by others and how they will evaluate themselves. They are also uncertain about whether they will experience physical harm or even injury and they are uncertain whether or to what extent they have control over the situation.

Forms of Anxiety in Sport In the following sections, competitive anxiety, sport injury anxiety, and social physique anxiety will be introduced and differentiated. While these three sub-forms of anxiety vary in their characteristics, they are not entirely independent from one another and shape athlete anxiety in elite sport through their interplay (see Figure 15.1).

Competitive Anxiety Competitions provide conditions and stimuli that are – at least in their sum – fairly unique and that can be considered as potential triggers of anxiety (Ehrlenspiel & Mesagno, 2022) or competitive stressors (such as 227

Felix Ehrlenspiel et al.

Figure 15.1

Anxiety in Elite Sport Revolves Mainly Around the Themes of Competition (“Competitive Anxiety”), Injury (“Injury Anxiety”), and of Presentation of Physical Attributes (“Social Physique Anxiety”). (Figure Available Under a CC-BY4.0 License at osf.io/et3b2/.)

an audience being present, a direct comparison of performance, rewards, or punishment that are contingent on performance). Competitive anxiety can be defined as a specific negative emotional response to these competitive stressors (Mellalieu et al., 2009). Since the seminal work by Martens (Martens et al., 1990), the understanding of competitive anxiety is shaped by a two-dimensional model of anxiety. This assumes that the experiential (or “feelings”) component of the anxiety response encompasses a cognitive and a somatic or “emotionality” dimension (Liebert & Morris, 1967). Under competitive stress, athletes experience worries about success or failure or concerns about the (social) evaluation of their performance. In addition, they may experience changes in physiological symptoms, such as their heart pumping or their hands getting sweaty and cold. The latter experience is only loosely related to the actual physiological response (Mauss & Robinson, 2009). More recently, a third, regulatory dimension was suggested (Cheng et al., 2009) that considers the adaptive nature of anxiety and has been shown to relate more directly to performance. Athletes differ in the extent of their emotional response to a competition – intra-individually between different competitions but also within a competition inter-individually. And it is assumed that these differences can explain differences in performance. Competitive anxiety is considered a core topic for research in sport psychology (Mellalieu et al., 2006) and in applied sport psychology, possibly because we can assume a direct relationship between anxiety and performance. Large-scale studies investigating the prevalence of competitive anxiety as a presenting issue in sport psychology consulting are missing. But performance anxiety is a prevailing issue, as it was a subject for up to 75% of psychology consultations offered at U.S. Olympic festivals (Kirschenbaum et al., 1993) and, for example, during the 2004 Olympics, pre-competitive anxiety was the third most frequently detected psychological problem among the Brazilian athletes (Samulski & Lopes, 2008).

Injury Anxiety According to Kleinert (2002), sport injury anxiety can be defined as a widely indefinite concern or worry to sustain an injury in different sport situations. The content of these worries and concerns has been analysed mainly with respect to a competitive context. Qualitative interviews revealed that elite athletes worry about various themes, such as risk of injury, risk of being injured by an opponent, competing

228

Fear and Anxiety in Elite Sport

despite injury, the risk of aggravating a previous injury, and the uncertainty of ability after injury (Hanton, Fletcher & Coughlan, 2005). There is also some indication that anticipation of pain after injury may be the content of concerns (Hsu et al., 2017). Injury anxiety often also comes in the form of re-injury anxiety in those athletes who had sustained an injury report worries of being re-injured. It is thought to occur predominantly during later stages of a rehabilitation process prior to return to sport (Walker et al., 2004). There is some argument whether the term fear of (re-)injury and or (re-)injury anxiety should be used. Somewhat following the earlier made distinction between fear and anxiety, injury anxiety then is argued to be about worries and concerns about consequences of (re-)injury (potential surgery and its outcome, the rehabilitation process, time to return or even end of career). Fear of (re-)injury, on the other hand, would be about the fear of sustaining an injury itself (Hsu et al., 2017). Still, the two constructs have not been separated consistently and there is no differential evidence of either in relation to antecedents or consequences; therefore, we will stick with injury anxiety. From a quantitative perspective, the relevance of injury anxiety in elite sport is difficult to assess, as there is no data on prevalence rates. Yet, injury anxiety is a recurrent theme in qualitative analyses of stressors in sport (Dunn, 1999; Hanton, Fletcher & Coughlan, 2005). A study among injured members of a ski team found that almost 60% reported fear of injury (Gould et al., 1997). Moreover, injury anxiety has been identified as an important factor in injury occurrence and rehabilitation, increasing the likelihood of injury occurrence (Short et al., 2004) and prolonging the rehabilitation process (Hsu et al., 2017).

Social Physique Anxiety Given the social nature of elite sport, athletes present themselves to others – and this motivates strategies to present oneself favourably. Such strategies have been termed self-presentation and they aim at conveying desired impressions and concealing undesired impressions in a social situation (Leary, 1992). When athletes are concerned whether they are making the desired impressions, social anxiety or self-presentation concerns may follow. Such concerns can be related to any aspect of the athletes’ self, from psychological (e.g., hardiness or competitiveness; Mesagno et al., 2011) to physical attributes. Social anxiety related to physical attributes, or the physique, has been coined social physique anxiety (Hart et al., 1989). Athletes may be afraid that others negatively evaluate their body composition or proportions, muscularity, or tone (Crawford & Eklund, 1994). Social physique anxiety has been mainly studied in relation to exercise behaviour rather than in elite sport, assuming that social physique anxiety may for example affect adherence to an exercise class. Nevertheless, elite athletes can be expected to have higher social physique anxiety due to the social nature of elite sport; on the other hand, the fact that they are active and train their body might also lead to lower levels. Research is somewhat inconclusive with a slight trend towards elite athletes reporting higher levels of social physique anxiety compared to athletes active at lower levels of competition or to persons less physically active (Sabiston et al., 2014). Moreover, social physique anxiety not only appears to be an issue in sport psychology counselling (Samuel, 2013) but especially appears to play a role in the development of maladaptive attitudes to eating and disordered eating in female athletes (Sabiston et al., 2014).

Relation of Anxiety with Performance, Well-Being, and Mental Health Performance Research on the relationship between anxiety and sport performance has not led to an unequivocal understanding of anxiety. Different hypotheses exist on the relation between anxiety and performance, with the most prominent, the “Inverted-U-Hypothesis”, presumably dating back to a study by Yerkes and Dodson (1908) on the effects of electro shocks on discriminant learning in mice. It postulates that 229

Felix Ehrlenspiel et al.

performance is best at a medium intensity of anxiety. Stronger empirical support is available for claims that cognitive anxiety or worry is negatively related to performance in a linear fashion (e.g., Woodman & Hardy, 2003). Other models assume that cognitive anxiety may interact with the somatic component or even physiological response, potentially leading to a “catastrophe” (Hardy, 1990; Hardy & Parfitt, 1991). Researchers have also argued that it may be less the intensity of the anxiety response than the interpretation as more or less facilitative that affects performance (Hanin, 1978, 1995). This more individual perspective culminates in the idea of an individual zone of optimal functioning that expands from anxiety to other pleasant and unpleasant emotions (Hanin, 2000, 2004, 2007). Only if anxiety falls outside an optimal zone does it negatively affect performance. This idiographic approach may be the closest to an applied perspective but is difficult to test empirically. It has also been of some question, how anxiety affects performance, with the current research focusing on attentional mechanisms. Anxiety is assumed to lead to increased self-monitoring of usually automatic motor skills or to the re-investment of declarative knowledge acquired during learning of a skill that is now proceduralized. This in turn leads to disruption of execution and subsequent performance failure (e.g., Beilock & Carr, 2001; Eysenck et al., 2007; Masters & Maxwell, 2008). Somewhat in contrast, anxiety may also lead to problems in executive functioning resulting in a loss of focus and higher distraction by task-irrelevant stimuli (e.g., Eysenck, 1979; Wine, 1971). Injury anxiety and social physique anxiety have a more indirect relationship with performance in a competition but may have more direct relationships with performance over time and a career as an elite athlete. Within his psychophysiological model of fear of injury, Heil (1993) proposes that injury anxiety (“fear of injury” in his terms) negatively affects physiology (e.g., muscle tension) and psychology (e.g., concentration), which then negatively affects performance (e.g., disruption of skill execution and balance) leading to an increased risk of injury. Sense of poor performance is likely to initiate a vicious cycle in that it exacerbates physiological (tension, arousal) and psychological (concentration, self-confidence) responses. As a more chronic effect, injury anxiety will also be heightened. In a similar vein, social physique anxiety and self-presentation concerns appear to contribute to competitive trait anxiety – at least in female athletes (Martin & Mack, 1996).

Mental Health and Well-Being Anxiety disorders are among the most common disorders (Bandelow et al., 2014; see Chapter 11). They are often associated with depression and addictions. Even if no clinically relevant anxiety disorder has developed, experiencing anxiety constitutes an unpleasant state negatively affecting subjective well-being, which basically reflects how individuals look at their lives and to what extent they feel happy or satisfied (Diener, 2009). Beyond a more “simple” effect on emotional well-being, anxiety can also be linked to a reduction in psychological functioning. Athletes who experience sport-related anxiety may also suffer from feelings of worthlessness, physical/emotional exhaustion, and a reduced sense of fulfilment (Lemyre et al., 2007). The stress and anxiety before competitions has been found to adversely affect sleep. Most athletes have experienced poor sleep before competitions (Erlacher et al., 2011). Further research showed that when athletes worried a lot, their sleep quality deteriorated over the nights before a competition (Ehrlenspiel et al., 2018). The repeated or even continuous experience of anxiety under high trait anxiety also has a more chronic effect and might even be associated with mental illness. Poor sleep as a consequence of anxiety might also be one underlying cause for a relation between anxiety, recovery, and rehabilitation after injury. Injury anxiety often turns into re-injury anxiety and during the rehabilitation process anxiety is also seen to be directed towards the rehabilitation process. Anxiety then hinders smooth rehabilitation and often interferes with a timely return to sport (Ford et al., 2017). Considering long-term effects, anxiety in general and injury anxiety in particular have been found to be related to injury and injury rehabilitation (Heil, 1993; Brewer & Redmond, 2016). For example, a 230

Fear and Anxiety in Elite Sport

review found that 2/3 of studies confirmed a relationship between (competitive) trait anxiety and the occurrence of musculoskeletal sport injuries (Cagle et al., 2017). Most importantly, however, experiencing anxiety in the sport context may have adverse effects on sport participation. Former gymnasts, for example, cited not liking the pressure of their sport as one key reason for dropping out (Klint & Weiss, 1986). Studies also show a clear relation between poor motivational climate (focus on ego-orientation, less autonomy support) and sport attrition (Barnett et al., 1992; Sarrazin et al., 2002). In the general population, experiencing social physique anxiety is negatively linked to physical activity and exercise adherence (Sabiston et al., 2014). Social physique anxiety clearly thwarts enjoyment of physical activity. In elite athletes, a link between social physique anxiety and disordered eating has been established. In male and female college athletes, negative perfectionism was a predictor of disordered eating, but in females, social physique anxiety was an independent predictor of disturbed eating (Haase et al., 2002). It is difficult to evaluate the relation between anxiety in sport and other mental health issues. Studies that investigate mental health of athletes usually use clinical measures such as the Generalised Anxiety Disorder (GAD-7, Spitzer et al., 2006) to assess anxiety. Such studies find a positive relation between anxiety and depression in athletes (Junge & Feddermann-Demont, 2016). But there is also indication that competitive trait anxiety more directly is related to symptoms of depression (Jensen et al., 2018). A potential route could be through extended worry and rumination, which is considered a clinical symptom of depressive and anxiety disorders (McEvoy et al., 2013). Interestingly, the relation between competitive anxiety and anxiety disorders is even less clear. Prevalence rates of anxiety disorders in the athlete population appear to vary somewhat around the general population with some studies showing clearly reduced rates (Walton et al., 2021). With respect to the relation between competitive anxiety and anxiety disorder, Walton et al. suggest that athletes with trait competitive anxiety may be more generally prone to show heightened fear and anxiety especially in social situations. Following experiences of choking under pressure, elite athletes have also shown more general maladaptive emotional and behavioural responses. Through qualitative interviews with athletes that had experienced “choking”, Hill and colleagues (2019) were able to show that destructive behaviours such as drunk driving were used for coping with that experience. Moreover, they found that athletes went so far as to think about committing suicide after a choking experience (Hill et al., 2011). But experiencing anxiety in sport situations might not be only detrimental to well-being or even mental health. Looking at the motivation for engaging in high-risk sport research has found that beyond the prototypical “sensation seeker”, some persons engage in such activities as mountain climbing for more adaptive reasons (Barlow et al., 2013). These activities offer the opportunity to experience a strong and concrete emotion such as anxiety. However, persons then experience how this emotion can be mastered and regulated and they experience successful emotion regulation. Moreover, at least the worry component of anxiety has been linked to psychological functioning (Sweeny & Dooley, 2017). Worry prompts people to prepare for an action and take precautions. And worry also helps to attend to the eminent and most relevant stimuli when acting, very often the obstacles on the way to success. The idea, that (competitive) anxiety may have a positive side, is also considered in the idea that athletes themselves often view anxiety as facilitative and not debilitative to their performance (Jones & Swain, 1995).

Assessment of Anxiety in Sport Although anxiety, as any emotion, may be assessed via physiological (e.g., heart rate, cortisol), behavioural (avoidance behaviour), or phenomenological markers (self-report), the assessment via self-report clearly dominates (Ehrlenspiel & Mesagno, 2022). The phenomenological experience of anxiety in sport has been assessed both qualitatively and quantitatively. 231

Felix Ehrlenspiel et al.

Qualitative research into competitive anxiety has mainly employed semi-structured interviews that have shed light on temporal dynamics of the anxiety response in face of a competition (Thomas et al., 2007), on the interpretation of anxiety as debilitative to performance (Hanton, Wadey & Connaughton, 2005), on choking experiences (Hill et al., 2017), or on the stressors as part of a competition (Mellalieu et al., 2009). But other methods such as the Event Sampling Method, open-ended questionnaire items, diaries, or protocols of verbalisations during a competition have also provided important insights into the competitive anxiety response (Neil et al., 2009). Similarly, mostly (semi-structured) interviews have been employed to explore experiences of social physique anxiety (e.g., McHugh et al., 2008) and the emotional response to sport injury (Johnston & Carroll, 1998). Oftentimes, qualitative analyses of qualitative research led to the development of questionnaires (Neil et al., 2009). Within the realm of sport, often general, unspecific questionnaires have been employed but also areaspecific questionnaires exist to assess anxiety and specifically trait anxiety. From a general approach, the Manifest Anxiety Scale (Taylor, 1956) or Cattell and Scheier’s (1961) trait-anxiety factor have been early approaches to measure trait anxiety and relate it to performance in motor skills (Spielberger, 1989). More commonly used, however, is the trait version of the State-Trait Anxiety Inventory (Spielberger et al., 1983) that assesses trait anxiety uni-dimensionally and globally with 20 items. Originally developed in English, the questionnaire has been translated in many other languages. The most common measure to assess competitive trait anxiety is the Sport Anxiety Scale (SAS; Smith & Smoll, 1990), more recently in its revised form (Smith et al., 2006). The SAS has seen translations and adaptations into French, German, Norwegian, Spanish, and other languages (Ehrlenspiel & Mesagno, 2022). It is based on a multi-dimensional model and assesses anxiety through scales on competition related worry, somatic anxiety, and concentration disruption. Experiences (“I feel jittery”) are described and one has to indicate to what extent one usually feels that way. Social physique anxiety is commonly assessed with the Social Physique Anxiety Scale (Hart et al., 1989). It originally included 12 items, but problems with its factorial validity have been identified leading to a 9-item (Martin et al., 1997) and a 7-item version (Motl & Conroy, 2001). The questionnaire asks to indicate to what extent statements are characteristic of oneself (e.g., “In the presence of others, I feel apprehensive about my physique/figure”). For the assessment of sport injury anxiety, the sport Injury Trait Anxiety Scale (SITAS; Kleinert, 2002) is often used. It describes 22 situations (e.g., “I already was injured in such a situation”) that indicative of three different types of situations: low situational competency, high situational importance and situational loss of control. Respondents have to identify for each situation to what degree it raises concerns about injury.

Determinants and Risk Factors Early approaches addressed anxiety mainly as a motive disposition that would make people more prone to anxiety reactions paying almost no attention to the function of the situation, (e.g., Taylor, 1953). Modern views conceive of anxiety as being determined by an interaction of personal (trait) and situational factors. The personality trait (trait anxiety) then determines how strong the anxiety reactions to a given situation will be. In the following, person-related and situation-related factors will be introduced separately, whereby the interaction between both factors will also be acknowledged in both sections.

Person Factors In relation to personal factors impacting an individual’s trait anxiety, individual motivational factors and goal setting appear to play a major role. Roberts (1986) argues that achievement motivated athletes are more likely to suffer from anxiety in competitions because they evaluate their performance based on social comparisons 232

Fear and Anxiety in Elite Sport

and outcomes of competitions. These findings were supported by Vealey and Campbell (1988), who found that youth ice skaters were less susceptible to anxiety when they were motivated by learning and applying effort (task orientation) compared to those youth ice skaters comparing themselves to others (ego orientation). Hall and colleagues (1998) similarly show that athletes’ win orientation predicts cognitive anxiety. Taking these findings into account, it is not surprising that many further studies report the personality trait of perfectionism to be a consistent predictor of cognitive anxiety (e.g., Coen & Ogles, 1993; Hall et al., 1998; Saboonchi & Lundh, 1997) and social physique anxiety (e.g., Haase, 2002) in athletes. Perfectionism is associated with the setting of high personal standards and thus with a positive achievement striving in sport (Frost & Henderson, 1991), whereby especially the more extreme form of neurotic perfectionism is a risk factor for anxiety (Hall et al., 1998). Hall and colleagues (1998) furthermore argue that the concern over mistakes, doubts about actions, and personal standards that are associated with neurotic perfectionism, are what foster cognitive as well as somatic anxiety in individuals. These findings go in line with research showing that anxiety may increase in individuals with a high baseline of negative emotionality, or, in other words, individuals scoring high on neuroticism (Krueger, 1999). Balyan et al. (2016) confirm that the personality trait of neuroticism is related to increased somatic anxiety and cognitive anxiety and to decreased self-confidence. Building up on this, it is logical that the personality factors of action and state orientation are also related to anxiety in both athletes (e.g., Landman et al., 2016) and non-athletes (e.g., Chatterjee et al., 2018; Kuhl, 1992). While actionoriented athletes have a good ability to downregulate negative affect, state-oriented athletes tend to struggle with coping after failure and the negative emotions associated with it (Kuhl, 1992). In addition to personality traits, athletes’ identification with their role as an athlete has shown to impact their experienced levels of anxiety (Cosh et al, 2013). Athletes with an exclusive identity as an athlete appear to suffer from higher levels of stress and anxiety (Grove et al., 1997) and show a higher susceptibility to depression and emotional difficulties following injury (Brewer et al., 2010; Green & Weinberg, 2001) and retirement (Horton & Mack, 2000). This is explained by athletes focusing so much on their athlete identity that they experience a crisis when their identity is threatened (Cosh et al., 2013). Looking at self-identity, a different picture emerges. Masten and colleagues (2006) report that higher levels of self-identity, which is more related to self-confidence, are associated with lower levels of trait anxiety in athletes. In other words, athletes who have a clear view of their identity and higher levels of self-confidence have lower levels of trait anxiety, because they are usually better able to cope with stress and have more effective coping strategies. According to Masten et al. (2006), this may also be an explanation for why female athletes are more susceptible to anxiety, since male athletes tend to have higher levels of self-identity. Research has further shown that female athletes show higher levels of depression and eating disorders than male athletes (Kuettel & Larsen, 2020). This can partly be explained to a heightened social physique anxiety in female vs. male athletes (Haase 2002; Hart et al., 1989; Snow & Harris, 1986; Rice et al., 2019). Haase and colleagues (2009) in this context found social physique anxiety and eating disorders in female athletes to be related to the situational factor of whether they performed and individual or team sport. Individual female athletes were more likely to suffer from social physique anxiety than female team sport athletes, especially when they performed an aesthetic individual sport (Gay et al., 2011). A further individual risk factor could be age, as younger athletes are reported to be at higher risk to suffer from anxiety (Rice et al., 2019). This may be due to younger athletes’ lower level of experience with stressful situations and anxiety and due to youth athletes using less efficient coping strategies (Dias et al., 2010). According to Kamal et al. (1995) more experienced athletes also have a higher self-image than less experienced athletes, which may be another explanation for higher levels of anxiety in younger athletes.

Situation Factors Besides individual risk factors increasing a person’s susceptibility to anxiety, studies show that individual differences in anxiety are related to greater lifetime stress exposure (e.g., Slavich et al., 2019; Toussaint et al., 233

Felix Ehrlenspiel et al.

2016). McLoughlin and colleagues (2021) find that the number of experiences of adulthood adversities significantly predicted anxiety independent of age and gender. Furthermore, athletes who had recently experienced adverse life events showed higher levels of anxiety (Rice et al., 2019). Additionally, Rice et al. (2019) report that athletes, who had previously suffered from a concussion or musculoskeletal injury, reported higher global anxiety scores. Foskett and Longstaff (2018) assume that an injury increases anxiety because athletes may not have developed an identity apart from being an athlete. Therefore, as described earlier, an injury constitutes a threat to an athlete’s identity and can cause anxiety as a result. This may also explain why athletes with a lower career satisfaction suffer from higher anxiety levels (Rice et al., 2019). If they are not successful in their career or at least not satisfied with their success, their status as an athlete and therefore the only identity that they have is threatened. A further important factor for the experience of anxiety in athletes is coaching behaviour. Baker and colleagues (2000) report that negative personal rapport significantly predicts a variety of anxieties in sport, presumably because it increases the negative consequences of a bad performance of the athlete. Vealey et al. (1998) even find that coaching styles and behaviour are related to athlete burnout. This appears to be especially the case for controlling coaching behaviours, while autonomy-supportive coaching behaviours are not related to athlete anxiety (Cho et al., 2019). Similarly, Kenow and Williams (1992) suggest that coaches should be supportive and positive when coaching, especially if their athletes are anxious with low levels of self-confidence. Parents’ expectations and their behaviours have a similar impact on anxiety, especially in youth athletes. Athletes who perceive their parents to have high expectations tend to suffer from more anxiety, especially if parental pressure is combined with a low mastery climate (O’Rourke et al., 2011). Furthermore, Kaye and colleagues (2014) found that anxiety experienced as an outcome of parents’ expectations is linked to parents’ achievement motives and their performance-based goals, for example when parents wanted their children to outperform others. Not only coaches or parents, but also the audience increases pressure to perform well (Beilock & Gray, 2012) and competitive anxiety (Paivio & Lambert, 1959) in athletes. Especially aggressive audiences exert a negative impact and increase athletes’ anxiety levels (Purnomo et al., 2019). Besides the experience of stressful life events, injuries, or the behaviour of coaches, parents, and the public, it appears to matter whether athletes exercise a team or individual sport. Pluhar and colleagues (2019) found that team sport may function as a buffering factor against anxiety. According to the authors, this may be due to the individual sport athletes engaging in sport primarily for goal-oriented reasons, compared to team sport athletes exercising their sport for fun. Nixdorf et al. (2016) found higher scores in depression in athletes in individual sport than in athletes in team sport. A strong mediator of the depression scores were negative attributions after failure that was associated with individual sport rather than team sport. A tendency towards negative attributions after failure in terms of attributing failure to a lack of ability is typical for persons high in fear of failure. Overall, to reduce anxiety problems and more generally preserve athletes’ mental health and wellbeing a change in the sport system appears to be necessary. Adjusting the system to the needs of the athletes would involve creating an environment that reduces fears and promotes learning and performance. Psychological research has shown over and over again that energy directed toward fear- and constraint-removal is not only promoting athletes’ mental health and well-being but also in the long-run proves to be more productive than energy directed toward increasing pressures (Gibb 1978, p. 51).

Practical Implications The presented person and situation-related factors offer a variety of starting points for practical prevention and intervention strategies. Strategies that have been shown to be effective in preventing or downregulating anxiety will be discussed following the process model of emotion regulation by Gross (1998). 234

Fear and Anxiety in Elite Sport

According to Gross (1998, 2015), emotions result from different valuation systems and can be regulated at different stages in the process of emotion generation: By selecting a situation, by modifying a situation, through attentional deployment, through cognitive change, or through response modulation. While the first four strategies aim at changing antecedents and thus preventing anxiety to occur, the fifth strategy focuses on changing the anxiety reaction and therefore constitutes an intervention strategy.

Prevention Strategies The first strategy proposed by Gross (1998), situation selection, suggests that situations that create anxiety are avoided. However, in the sport context, this cannot be applied to every situation and, furthermore, avoidance behaviour is usually considered to be maladaptive especially in the treatment of anxiety disorders. Avoidance helps to maintain anxiety through negative reinforcement but may still be useful in some cases (Hofmann & Hay, 2018). An athlete who competes cannot avoid the competition, but if, for example, anxiety increases when an athlete is watching other athletes perform, this situation can easily be avoided or shortened. In this sense, the treatment of anxiety may also involve the gradual selection of situations that the athlete can bear in order to learn and apply the further emotion-regulation strategies. The second of Gross’ (1998) strategies, which can be applied if the situation cannot be selected, is modification of a situation. There are many possible ways in which a situation can be modified. From a prevention perspective, athletes can work on their self-confidence and resilience to anxiety. Famous techniques to increase self-confidence include awareness on strengths and skills. To increase resilience towards anxiety, simulation trainings that simulate a situation, which is expected to increase anxiety, can be used. Furthermore, social support, for example through a team, has been shown to increase athletes’ resilience (Beckmann & Zier, 2011). Sometimes, however, athletes are afraid of unforeseen things that might happen during a competition. Beckmann and Elbe (2015) recommend to make a list of these unforeseen events, along with practicing how to react to them. Additionally, it is useful to familiarise oneself with an unknown competition location before the start of the competition and to identify the potential threats in the competitive situation. The goal is to transform the more abstract threat that can be seen as characteristic of anxiety, to more concrete and imminent potential threats related to fear, so that the athlete can plan ahead on how to deal with the potential threats and thus change the upcoming situation for him or her. The third strategy (Gross, 1998) is to prevent the development of anxiety through attentional deployment. Athletes can learn to control their attention and direct it away from potentially threatening stimuli (e.g., opponent or audience) towards stimuli that have a calming effect (e.g., own breath). This process of attentional deployment can further be supported by the use of pre-performance routines (e.g., Mesagno & Mullane-Grant, 2010) or strategic self-talk (Galanis et al., 2021). Gross’ (1998) fourth strategy of cognitive change aims at a cognitive re-evaluation of potential threats by the athlete. One of the most prominent approaches is cognitive reframing. Athletes learn to recognise negative thoughts and to restructure their content into positive thoughts. A further strategy includes relativisation of the situation. With this strategy, the athlete attempts to put the situation into a broader perspective, reaching the perception that the situation may seem threatening but, compared to other, rationally more important situations in life, is not all that significant and thus less threatening. The fifth of Gross’ strategies constitutes a strategy that addresses the regulation of an emotion that has already emerged. Once anxiety occurs, there are several response modulation techniques that can be used as an intervention.

Intervention Strategies Response modulation strategies include all strategies that change a person’s response to anxiety (Gross, 1998). A simple but effective form consists of concentration on breathing (e.g., Koole, 2010). Particularly, a focus 235

Felix Ehrlenspiel et al.

on prolonged exhalation has proven to effectively eliminate disturbing, anxiety-inducing thoughts and the physiological arousal that accompanies them. In the breathing intervention, inhaling occurs automatically, while exhaling is actively prolonged. Breathing techniques are furthermore incorporated in a variety of relaxation methods that can be used to downregulate anxiety, once they are trained on a regular basis. Relaxation trainings like progressive muscle relaxation or autogenic training have proven to be effective in helping athletes cope with anxiety, but an application immediately before participating in a competition is not recommended, as the techniques may interfere with the optimal level of functioning. Thus, progressive muscle relaxation and autogenic training need to be taught well in advance to educate athletes about the regulation of anxiety responses and about finding their optimal level of performance. Another technique that may be used to intervene with an anxiety response is “embodiment”, the regulation of the mental state through bodily states (Gallagher, 2005). Bodily states, for example, include physical expression, posture, and body tension. The body posture influences information processing, motivation, and particularly how one feels. The body posture can be consciously controlled. Some embodiment techniques have proven to be useful in reducing acute anxiety or fear (e.g., Fuchs & Koch, 2014). An upright stance can support feelings of self-confidence and reduce anxiety-induced worries (e.g., Weineck et al., 2020). Another embodiment technique is the dynamic handgrip executed with the left hand. The left hand is clenched dynamically for about 10 to 15 seconds which interferes with worries and generates a relaxed mind. The dynamic handgrip has proven to be effective in reducing anxiety and chocking under pressure in right-handed athletes in several studies and practical experiences (cf. Beckmann et al., 2013; Beckmann et al., 2021). In addition to relaxation methods and embodiment, systematic desensitisation can be used in sport (e.g, Feltz & Landers, 1980; Kish, & Badami, 2019). For example, if a gymnast is afraid of practice on a gymnastic apparatus after injuring him or herself painfully on the high bar. Step by step, from just watching the high bar from a safe distance to seeing himself actually perform, the athlete will be brought back to the high bar. An important element is that each step is preceded by the induction of a relaxed and comfortable state. Frequently, athletes are overwhelmed by anxiety instead of fully immersing themselves in the present moment. Mindfulness is an approach that is increasingly addressed in sport psychology (Moore, 2009). Mindfulness, or non-judgmental present-moment awareness, may help athletes improve their concentration, thus helping them improve their sport performances (Bernier et al., 2009). Furthermore, being mindful can also help athletes enjoy their sport and reduce anxiety which can reduce the potential for mental health issues and improve well-being (Bernier et al., 2009). Personalising anxiety has also proven to be helpful, especially in younger athletes, if the preceding approaches do not work. The athlete can be asked to describe his or her anxiety in terms of something concrete, a fictitious person or animal, or a substance. Questions are asked on how big the anxiety is, what colour it is, and so forth in order to make the anxiety more tangible. The athlete should then name the anxiety. In the next step, it is possible to address and talk to the “red dragon Jeremy”, so that one may learn to accept it and perhaps even find something positive about it. One could then find ways to close it off (cf, Boyes, 2015; Seemann, 2009).

Future Directions The presented findings illustrate that high anxiety threatens mental health and well-being significantly. Thus, a main implication for applied sport psychology should be the development of interventions to prevent and intervene with high anxiety. Research, on the other hand, should further our understanding of the relation between anxiety and anxiety disorders in athletes. Repeated exposure to anxiety within the sport domain could be both a risk factor as well as an opportunity to develop coping skills to be used in other contexts. 236

Fear and Anxiety in Elite Sport

To reach sustainable changes and prevent anxiety, research should investigate how children and adolescents in elite sport experience anxiety and what the main sources of their anxiety are. Complementary, long-term effects of sport enjoyment and sport participation on well-being need to be investigated. Looking at prevention possibilities from an applied perspective, child and youth development plays a major role. Personality development should be implemented in elite sport from an early age on. Youth athletes could for example be educated on the recognition of individual age specific stressors and need to be guided in developing effective coping techniques based on their individual personality characteristics. Therefore, the development of observational measures for the assessment of anxiety is needed. In addition to the development of sustainable youth development approaches, situational factors fostering anxiety in elite athletes should be altered, in order to create an environment with fewer stressors and sources of anxiety. Furthermore, the gender aspect needs to be included. Particularly, anxiety in female athletes should be considered more detailed in both applied sport psychology and research. Although it has become clear that females tend to report and experience higher levels of anxiety, the specific mechanisms behind that phenomenon are mostly unclear. Research needs to take a more comprehensive approach considering cultural, social and environmental factors and take a quantitative and qualitative approach (Perry et al., 2021). Such research could provide ideas for creating sport psychological support that is more gender sensitive. Another topic that should be subject of discussion in future research and practice is the topic of anxiety in para-elite athletes. While some research on the topic of anxiety in para-elite athletes exists (e.g., Bosma & Van Yperen, 2020; Silva et al., 2012; Rodrigues et al., 2015, 2017), research and interventions addressing the anxiety of para-elite athletes are still underrepresented (Rice et al., 2019). Overall, a new perspective on anxiety needs to be established in the future, focusing on the benefits of experiencing and managing anxiety on personal development. For example, the development of coping skills and the feelings of mastery and success, associated with the overcoming of anxiety, constitute factors that connect the seemingly negative emotion of anxiety with functional aspects, like using anxiety to improve competitive preparation, and positive outcomes, such as reduced stress and increased well-being.

Summary Elite sport can be accompanied by a variety of forms of anxiety such as competitive anxiety, sport injury anxiety, or social physique anxiety. Anxiety potentially decreases well-being and mental health in athletes. Risk factors to increase the likelihood of experiencing anxiety include individual factors, mainly characterised by different personality traits, or situational factors like life-time stress exposure or coaching style. Whenever possible, prevention strategies should be used and implemented particularly in the development of youth athletes. In addition to their regular training and practice they should acquire possible intervention strategies to cope with perceived threat situations. Thus, future prevention and intervention strategies should especially focus on youth development based on individual characteristics and on the creation of an elite sport environment with reduced pressures resulting in anxiety. A focus on the positive effects of anxiety management on personal development and life mastery would support a sustainable implementation.

References Bandelow, B., Lichte, T., Rudolf, S., Wiltink, J., & Beutel, E.M. (2014). The diagnosis of and treatment recommendations for anxiety disorders. Deutsches Ärzteblatt International, 111(27-28), 473. 10.3238/arztebl.2014.0473 Baker, J., Côté, J., & Hawes, R. (2000). The relationship between coaching behaviours and sport anxiety in athletes. Journal of Science and Medicine in Sport, 3, 110–119. 10.1016/S1440-2440(00)80073-0 Balyan, K.Y., Tok, S., Tatar, A., Binboga, E., & Balyan, M. (2016). The relationship among personality, cognitive anxiety, somatic anxiety, physiological arousal, and performance in male athletes. Journal of Clinical Sport Psychology, 10, 48–58. 10.1123/jcsp.2015-0013.

237

Felix Ehrlenspiel et al. Barlow, M., Woodman, T., & Hardy, L. (2013). Great expectations: Different high-risk activities satisfy different motives. Journal of Personality and Social Psychology, 105, 458–475. 10.1037/a0033542 Barnett, N.P., Smoll, F.L., & Smith, R.E. (1992). Effects of enhancing coach-athlete relationships on youth sport attrition. The Sport Psychologist, 6, 111–127. 10.1123/tsp.6.2.111 Beckmann, J., & Elbe, A.M. (2015). Sport psychological interventions in competitive sport. Newcastle, UK: Cambridge Scholars Publishing. Beckmann J., Fimpel L., & Wergin V.V. (2021). Preventing a loss of accuracy of the tennis serve under pressure. PLoS ONE, 16, e0255060. 10.1371/journal.pone.0255060 Beckmann, J., Gröpel, P., & Ehrlenspiel, F. (2013). Preventing motor skill failure through hemisphere-specific priming: Cases from choking under pressure. Journal of Experimental Psychology: General, 142, 679–691. 10.1037/ a0029852 Beckmann, J., & Zier, E. (2011). Extreme Beanspruchung und ihre Folgen beim jugendlichen Leistungssportler. In T. Wörz & J. Lecheler (Hrsg.), Die Psyche des Leistungssportlers: Die komplexe Herausforderung, ein Talent zu begleiten (S. 23–28). Lengerich: Pabst Science Publishers. Beilock, S.L., & Carr, T.H. (2001). On the fragility of skilled performance: What governs choking under pressure? Journal of Experimental Psychology: General, 130, 701–725. 10.1037/0096-3445.130.4.701 Beilock, S.L., & Gray, R. (2007). Why do athletes choke under pressure? In G. Tenenbaum & R.C. Eklund (Eds.), Handbook of sports psychology (pp. 425–444). John Wiley & Sons, Inc. Beilock, S.L., & Gray, R. (2012). From attentional control to attentional spillover: A skill‐level investigation of attention, movement, and performance outcomes. Human Movement Science, 31(6), 1473–1499. Bernier, M., Thienot, E., Codron, R., & Fournier, J.F. (2009). Mindfulness and acceptance approaches in sport performance. Journal of Clinical Sport Psychology, 4, 320–333. 10.1123/jcsp.3.4.320 Bosma, N., & Van Yperen, N.W. (2020). A quantitative study of the impact of functional classification on competitive anxiety and performance among wheelchair basketball athletes. Frontiers in Psychology, 11, 2462. 10.3389/ fpsyg.2020.558123 Boyes, A. (2015). The anxiety toolkit. New York: Penguin Putnam. Brewer, B., Cornelius, A.E., Stephan, Y., & Van Raalte, J., (2010). Self-protective changes in athletic identity following anterior cruciate ligament reconstruction. Psychology of Sport and Exercise, 11, 1–5. 10.3389/fpsyg.2020.55 8123 Brewer, B.W., & Redmond, C. (2016). Psychology of sport injury. Human Kinetics. Cagle, J.A., Overcash, K.B., Rowe, D.P., & Needle, A.R. (2017). Trait anxiety as a risk factor for musculoskeletal injury in athletes: A critically appraised topic. International Journal of Athletic Therapy and Training, 22, 26–31. 10.1123/ijatt.2016-0065 Cattell, R.B., & Scheier, I.H. (1961). The meaning and measurement of neuroticism and anxiety. Ronald Press. Chatterjee, M.B., Baumann, N., Osborne, D., Mahmud, S.H., & Koole, S.L. (2018). Cross-cultural analysis of volition: Action orientation is associated with less anxious motive enactment and greater well-being in Germany, New Zealand, and Bangladesh. Frontiers in Psychology, 9, 1043. 10.3389/fpsyg.2018.01043 Cheng, W.N.K., Hardy, L., & Markland, D. (2009). Toward a three-dimensional conceptualization of performance anxiety: Rationale and initial measurement development. Psychology of Sport & Exercise, 10, 271–278. 10.1016/ j.psychsport.2008.08.001 Cho, S., Choi, H., & Kim, Y. (2019). The relationship between perceived coaching behaviors, competitive trait anxiety, and athlete burnout: A cross-sectional study. International Journal of Environmental Research and Public Health, 16(8), 1424. 10.3390/ijerph16081424 Coen, S.P., & Ogles, B.M. (1993). Psychological characteristics of the obligatory runner: A critical examination of the anorexia analogue hypothesis. Journal of Sport and Exercise Psychology, 15, 338–354. Cosh, S., LeCouteur, A., Crabb, S., & Kettler, L. (2013). Career transitions and identity: A discursive psychological approach to exploring athlete identity in retirement and the transition back into elite sports. Qualitative Research in Sport, Exercise and Health, 5, 21–42. 10.1123/jsep.15.3.338 Crawford, S., & Eklund, R.C. (1994). Social physique anxiety, reasons for exercise, and attitudes toward exercise settings. Journal of Sport and Exercise Psychology, 16, 70–82. 10.1123/jsep.16.1.70 Dias, C., Cruz, J.F.A., & Fonseca, A.M. (2010). Coping strategies, multidimensional competitive anxiety and cognitive threat appraisal: Differences across sex, age and type of sport. Serbian Journal of Sport Sciences, 1, 4–9. Diener E. (2009) Subjective well-being. In E. Diener (ed.), The science of well-being. Social Indicators Research Series, vol. 37 (pp. 11–58). Springer, Dordrecht. 10.1007/978-90-481-2350-6_2 Dunn, J.G. (1999). A theoretical framework for structuring the content of competitive worry in ice hockey. Journal of Sport and Exercise Psychology, 21, 259–279. 10.1123/jsep.21.3.259

238

Fear and Anxiety in Elite Sport Ehrlenspiel, F., Erlacher, D., & Ziegler, M. (2018). Changes in subjective sleep quality before a competition and their relation to competitive anxiety. Behavioral Sleep Medicine, 16, 553–568. 10.1080/15402002.2016.1253012 Ehrlenspiel, F., Graf, K., Kühn, C., & Brand, R. (2011). Stabilitat und Variabilitat von Wettkampfangst [Stability and variability of competitive anxiety]. Zeitschrift für Sportpsychologie, 18, 31–43. 10.1026/1612-5010/a000034 Ehrlenspiel, F., & Mesagno, C. (2022). Anxiety in sport. In J. Schüler, M. Wegner, H. Plessner, & R.C. Eklund (Eds.), Sport psychology - theory and application (in print). Springer Nature. Erlacher, D., Ehrlenspiel, F., Adegbesan, O.A., & Galal El-Din, H. (2011). Sleep habits in German athletes before important competitions or games. Journal of Sports Sciences, 29, 859–866. 10.1080/02640414.2011.565782 Eysenck, M.W. (1979). Anxiety, learning, and memory: A reconceptualization. Journal of Research in Personality, 13, 363–385. 10.1016/0092-6566(79)90001-1 Eysenck, M.W., Derakshan, N., Santos, R., & Calvo, M.G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336–353. 10.1037/1528-3542.7.2.336 Feltz, D.L., & Landers, D.M. (1980). Stress management techniques for sport and physical education. Journal of Physical Education and Recreation, 51(2), 41–43. 10.1080/00971170.1980.10624087 Ford, J.L., Ildefonso, K., Jones, M.L., & Arvinen-Barrow, M. (2017). Sport-related anxiety: current insights. Open Access Journal of Sports Medicine, 8, 205–212. 10.2147/OAJSM.S125845 Foskett, R.L., & Longstaff, F. (2018). The mental health of elite athletes in the United Kingdom. Journal of Science and Medicine in Sport, 21, 765–770. 10.1016/j.jsams.2017.11.016 Frost, R.O., & Henderson, K.J. (1991). Perfectionism and reactions to athletic competition. Journal of Sport and Exercise Psychology, 13, 323–335. 10.1123/jsep.13.4.323 Fuchs, T., & Koch, S.C. (2014). Embodied affectivity: On moving and being moved. Frontiers in Psychology, 5, 508. 10.3389/fpsyg.2014.00508 Galanis, E., Hatzigeorgiadis, A., Comoutos, N., Papaioannou, A., Morres, I.D., & Theodorakis, Y. (2021). Effects of a strategic self-talk intervention on attention functions. International Journal of Sport and Exercise Psychology, 1–15. 10. 1080/1612197X.2021.1963304 Gallagher, S. (2005).How the body shapes the mind. Oxford, England: Oxford University Press. Gay, J.L., Monsma, E.V., & Torres-McGehee, T.M. (2011). Developmental and contextual risks of social physique anxiety among female athletes. Research Quarterly for Exercise and Sport, 82, 168–177. 10.1080/02701367.2011.105 99744 Gibb, J. (1978). Trust: A new view of personal and organizational development. Los Angeles, CA: Guild of Tutors Press. Gould, D., Bridges, D., Udry, E., & Beck, L. (1997). Stress sources encountered when rehabilitating from seasonending ski injuries. The Sport Psychologist, 11, 361–378. 10.1123/tsp.11.4.361 Green, S., & Weinberg, R., 2001. Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational participants. Journal of Applied Sport Psychology, 13, 40–59. 10.1080/ 10413200109339003 Gross, J.J. (1998). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74, 224–237. 10.1037/0022-3514.74.1.224 Gross, J.J. (2015). The extended process model of emotion regulation: Elaborations, applications, and future directions. Psychological Inquiry, 26, 130–137. 10.1080/1047840X.2015.989751 Grove, J.R., Lavallee, D., & Gordon, S., 1997. Coping with retirement from sport: The influence of athletic identity. Journal of Applied Sport Psychology, 9, 191–203. 10.1080/10413209708406481 Haase, A.M. (2009). Physique anxiety and disordered eating correlates in female athletes: Differences in team and individual sports. Journal of Clinical Sport Psychology, 3, 218–231. 10.1123/jcsp.3.3.218 Haase, A.M., Prapavessis, H., & Owens, R.G. (2002). Perfectionism, social physique anxiety and disordered eating: A comparison of male and female elite athletes. Psychology of Sport and Exercise, 3, 209–222. 10.1016/S1469-0292(01) 00018-8 Hall, H.K., Kerr, A.W., & Matthews, J. (1998). Precompetitive anxiety in sport: The contribution of achievement goals and perfectionism. Journal of Sport and Exercise Psychology, 20, 194–217. 10.1123/jsep.20.2.194 Hanin, Y. (1978) A study of anxiety in sports. In W.F. Straub (Ed.), Sport psychology: An analysis of athlete behavior (pp. 236–249). Movement Publications. Hanin, Y.L. (1995). Individual zones of optimal functioning (IZOF) model: An idiographic approach to performance anxiety. In K. Henschen & W. Straub (Eds.), Sport Psychology: an Analysis of Athlete Behavior. (pp. 103–119). Movement Publications. Hanin, Y.L. (Ed.). (2000). Emotions in sport. Champaign, Illinois: Human Kinetics. Hanin, Y.L. (2004). Emotions in sport: An individualized approach. In C.D. Spielberger (Ed.), Encyclopedia of Applied Psychology, vol. 1 (pp. 739–750). Elsevier Academic Press.

239

Felix Ehrlenspiel et al. Hanin Y. (2007). Emotions in sport: Current issues and perspectives. In G. Tenenbaum & R.C. Eklund (Eds.), Handbook of sports psychology 3rd ed. (pp. 31–58). John Wiley & Sons. Hanton, S., Fletcher, D., & Coughlan, G. (2005). Stress in elite sports performers: A comparative study of competitive and organizational stressors. Journal of Sports Sciences, 23(10), 1129–1141. 10.1080/02640410500131480 Hanton, S., Wadey, R., & Connaughton, D. (2005). Debilitative interpretations of competitive anxiety: A qualitative examination of elite performers. European Journal of Sport Science, 5, 123–136. 10.1080/17461390500238499 Hardy, L. (1990). A catastrophe model of performance in sport. In J.G. Jones & L. Hardy (Eds.), Stress and performance in sport (pp. 81–106). John Wiley & Sons. Hardy, L., & Parfitt, G. (1991). A catastrophe model of anxiety and performance. British Journal of Psychology, 82, 163–178. 10.1111/j.2044-8295.1991.tb02391.x Hart, E.A., Leary, M.R., & Rejeski, W.J. (1989). The measurement of social physique anxiety. Journal of Sport and Exercise Psychology, 11, 94–104. 10.1123/jsep.11.1.94 Heil, J. (1993). Mental training in injury management. In J. Heil (Ed.), Psychology of sport injury (pp. 151–174). Human Kinetics. Hill, D.M., Carvell, S., Matthews, N., Weston, N.J., & Thelwell, R.R. (2017). Exploring choking experiences in elite sports: The role of self-presentation. Psychology of Sport and Exercise, 33, 141–149. 10.1016/j.psychsport. 2017.09.001 Hill, D.M., Cheesbrough, M., Gorczynski, P., & Matthews, N. (2019). The consequences of choking in sport: A constructive or destructive experience? The Sport Psychologist, 33, 12–22. 10.1123/tsp.2018-0070 Hill, D.M., Hanton, S., Matthews, N., & Fleming, S. (2011). Alleviation of choking under pressure in elite golf: An action research study. The Sport Psychologist, 25, 465–488. 10.1123/tsp.25.4.465 Hofmann, S.G., & Hay, A.C. (2018). Rethinking avoidance: Toward a balanced approach to avoidance in treating anxiety disorders. Journal of Anxiety Disorders, 55, 14–21. 10.1016/j.janxdis.2018.03.004 Horton, R.S., & Mack, D.E. (2000). Athletic identity in marathon runners: Functional focus or dysfunctional commitment? Journal of Sport Behavior, 23, 101–119. Hsu, C.J., Meierbachtol, A., George, S.Z., & Chmielewski, T.L. (2017). Fear of reinjury in athletes: Implications for rehabilitation. Sports Health, 9, 162–167. 10.1177/1941738116666813 Jensen, S.N., Ivarsson, A., Fallby, J., Dankers, S., & Elbe, A.M. (2018). Depression in Danish and Swedish elite football players and its relation to perfectionism and anxiety. Psychology of Sport and Exercise, 36, 147–155. 10.1016/ j.psychsport.2018.02.008 Johnston, L.H., & Carroll, D. (1998). The context of emotional responses to athletic injury: a qualitative analysis. Journal of Sport Rehabilitation, 7, 206–220. 10.1123/jsr.7.3.206 Jones, G., & Swain, A. (1995). Predispositions to experience debilitative and facilitative anxiety in elite and nonelite performers. The Sport Psychologist, 9, 201–211. 10.1123/tsp.9.2.201 Junge, A., & Feddermann-Demont, N. (2016). Prevalence of depression and anxiety in top-level male and female football players. BMJ Open Sport & Exercise Medicine, 2, e000087. 10.1136/bmjsem-2015-000087 Kamal, A.F., Blais, C., Kelly, P., & Ekstrand, K. (1995). Self-esteem attributional components of athletes versus nonathletes. International Journal of Sport Psychology, 26, 189–195. Kaye, M.P., Frith, A., & Vosloo, J. (2014). Dyadic anxiety in youth sport: The Relationship of achievement goals with anxiety in young athletes and their parents. Journal of Applied Sport Psychology, 27, 171–185. 10.1080/104132 00.2014.970717 Kenow, L.J., & Williams, J.M. (1992). Relationship between anxiety, self-confidence, and evaluation of coaching behaviors. The Sport Psychologist, 6, 344–357. 10.1123/tsp.6.4.344 Koole, S.L. (2010). The psychology of emotion regulation: An integrative review. In Houwer, & Hermans (Eds.), Cognition and emotion – Reviews of current research and theories (pp. 138–177). Psychology Press. Kleinert, J. (2002). An approach to sport injury trait anxiety: Scale construction and structure analysis. European Journal of Sport Science, 2(3), 1–12. 10.1080/17461390200072305 Klint, K.A., & Weiss, M.R. (1986). Dropping in and dropping out: Participation motives of current and former youth gymnasts. Canadian Journal of Applied Sport Sciences, 11(2), 106–114. Kirschenbaum, D.S., Parham, W.D., & Murphy, S.M. (1993). Provision of sports psychology services at Olympic events: The 1991 US Olympic Festival and beyond. The Sport Psychologist, 7, 419–440. Kuettel, A., & Larsen, C.H. (2020). Risk and protective factors for mental health in elite athletes: A scoping review. International Review of Sport and Exercise Psychology, 13, 231–265. 10.1080/1750984X.2019.1689574 Kuhl, J. (1992). A theory of self‐regulation: Action versus state orientation, self‐discrimination, and some applications. Applied Psychology, 41, 97–129. 10.1111/j.1464-0597.1992.tb00688.x Krueger, R.F. (1999). Personality traits in late adolescence predict mental disorders in early adulthood: A perspective‐epidemiological study. Journal of Personality, 67, 39–65. 10.1111/1467-6494.00047

240

Fear and Anxiety in Elite Sport Laborde, S., Allen, M.S., Katschak, K., Mattonet, K., & Lachner, N. (2020). Trait personality in sport and exercise psychology: A mapping review and research agenda. International Journal of Sport and Exercise Psychology, 18, 701–716. 10.1080/1612197X.2019.1570536 Landman, A., Nieuwenhuys, A., & Oudejans, R.R. (2016). Decision-related action orientation predicts police officers’ shooting performance under pressure. Anxiety, Stress, & Coping, 29, 570–579. 10.1080/10615806.2015. 1070834 Lazarus, R.S. (1999). Stress and emotion: A new synthesis. Springer. Leary, M.R. (1992). Self-presentational processes in exercise and sport. Journal of Sport and Exercise Psychology, 14, 339–351. 10.1123/jsep.14.4.339 Leary, M.R., & Kowalski, R.M. (1997). Social anxiety. Guilford Press. Lemyre, P.-N., Roberts, G.C., & Stray-Gunderson, J. (2007). Motivation, overtraining, and burnout: Can selfdetermined motivation predict overtraining and burnout in elite athletes? European Journal of Sport Science, 7, 115–126. 10.1080/17461390701302607 Liebert, R.M., & Morris, L.W. (1967). Cognitive and emotional components of test anxiety: A distinction and some initial data. Psychological Reports, 20, 975–978. 10.2466/pr0.1967.20.3.975 Martens, R.S., Vealey, R.S., & Burton, D. (1990). Competitive anxiety in sport. Human Kinetics. Martin, K.A., & Mack, D. (1996). Relationships between physical self-presentation and sport competition trait anxiety: A preliminary study. Journal of Sport and Exercise Psychology, 18, 75–82. 10.1123/jsep.18.1.75 Martin, K.A., Rejeski, W.J., Leary, M.R., McAuley, E., & Bane, S. (1997). Is the social physique anxiety scale really multidimensional? Conceptual and statistical arguments for a unidimensional model. Journal of Sport and Exercise Psychology, 19, 359–367. 10.1123/jsep.19.4.359 Masten, R., Tušak, M., & Faganel, M. (2006). Impact of identity on anxiety in athletes. Kinesiology, 38, 126–134. Masters, R., & Maxwell, J. (2008). The theory of reinvestment. International Review of Sport and Exercise Psychology, 1, 160–183. 10.1080/17509840802287218 Mauss, I.B., & Robinson, M.D. (2009). Measures of emotion. A review. Cognition and Emotion, 23, 209–237. 10.1080/ 02699930802204677 McEvoy, P.M., Watson, H., Watkins, E.R., & Nathan, P. (2013). The relationship between worry, rumination, and comorbidity: Evidence for repetitive negative thinking as a transdiagnostic construct. Journal of Affective Disorders, 151, 313–320. 10.1016/j.jad.2013.06.014 McHugh, T.L.F., Kowalski, K.C., Mack, D.E., Crocker, P.R., Junkin, S.E., Lejbak, L.K., & Martin, S. (2008). Young women’s experiences of social physique anxiety. Feminism & Psychology, 18, 231–252. 10.1177/09593535 07088593 McLoughlin, E., Fletcher, D., Slavich, G.M., Arnold, R., & Moore, L.J. (2021). Cumulative lifetime stress exposure, depression, anxiety, and well-being in elite athletes: A mixed-method study. Psychology of Sport and Exercise, 52, 101823. 10.1016/j.psychsport.2020.101823 Meijen, C., Jones, M.V., McCarthy, P.J., Sheffield, D., & Allen, M.S. (2013). Cognitive and affective components of challenge and threat states. Journal of Sports Sciences, 31(8), 847–855. 10.1080/02640414.2012.753157 Mellalieu, S.D., Hanton, S., & Fletcher, D. (2006). A competitive anxiety review: Recent directions in sports psychology research. Nova Science Publishers. Mellalieu, S.D., Neil, R., Hanton, S., & Fletcher, D. (2009). Competition stress in sport performers: Stressors experienced in the competition environment. Journal of Sports Sciences, 27, 729–744. 10.1080/02640410902889834 Mesagno, C., & Beckmann, J. (2017). Choking under pressure: Theoretical models and interventions. Current opinion in psychology, 16, 170–175. 10.1016/j.copsyc.2017.05.015 Mesagno, C., Harvey, J.T., & Janelle, C.M. (2011). Self-presentation origins of choking: Evidence from separate pressure manipulations. Journal of Sport and Exercise Psychology, 33, 441–459. 10.1123/jsep.33.3.441 Mesagno, C., & Hill, D. (2013). Choking under pressure: Is there chaos in the brickyard. International Journal of Sport Psychology, 44, 288–293. 10.7352/IJSP2013.44.267 Mesagno, C., & Mullane-Grant, T. (2010). A comparison of different pre-performance routines as possible choking interventions. Journal of Applied Sport Psychology, 22, 343–360. 10.1080/10413200.2010.491780 Moore, Z.E. (2009). Theoretical and empirical developments of the mindfulness-acceptance-commitment (MAC) approach to performance enhancement. Journal of Clinical Sport Psychology, 4, 291–302. Motl, R.W., & Conroy, D.E. (2001). The social physique anxiety scale: Cross validation, factorial invariance, and latent mean structure. Measurement in Physical Education and Exercise Science, 5, 81–95. 10.1207/S15327841 MPEE0502_2 Neil, R., Mellalieu, S.D., & Hanton, S. (2009). The contribution of qualitative inquiry towards understanding competitive anxiety and competition stress. Qualitative Research in Sport and Exercise, 1, 191–205. 10.1080/1939844 0902909058

241

Felix Ehrlenspiel et al. Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7, 313–326. 10.1123/jcsp.7.4.313 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893 O’Rourke, D., Smith, R.E., Smoll, F.L., & Cumming, S.P. (2011) Trait anxiety in young athletes as a function of parental pressure and motivational climate: Is parental pressure always harmful? Journal of Applied Sport Psychology, 23(4), 398–412, 10.1080/10413200.2011.552089 Paivio, A., & Lambert, W.E. (1959). Measures and correlates of audience anxiety. Journal of Personality, 27, 1–17. 10.1111/j.1467-6494.1959.tb01813.x Perry, C., Champ, F.M., Macbeth, J., & Spandler, H. (2021). Mental health and elite female athletes: A scoping review. Psychology of Sport and Exercise, 56, 101961. 10.1016/j.psychsport.2021.101961 Pluhar, E., McCracken, C., Griffith, K.L., Christino, M.A., Sugimoto, D., & Meehan III, W.P. (2019). Team sport athletes may be less likely to suffer anxiety or depression than individual sport athletes. Journal of Sports Science & Medicine, 18, 490–496. Rice, S.M., Gwyther, K., Santesteban-Echarri, O., Baron, D., Gorczynski, P., Gouttebarge, V., … & Purcell, R. (2019). Determinants of anxiety in elite athletes: A systematic review and meta-analysis. British Journal of Sports Medicine, 53(11), 722–730. 10.1136/bjsports-2019-100620 Roberts, G.C. (1986). The perception of stress: A potential source and its development. In M.R. Weiss & D.R. Gould (Eds.), Sport for children and youths (pp. 119–126). Human Kinetics. Robinson, G., & Freeston, M. (2015). Intolerance of uncertainty as a predictor of performance anxiety and robustness of sport confidence in university student-athletes. Journal of Clinical Sport Psychology, 9, 335–344. 10.1123/jcsp.2 015-0008 Rodrigues, D.F., Silva, A., Rosa, J.P.P., Ruiz, F.S., Veríssimo, A.W., Winckler, C., … & de Mello, M.T. (2015). Sleep quality and psychobiological aspects of Brazilian Paralympic athletes in the London 2012 pre-Paralympics period. Motriz: Revista de Educação Física, 21, 168–176. 10.1590/S1980-65742015000200007 Rodrigues, D.F., Silva, A., Rosa, J.P.P., Ruiz, F.S., Veríssimo, A.W., Winckler, C., … & de Mello, M.T. (2017). Profiles of mood states, depression, sleep quality, sleepiness, and anxiety of the Paralympic athletics team: A longitudinal study. Apunts. Medicina de l’Esport, 52(195), 93–101. 10.1016/j.apunts.2016.11.002 Sabiston, C.M., Pila, E., Pinsonnault-Bilodeau, G., & Cox, A.E. (2014). Social physique anxiety experiences in physical activity: A comprehensive synthesis of research studies focused on measurement, theory, and predictors and outcomes. International Review of Sport and Exercise Psychology, 7, 158–183. 10.1080/1750984X.2014.904392 Saboonchi, F., & Lundh, L.G. (1997). Perfectionism, self-consciousness and anxiety. Personality and Individual Differences, 22, 921–928. 10.1016/S0191-8869(96)00274-7 Sallis, R.E., Jones, K., Sunshine, S., Smith, G., & Simon, L. (2001). Comparing sports injuries in men and women. International Journal of Sports Medicine, 22, 420–423. 10.1055/s-2001-16246 Samuel, R.D. (2013). Counseling athletes in career change-events: Applying the scheme of change for sports psychology practice. Journal of Sport Psychology in Action, 4, 152–168. 10.1080/21520704.2013.804015 Samulski, D.M., & Lopes, M.C. (2008). Counseling Brazilian athletes during the Olympic Games in Athens 2004: Important issues and intervention techniques. International Journal of Sport and Exercise Psychology, 6, 277–286. 10.1 080/1612197X.2008.9671872 Sarrazin, P., Vallerand, R., Guillet, E., Pelletier, L., & Cury, F. (2002). Motivation and dropout in female handballers: A 21-month prospective study. European Journal of Social Psychology, 32, 395–418. 10.1002/ejsp.98 Seemann,H. (2009). Psychosomatische Schmerzen. In D. Revenstorf & B. Peter (Eds.), Hypnose in Psychotherapie, Psychosomatik und Medizin (2nd ed., pp. 585–602). Springer. Short, S.E., Reuter, J., Brandt, J., Short, M.W., & Kontos, A.P. (2004). The relationships among three components of perceived risk of injury, previous injuries and gender in contact sport athletes. Athletic Insight, 6, 78–85. Silva, A., Queiroz, S.S., Winckler, C., Vital, R., Sousa, R.A., Fagundes, V., … & de Mello, M.T. (2012). Sleep quality evaluation, chronotype, sleepiness and anxiety of Paralympic Brazilian athletes: Beijing 2008 Paralympic Games. British Journal of Sports Medicine, 46, 150–154. 10.1136/bjsm.2010.077016 Slavich, G.M., Stewart, J.G., Esposito, E.C., Shields, G.S., & Auerbach, R.P. (2019). The stress and adversity inventory for adolescents (Adolescent STRAIN): Associations with mental and physical health, risky behaviors, and psychiatric diagnoses in youth seeking treatment. Journal of Child Psychology and Psychiatry, 60(9), 998–1009. 10.1111/jcpp.13038 Smith, R.E., Smoll, F.L., & Schutz, R.W. (1990). Measurement and correlates of sport-specific cognitive and somatic trait anxiety: The sport anxiety scale. Anxiety Research, 2, 263–280. 10.1080/08917779008248733

242

Fear and Anxiety in Elite Sport Smith, R.E., Smoll, F.L., Cumming, S.P., & Grossbard, J.R. (2006). Measurement of multidimensional sport performance anxiety in children and adults: The sport anxiety scale-2. Journal of Sport and Exercise Psychology, 28, 479–501. 10.1123/jsep.28.4.479 Snow, J.T., & Harris, M.B. (1986). An analysis of weight and diet content in five women’s interest magazines. Journal of Obesity and Weight Regulation, 5, 194–214. Spielberger, C.D. (1966). Theory and research on anxiety. In C.D. Spielberger (Hrsg.), Anxiety and Behavior (S. 3–19). Academic Press. Spielberger, C.D. (1989). Stress and anxiety in sports. In D. Hackfort & D. Spielberger, (Eds.), Anxiety in sports: An international perspective (pp. 3–17). Hemisphere. Spielberger, C.D., Gorsuch, R.L., Lushene, T.E., Vagg, P.R., & Jacobs, G.A. (1983). Manual for the state-trait anxiety inventory. Consulting Psychologists Press. Spitzer, R.L., Kroenke, K., Williams, J.B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. 10.1001/archinte.166.10.1092 Sweeny, K., & Dooley, M.D. (2017). The surprising upsides of worry. Social and Personality Psychology Compass, 11, e12311. 10.1111/spc3.12311 Taylor, J.A. (1953). A personality scale of manifest anxiety. The Journal of Abnormal and Social Psychology, 48, 285–290. 10.1037/h0056264 Taylor, J.A. (1956). Drive theory and manifest anxiety. Psychological Bulletin, 53, 303–320. 10.1037/h0040353 Thomas, O., Hanton, S., & Maynard, I. (2007). Anxiety responses and psychological skill use during the time leading up to competition: Theory to practice I. Journal of Applied Sport Psychology, 19, 379–397. 10.1080/104132007015 99132 Toussaint, L., Shields, G.S., Dorn, G., & Slavich, G.M. (2016). Effects of lifetime stress exposure on mental and physical health in young adulthood: How stress degrades and forgiveness protects health. Journal of Health Psychology, 21, 1004–1014. 10.1177/1359105314544132 Tabatabai Kish, A., Badami, R. (2019). Effects of systematic desensitization on state anxiety, fear of depth and interest to continue to sport participation in female swimming beginners. Journal of Clinical Psychology, 10(4), 59–68. 10. 22075/jcp.2019.13658.1339 Vealey, R.S., Armstrong, L., Comar, W., & Greenleaf, C.A. (1998). Influence of perceived coaching behaviors on burnout and competitive anxiety in female college athletes. Journal of Applied Sport Psychology, 10, 297–318. 10.1 080/10413209808406395 Vealey, R.S., & Campbell, J.L., (1988). Achievement goals of adolescent skaters: Impact on self-confidence, anxiety, and performance. Journal of Adolescent Research, 3, 227–243. 10.1177/074355488832009 Walker, N., Thatcher, J., Lavallee, D., & Golby, D. (2004). The emotional response to athletic injury: Re-injury anxiety. In D. Lavallee, J. Thatcher, & M. Jones (Eds.), Coping and emotion in sport (pp. 87–99). Nova Science. Walton, C.C., Rice, S., Hutter, R. I. (Vana), Currie, A., Reardon, C.L., & Purcell, R. (2021). Mental health in youth athletes. Advances in Psychiatry and Behavioral Health, 1, 119–133. 10.1016/j.ypsc.2021.05.011 Weineck, F., Schultchen, D., Hauke, G., Messner, M., & Pollatos, O. (2020). Using bodily postures to reduce anxiety and improve interoception: A comparison between powerful and neutral poses. PLoS ONE, 15(12): e0242578. 10.1371/journal.pone.0242578 Wine, J. (1971). Test anxiety and direction of attention. Psychological Bulletin, 76, 92–104. 10.1037/h0031332 Woodman, T., & Hardy, L. (2001). Stress and anxiety. In R. Singer, H.A. Hausenblas, & C.M. Janelle (Eds.), Handbook of research on sports psychology (pp. 290–318). Wiley. Woodman, T., & Hardy, L. (2003). The relative impact of cognitive anxiety and self-confidence upon sport performance: A meta-analysis. Journal of Sports Sciences, 21, 443–457. 10.1080/0264041031000101809 Yerkes, R.M., & Dodson, J.D. (1908). The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology, 18, 459–482. 10.1002/cne.920180503

243

16 STRESS IN ELITE SPORT Jennifer A. Hobson, Martin J. Turner, and Marc V. Jones

Introduction Stress is a complex transactional process that takes place between the individual and the environment (Semmer et al., 2005), occurring when an individual perceives an inability to cope with anticipated demands, or when there is an anticipated threat to well-being (Lazarus & Folkman, 1984). Sources of stress (stressors) may be external (i.e., physical, environmental, social) or internal (i.e., psychological, biological; Lovallo, 2005). Similarly, stress responses may manifest externally (i.e., expression of emotions and changes in behaviour) or internally (i.e., thoughts, changes to mood, the neuroendocrinal system, physiological reactivity; Semmer et al., 2005). The study of stress is challenging since it can involve the investigation of stressors, appraisals, responses, coping, and interactions between these aspects (Segerstrom & O’Connor, 2012). In this chapter, we begin by briefly summarising the stress research in sport. Then, we explain the core tenets of the TCTSA-R (Meijen et al., 2020) and present issues associated with measuring components of the TCTSA-R and mental health in athletes. Following this, we make the case for using the TCTSA-R as a holistic framework for explaining stress implications for athletes’ mental health. Finally, practical implications for applied sport and exercise psychologists are presented, and unanswered research questions are addressed to guide areas for future research.

Stress in Sport Much research within sport has documented the stressors experienced and coping strategies used by athletes (Sarkar & Fletcher, 2014), coaches (Norris et al., 2017; Dixon et al., 2017), and parents (Lienhart et al., 2020). Stressors have been categorised as organisational (e.g., admin), contextual (e.g., level of competition), performance related (e.g., one’s own performance), interpersonal (e.g., others’ expectations), and intrapersonal (e.g., one’s own expectations). Taking a transactional perspective to understanding stress (e.g., Lazarus, 1999), “stressors” do not cause or constitute “stress” alone. That is, the stress process involves idiosyncratic appraisals of potential stressors which may or may not bring about the experience of stress (Lazarus, & Folkman, 1984). A list of stressors experienced by some people under some conditions provides limited insight into the complexity of the stress process; stressors are only stressors when they are appraised as such by appraisers (i.e., athletes, coaches, etc). The expectations of others may represent a stressor in some but not all contexts, some but not all people, and some but not all 244

DOI: 10.4324/9781003099345-22

Stress in Elite Sport

the time. In other words, stress is subject to individual differences, which includes cognitive appraisals. The two categories of cognitive appraisal frequently considered in sport and performance literature are demand and resource appraisals (Blascovich et al., 2004; Lazarus, 2000; see Table 16.1), which can help explain why some sport performers excel under pressure, whilst others do not.

Table 16.1 Key Terms and Definitions Term

Definition

Demand appraisals

Perception of danger (physical and/or esteem), uncertainty and required effort (physical and/or mental, Meijen et al., 2020). Internal and/or external factors which tax an individual’s coping resources ( Lazarus & Folkman, 1984) An appraisal comprising self-efficacy, perceived control, achievement goals and perceived social support ( Meijen et al., 2020). Perceptions of responsibility (for blame/credit), the quality of one’s own resources (behavioural and cognitive) needed to manage the stressful event (coping potential), future expectations of the outcome of the event, and the extent to which this interferes with one’s own goals ( Lazarus & Folkman, 1984). An anticipatory psychophysiological motivational state reflecting a perceived ability to cope with anticipated demands, adaptive physiological and behavioural responses ( Meijen et al., 2020). An anticipatory psychophysiological motivational state reflecting a perceived inability to cope with anticipated demands, maladaptive physiological and behavioural responses ( Meijen et al., 2020). Judgements of what an individual can achieve within their skills ( Bandura, 1977). individuals’ “perceived self-efficacy for coping with challenges or threats” ( Chesney et al., 2006, p. 2). Beliefs an individual has about how much control is available ( Skinner, 1996).

Resource appraisals

Challenge state

Threat state

Self-efficacy Coping self-efficacy Perceived (subjective) control Objective control Job control Emotion control / regulation

Social identity Social support

Approach goals Avoidance goals Mastery goals Performance goals

How much control is actually available ( Skinner, 1996). Perceived control over job related activities or events including decision authority and skill discretion ( Karasek, 1979). “The processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions. Emotion regulatory processes may be automatic or controlled, conscious or unconscious, and may have their effects at one or more points in the emotion generative process” ( Gross, 1998, p. 275). A person’s sense of who they are based on their group memberships ( Tajfel, 1979). “An exchange of resources between at least two individuals perceived by the provider or recipient to be intended to enhance the well-being of the recipient” ( Shumaker & Brownell, 1984, p. 13). Goals reflecting a desire for achievement and competence ( Elliot & McGregor, 2001). Goals reflecting a desire to avoid failure and incompetence ( Elliot & McGregor, 2001). Goals reflecting a desire to develop or master skills and tasks ( Elliot & McGregor, 2001). Goals reflecting a desire to demonstrate competence relative to others ( Elliot & McGregor, 2001).

245

Jennifer A. Hobson et al.

Demand and resource appraisals (see Table 16.1) were proposed by Lazarus and Folkman in their theory of stress and coping (1984) and are key aspects of whether an individual sees an event as a challenge or a threat. Before covering challenge and threat as applied to sport, we first outline the main theoretical foundations for challenge and threat. The biopsychosocial model (BPSM) of challenge and threat (Blascovich, 2008) neatly ties cognitive (i.e., Lazarus & Folkman, 1984) and physiological (i.e., Dienstbier, 1989) factors within the stress process. A framework that extends the BPSM and is more specific to sport, is the TCTSA-R (Meijen et al., 2020). The TCTSA-R is advantageous because individuals’ perceptions are at the centre of the stress process; factors dictating whether an event is deemed a stressor are elucidated. Furthermore, by taking the perspective that stress is not always negative and that individuals can control their response to a stressor, the framework lends itself well to applied sport psychology practitioners seeking to develop interventions which enable athletes to excel under pressure. The theory’s binary nature is advantageous not only for the study of stress but also for the study of mental health, based on Selye’s (1956) concepts of eustress (positive stress) and distress (negative stress). In the TCTSA-R it is not assumed that stress is categorically unhelpful, that more stress always results in worse outcomes or that stress should be reduced (Meijen et al., 2020). Instead, the type of stress experienced as a function of psychophysiological processes and behavioural outcomes, dictates whether the response is adaptive or maladaptive. Changing these processes would allow the experience of adaptive rather than less stress. To illustrate, whether an individual is motivated to take on or avoid engaging with a stressor influences the activation of physiological systems, the experience, and appraisal of emotions. The behavioural implications of these processes dictate whether the stress response is adaptive or maladaptive (Meijen et al., 2020). Thus, instead of reducing stress, one could look to alter one’s appraisals to facilitate an adaptive response to stress. This binary approach to understanding stress and emotion differs from most mental health models which are unitary in nature; whilst emotional distress (e.g., anxiety and depression) is measured on a continuum ranging from low to high levels of symptomatology, interventions are aimed at reducing symptomatology scores. But anxiety can be helpful and healthy if it is associated with adaptive behaviours such as preparedness and action (i.e., approach rather than avoidance). The idea that negative emotions can be helpful and healthy is not a new concept (see Ellis & DiGiusepe, 1993); whether a negative emotion is healthy or unhealthy is distinguished by the behavioural consequences rather than the overall strength (i.e., degree of symptomatology) of the emotion. Indeed, depression and anxiety disorders are not diagnosed via questionnaire; within the context of losing a family member for example, a high score on a measure of depression might be appropriate, expected, and healthy. Without clear-cut points on symptomatology scores for the diagnosis of such disorders, unitary mental health models overlook the potential adaptiveness of negative emotions. Thus, applying a binary approach to the study of mental health is advantageous; whether negative emotions are healthy or unhealthy depends upon the nature of stress, appraisals, and the physiological and behavioural consequences. Rather than seeking to reduce the severity of negative emotions, it may be appropriate for mental health practitioners to support those they work with to experience the healthy rather than unhealthy version of their negative emotions (see Ellis & DiGiusepe, 1993). The TCTSA-R provides a framework that can facilitate the study of this concept within athletes.

TCTSA-R Framework The TCTSA-R (Meijen et al., 2020) is a psychophysiological framework explaining sporting performance using a 2×2 bifurcation theory of challenge and threat (see Figure 16.1), unlike its predecessor the TCTSA (Jones et al., 2009). In brief, in motivated performance situations, challenge results when an athlete perceives that the conditions are favourable for success. Threat results when an athlete perceives that the conditions are not favourable for success. Challenge reflects the perception that the athlete can bring the 246

Stress in Elite Sport

Disposition

Challenge

Figure 16.1

Threat

Sufficient Resources

Insufficient Resources

Sufficient Resources

Insufficient Resources

High Challenge State

Low Challenge State

Low Threat State

High Threat State

Positive Emotional Valance and Perception

Negative and Positive Emotional Valance, Negative Perception

Negative and Positive Emotional Valance, Positive Perception

Negative Emotional Valance, and Perception

Unlikely to Experience Mental Illness, likely to Experience Positive Mental Health

Less Unlikely to Experience Mental Illness, Less likely to Experience Positive Mental Health

Less Likely to Experience Mental Illness, Less Unlikely to Experience Positive Mental Health

Likely to Experience Mental Illness, Unlikely to Experience Positive Mental Health

{ Reappraisal }

Primary Appraisal

Processes Within the TCTSA-R and How They Might Relate to Mental Health Outcomes. (Adapted from Meijen et al., 2020.)

challenge to fruition. Threat reflects the perception that the athlete cannot ameliorate the threat. Even though an initial appraisal of threat is made, this doesn’t mean an athlete will underperform. If the athlete perceives sufficient resources to meet the situation demands (reappraisal, akin to Lazarus’ secondary appraisal process, 1999), then low threat is the result, and performance is less likely to be deleteriously affected (compared to high threat). Situational demands refer to perceptions of danger (which may be physical or related to esteem), uncertainty and required effort (which may be physical or mental); judgements taken from the biopsychosocial model of challenge and threat (Blascovich & Mendes, 2000). Personal resources refer to self-efficacy, perceptions of control, achievement goals, and social support (Meijen et al., 2020); high self-efficacy, high perceived control, approach goals, and high perceived support are favourable resource appraisals. This appraisal-reappraisal bifurcation offers a more nuanced perspective on how challenge and threat can influence performance, across high threat, low threat, low challenge, and high challenge outcomes. The greater the challenge, the higher likelihood for fulfilment of performance potential. The TCTSA-R includes several pre-dispositional factors that influence cognitive appraisals (Meijen et al., 2020). For instance, since trait cognitive appraisal style is associated with state cognitive appraisal style (Cumming et al., 2017), those who are predisposed to appraise situations as a challenge (trait) are likely to report a cognitive appraisal of challenge on approach to specific motivated performance situations 247

Jennifer A. Hobson et al.

(state). Likewise, a predisposition towards threat will likely result in acute threat appraisals (Cumming et al., 2017). Furthermore, individuals with more irrational beliefs are more likely to approach motivated performance situations in a threat state relative to those with less irrational beliefs (Chada et al., 2019; Dixon et al., 2017; Evans et al., 2018). Regarding personality research in sport, a strong body of evidence illustrates the direct predictive power of personality on long-term performance and on behaviours related to success in sport (see Allen et al., 2013). Specifically, lower levels of neuroticism and higher levels of conscientiousness and agreeableness differentiated national and international competitors from club or regional-level athletes (Allen et al., 2011), whilst higher conscientiousness was positively associated with preparation quality in the leadup to competition (Woodman et al., 2010). Furthermore, extraversion was shown to moderate the effect of anger on performance; when angry, extraverts’ peak force increased more than introverts’ (Woodman et al., 2009). Regardless of the theoretical background (i.e., BPSM, TCTSA, TCTSA-R), challenge is associated with superior athletic performance compared to threat (see Behnke & Kaczmarek, 2018; Hase et al., 2019; Uphill et al., 2019). The TCTSA-R accounts for observations of superior performance in threatened individuals (i.e., Turner et al., 2013; Dixon et al., 2019); performance may still be high when in threat if self-efficacy, perceived control, and social support are high and approach goals are adopted, because positive performance mechanisms are activated (Meijen et al., 2020). Within the TCTSA-R, individuals in challenge are expected to experience more positive emotions than negative emotions, and more positive emotions than individuals in threat. Individuals in high challenge are unlikely to experience negative emotions, with any interpreted as helpful for performance. By comparison, individuals in low challenge are likely to experience negative emotions and interpret these emotions as unhelpful for performance (Meijen et al., 2020). Individuals in low threat are likely to experience both positive and negative emotions, with negative emotions perceived as helpful for performance. Finally, individuals in high threat are unlikely to experience positive emotions and likely to experience negative emotions which are interpreted as unhelpful for performance. Following appraisal and reappraisal, physiological changes occur reflective of a challenge or threat state (Blascovich, 2008; Dienstbier, 1989). Specifically, there are changes in cardiovascular reactivity (CVR), neuropeptide Y, and oxytocin release (Meijen et al., 2020). Regarding CVR, a challenge state is characterised by increased sympatho-adrenomedullary (SAM) activity, adrenaline and noradrenaline release, and heart rate and decreased peripheral vascular resistance. The increase in SAM activity results from increased heart rate and left-ventricular contractility, which increases stroke volume/cardiac output. SAM activation prompts the release of adrenaline and noradrenaline that causes vasodilation and an increase in systematic vascular resistance (Blascovich & Mendes, 2000). These changes allow more efficient mobilisation of energy enabling immediate action and coping (Blascovich et al., 1999). The increased blood flow to the brain and muscles, higher blood glucose levels, and free fatty acids provide this efficiency. Thus, performance is facilitated by a challenge state. A threat state is characterised by increased activity in the SAM and pituitary-adrenocortical systems and the hypothalamic–pituitary–adrenal (HPA) axis, cortisol release and increased heart rate (although the increase is smaller than that in a challenge state), and either no change or an increase in peripheral vascular resistance. Whilst heart rate increases slightly, there is no decrease in systemic vascular resistance; it may even increase (Dienstbier, 1989). Thus, blood pressure increases (Blascovich & Mendes, 2000) which, together with the increased cardiac activity and increased/ stable systemic vascular resistance reduces the efficiency of blood flow to the brain and muscles. Stored fat and proteins are repeatedly converted into energy and used over a prolonged period. These changes are ultimately less efficient patterns for coping compared to those described in a challenge state (cf. Dienstbier, 1989) and are largely maladaptive for performance. A challenge state aids performance by preventing reinvestment, allowing the maintenance of concentration to the task; since less self-regulation skills are required, more resources are available for task 248

Stress in Elite Sport

execution and the management of task demands, which benefits effort and performance. Similarly, since a positive and approach-focused strategy to dealing with demands is taken when challenged, this too aids performance. The efficiency of physiological processes indicative of challenge improve decision making and anaerobic power, which in turn aids sport performance (Jones et al., 2009). Since its original conceptualisation in 2009 (Jones et al.), TCTSA predictions have been tested across sport and business contexts (see Meijen et al., 2020; Uphill et al., 2019 for reviews) whilst a recent meta-analysis supported the relationship between CVR challenge and threat states and performance (Behnke & Kaczmarek, 2018). Given the multi-level and complex nature of stress, it is difficult to measure (Epel et al., 2018); the same is true for challenge and threat within the TCTSA-R, since the theory accommodates internal (appraisals, emotions, and CVR) and external (behavioural consequences) manifestations of stress (Semmer et al., 2005). Discussion around the best way to measure challenge and threat is ongoing (see Blascovich, et al., 2011; Meijen et al., 2020; Uphill et al., 2019). Cognitive and affective processes within the TCTSA-R are often measured via self-report methods. Some studies have measured demand and resource appraisals using a one or two-item questionnaire (e.g., Turner et al., 2014) whilst others have administered a battery of psychometrics to measure each resource individually (e.g., Turner et al., 2013). Cardiovascular indicators of challenge and threat may be measured via impedance cardiography (Kubicek et al., 1966), BIOPAC devices (Ogedegbe & Pickering, 2010) or the Finometer Pro® (see Dixon et al., 2019). There are many benefits to collecting both self-report and physiological data when researching stress (see Epel et al., 2018). However, when studies have taken a multi-modal approach, self-reported challenge and threat states have only weakly associated with cardiovascular challenge and threat states (e.g., Dixon et al., 2019). This is likely because cognitive and biological indicators of stress are measured in very different ways, providing data which is difficult to directly compare (Epel et al., 2018).

TCTSA-R and Mental Health Athletes have mental health and experience stress much like any other human; theories of human mental health, stress, and emotion apply, regardless of context. We do not consider athletes to be unique in this sense (see Vella et al., 2021, for a valid opposing view). Indeed, the observation that athletes experience larger than typical levels of mental distress alongside higher levels of well-being can be explained by the mental health continuum (c.f., Keyes, 2002). Stress research both within and outside of sport has historically used a negative conceptualisation of mental health (i.e., the presence or absence of mental illness) but more recently, positive aspects of mental health (i.e., well-being) alongside an individual’s level of functioning have been considered (Schinke et al., 2017). As such, there are inconsistencies in both the definition and measurement of mental health. Indeed, when reviewing the stress and mental health literature in this chapter, global health, strain, depression and anxiety symptomology, well-being, subjective well-being, and burnout were all used as measures of mental health. Mental health research in general and particularly within sport needs greater conceptual and methodological clarity and consistency in how this is pursued (Giles et al., 2020). Keyes’ (2002) two-continuum model of mental health may be an appropriate framework to consider when discussing mental health within general and sport-specific stress research. In this model, both positive (mental health) and negative (mental illness) are considered along two separate but related continua; mental health may be present or absent and mental illness may be present or absent (Keyes, 2002, see also Chapter 1 for more details). To progress the research and understanding of mental health, clear definitions, and appropriate measures are required. Sport specific measures of mental health are also warranted due to the overlap between symptoms of burnout, depression and anxiety and the normal effects of physical exercise (i.e., fatigue, insomnia, appetite change, weight loss, lack of motivation, and concentration difficulties, Gustafsson et al., 2017; Reardon & Factor, 2010). Still, rather than needing their own mental healthcare model, it may be how and when mental health support is delivered that is unique in the athletic population, and the specific nature of what constitutes 249

Jennifer A. Hobson et al.

mental health risks (e.g., deselection, injury, physical hardship, see Frank et al., 2013; Küettel & Larsen, 2019). Thus, a framework for understanding mental health in sport, underpinned by core theories of stress and emotion may be helpful and is presented in this chapter. The TCTSA-R can be a useful framework for understanding how responses to stress may contribute to mental health problems, while also recognising that there are many other potential contributory factors. Stress is considered the main cause of athletes’ mental health problems, such as depression, anxiety, and burnout (Rice et al., 2016; Gerber et al., 2018). The elite sport environment contains numerous stressors and constraints that may contribute to depression and therefore undermine performance (Doherty et al., 2016), whilst greater demands are faced by recreational and elite-level athletes due to the fast-changing and increasingly competitive environment (Soligard et al., 2016). Clearly, understanding the factors which determine mental health within sport is vital, and stress appears to be an important factor. As a theory of stress, the implications of the TCTSA-R could extend beyond explaining sporting performance, towards understanding and potentially supporting mental health and well-being. Indeed, the theories that underpin and precede the TCTSA-R sought to explain the impact of stress on both mental and physical health (i.e., Dienstbier, 1989; Lazarus & Folkman, 1984; Selye, 1956); explaining health was the intention of the theories. The TCTSA-R extended these theories to explain sporting performance, but in so doing, ignored the possibility of explaining mental health. That is the TCTSA-R could be a useful framework for understanding and explaining mental health in athletes. Throughout the remainder of this chapter, literature within and beyond sport will be drawn upon to demonstrate the implications for mental health of each component of the TCTSA-R, thereby illustrating the feasibility of using the TCTSA-R to understand and potentially support mental health in athletes.

Pre-Dispositions The TCTSA-R includes pre-dispositional factors which influence the stress-performance relationship, such as appraisal style (trait challenge/threat), irrational beliefs, and personality. Irrational beliefs and personality have clear implications for athlete mental health. Research has revealed consistent associations between greater irrational beliefs and poorer mental health in the general population (see Vîslă et al., 2016) and athletes (Turner et al., 2019; Turner et al., 2018; Turner & Moore, 2016). In addition, reductions in irrational beliefs enhanced well-being and sleep quality (Davis & Turner, 2020) whilst both irrational beliefs and challenge and threat mediated the relationship between primary and secondary cognitive appraisals and affect in golfers prior to a golf competition (Chadha et al., 2019). Specifically, threat was associated with greater irrational beliefs, negative affect, and less facilitative perceptions of anxiety. Furthermore, in soccer coaches, greater irrational beliefs were related to a more threatening interpretation of a recent stressor (Dixon et al., 2017). Regarding personality, extensive evidence illustrates the association between personality and mental health disorders including depression, anxiety, and substance use disorders (see Kotov et al., 2010; see Chapter 10). In a large meta-analysis documenting the associations between ‘Big 5’ personality traits and mental health disorders, neuroticism displayed the strongest links to psychopathology; higher levels predicted substance use disorders (d = 0.5), depression (d = 1.33), and all anxiety disorders (average d = 1.91) except specific phobia (Kotov et al., 2010). Lower levels of conscientiousness and extraversion also related to depression (d = −0.90 and d = −0.62, respectively) and anxiety (d = −1.02 and d = −1.05, respectively) whilst agreeableness and openness were unrelated (Kotov et al., 2010). Similarly, in studies of academic work stress, students with higher neuroticism were more likely to adopt a threat appraisal in response to a stressor, whilst those higher in extraversion responded with greater amounts of challenge (Gallagher, 1990; Mak et al., 2004). Furthermore, assertiveness predicted challenge and threat appraisals in a sample of 95 women; high levels of assertiveness was related to challenge, less stress, fewer negative emotions, and more positive emotions in response to a stressor whilst low levels of assertiveness was related to threat, more stress, more 250

Stress in Elite Sport

negative emotions, and fewer positive emotions (Tomaka, et al., 1999). Collectively this evidence indicates that personality influences both stress appraisals and mental health outcomes. The relationship between personality and mental health in sport is less well evidenced. Nevertheless, higher levels of neuroticism were associated with the use of avoidance coping strategies in athletes (Allen et al., 2011) which itself is a hallmark of anxiety (American Psychiatric Association, 2013). Studies have also found that high levels of neuroticism, extraversion and conscientiousness, and low levels of agreeableness relate to exercise addiction (e.g., Lichtenstein et al., 2014) which itself can result in depression, body-image concern, and eating disorders (Berczik et al., 2012). Furthermore, in a cross-sectional, crosscultural investigation of athlete mental health during the first COVID-19 lockdown in April 2020, maladaptive perfectionism was related to lower mood, more depression, state anxiety, and stress (Leguizamo et al., 2021). Within the exercise literature, mental health was negatively related to neuroticism and positively to extraversion and personality moderated the relationship between physical activity and mental health (Wilson et al., 2016). The extant literature suggests personality may play a role in the relationship between stress and mental health in athletes, but considerably more research beyond the context of COVID-19 is required to establish such links.

Demands Versus Resources The extant literature exploring stress across organisational, educational, and sporting domains shares a common theme; models of stress incorporate measures of perceived demands and resources (e.g., Demerouti et al., 2001; Karasek, 1979; Smith, 1986; demand-control model). These theories predict stress from measures of demands and resources where high demands and high resources are associated with positive outcomes (for health, well-being, mental health, and performance) whilst high demands and low resources are associated with negative outcomes. The demands might refer to characteristics of the environment, such as the degree of physical and psychological effort required (Demerouti et al., 2001), workload, time, pressure, role conflict, and physical exertion (De Jonge & Dormann, 2017). Resources on the other hand might refer to functional aspects of the environment and strategies which enhance engagement and support goal achievement (Demerouti et al., 2001). Resources also include job control, job variety, workplace social support (De Jonge & Dormann, 2017) and personal resources such as selfefficacy, optimism, self-esteem (Xanthopoulou et al., 2009) hope, resilience (Vink et al., 2011), and neuroticism (Bakker et al., 2010). Clearly, whilst these conceptualisations of resources are broader than resources within TCTSA-R, similarities may be drawn (see Table 16.1); the adaptive nature of experiencing high demands alongside high resources reflects challenge whilst the maladaptive nature of high demands and low resources reflects threat (Meijen et al., 2020). In lieu of reference to Lazarus and challenge and threat states across these domains of research, the research showing mental health outcomes as a function of identified demands and resources will be summarised here. Burnout is a psychological phenomenon of prolonged exhaustion and disinterest that can result in anxiety, depression, decreases in self-esteem, and health problems (Maslach et al., 2001). Within the organisational psychology literature, whilst higher job resources have a positive impact on work engagement, mental strain and subsequent job performance, increases in job demands relate to job burnout, and increased mental strain (Bakker & Demerouti, 2007; Mayer et al., 2017). Furthermore, a longitudinal study tested the job demands-resources model within a school setting (Salmelo-Aro & Upadyaya, 2014). A total of 1,709 adolescent students completed measures of perceived demands, resources, burnout, engagement, and life satisfaction over a period of four years. These years coincided with the transition from comprehensive to post-comprehensive education; a time of increased stress. Analyses indicated that study demands were significantly positively related to subsequent school burnout and resources were significantly positively related to engagement (Salmelo-Aro & Upadyaya, 2014). Furthermore, burnout was significantly related to less engagement with studies one year later and depressive symptoms two years 251

Jennifer A. Hobson et al.

later, whilst engagement was significantly positively related to life satisfaction two years later (Salmelo-Aro & Upadyaya, 2014). This evidence suggests that considering demands against resources is appropriate when seeking to understand the nature of the relationship(s) between stress and mental health outcomes. Within sport, the relationship between perceived demands and resources and mental health outcomes has been less well explored. Smith (1986) showed that athlete burnout is associated with high perceived demand and low perceived resources. Similarly, when demands outweigh perceived resources, athlete health and well-being suffer (Raedeke & Smith, 2004; Williams et al., 1991). Whilst evidence from organisational and educational domains appears promising, more longitudinal research is required to illustrate the relationship between perceived demands and resources and athlete mental health and wellbeing more convincingly (Hobson, 2022).

Self-Efficacy In his early conceptualisations, Bandura described the health implications and adaptive benefits of self-efficacy and holding positive outcome expectancies; they enhance well-being and reduce depression (1994, 1997). Since then, self-efficacy has been shown to strongly predict mental health (e.g., Chan, 2002) and negatively relate to depression and stress (e.g., Endler et al., 2001; Takaki et al., 2003). Indeed, robust self-confidence and positive outcome expectancies buffer against the debilitating effects of stress (Baumeister & Showers, 1986; Thomas et al., 2011); Olympic champions described confidence as protecting against the negative effects of stress and promoting challenge appraisals (Fletcher & Sarkar, 2012) and in a sample of 140 Australian officials, self-efficacy and challenge appraisals predicted psychological resilience (Grylls et al., 2021). Furthermore, in support of the predictions of the TCTSA-R, self-efficacy has shown to increase anxiety tolerance and encourage helpful perceptions of anxiety, enabling superior performance under pressure (Moore et al., 2012; Williams et al., 2010). Confidence was also directly associated with better performance on a stress task (Williams et al., 2021). In UK based adolescent male soccer players, self-efficacy was positively associated with soccer performance (Dixon et al., 2019) and youth male cricketers (UK) with high levels of self-efficacy produced better batting performances in a pressure test than those with lower levels of confidence, providing further support that self-efficacy facilitates adaptive stress responses (Turner et al., 2013). However, this relationship was not replicated in a subsequent study involving youth female netball players in the UK (Turner et al., 2021). In general, these findings support the predictions made within the TCTSA-R and indicate the powerful role that self-efficacy has on the experience of stress and performance under pressure. Regarding the effect of self-efficacy on mental health outcomes, coping self-efficacy (CSE, see Table 16.1) has been shown to have a positive effect on athletes’ ability to cope with stress, and on mental health outcomes (Watson & Watson, 2016). In a sample of 106 high-level basketball players who completed an acute stress-inducing mental arithmetic test, those with higher CSE coped better than those with low CSE (Guo et al., 2019). Individuals higher in CSE are more confident in their ability to overcome the challenges of stress, adopting more effective coping strategies which help to maintain physical and mental health (Watson & Watson, 2016). Correspondingly, those low in CSE hold insufficient confidence and thus cannot effectively relieve physical and psychological symptoms caused by stress, which results in decrements to health. Similarly, in a study of Norwegian students’ mental health, academic self-efficacy was associated with symptoms of mental distress and study progress (Grøtan et al., 2019). Specifically, students who reported symptoms of severe mental health problems were four times as likely to experience low self-efficacy as those reporting few or moderate symptoms (Grøtan et al., 2019). Further, in a sample of 100 undergraduate engineering students in Iran, self-efficacy was significantly negatively correlated with psychological distress, and positively with psychological well-being (Gull, 2016). Whilst cross-sectional and correlational in nature (meaning causation cannot be inferred), this research suggests self-efficacy plays a role in the experience of mental health both when using positive (i.e., well-being) and negative (i.e., distress, pathologies) definitions of mental health. 252

Stress in Elite Sport

More convincing evidence of the impact of self-efficacy on mental health comes from mediation and longitudinal analyses. In recent work published by Schönfeld and colleagues, self-efficacy mediated the effect of daily stressors on mental health (2016; 2019). In the first cross-sectional study, self-efficacy acted as a buffer protecting mental health from decline following daily stressor exposure in a cross-cultural sample (2016). This relationship was supported in a follow-up study investigating the longitudinal effects of daily life stressors on positive (subjective well-being) and negative (psychopathological symptoms) mental health. All cross-lagged mediational paths via self-efficacy were significant (Schönfeld et al., 2019); self-efficacy represents part of the mechanism that explains the effect of stress on mental health. Compared with other psychology disciplines, the impact of self-efficacy on mental health outcomes has received less study in sport and exercise psychology. Of the limited literature that is available, the positive relationship between self-efficacy and mental health is evidenced; a negative correlation between selfefficacy and depression was found in a sample of 231 Chinese national-level boxers (Chen et al., 2020). Furthermore, a longitudinal study tracking 5,961 adolescents found that higher self-perceptions of athletic competence was related to better health and fewer depressive symptoms (Agans et al., 2017). Once more, literature beyond sport provides the strongest evidence of a relationship between a TCTSA-R resource and mental health outcomes. Further research is needed to illustrate that self-efficacy influences mental health in sport and exercise samples.

Control In the TCTSA-R, control is derived from Skinner’s constructs of control which include objective, perceived (subjective) and experiences of control (see Table 16.1), with perceived control representing the best predictor of functioning (Skinner, 1996). Within the extant psychology literature, a plethora of similar terms exist such as volition, locus of control, job control, autonomy, and emotional control. Whilst perceived control features within the TCTSA-R, with so many similar terms available, greater clarity on what is meant by control and thus how it should be measured is warranted.

Perceived Control Regarding perceived control in the context of mental health, existing theory and research suggests it plays an important role. Indeed, perceived control features heavily within the learned helplessness model of depression (Seligman, 1972). Looking towards occupational psychology literature where the concept of job control is often used, 343 German participants were divided into a case group and a mentally healthy control group. Those employees in the case group perceived significantly less job control than the mentally healthy group, whilst objective job control was not related to depression (Rau et al., 2010). Furthermore, objective job demand and perceived job control but not objective job control was positively related to depression (Rau et al., 2010). In women who were exposed to a high number of acute and chronic stressors, optimism and perceived control were associated with less severe depression (Grot et al., 2007). Collectively, these findings resonate with Skinner’s contention that perceived control predicts functioning (1996) and indicates a negative relationship between perceived control and depression. A meta-analytic review of 51 studies exploring the relationship between perceived control and vulnerability to anxiety disorders indicated that perceived control is largely negatively associated with both trait anxiety and anxiety disorders (Gallagher et al., 2014). Furthermore, in a sample of Australian patients having coronary heart grafts, those with stronger perceptions of control were less anxious and less depressed before surgery, after surgery during hospitalisation and two weeks post-hospital discharge (Gallagher & McKinley, 2009). Studies exploring the relationship between perceived control and broader measures of mental health have produced similar results; perceived control over salient areas of one’s life was related to better mental health (less psychological distress) in Norweigan professional musicians 253

Jennifer A. Hobson et al.

(Aalberg et al., 2019). A cross-sectional study of UK prison officers showed that poor interpersonal relationships and low job control was significantly related to worse mental health (Kinman et al., 2017). Clearly the perception of control is important for mental health and general well-being outcomes. Given that much of the evidence referenced here has come from non-sport settings, more research within sport is needed to support claims that perceived control impact athletes’ mental health and well-being.

Emotion Control Alongside perceived control, emotion control (or regulation, see Table 16.1) is mentioned as a resource within the TCTSA-R (Meijen et al., 2020). According to Gross (1998), emotions may be regulated via situation selection (choosing not to approach an emotion-evoking situation), situation modification (changing the situation), attention regulation (distracting oneself or thinking about something else), changing cognitions (alter appraisals prior to emotion onset) and changing emotions (alter emotion via reappraisal). Of the regulation strategies listed above, situation selection and modification are largely inaccessible for athletes since the competitive environment cannot be controlled or easily influenced. Indeed, athletes aim to master performance within the challenging competitive environment; to avoid the environment would be to avoid performing, thus making their goals unachievable. Distraction may provide short-term benefits but may also lead to performance decrements if athletes are distracted by task irrelevant cues. Thus, cognitive appraisal and reappraisal represent the most useful and suitable emotion control strategies for athletes to learn and adopt (Skinner & Brewer, 2002). Emotion control is vital for positive mental health and well-being; the inability to regulate one’s own emotions typically characterises mood and anxiety disorders (Gross & Thompson, 2007). Cognitive reappraisal techniques are the most well-studied and most effective of the emotion regulation strategies; a meta-analysis of Eastern, Western and Mixed studies exploring the relationship between cognitive reappraisal and mental health observed a strong, significant positive relationship between cognitive reappraisal and positive measures of mental health (positive affect, life satisfaction, correlation of r = .26) and a strong significant negative relationship between cognitive reappraisal and negative measures of mental health (depression, anxiety, negative affect, correlation of r = -.20, Hu et al., 2014). Furthermore, for individuals based in the US experiencing uncontrollable stress, the use of cognitive reappraisal was related to less depressive symptoms (Troy et al., 2013). However, the opposite was true when individuals experienced controllable stress; cognitive reappraisal was related to more depressive symptoms (Troy et al., 2013), suggesting that the benefits of reappraisal may be context dependent and most suitable in uncontrollable stressful environments, such as competitive sport.

Social Support Social support is heavily implicated within the stress process, featured within Lazarus and Folkman’s definition of perceived resources (1984). The negative effect of stress on health outcomes is reduced when high levels of social support are present (e.g., Cobb, 1976), possibly because perceived social support influences both demand (i.e., redefining the situational threat) and resource appraisals (i.e., promoting perceived control Slater et al., 2016). The mental health benefits of social support have been consistently reported (Kawachi & Berkman, 2001); increased support is usually associated with lower risk of psychopathology (Goldmann & Galea, 2014). Cross-culturally, the positive association between perceived stress and depressive symptoms (Hammen, 2005) has been shown to be reduced by social support (LicitraKlecker & Waas, 1993; Raffaelli et al., 2012;) and in a meta-analysis of 182 studies, social support predicted a plethora of health outcomes including well-being, depression, psychologic symptoms and responses, stress, coping behaviours, and psychosocial adjustment (Wang et al., 2009). The impact of social environments and support on cardiovascular reactivity and performance has also been recognised in some 254

Stress in Elite Sport

(e.g., Uchino et al., 2011) but not all cases (e.g., Closa León et al., 2007) whilst in the absence of social support, individuals may experience feelings of loneliness which increases one’s vulnerability to depression (Cacioppo et al., 2006). Similarly, the sense of belonging and social connectedness is associated with better mental health outcomes (e.g., Saeri et al., 2017). In a study that measured mental health and belonging prior to and following the uptake of team sport in 10,149 Canadian adolescent schoolchildren, taking up a team sport was related to better mental health, a relationship that was fully mediated by a sense of belonging (Oberle et al., 2019). The positive relationship between social support and better mental health has been replicated within sport settings. In a sample of 612 Danish elite athletes, relative to those with poor mental health, those with good mental health reported lower stress levels, received higher support, and perceived their sporting environment as more supportive (Kuettel et al., 2021). Furthermore, low perceived social support and negative social interactions contributed to more burnout and worse well-being in 465 collegiate American athletes throughout a competitive season (DeFreese & Smith, 2014). Together these findings indicate the risk factors of low and the benefits of high perceptions of social support both within and beyond sport settings. Within the sport and exercise literature, the use of instructional sets to induce challenge and threat states (e.g., Turner et al., 2013) demonstrates the potential impact providers of social support can have on performers’ demand and resource appraisals (and challenge and threat states) and thus potentially their mental health. For instance, a coach may provide social support by referencing an athlete’s preparedness for upcoming demands and by drawing attention to factors within the athlete’s control (Turner et al., 2014; Turner & Barker, 2014). Such effects may be enhanced when athletes identify or feel a sense of connectedness with their coach (Miller et al., 2020); performers who identified with their task leader reported greater resource appraisals and performed better in a cognitive task relative to those who did not (Slater et al., 2018). Furthermore, when performers were led by an individual they did not connect with, CVR indicative of threat was observed prior to a pressurised task (Slater et al., 2018). Thus, social support can be both a resource and a factor which enhances other resources via communication (see Slater et al., 2016). Collectively, whilst this research demonstrates the importance of considering social support when researching stress, taking a social identity approach may shine more light on the social contextual factors at play.

Achievement Goals Achievement goals comprise mastery approach, mastery avoidance, performance approach, and performance avoidance goals (Elliot & McGregor, 2001; see Table 16.1). The approach goals relate to performers striving for improvement regarding their skills (mastery) or the outcome of their efforts (performance). Avoidance goals refer to striving to avoid regression in skills (mastery) or negative performance outcomes (Elliot & McGregor, 2001). The impact of achievement goals on psychosocial outcomes has been predominantly explored within academic settings. Students’ general subjective wellbeing is significantly associated with the nature of their achievement goals (Ariani, 2022; Kaplan & Maehr, 1999). Whilst mixed relationships have been observed across the literature, the notion that mastery approach goals and in some cases performance approach goals offer mental health and well-being benefits over avoidance goals is broadly supported. Indeed, the negative effects of avoidance are typically more salient than the positive effects of mastery (Senko & Freund, 2015). First, drawing upon research conducted in the US and in China, mastery is associated with various positive and adaptive patterns of coping, positive affect, and relationships (e.g., Linnenbrink, 2005) and better subjective well-being in school (Tian et al., 2017; Zhao & Jin, 2008). Mastery goals correlated with better mental health in a sample of 600 Iranian students (Kareshki et al., 2012) and less depressive symptoms (unless the students were disengaged in their education) in 1,321 Finnish adolescents 255

Jennifer A. Hobson et al.

(Tuominen-Soini et al., 2008). Using structural equation modelling, mastery goals (not performance goals) showed significant indirect positive effects on subjective well-being (comprising life satisfaction, affect and satisfaction with specific life domains) via self-esteem in a three-year longitudinal examination of 894 Chinese adolescent students (Zhou et al., 2019). Within the sport literature, associations between achievement goals, burnout, and psychosomatic stress symptoms were explored in 125 German elite athletes. Path modelling showed that strong mastery approach goals related to less burnout and psychosomatic stress symptoms, whilst performance approach and mastery avoidance goals were associated with higher-level burnout (Daumiller et al., 2021). This is a convincing body of evidence that indicated the mental health and well-being benefits bestowed by the adoption of mastery approach goals. Regarding performance approach goals, the association with psychosocial outcomes is more mixed; some studies have shown positive associations between performance approach goals and subjective well-being (Tian et al., 2017; Tuominen-Soini et al., 2012; Zhao & Jin, 2008) and better mental health (Kareshki et al., 2012) whilst others have not (e.g., Zhou et al., 2019). Indeed, whilst Sideridis (2005) showed that without being adaptive, performance approach goals were not maladaptive, Daumiller and colleagues found that performance avoidance goals were associated with higher levels of burnout (2021). Attempting to explain these mixed outcomes, the impact of performance approach goals on mental health and well-being may be dependent upon the pattern of achievement goals held. A cluster analysis of 1,697 Singaporean adolescent students’ achievement goals indicated that when performance approach and performance avoidance goals are simultaneously strong, negative affective outcomes are most likely (Luo et al., 2011). The most adaptive cluster of achievement goals involved more performance and mastery approach goals, and less performance avoidance goals, with less test anxiety and negative affect observed (Luo et al., 2011). Furthermore, in a longitudinal examination of 1,002 Canadian undergraduate students’ mastery approach and performance approach goals, the least adaptive cluster was for individuals who displayed low mastery and performance approach goals (Daniels et al., 2008). Interestingly, the cluster of individuals with a dominant goal orientation of performance approach were more psychologically and emotionally vulnerable (sensitive to anxiety) than either individuals with a dominant goal orientation of mastery approach or individuals holding strong mastery and performance approach goals simultaneously (Daniels et al., 2008). Whilst Isoard-Gautheur and colleagues (2013) found no significant relationship between performance avoidance goals and physical and mental exhaustion, these goals were related to lower self-esteem (Zhou et al., 2019) and subjective well-being (Zhao & Jin, 2008), more depressive symptoms (Chen & Luo, 2015), hopelessness and shame (Pekrun et al., 2006), and stress and anxiety (Sideridis, 2005). Mastery avoidance goals have been less thoroughly investigated, often excluded from measurement (i.e., Daniels et al., 2008; Luo et al., 2011). When mastery avoidance goals have been measured, findings have been unclear, typically showing no associations or unfavourable associations. However, mastery avoidance goals positively correlated with burnout in German elite athletes (Daumiller et al., 2021) and depressive symptoms in Taiwanese college students (Chen & Luo, 2015). Furthermore, mastery avoidance goals negatively predicted (and mastery approach goals positively predicted) withinperson changes in well-being in a sample of 91 male elite youth soccer players in the UK (Adie et al., 2010). Mastery avoidance goals have been criticised for being counter intuitive and uncommon in the sport domain (Ciani & Sheldon, 2010); it may be that these goals apply more so in late adulthood when decreases in many cognitive, physical, and social abilities are faced, resulting in the desire to maintain existing skills rather than learn new ones (Senko & Freund, 2015).

Physiological Indicators of Challenge and Threat That physiological indicators of challenge and threat are related to sporting performance is well evidenced in the extant literature (Behnke & Kaczmarek, 2018; Blascovich et al., 2004; Dixon et al., 2019). In contrast, 256

Stress in Elite Sport

the relationship between psychophysiological indicators of challenge and threat and long-term mental health outcomes has only recently been explored (Epel et al., 2018; Turner et al., 2020). The HPA axis is involved in the neurobiology of depression and anxiety disorders; both hyper- or hypoactivity is a risk factor to mental health and well-being (Baumeister et al., 2014). Indeed, a recent meta-analysis of studies investigating the health implications of physiological indicators of challenge and threat showed that exaggerated and blunted SAM system and HPA axis reactivity appears to be associated with worse mental and physical health outcomes over time (Turner et al., 2020). Specifically, blunted HPA reactivity implicated cortisol reactivity and predicted more depression (Phillips et al., 2011) and more anxiety symptoms (Yuenyongchaiwat & Sheffield, 2017). Indeed, when cortisol reactivity was also blunted, this was associated with more T cells, fewer responder T cells and ultimately worse physical and mental health and more depressive symptoms (Ronaldson et al., 2016). Furthermore, blunted cortisol reactivity was associated with more PTSD symptomology in soldiers who experienced new on-set traumatic events (Steudte-Schmiedgen et al., 2015). A review of the stress research conducted within the context of the biopsychosocial model of challenge and threat indicated that blunted CVR reflects task and motivational disengagement that is associated with threat and avoidance and may explain the association between blunted stress responses and depression (Hase et al., 2020), and in a meta-analysis of CVR responses to challenge and threat, a challenge state was shown to be an adaptive response to a stressor, leading to better performance and well-being (Behnke & Kaczmarek, 2018).

Conclusion Practical Implications For applied sport and exercise psychologists seeking to maintain and enhance athlete mental health whilst remaining within their boundary of practice, the TCTSA-R provides a framework within which to ground such interventions. Specifically, the psychologist could focus on enhancing athletes’ personal resources to develop a challenge state, since it can be difficult, inappropriate, or even impossible to lower the demands of sport (cf. Turner & Jones, 2018). Therefore, athletes should be supported to develop their personal resources, and this can be achieved via an individual or environmental approach. Using an individual approach, it makes sense to use personal resources as the foundation of a psychoeducational programme. Athletes who are taught psychological skills such as reappraisal when faced with a stressor (Slater et al., 2016) could reduce their chances of performing in a threat state (and develop a challenge state) through reappraising stressful events prior to performing. For example, an important knock-out cup match initially appraised as presenting a risk of being knocked out, could be reappraised as an opportunity to progress to the next round of the competition (Jamieson et al., 2018). Equally, athletes could learn to appraise their pre-match anxiety symptoms as helpful and conducive for performance, which may help to reduce the onset of negative and unhelpful meta-emotions and therefore protect mental health and well-being (Jamieson et al., 2012). Furthermore, whilst goal-setting interventions such as the “best possible selves” activity could be utilised to help maximise athletes’ perceived control and approach focus (Schwerdtfeger et al., 2020), the use of mastery imagery interventions involving athletes imaging being confident, in control, supported, and positively responding to a setback could help to increase personal resources and foster a challenge state (Williams et al., 2021). Finally, when used regularly, relaxation strategies such as diaphragmatic breathing can increase athletes’ CVR to stress and develop a challenge state, evidenced by more positive emotional responses to stressors (Bornas et al., 2005). At an environmental level, training environments should regularly expose athletes to stressful situations. Such experience aides the development of coping self-efficacy, fostering resilience, and personal resources within the individual (Seery, 2011). Thus, athlete training programmes should regularly involve 257

Jennifer A. Hobson et al.

evaluative, pressurised training sessions (Low et al., 2021) and provide ample opportunity for participation in tournaments and competitions. The process of becoming familiar with performing under pressure, high demands and high expectation could enhance personal resources, promote a challenge state, and ultimately support well-being and performance (Quigley et al., 2002). Training environments can be made more psychologically demanding through enhancing perceived importance of high performance in a training session, using consequences to generate risk/reward outcomes, making training more uncertain, increasing the degree of difficulty, and altering athletes’ perceptions of effort. Athletes’ perceptions can be altered via communications before and during performance. Instructions which emphasise the importance of successful performance, exacerbate the task’s degree of difficulty and demand quick decisions and actions increase perceived pressure (i.e., demand appraisals, see Alter et al., 2010; Feinberg & Aiello, 2010; Moore et al., 2012; Tomaka et al., 1997). In the same way, messages given to athletes within sporting contexts could enhance personal resources including perceived support (Moore et al., 2014), self-efficacy, perceived control, and an approach focus (Turner et al., 2014). This may be particularly important when athletes experience particularly stressful events such as injury or retirement. Educating staff regarding the criteria that equate to psychological stress (e.g., high level of importance, uncertainty, perceived effort, degree of risk and perceived difficulty) may help to ensure sport environments are psychologically informed and better placed to display empathy when athletes experience challenges, thus in turn enhancing their sense of support. However, much more research is required in this area to substantiate these claims.

Research Perspectives Before this research can take place, several important milestones need to be reached. First, a questionnaire measure which adequately represents demand and resource appraisals as defined within the TCTSA-R is required; ideally there would also be child and adolescent specific versions. Second, sport-specific questionnaire measures of mental health validated within a broad range of sporting samples and representing the entire mental health continuum (Keyes, 2002) are required (c.f., Rice et al., 2019). Then the claims made within this chapter can be tested; can the TCTSA-R be used to explain mental health in sport performers? Do CVR indicators of challenge and threat relate to mental health in athletes? What is the relationship between cognitive and hormonal indicators of challenge and threat in sport participants and, collectively, can they predict athlete mental health? Does enhancing perceived resources improve mental health outcomes in athletes?

Summary The TSTSA-R drew upon seminal theories of stress to explain why some performers excel under pressure whilst others do not (Meijen et al., 2020). These theories were originally preoccupied with explaining the effect of stress on both mental and physical health (i.e., Dienstbier, 1989; Lazarus & Folkman, 1984; Selye, 1956). With this point in mind and through the presentation of empirical evidence, in this chapter we have made the case for taking the TCTSA-R back to its roots, towards explaining mental health in athletes. Specifically, athletes high in self-efficacy, who perceive control and support and who adopt approach goals are likely to experience mental health. Those who adopt avoidance goals, have low self-efficacy, do not perceive control or support are unlikely to experience mental health (see Figure 16.1). Of course, whilst these assertions are informed by extant literature, they are tentative and require empirical testing with sport and exercise samples. In addition, it may be worthwhile to explore relationships between concepts similar to those within the TCTSA-R that relate to mental health, such as perceived autonomy, competence, relatedness, and approach and avoidance coping (e.g., Ng et al., 2012; Wheaton, 1985). 258

Stress in Elite Sport

References Aalberg, A.L., Saksvik-Lehouillier, I., & Vaag, J.R. (2019). Demands and resources associated with mental health among Norwegian professional musicians. Work, 63(1), 39–47. 10.3233/WOR-192906 Adie, J.W., Duda, J.L., & Ntoumanis, N. (2010). Achievement goals, competition appraisals, and the well- and illbeing of elite youth soccer players over two competitive seasons. Journal of Sport & Exercise Psychology, 32(4), 555–579. 10.1123/jsep.32.4.555 Agans, J.P., Johnson. S.K., & Lerner, R.M. (2017). Adolescent athletic participation patterns and self-perceived competence: Associations with later participation, depressive symptoms, and health. Journal of Research on Adolescence, 27(3), 594–610. 10.1111/jora.12301 Allen, M.S., Greenlees, I., & Jones, M.V. (2011). An investigation of the five-factor model of personality and coping behaviour in sport. Journal of Sports Sciences, 29(8), 841–850. 10.1080/02640414.2011.565064 Allen, M.S., Greenlees, I., & Jones, M.V. (2013). Personality in sport: A comprehensive review. International Review of Sport and Exercise Psychology, 6(1), 18–208. 10.1080/1750984X.2013.769614 Alter, A.L., Aronson, J., Darley, J.M., Rodriguez, C., & Ruble, D.N. (2010). Rising to the threat: Reducing stereotype threat by reframing the threat as a challenge. Journal of Experimental Social Psychology, 46(1), 166–171. 10. 1016/j.jesp.2009.09.014 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. 10.1176/appi.books.9780890425596 Ariani, D.W. (2022). How achievement goals affect students’ well-being and the relationship model between achievement goals, academic self-efficacy and affect at school. Journal of Applied Research in Higher Education, 14(1), 111–134. https://doi.org/10.1108/JARHE-08-2020-0273 Bakker, A.B., Boyd, C.M., Dollard, M., Gillespie, N., Winefield, A.H., & Stough, C. (2010). The role of personality in the job demands-resources model. Career Development International, 15, 622–636. 10.1108/13620431011094050 Bakker, A.B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309–328. 10.1108/02683940710733115 Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 91–215. Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71–81). Academic Press. Bandura, A. (1997). Self-efficacy. Freeman. Baumeister, D., Lightman, S.L., & Pariante, C.M. (2014). The interface of stress and the HPA axis in behavioural phenotypes of mental illness. Behavioural Neurobiology of Stress-related Disorders, 18, 13–24. 10.1007/7854_2014_304. Baumeister, R.F., & Showers, C.J. (1986). A review of paradoxical performance effects: Choking under pressure in sports and mental tests. European Journal of Social Psychology, 16, 361–383. 10.1002/ejsp.2420160405 Behnke, M., & Kaczmarek, L.D. (2018). Successful performance and cardiovascular markers of challenge and threat: A meta-analysis. International Journal of Psychophysiology, 130, 73–79. 10.1016/j.ijpsycho.2018.04.007 Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B., Urbán, R., & Demetrovics, Z. (2012). Exercise addiction: Symptoms, diagnosis, epidemiology, and etiology. Substance Use & Misuse, 47(4), 403–417. 10.3109/ 10826084.2011.639120 Blascovich, J. (2008). Challenge and threat. In A.J. Elliot (Eds.), Handbook of approach and avoidance motivation science (pp. 431–445). Psychology Press. Blascovich, J., & Mendes, W.B. (2000). Challenge and threat appraisals: The role of affective cues. In J.P. Forgas (Ed.), Feeling and thinking: The role of affect in social cognition (pp. 59–82). Cambridge University Press. Blascovich, J., Mendes, W.B., Hunter, S.B., & Salomon, K. (1999). Social “facilitation” as challenge and threat. Journal of Personality and Social Psychology, 76, 68–77. 10.1037/0022-3514.77.1.68 Blascovich, J., Seery, M.D., Mugridge, C.A., Norris, R.K., & Weisbuch, M. (2004). Predicting athletic performance from cardiovascular indexes of challenge and threat. Journal of Experimental Social Psychology, 40(5), 683–688. 10.1016/j.jesp.2003.10.007 Blascovich, J., Vanman, E., Mendes, W.B., & Dickerson, S.S. (2011). Social psychophysiology for social and personality psychology. Sage Publications Ltd. 10.4135/9781446287842 Bornas, X., Llabrés, J., Noguera, M., López, A.M., Barceló, F., Tortella-Feliu, M., & Fullana, M.A. (2005). Looking at the heart of low and high heart rate variability fearful flyers: Self-reported anxiety when confronting feared stimuli. Biological Psychology, 70(3), 182–187. 10.1016/j.biopsycho.2005.01.002 Cacioppo, J.T., Hughes, M.E., Waite, L.J., Hawkley, L.C., & Thisted, R.A. (2006). Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychology and Aging, 21(1), 140–151. 10.1037/ 0882-7974.21.1.140

259

Jennifer A. Hobson et al. Chadha, N.J., Turner, M.J., & Slater, M.J. (2019). Investigating irrational beliefs, cognitive appraisals, challenge and threat, and affective states in golfers approaching competitive situations. Frontiers in Psychology, 10, 2295. 10.3389/ fpsyg.2019.02295 Chan, W. (2002). Stress, self-efficacy, social support, and psychological distress among perspective Chinese teachers in Hongkong. Educational Psychology, 22(5), 557–569. 10.1080/0144341022000023635 Chen, S.-Y., & Luo, L. (2015). The role of achievement motivations and achievement goals in Taiwanese college students’ cognitive and psychological outcomes. Journal of College Student Development, 56(4), 397–412. 10.1353/ csd.2015.0040 Chen, X., Qiu, N., Chen, C., Wang, D., Zhang, G., & Zhai, L. (2020). Self-efficacy and depression in boxers: A mediation model. Frontiers in Psychiatry, 11, 00791. 10.3389/fpsyt.2020.00791 Chesney, M.A., Neilands, T.B., Chambers, D.B., Taylor, J.M., & Folkman, S. (2006). A validity and reliability study of the coping self-efficacy scale. British Journal of Health Psychology, 11(3), 421–437. 10.1348/135910705X53155 Ciani, K.D., & Sheldon, K.M. (2010). Evaluating the mastery-avoidance goal construct. Psychology of Sport and Exercise, 11, 127–132. 10.1016/j.psychsport.2009.04.005 Closa León, T., Nouwen, A., & Sheffield, D. (2007). Social support and individual variability in patterns of haemodynamic reactivity and recovery. Psychology and Health, 22, 473–492. 10.1080/14768320600941806 Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic Medicine, 38(5), 300–314. 10.1097/ 00006842-197609000-00003 Cumming, S.J.D., Turner, M.J., & Jones, M.V. (2017). Longitudinal changes in elite rowers’ challenge and threat appraisals of pressure situations: A season-long observational study. The Sport Psychologist, 31(3), 217–226. 10.1123/tsp.2016-0087 Daniels, L.M., Haynes, T.L., Stupnisky, R.H., Perry, R.P., Newall, N.E., & Pekrun, R. (2008). Individual differences in achievement goals: A longitudinal study of cognitive, emotional, and achievement outcomes. Contemporary Educational Psychology, 33, 584–608. 10.1016/j.cedpsych.2007.08.002 Daumiller, M., Rinas, R., & Breithecker, J. (2022). Elite athletes’ achievement goals, burnout levels, psychosomatic stress symptoms, and coping strategies. International Journal of Sport and Exercise Psychology, 20(2), 416–435. 10.1080/1612197X.2021.1877326 Davis, H., & Turner, M.J. (2020). The use of rational emotive behavior therapy (REBT) to increase the self‐determined motivation and psychological well‐being of triathletes. Sport, Exercise, and Performance Psychology, 9(4), 489–505. https://doi.org/10.1037/spy0000191 DeFreese, J.D., & Smith, A.L. (2014). Athlete social support, negative social interactions, and psychological health across a competitive sport season. Journal of Sport and Exercise Psychology, 36, 619–630. 10.1123/jsep.2014-0040 De Jonge, J., & Dormann, C. (2017). Why is my job so stressful? Characteristics, processes, and models of stress at work. In N. Chmiel, F. Fraccaroli, & M. Sverke, (Eds.), An introduction to work and organisational psychology (pp. 80–101). Wiley-Blackwell. 10.1002/9781119168058.ch5 Demerouti, E., Bakker, A.B., Nachreiner, F., & Schaufeli, W.B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86, 499–512. 10.1037/0021-9010.86.3.499 Dienstbier, R.A. (1989). Arousal and physiological toughness: Implications for mental and physical health. Psychological Review, 96, 84–100. 10.1037/0033-295X.96.1.84 Dixon, J.G., Jones, M.V., & Turner, M.J. (2019). The benefits of a challenge approach on match day: Investigating cardiovascular reactivity in professional academy soccer players. European Journal of Sport Sciences, 23, 1–11. 10. 1080/17461391.2019.1629179 Dixon, M., Turner, M.J., & Gillman, J. (2017). Examining the relationships between challenge and threat cognitive appraisals and coaching behaviours in football coaches. Journal of Sports Sciences, 35(24), 2446–2452. 10.1080/0264 0414.2016.1273538 Doherty, S., Hannigan, B., & Campbell, M.J. (2016). The experience of depression during the careers of elite male athletes. Frontiers in Psychology, 7. 10.3389/fpsyg.2016.01069 Elliot, A.J., & McGregor, H.A. (2001). A 2x2 achievement goal framework. Journal of Personality and Social Psychology, 80(3), 501–519. 10.1037/0022-3514.80.3.501 Ellis, A., & DiGiuseppe, R. (1993). Are inappropriate or dysfunctional feelings in rational-emotive therapy qualitative or quantitative? Cognitive Therapy and Research, 5, 471–477. 10.1007/BF01173058 Endler, N.S., Kocovski, N.L., & Macrodimitris, S.D. (2001). Copping, efficacy, and perceived control in acute vs chronic illnesses. Personality and Individual Differences, 30, 617–625. 10.1016/S0191-8869(00)00060-X Epel E.S., Crosswell A.D., Mayer S.E., Prather A.A., Slavich, G.M., Puterman, E., et al., (2018). More than a feeling: A unified view of stress measurement for population science. Frontiers in Neuroendocrinology, 49, 146–169. 10.1016/ j.yfrne.2018.03.001

260

Stress in Elite Sport Evans, A.L., Turner, M.J., Pickering, R., & Powditch, R. (2018). The effects of rational and irrational coach team talks on the cognitive appraisal and achievement goal orientation of varsity football athletes. International Journal of Sports Science & Coaching, 13, 431–438. 10.1177/1747954118771183 Fletcher, D., & Sarkar, M. (2012). A grounded theory of psychological resilience in Olympic champions. Psychology of Sport and Exercise, 13(5), 669–678. 10.1016/j.psychsport.2012.04.007 Frank, R., Nixdorf, I., & Beckmann, J. (2013). Depression among elite athletes: Prevalence and psychological factors. Deutsche Zeitschrift für Sportmedizin, 64(11), 320–326. 10.5960/dzsm.2013.088 Feinberg J.M., & Aiello, J.R. (2010). The effect of challenge and thraet appraisals under evaluative presence. Journal of Applied Social Psychology, 40(8), 2071–2104. 10.1111/j.1559-1816.2010.00651.x Gallagher, D.J. (1990). Extraversion, neuroticism and appraisal of stressful academic events. Personality and Individual Differences, 11(10), 1053–1057. https://doi.org/10.1016/0191‐8869(90)90133‐C Gallagher, R., & McKinley, S. (2009). Anxiety, depression and perceived control in patients having coronary artery bypass grafts. Journal of Advanced Nursing, 65(11), 2386–2396. 10.1111/j.1365-2648.2009.05101.x Gallagher, M.A., Bentley, K.H., & Barlow, D.H. (2014). Perceived control and vulnerability to anxiety disorders: A meta-analytic review. Cognitive Therapy and Research, 38, 571–584. 10.1007/s10608-014-9624-x Gerber, M., Best, S., Meerstetter, F., Walter, M., Ludyga, S., Brand, S., et al. (2018). Effects of stress and mental toughness on burnout and depressive symptoms: A prospective study with young elite athletes. Journal of Science and Medicine in Sport, 21, 1200–1205. 10.1016/j.jsams.2018.05.018 Giles, S., Fletcher, D., Arnold, R., Ashfield, A., & Harrison, J. (2020). Measuring well-being in sport performers: Where are we now and how do we progress? Sports Medicine, 50, 1255–1270. 10.1007/s40279-020-01274-z Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35, 169–183. Gross, J.J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2, 271–299. 10.1037/1089-2680.2.3.271 Gross, J.J., & Thompson, R.A. (2007). Emotion regulation: Conceptual foundations. In J.J. Gross (Ed.), Handbook of emotion regulation (pp. 3–24). The Guilford Press. Grot, N.K., Bledsoe, S.E., Larkin, J., Lemay Jr., E.P., & Brown, C. (2007). Stress exposure and depression in disadvantaged women: The protective effects of optimism and perceived control. Social Work Research, 31(1), 19–33. 10.1093/swr/31.1.1 Grøtan, K., Sund, E.R., & Bjerkeset, O. (2019). Mental health, academic self-efficacy and study progress among college students – the SHoT study, Norway. Frontiers in Psychology, 10, 10.3389/fpsyg.2019.00045 Grylls, E., Turner, M.J., & Erskine, J. (2021). The Challenge of the Umpire’s Chair: Challenge and threat, selfefficacy, and psychological resilience in Australian tennis officials. International Journal of Sport Psychology, 52(5), 381–401. 10.7352/IJSP.2021.52.381 Gull, M. (2016). Self-efficacy and mental health among professional students: A correlational study. International Journal of Modern Social Sciences, 5(1), 42–51. Guo, T., Ni, Y., Li, Q., & Hong, H. (2019). The power of faith: The influence of athletes’ coping self-efficacy on the cognitive processing of psychological stress. Frontiers in Psychology, 10, 1565. 10.3389/fpsyg.2019.01565 Gustafsson, H., DeFreese, J.D., & Madigan, D.J. (2017). Athlete burnout: Review and recommendations. Current Opinion in Psychology, 16, 109–113. 10.1016/j.copsyc.2017.05.002 Hammen, C. (2005). Stress and depression. Annual Review of Clinical Psychology, 1, 293–319. 10.1146/annurev.clinpsy. 1.102803.143938 Hase, A., Aan Hen Rot, M., de Miranda Azevedo, R., & Freeman, P. (2020). Threat-related motivational disengagement: Integrating blunted cardiovascular reactivity to stress into the biopsychosocial model of challenge and threat. Anxiety Stress Coping, 33(4), 355–369. 10.1080/10615806.2020.1755819 Hase, A., O’Brien, J., Moore, L.J., & Freeman, P. (2019). The relationship between challenge and threat states and performance: A systematic review. Sport, Exercise, and Performance Psychology, 8, 123–144. 10.1037/spy0000132 Hobson, J.A. (2022, July 12). Youth academy soccer players’ challenge and threat states: longitudinal and temporal change over time [Conference presentation]. FEPSAC 2022 16th European Congress of Sport and Exercise Psychology, Padova, Italy. Hu, T., Zhang, D., Wang, J., Mistry, R., Ran, G., & Wang, X. (2014). Relation between emotion regulation and mental health: A meta-analysis review. Psychological Reports, 114(2), 341–362. 10.2466/03.20.PR0.114k22w4 Isoard-Gautheur, S., Guillet-Descas, E., & Duda, J. (2013). How to achieve in elite training centers without burning out? An achievement goal theory perspective. Psychology of Sport and Exercise, 14(1), 72–83. 10.1016/j.psychsport. 2012.08.001 Jamieson, J.P., Crum, A.J., Goyer, A.J., Marotta, M.E., & Akinola, M. (2018). Optimizing stress responses with reappraisal and mindset interventions: An integrated model. Anxiety, Stress, Coping, 31(3), 24561. 10.1080/10615 806.2018.1442615

261

Jennifer A. Hobson et al. Jamieson, J.P., Nock, M.K., & Mendes, W.B. (2012). Mind over matter: Reappraising arousal improves cardiovascular and cognitive responses to stress. Journal of Experimental Psychology, 141(3), 417–422. 10.1037/a0025719 Jones, M.V., Meijen, C., McCarthy, P.J., & Sheffield, D. (2009). A theory of challenge and threat states in athletes. International Review of Sport and Exercise Psychology 2(2), 161–180. 10.1080/17509840902829331 Kaplan, A., & Maehr, M.L. (1999). Achievement goals and student well-being. Contemporary Educational Psychology, 24, 330–358. 10.1006/ceps.1999.0993 Kareshki, H., Mirdorghi, F., & Hamzehlo, M. (2012). The role of students’ achievement goals in their mental health. Quarterly Journal of Psychological Studies, 8(3), 159–178. 10.22051/PSY.2012.1727 Karasek, R.A. (1979). Job demands, job decision latitude, and mental strain: Implications for job design. Administrative Science Quarterly, 24, 285–308. 10.2307/2392498 Kawachi, I., & Berkman, L.F. (2001). Social ties and mental health. Journal of Urban Health, 78, 458–467. Keyes, C.L.M. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43(2), 207–222. 10.2307/3090197 Kinman, G., Clements, A.J., & Hart, J. (2017). Job demands, resources and mental health in UK prison officers. Occupational Medicine, 67(6), 456–460. 10.1093/occmed/kqx091 Kotov, R., Gámez, W., Schmidt, F.L., & Watson, D. (2010). Linking “big” personality traits to anxiety, depressive, and substance use disorders: A meta-analysis. Psychological Bulletin, 136(5), 76–821. 10.1037/a0020327 Kubicek, W.G., Karnegis, J.N., Patterson, R.P., Witsoe, D.A., & Mattson, R.H. (1966). Development and evaluation of an impedance cardiac output system. Aerospace Medical Association, 37, 1208–1212. Küettel, A., & Larsen, C.H. (2019). Risk and protective factors for mental health in elite athletes: A scoping review. International Review of Sport and Exercise Psychology, 13(2), 1–35. 10.1080/1750984X.2019.1689574 Kuettel, A., Pedersen, A.K., & Larsen, C.H. (2021). To Flourish or languishing, that is the question: Exploring the mental health profiles of Danish elite athletes. Psychology of Sport and Exercise, 52, 101837. 10.1016/j.psychsport. 2020.101837 Lazarus, R.S. (1999). Stress and emotions: A new synthesis. Free Association Books. Lazarus, R.S. (2000). How emotions influence performance in competitive sports. The Sport Psychologist, 14(3), 229–252. 10.1123/tsp.14.3.229 Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer. Leguizamo, F., Olmedilla, A., Núñez, A., Verdaguer, F.J.P., Gómez-Espejo, V., Ruiz-Barquín, R., & Garcia-Mas, A. (2021). Personality, coping strategies and mental health in high performance athletes during confinement derived from the COVID-19 pandemic. Frontiers in Public Health. 10.3389/fpubh.2020.561198 Licitra-Klecker, D.M., & Waas, G.A. (1993). Perceived social support among high-stress adolescents: The role of peers and family. Journal of Adolescent Research, 8, 381–402. 10.1177/074355489384003 Lichtenstein, M.B., Christiansen, E., Elklit, E., Bilenberg, N., & Støving, R.L. (2014). Exercise addiction: A study of eating disorder symptoms, quality of life, personality traits and attachment styles. Psychiatry Research, 215(2), 410–416. 10.1016/j.psychres.2013.11.010 Lienhart, N., Nicaise, V., Knight, C.J., & Guillet-Descas, E. (2020). Understanding parent stressors and coping experiences in elite sports contexts. Sport, Exercise, and Performance Psychology, 9(3), 390–404. 10.1037/spy0000186 Linnenbrink, E.A. (2005). The dilemma of performance-approach goals: The use of multiple goal contexts to promote students’ motivation and learning. Journal of Educational Psychology, 97, 197–213. 10.1037/0022-0663.97.2.197 Lovallo, W.R. (2005). Cardiovascular reactivity: Mechanisms and pathways to cardiovascular disease. International Journal of Psychophysiology, 58(2-3), 119–132. 10.1016/j.ijpsycho.2004.11.007 Low, W.R., Sandercock, G.R.H., Freeman, P., Winter, M.E., Butt, J., & Maynard, I. (2021). Pressure training for performance domains: A meta-analysis. Sport, Exercise, and Performance Psychology, 10(1), 149–163. 10.1037/spy0000202 Luo, W., Paris, S.G., Hogan, D., & Luo, Z. (2011). Do performance goals promote learning? A pattern analysis of Singapore students’ achievement goals. Contemporary Educational Psychology, 36, 165–176. 10.1016/j.cedpsych. 2011.02.003 Mak, A.S., Blewitt, K., & Heaven, P.C.L. (2004). Gender and personality influnces in adolescent threat and challenge appraisals and depressive symptoms. Personality and Individual Differences, 36(6), 1483–1496. 10.1016/S01918869(03)00243-5 Maslach, C., Schaufeli, W.B., & Leiter, M.P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422. 10.1146/ annurev.psych.52.1.397. Mayer, H., Stolz, E., Großschädl, F., Rásky, E., & Freidl, W. (2017). The moderating role of personal resources in the relationship between psychosocial job demands and health: a cross-sectional study. BMJ Open, 7, e015710. 10.113 6/bmjopen-2016-015710 Meijen, C., Turner, M., Jones, M.V., Sheffield, D., & McCarthy, P. (2020). A theory of challenge and threat states in athletes: A revised conceptualization, 11. Frontiers in Psychology, 10.3389/fpsyg.2020.00126

262

Stress in Elite Sport Miller, A.J., Slater, M.J., & Turner, M.J. (2020). Coach identity leadership behaviours are positively associated with athlete resource appraisals: The mediating roles of relational and group identification. Psychology of Sport and Exercise, 51, 101755. 10.1016/j.psychsport.2020.101755 Moore, L.J., Vine, S.J., Wilson, M.R., & Freeman, P. (2012). The effect of challenge and threat states on performance: An examination of potential mechanisms. Psychophysiology, 49, 1417–1425. 10.1111/j.1469-8986.2012. 01449.x Moore, L.J., Vine, S.J., Wilson, M.R., & Freeman, P. (2014). Examining the antecedents of challenge and threat states: The influence of perceived required effort and support availability. International Journal of Psychophysiology, 93, 267–273. 10.1016/j.ijpsycho.2014.05.009 Ng, J.Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E.L., Ryan, R.M., Duda, J.L., & Williams, G.C. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7, 325–340. 10.1177/1745691612447309 Norris, L.A., Didymus, F.F., & Kaiseler, M. (2017). Stressors, coping, and well-being among sports coaches: A systematic review. Psychology of Sport and Exercise, 33, 93–112. 10.1016/j.psychsport.2017.08.005 Oberle, E., Ji, X.R., Guhn, M., Schonert-Reichl, K.A., & Gadermann, A.M. (2019). Benefits of extracurricular participation in early adolescence: Associations with peer belonging and mental health. Journal of Youth and Adolescence, 48, 2255–2270. 10.1007/s10964-019-01110-2 Ogedegbe, G., & Pickering, T. (2010). Principles and techniques of blood pressure measurement. Cardiology Clinics, 28, 571–586. 10.1016/j.ccl.2010.07.006 Pekrun, R., Elliot, A.J., & Maier, M.A. (2006). Achievement goals and discrete achievement emotions: A theoretical model and prospective test. Journal of Educational Psychology, 98, 583–597. 10.1037/0022-0663.98.3.583 Phillips, A.C., Hunt, K., Der, G., & Carroll, D. (2011). Blunted cardiac reactions to acute psychological stress predict symptoms of depression five years later: Evidence from a large community study. Psychophysiology, 48, 142–148. 10.1111/j.1469-8986.2010.01045.x Quigley, K.S., Barrett, L.F., & Weinstein, S. (2002). Cardiovascular patterns associated with threat and challenge appraisals: Individual responses across time. Psychophysiology, 39, 1–11. 10.1017/s0048577201393046 Raedeke, T.D., & Smith, A.L. (2004). Coping resources and athlete burnout: An examination of stress mediated and moderation hypotheses. Journal of Sport and Exercise Psychology, 26, 525–541. 10.1123/jsep.26.4.525 Raffaelli, M., Andrafe, F.C.D., Wiley, A.R., Sanchez-Armass, O., Edwards, L.L., & Aradillas-Garcia, C. (2012). Stress, social support, and depression: A test of the stress‐buffering hypothesis in a Mexican sample. Journal of Research on Adolescence, 23(2), 283–289. 10.1111/jora.12006 Rau, R., Morling, K., & Rösler, U. (2010). Is there a relationship between major depression and both objectively assessed and perceived demands and control? Work & Stress, 24(1), 88–106. 10.1080/02678371003661164 Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Medicine, 40(11), 961–980. 10.2165/11536580-000000000-00000 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46, 1333–1353. 10.1007/s40279-016-0492-2 Rice, S.M., Parker, A.G., Mawren, D., Clifton, P., Harcourt, P., Lloyd, M., Kountouris, A., Smith, B., McGorry, P.D., & Purcell, R. (2019). Preliminary psychometric validation of a brief screening tool for athlete mental health among male elite athletes: The Athlete Psychological Strain Questionnaire. International Journal of Sport and Exercise Psychology, 6(18), 850–865. 10.1080/1612197X.2019.1611900 Ronaldson, A., Gazali, A.M., Zalli, A., Kaiser, F., Thompson, S.J., Henderson, B., Steptoe, A. & Carvalho, L. (2016). Increased percentages of regulatory T cells are associated with inflammatory and neuroendocrine responses to acute psychological stress and poorer health status in older men and women. Psychopharmacology, 233, 1661–1668. 10.1007/s00213-015-3876-3 Saeri, A.K., Cruwys, T., Barlow,F.K., Stronge, S., & Sibley, C.G. (2017). Social connectedness improves public mental health: Investigating bidirectional relationships in the New Zealand attitudes and values survey. Australian & New Zealand Journal of Psychiatry, 52(4), 365–374. 10.1177/0004867417723990 Salmelo-Aro, K., & Upadyaya, K. (2014). School burnout and engagement in the context of demands-resources model. British Journal of Educational Psychology, 84(1), 137–151. 10.1111/bjep.12018 Sarkar, M., & Fletcher, D. (2014). Psychological resilience in sport performers: A review of stressors and protective factors. Journal of Sports Sciences, 32(15), 1419–1434. 10.1080/02640414.2014.901551 Seery, M.D. (2011). Challenge or threat? Cardiovascular indexes of resilience and vulnerability to potential stress in humans. Neuroscience & Biobehavioural Reviews, 35, 1603–1610. 10.1016/j.neubiorev.2011.03.003 Schinke, R.J., Stambulova, N.B., Si, G., & Moore, Z. (2017). International Society of Sport Psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 1–18. 10.1080/1612197X.2017.1295557

263

Jennifer A. Hobson et al. Schönfeld, P., Brailovskaia, J., Bieda, A., hang, X.C., & Margraf, J. (2016). The effects of daily stress on positive and negative mental health: Mediation through self-efficacy. International Journal of Clinical and Health Psychology, 16(1), 1–10. 10.1016/j.ijchp.2015.08.005 Schönfeld, P., Brailovskaia, J., Zhang, X.C., & Margraf, J. (2019). Self-efficacy as a mechanism linking daily stress to mental health in students: A three-wave cross-lagged study. Psychological Reports, 122(6), 2074–2095. 10.1177/ 0033294118787496 Schwerdtfeger, A.R., Rominger, C., Weber, B., & Aluani, I. (2020). A brief positive psychological intervention prior to a potentially stressful task facilitates more challenge-like cardiovascular reactivity in high trait anxious individuals. Psychophysiology, 58(1), e13709. 10.1111/psyp.13709 Segerstrom, S.C., & O’Connor, D.B. (2012). Stress, health and illness: Four challenges for the future. Psychology and Health, 27, 128–140. 10.1080/08870446.2012.659516 Seligman, M.E. (1972). Learned helplessness. Annual Review of Medicine, 23, 407–412. 10.1146/annurev.me.23.0201 72.002203 Selye, H. (1956). The stress of life. McGraw Hill. Semmer, N.K., McGrath, J.E., & Beehr, T.A. (2005). Conceptual issues in research on stress and health. In C.L. Cooper (Ed.), Handbook of stress, medicine and health (2nd ed. pp. 1–44). CRC Press. 10.1201/9781420039702.ch1 Senko, C., & Freund, A.M. (2015). Are mastery-avoidance achievement goals always detrimental? An adult development perspective. Motivation & Emotion, 39(4), 477–488. 10.1007/s11031-015-9474-1 Shumaker, S.A., & Brownell, A. (1984). Toward a theory of social support: Closing conceptual gaps. Journal of Social Issues, 40, 11–36. 10.1111/j.1540-4560.1984.tb01105.x Sideridis, G.D. (2005). Goal orientation, academic achievement, and depression: Evidence in favor of a revised goal theory framework. Journal of Educational Psychology, 97, 366–375. 10.1037/0022-0663.97.3.366 Skinner, E.A. (1996). A guide to constructs of control. Personality Processes and Individual Differences, 71(3), 549–570. 10.1037/0022-3514.71.3.549 Skinner, N., & Brewer, N. (2002). The dynamics of threat and challenge appraisals prior to stressful achievement events. Journal of Personality and Social Psychology, 83, 678–692. 10.1037/0022-3514.83.3.678 Slater, M.J., Evans, A.L., & Turner, M.J. (2016). Implementing a social identity approach for effective change management. Journal of Change Management, 16, 18–37. 10.1080/14697017.2015.1103774 Slater, M.J., Turner, M.J., Evans, A.L., & Jones, M.V. (2018). Capturing hearts and minds: The influence of relational identification with the leader on followers’ mobilization and cardiovascular reactivity. The Leadership Quarterly, 29(3), 379–388. 10.1016/j.leaqua.2017.08.003. Smith, R.E. (1986). Toward a cognitive-affective model of athletic burnout. Journal of Sport Psychology, 8, 36–50. 10.1123/jsp.8.1.36 Soligard, T., Schwellnus, M., Alonso, J.M., Bahr, R., Clarsen, B., Dijkstra, H.P., Gabbett, T.J., Gleeson, M., Hägglund, M., Hutchinson, M.R., Janse Van Rensburg, C., Meeusen, R., Orchard, J.W., Pluim, B.M., Raftery, M., Budgett, R., & Engebretsen, L. (2016). How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine 50(17), 1030–1041. 10.113 6/bjsports-2016-096581 Steudte-Schmiedgen, S., Stalder, T., Schönfeld, S., Wittchen, H.-U., Trautmann, S., Alexander, N., Miller, R., & Kirschbaum, C. (2015). Hair cortisol concentrations and cortisol stress reactivity predict PTSD symptom increase after trauma exposure during military deployment. Psychoneuroendocrinology, 59, 123–133. 10.1016/j.psyneuen. 2015.05.007 Tajfel, H. (1979). Individuals and groups in social psychology. Journal of Social and Clinical Psychology, 18(2), 183–190. 10.1111/j.2044-8260.1979.tb00324.x Takaki, J., Nishi, T., Shimogama, H., Inada, T., Matsuyama, N., Kumano, H., & Kuboki, T. (2003). Interaction among a stressor, depression, and anxiety in maintenance hemodialysis patients. Behavioral Medicine, 29, 107–112. 10.1080/08964280309596063 Thomas, O., Lane, A., & Kingston, K. (2011). Defining and contextualizing robust sport-confidence. Journal of Applied Sport Psychology, 23(2), 189–208, 10.1080/10413200.2011.559519 Tian, L., Yu, T., & Huebner, E.S. (2017). Achievement goal orientations and adolescents’ subjective well-being in school: The mediating roles of academic social comparison directions. Frontiers in Psychology, 8, Article 37. 10.3389/ fpsyg.2017.00037 Tomaka, J., Blascovich, J., Kibler, J., & Ernst, J.M. (1997). Cognitive and physiological antecedents of threat and challenge appraisal. Journal of Personality and Social Psychology, 73(1), 63–72. 10.1037/0022-3514.73.1.63 Tomaka, K., Palacios, R., Schneider, K.T., Colotla, M., Concha, J.B., & Herald, M.M. (1999). Assertiveness predicts threat and challenge reactions to potential stress among women. Journal of Personality and Social Psychology, 76(6), 1008–1021. 10.1037//0022-3514.76.6.1008

264

Stress in Elite Sport Troy, A.S., Shallcross, A.J., & Mauss, I.B. (2013). A person-by-situation approach to emotion regulation: Cognitive reappraisal can either help or hurt, depending on the context. Psychological Science, 24(12), 2505–2514. 10.1177/ 0956797613496434 Tuominen-Soini, H., Salmela-Aro, K., & Niemivirta, M. (2008). Achievement goal orientations and subjective wellbeing: A person-centred analysis. Learning and Instruction, 18, 251–266. 10.1016/j.learninstruc.2007.05.003 Turner, A.I., Smyth, N., Hall, S.J., Torres, S.J., Hussein, M., Jayasinghe, S.U., Ball, K., & Clow, A. (2020). Psychological stress reactivity and future health and disease outcomes: A systematic review of prospective evidence. Psychoneuroendocrinology, 114, 104599. 10.1016/j.psyneuen.2020.104599 Turner, M.J., Aspin, G., & Gillman, J. (2019). Maladaptive schemas as a potential mechanism through which irrational beliefs relate to psychological distress in athletes. Psychology of Sport and Exercise, 44, 9–16. 10.1016/j.psychsport. 2019.04.015 Turner, M.J., & Barker, J.B. (2014). Tipping the balance: The mental skills handbook for athletes. Bennion Kearny. Turner, M.J., Carrington, S., & Miller, A. (2018). Psychological distress across sport participation groups: The mediating effects of secondary irrational beliefs and symptoms of anxiety, anger and depression. Journal of Clinical Sport Psychology, 38, 148–153. 10.1016/j.psychsport.2018.06.012 Turner, M.J., Massie, R., Slater, M.J., & Braithwaite, E. (2021). Do challenge and threat evaluations predict netball performance and selection at trials in youth netball players? Sport, Exercise, and Performance Psychology, 10(1), 71–87. 10.1037/spy0000248 Turner, M.J., & Jones, M.V. (2018). Arousal control in sport. Oxford Research Encyclopedia of Psychology. 10.1093/ acrefore/9780190236557.013.155 Turner, M.J., Jones, M.V., Sheffield, D., Barker, J.B., & Coffee, P. (2014). Manipulating cardiovascular indices of challenge and threat using resource appraisals. International Journal of Psychophysiology, 94(1), 9–18. 10.1016/ j.ijpsycho.2014.07.004 Turner, M.J., Jones, M.V., Sheffield, D., Slater, M.J., Barker, J.B., & Bell, J.J. (2013). Who thrives under pressure? Predicting the performance of elite academy cricketers using the cardiovascular indicators of challenge and threat states. Journal of Sport and Exercise Psychology, 35, 387–397. 10.1123/jsep.35.4.387 Turner, M.J., & Moore, M. (2016). Irrational beliefs predict increased emotional and physical exhaustion in Gaelic football athletes. International Journal of Sport Psychology, 47(2), 187–201. 10.7352/IJSP.2016.47.187 Uchino, B.N., Carlisle, M., Birmingham, W., & Vaughn, A.A. (2011). Social support and the reactivity hypothesis: Conceptual issues in examining the efficacy of received support during acute psychological stress. Biological Psychology, 86, 137–142. 10.1016/j.biopsycho.2010.04.003 Uphill, M.A., Rossato, C.J.L., Swain, J., & O’Driscoll, J. (2019). Challenge and threat: A critical review of the literature and an alternative conceptualization. Frontiers in Psychology, 10, 1255. https://doi.org/10.3389/fpsyg.2019.01255 Vella, S.A., Swann, C., & Tamminen, K.A. (2021). Reflections on the field of mental health in sport: Critical issues and ways of moving forward. Journal of Applied Sport Psychology, 33(1), 123–129. 10.1080/10413200.2020.1854898 Vink, J., Ouweneel, A., & Le Blanc, P. (2011). Psychologische energiebronnen voor bevlogen werknemers: Psychologisch kapitaal in the job demands-resources model. Gedrag & Organisatie, 24, 101–120. 10.5117/2011.024. 002.101 Vîslă, A., Flückiger, C., Grosse Holtforth, M., & David, D. (2016). Irrational beliefs and psychological distress: A meta-analysis. Psychotherapy and Psychosomatics, 85(1), 8–15. 10.1159/000441231 Wang, H.-H., Wu, S.-Z., & Liu, Y.-Y. (2009). Association between social support and health outcomes: A meta‐analysis. The Kaohsiung Journal of Medical Sciences, 19(7), 345–350. 10.1016/S1607-551X(09)70436-X Watson, J.C., & Watson, A.A. (2016). Coping self-efficacy and academic stress among hispanic first-year college students: the moderating role of emotional intelligence. Journal of College Counselling, 19, 218–230. 10.1002/ jocc.12045 Wheaton, B. (1985). Models for the stress-buffering functions of coping resources. Journal of Health and Social Behavior, 26(4), 352–364. Williams, J.M., Tonymon, P., & Andersen, M.B. (1991). The effects of stressors and coping resources on anxiety and peripheral narrowing. Journal of Applied Sport Psychology, 3(2), 126–141. Williams, S.E., Cumming, J., & Balanos, G.M. (2010). The use of imagery to manipulate challenge and threat appraisal states in athletes. Journal of Sport and Exercise Psychology, 32, 339–358. 10.1123/jsep.32.3.339 Williams, S.E., Quinton, M.L., Veldhuizen van Zanten, J.J.C.S., Davies, J., Möller, C., Trotman, G.P., & Ginty, A.T. (2021). Mastery imagery ability is associated with positive anxiety and performance during psychological stress. Frontiers in Psychology, 12, 568580. 10.3389/fpsyg.2021.568580 Wilson, K.E., Das, B.M., Evans, E.M., & Dishman, R.K. (2016). Structural equation modeling supports a moderating role of personality in the relationship between physical activity and mental health in college women. Journal of Physical Activity & Health, 13, 67–78. 10.1123/jpah.2014-0455

265

Jennifer A. Hobson et al. Woodman, T., Zourbanos, N., Hardy, L., Beattie, S., & McQuillan, A. (2010). Do performance strategies moderate the relationship between personality and training behaviors? An exploratory study. Journal of Applied Sport Psychology, 22, 183–197. 10.1080/10413201003664673 Woodman, T., Davis, P.A., Hardy, L., Callow, N., Glasscock, I., & Yuill-Proctor, J. (2009). Emotions and sport performance: An exploration of happiness, hope and anger. Journal of Sport & Exercise Psychology, 31, 169–188. 10.1123/jsep.31.2.169 Xanthopoulou, D., Bakker, A.B., Demerouti, E., & Schaufeli, W.B. (2009). Work engagement and financial returns: A diary study on the role of job and personal resources. Journal of Organizational and Occupational Psychology, 82, 183–200. 10.1348/096317908X285633 Yuenyongchaiwat, K., & Sheffield, D. (2017). Blunted cardiovascular reactions are a predictor of negative health outcomes: A prospective cohort study. Journal of Applied Biobehavioral Research, 22, 1–11. 10.1111/jabr.12091 Zhao, C., & Jin, Z. (2008). Researches on the relationship between achievement goal and subjective well-being in college students. Social Psychological and Personality Science, 23, 33–36. Zhou, J., Huebner, E.S., & Tian, L. (2019). Longitudinal associations and mechanisms between achievement goals and subjective well-being in school in Chinese adolescents. School Mental Health: A Multidisciplinary Research and Practice Journal, 12, 353–365. 10.1007/s12310-019-09356-8

266

17 STIGMATISATION OF MENTAL ILLNESS AND SEEKING SPORT PSYCHOLOGY SERVICES Rebecca A. Zakrajsek, Scott B. Martin, Shane R. Thomson, and Amelia Gulliver

Introduction Mental illness and its associated stigma have been part of human existence throughout history (Bauman, 2016; Porter, 2002). For example, in ancient Greece, a ‘stigma’ was a brand to mark slaves or criminals (Rössler, 2016) and was used to identify, devalue, discredit, and discriminate those who were viewed as different (Javed et al., 2021; Van Slingerland et al., 2019). Figure 17.1 shows how stigma exists at the individual (i.e., self-stigma), interpersonal (i.e., social stigma), and systemic (i.e., structural stigma) levels. At the individual level, stigma has been conceptualised as a cognitive, emotional, and behavioural construct, which allows it to be separated from prejudice and discrimination. Self-stigma (i.e., intrapersonal) occurs when individuals with negatively stereotyped characteristics (e.g., gender, mental illness, race, sexual orientation) adopt negative attitudes toward themselves, and is associated with lack of ability or hopelessness, reduced self-esteem, disempowerment, and decreased quality of life. Social stigma (i.e., interpersonal) is expressed through interpersonal behaviour and creates a social standard of acceptable ways of behaving toward members of an oppressed group. Structural stigma refers to the rules, policies, and practices of social institutions that arbitrarily restrict the rights of, and opportunities for, people to achieve their goals. Sport cultures and associated institutions through their dominant cultural ideology can result in individuals being excluded, bullied, or harassed due to apparent differences (e.g., experiencing symptoms of mental illness). Consequently, mental toughness and mental health have been viewed as possibly contradictory concepts in high-performance domains such as sport, with mental illness and seeking assistance for psychological treatment being stigmatised (Ayala et al., 2022; Bauman, 2016; Gucciardi et al., 2017). To perform optimally, athletes are required to be physically tough, able to thrive in challenging and adverse circumstances through perseverance and passion to accomplish their goals. Athletes, especially those competing at the elite levels, are also expected to be mentally tough, display grit (i.e., sustain interest and effort to achieve goals), and have resilience (i.e., able to adapt in the face of challenges and “bounce back” from difficult experiences; see Mahmoud et al., 2022). However, athletes are not immune to mental illness and may experience rates of mental health issues similar to those in the general population (Gulliver, 2015). The mental health of elite athletes has gained both public and scientific interest, especially since several prominent elite athletes have discussed their mental health challenges publicly (Kuettel & Larsen, 2020; Nixdorf et al., 2013; Parrott et al., 2021). As recently highlighted by the media attention received by elite athletes such as Simone Biles, DeMar DeRozan, Kevin Love, Naomi Osaka, and Michael Phelps a DOI: 10.4324/9781003099345-23

267

Rebecca A. Zakrajsek et al.

Figure 17.1 Stigmatisation of Mental Health and Sport Psychology Ecological Model. (Modified from Javed et al., 2021.)

powerful message is being made to destigmatise mental health, one that emphasises the importance of treating elite athletes as human beings first. Unfortunately, athletes who have openly discussed their mental health issues have often subsequently experienced significant criticism from the public, media, and sport organisations (see Box 17.1). Athletes, like the general population, are vulnerable to mental health issues and disorders (Brown, 2014; Van Slingerland et al., 2019). In fact, elite athletes may be more vulnerable since they are regularly exposed to numerous stressors, such as injuries, pressure from coaches, family members, social media, and news media (see Arnold & Fletcher, 2012; Gulliver et al., 2012a; Parrott et al., 2021). Recently, the International Olympic Committee reported that up to 35% of elite athletes experience mental disorders (Reardon et al., 2019). Further, research conducted in Canada, Denmark, Germany, Norway, United Kingdom (UK), United States (US), and Sweden indicate that 14% to 47% of elite athletes experience symptoms of depression and anxiety (Akesdotter et al., 2020; Foskett & Lognstaff, 2018; Kuettel et al., 2021; Nixdorf et al., 2013; Pensgaard et al., 2021; Poucher et al., 2021; Rearden et al., 2019). A wealth of anecdotal and empirical evidence indicates that athletes and coaches, especially those attempting to achieve great success in their sport, believe that mental health and various biopsychosocial factors play a critical role in achieving exceptional performances (Connaughton et al., 2010; Gould & Maynard, 2009; 268

Stigmatisation of Mental Illness

Box 17.1 Naomi Osaka: Stigma and the Media Case Study (see Hassan, 2021; Osaka, 2021) Naomi Osaka became one of the world’s highest-profile female athletes after defeating Serena Williams in the 2018 US Open at 20 years old. Her win was booed by the crowd, leaving Osaka in tears, which she has identified as a key precipitating factor in the development of her mental health challenges. Since her historic victory, Osaka has been open about her experiences with mental health issues as a young Black and Asian woman, especially as related to her battles with social anxiety and depression and the pressure that comes with being ranked the number one tennis player. In 2020, Osaka experienced backlash after she pulled out of the New York Open in support of the Black Lives Matter (BLM) Movement, recognising her identity as a Black-Japanese woman. This, and her subsequent protest at the 2020 US Open, which involved wearing facemasks with the names of BLM victims, led to debate in Japan, where criticism focused on the appropriateness of athletes using their status and public platform to promote social justice. Then in 2021, Osaka withdrew from her first-round match in the French Open after public debate following her announcement that she would avoid press conferences to improve her performance and preserve her mental health due to the anxiety they induced. However, following her announcement, Osaka was reportedly threatened by French Open officials with disqualification and large fines if she refused to attend press conferences. Her withdrawal sparked a global debate on “mental toughness”and she was heavily criticised by some media outlets. While many across the world hailed Osaka’s bravery, there was also major media backlash, the argument being that despite feeling “vulnerable”, confronting media is part of the job. The British television personality Piers Morgan called her “world sport’s most petulant little madam”, a “narcissistic”, and “an arrogant spoiled brat whose fame and fortune appears to have inflated her ego”. Former British tennis player Andrew Castle mentioned that players are obliged to engage with the media and her role is more than “just hitting tennis balls”. At the same time, Japanese television personalities, fans, and chief cabinet secretary praised her courage, validated the pressures she faced, and encouraged her to take care of herself. Many elite athletes, such as Serena Williams, were compassionate about Osaka’s experience with scrutiny from the media and the prejudices that exist about mental health. Further, Osaka went on to publicly apologise for being a “distraction and I accept that my timing was not ideal, and my message could have been clearer”. Osaka also noted “I would never trivialise mental health or use the term lightly … when the time is right, I really want to work with the Tour to discuss ways we can make things better for the players”. Osaka’s case presents a clear example of the role that the media plays in fuelling stigma toward mental health. Of course, it is possible in this case, that the backlash was somewhat defensive – a response to her identifying the press specifically as a source of anxiety. However, there remains a lack of accommodation both in the media, and in sport organisations to consider that sport is also a work context, and that mental health challenges can cause significant disability. The inability to attend press conferences due to a physical illness, injury, or disability would likely have been accommodated; however, mental illness and any associated disabilities are not always accommodated – she was given the choice to attend or be disqualified. For Osaka to perform to the best of her ability, she recognised that due to her experience of social anxiety, participating in press conferences was going to be detrimental to her mental health and her performance, so she pre-emptively attempted to avoid them. In hindsight, as she acknowledged, it could have been approached differently; however, this is an example of an athlete clearly trying to make change within sports organisations to recognise, value, and accommodate elite athletes’ mental health in the same ways that physical health and disability is accommodated.

269

Rebecca A. Zakrajsek et al.

Greenleaf et al., 2001; Wrisberg et al., 2010; Zakrajsek, Martin, & Zizzi, 2011; Zakrajsek & Zizzi, 2007). The importance of mental health to performance success cannot be separate from one another (Bird et al., 2020; Reardon et al., 2019). Despite the perceived importance of mental factors to well-being and performance, reluctance to engage the services provided by mental health and sport psychology professionals continues to exist. In the United States, actual documented reports of athletes’ sport psychology or mental performance consultation service usage is currently limited due to a lack of data collection. Information that exists indicates service use is low, ranging from 3% at the high school and club level (Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2008) up to 30% at the more elite level (i.e., collegiate; Wrisberg et al., 2009, 2010; Zakrajsek & Zizzi, 2011). Service usage in the United Kingdom appears to be similar, with approximately 32% of a sample of elite youth athletes having experience with sport psychology services (Bell et al., 2022). Athletes may also differentiate between sport psychology and mental health services (Gulliver, 2012a), the former typically being focused on sport performance; thus, accurate rates of those who are accessing psychology services solely for their mental health is currently unknown. Recently, a report with a sample of the Swedish national team suggests that approximately 29% of elite athletes (63 different sport were represented) had sought mental health services (Akesdotter et al., 2020). In addition, recurring episodes of mental health problems was common and female elite athletes sought out mental health services more than males. As part of the sport culture, the ethos of “toughness”, which often emphasises “looking fit” and “winning at all costs”, may limit the search for professional help and the public display of practicing mental skills (Martin et al., 2012). Athletes in these highperformance settings often push themselves or are pressured by others to push their bodies to extremes (Biggins et al., 2017) and the messages often communicated (e.g., “No pain, no gain!”, “Give 110%”) may lead to stigmatising help-seeking, which may also contribute to poor performance and frustration, and ultimately injury or sport dropout. Training to become an elite athlete and the recognition gained can promote unhealthy behaviours and illness (e.g., fear of failure, perfectionism, and anxiety). For instances, athletes may try to be “toughminded” and suffer pain, injury, or illness in stoic silence because they worry competitors will take advantage of them or important others (peers, coaches, parents, etc.) will perceive them as weak or not understand their needs and challenges. Consequently, athletes tend not to seek help for mental health or mental performance challenges. This tendency not to seek help is complex, and may involve athletes’ stigma, lack of confidence, personal openness, and over the years a lack of specialised support from available sport personnel (Martin et al., 2012). Therefore, this chapter offers a thoughtful discussion on the stigma toward mental illness and attitudes of athletes, coaches, and personnel/support staff toward seeking sport psychology and mental health–related services. First, a conceptual framework for mental health and sport psychology service provision is introduced that is grounded in attitude and behaviour change theories. Next, this chapter highlights research assessing factors that influence the way in which attitudes and beliefs are formed. This information is then used to inform ways to make mental health and sport psychology services accessible and attractive as well as strategies to effectively decrease stigma and resistance to service use. Specifically, strategies discussed are focused on an intrapersonal, interpersonal, and structural level. Lastly, future directions related to attitudes and receptivity to mental health and sport psychology services are highlighted.

Stigma Toward Mental Health and Sport Psychology Services In his seminal work, Strong (1968) presented the importance of assessing individuals’ attitudes about seeking assistance designed to help address personal mental health-related problems, whether aimed at clinical or subclinical symptoms that interfere with daily functioning and quality of life. Shortly thereafter, Fischer and Turner (1970) further advanced counselling psychology by developing a survey instrument to examine attitudes toward seeking professional psychological assistance. Although exploring attitudes toward seeking professional assistance originally emerged from the counselling psychology field, it has since expanded to competitive sport settings (Martin et al., 2012). Since the late 1980s, athletes’ attitudes toward mental skills training and sport psychology services have been regularly investigated (e.g., Fenker & 270

Stigmatisation of Mental Illness

Lambiotte, 1987; Gould et al., 1989; Gould et al., 1990; Gould et al., 1991; Grove & Hanrahan, 1988; Hellstedt, 1987; Orlick & Partington, 1987; Partington & Orlick, 1987; Van Raalte et al., 1992). Interacting with athletes and important others in the elite sport environment (e.g., coaches, personnel/ support staff) in such a way that develops positive perceptions about sport psychology and mental health services is not only essential to the future of sport psychology, but also to athletes’ overall quality of life. Zakrajsek and Martin (in press) recently updated their Multidimensional Model of Sport Psychology Service Provision (M2SP2; see Martin et al., 2012) based on quantitative and qualitative research findings with various populations and contexts (see Figure 17.2). The M2SP2-Revised (M2SP2-R; Zakrajsek & Martin, in press) is a conceptual framework focused on perceptions and attitudes that influence gaining access, connecting with potential consumers, and earning trust and respect. This model is rooted in attitude and behaviour change theories, such as the Transtheoretical Model of Behaviuor Change (Prochaska & DiClemente, 1983) and Reasoned Action Approach (Fishbein & Ajzen, 2010). Antecedents such as personal characteristics of the sport psychology practitioner or mental health specialist (e.g., interpersonal skills) and important other characteristics (e.g., coach gender, previous experience, and interactions with sport psychology consultants), as well as situational factors (e.g., type of sport, competitive level) influence attitudes and beliefs about seeking professional help for sport performance-related issues and mental health concerns. Attitudes and beliefs that are of great interest include confidence in mental skills and services provided (i.e., belief that sport psychology and mental health services and mental training skills are beneficial), stigma tolerance (i.e., athletes, or others, will be viewed negatively if they seek assistance), personal openness (e.g., willingness to ask for professional help and use mental training skills), cultural preference (i.e., preference to interact with a sport psychology and mental health professional from a similar culture and background), normative beliefs (i.e., beliefs perceived to be held by others about sport psychology and mental health services and mental training skills), control beliefs (i.e., perceived control to access, initiate, and regularly use

Figure 17.2

Multidimensional Model of Sport Psychology Service Provision-Revised (M2SP2-R)

271

Rebecca A. Zakrajsek et al.

sport psychology and mental health services), and expectations about the process of sport psychology consulting and mental training. Attitudes and beliefs in turn produce consequences or intentions to use, actual use of, and satisfaction with sport psychology services and mental training skills. Overall, the more favourable the attitudes, normative and control beliefs, and expectations the stronger the intentions and actual use of sport psychology and mental health services. Intentions (i.e., readiness to engage in a behaviour) are considered determinants and predictors of behavioural usage patterns (Fishbein & Ajzen, 2010). It is important to remember that, when athletes and others (e.g., coaches) do engage in sport psychology and mental health services, and the actual use of mental training skills (i.e., behaviours), it is their satisfaction with the services that is essential to continued integration of mental skills training and future use of services. Therefore, a cyclical pattern is predicted in which the consequences (e.g., use of and satisfaction with services) become new antecedents, modifies subsequent attitudes and beliefs, which then affects future service use behaviours. The M2SP2-R is designed to help sport psychology and mental health practitioners be sensitive to the personal and situational characteristics that influence athletes’, coaches’, and personnel/support staffs’ receptivity to and use of sport psychology and mental health services. This model also encourages a scientist practitioner approach for sport psychology and mental health researchers to examine the connection between antecedents, attitudes, and subsequent behaviours (i.e., service and mental skills training use). Help-seeking is complex, and the relative importance and weight of the various attitudes and beliefs in determining intentions and use of sport psychology and mental health services may vary from one population and context to another. Overall, the attitudes and beliefs identified in the M2SP2-R (i.e., confidence, stigma tolerance, personal openness, normative and control beliefs, and expectations) have been found to impact intentions to use, and actual use of, sport psychology and mental health services and mental skills training (Allen, 2013; Anderson et al., 2004; Castaldelli-Maia et al., 2019; Clement et al., 2015; Hilliard et al., 2020; Martin et al., 2012; Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2007, 2008). Confidence in the benefits of sport psychology and mental health services has been considered one of the strongest predictors of intentions to seek out these services (Allen, 2013; Corrigan, 2004; Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2007). However, there are times when confidence in the benefits of mental health and sport psychology may not translate to actual service use (Castaldelli-Maia et al., 2019; Zakrajsek & Zizzi, 2008). Control beliefs, normative beliefs, and stigma may outweigh athletes’, coaches’, and personnel/support staffs’ confidence in the benefits of services and be enough of a barrier to the actual use of services. For example, coaches’ control beliefs (i.e., the belief they have little control over access to and use of service) helped explain why their usage of sport psychology services were low even though they were confident in the benefits of sport psychology consultation (Zakrajsek & Zizzi, 2008). Confidence in the ability to access information about mental health has also been found to have a positive relationship with increased help-seeking in male athletes (Liddle et al., 2021). While access to sport psychology and mental health services is only part of someone’s control beliefs, it has been found to be significantly associated with increased interactions with sport psychology consultants and use of services in other populations (e.g., support staff, Zakrajsek et al., 2016). Availability of mental health services inside the organisation or training facility has also been found to facilitate elite athletes use of mental health care (Castaldelli-Maia et al., 2019). Further, in their systematic reviews, Clement et al. (2015) concluded that stigma was the fourth highest rated barrier to help-seeking while Castaldelli-Maia and colleagues (2019) reported stigma as the strongest barrier to elite athletes help-seeking. External stigma (e.g., public and social network stigma) is reflective of normative beliefs, which have been found to be significantly associated with self-stigma and intentions (Hilliard et al., 2020). This seems to be particularly salient for athletes, whose intentions to use sport psychology services is influenced by the belief that they would be stigmatised by society or those in their social network, even if they have positive attitudes toward mental health services (e.g., coaches; Anderson et al., 2004; Bell et al., 2022; Castaldelli-Maia et al., 2019; Hilliard et al., 2020). In order to influence receptivity to sport psychology and mental health services, it is necessary to assess and understand the processes (i.e., personal and situational factors) by which attitudes and 272

Stigmatisation of Mental Illness

beliefs, such as stigma, are formed. The M2SP2-R represents the synthesis of a large body of research on athletes’ and important others’ stigma toward seeking sport psychology and mental health assistance. Thus, the following sections provide a more detailed discussion of the personal and situational factors that have been found to influence athletes, coaches, and personnel/support staff’s receptivity to sport psychology and mental health services. A common approach to examine attitudes toward seeking help includes using self-report inventories. For example, the Sport Psychology Attitudes – Revised form (SPA-R; Martin et al., 2002) has been frequently used in sport psychology provision research (Martin et al., 2012). This survey was created based on past counselling psychology and sport psychology research and established constructs assessed (i.e., Fischer & Turner, 1970; Martin et al., 1997). The SPA-R includes four subscales that measure athletes’ attitudes toward seeking sport psychology help, including stigma tolerance, confidence in sport psychology consultation, personal openness, and cultural preference (Martin et al., 2002). The SPA-R survey (Martin et al., 2002) has been used to examine various age groups of athletes’ (e.g., high school, college) attitudes toward using mental skills and seeking sport psychology services. For example, Martin et al. (2004) used the SPA-R instrument to identify athletes’ perception of sport psychology in three different countries: United States, Germany, and the United Kingdom. In this study, the types of sport athletes participated in was considered as a potential important variable that influences interest and willingness to use or seek sport psychology assistance. Sport were classified as either physical contact or physical noncontact sport. Results from the study indicated that athletes’ attitudes toward seeking sport psychology assistance were influenced by type of sport, nationality, and gender. That is, athletes from the United States reported higher stigma scores than those living in Germany and the United Kingdom. German and British athletes also had higher confidence scores than American athletes. These results shows that individuals’ nationality may play a significant role in their willingness and interest in seeking psychological assistance (Martin et al., 2004). Likewise, Martin (2005) examined adolescent (i.e., high school) and young adult (i.e., college) student-athletes’ attitudes toward seeking sport psychology assistance. Results indicated differences in age group (high school and college), type of sport (physical contact and physical noncontact), and gender (male and female). Specifically, physical contact athletes, male athletes, and younger athletes had higher stigma response scores than physical non-contact sport athletes, female athletes, and older athletes. In contrast, athletes who had some experiences working with sport psychology consultants were more confident toward seeking sport psychology services (Martin, 2005). Although age, athletic maturity, gender, and cultural differences existed, these studies demonstrated participants typically had positive perceptions about interacting with sport psychology consultants. However, as mentioned above it is difficult to accurately assess this as athletes often make distinctions between accessing services for the concepts of sport psychology focused on performance, and mental health, which may or may not be related to sport (Gulliver, 2012a). Throughout the past two decades, additional studies using the SPA-R instrument have been conducted to determine athletes’ attitudes toward seeking sport psychology (e.g., Anderson et al., 2004; Lavallee et al., 2005). For example, recently, Ong and Harwood (2018) identified a relationship between athletes’ “Eastern–Western” cultural affiliation, personality, and their attitudes toward seeking sport psychology service provision. This study involved Western and Eastern athletes who responded to the SPA-R instrument and the NEO-Five Factor Inventory (Costa & McCrae, 1992). Findings indicated that Eastern athletes reported higher stigma tolerance and cultural preference of sport psychology consultants than Western athletes. Conversely, Western athletes had higher confidence in and personal openness to sport psychology consultation compared to Eastern athletes (Ong & Harwood, 2018). Furthermore, the relationship between athletes’ culture, personality, and attitudes toward sport psychology services indicated that athletes who had lower scores in conscientiousness and openness reported higher stigma, whereas athletes who had lower scores in openness reported higher cultural preference (Ong & Harwood, 2018). This research provided an initial understanding of the relationships between athletes’ culture, personality, 273

Rebecca A. Zakrajsek et al.

and sport psychology consulting attitudes. The SPA-R instrument has been translated to many different languages. In addition, Checa et al. (2021) examined Spanish athletes’ attitudes toward sport psychology and found that they seemed to have stronger cultural preference for sport psychology consultants that are similar to them. Moreover, when comparing the results with American, German, and British athletes (Martin et al., 2004), Spanish athletes reported higher in personal openness and confidence in sport psychology consultation, while they scored lower in stigma tolerance (Checa et al., 2021). Many of these studies make comparisons with previously conducted research that have occurred years apart, which limits the accuracy of the interpretation of these comparisons. Although the field of sport psychology has evolved in Western cultures over the past three decades, the same cannot be said in other areas of the world, such as the Middle East. Consequently, there still exists a lack of research on athletes from certain parts of the world (e.g., Middle East), especially as it relates to athletes’ attitudes toward using mental skills and interest in seeking sport psychology services (Abdulshakur, 2022). For example, Arabians tend to take an informal approach to manage their mental health compared to seeking mental health services (Rayan & Fawaz, 2018; Rayan & Jaradat, 2016). According to Mahmoud (2018), Saudi male and females may not seek professional assistance even when needed, because they may feel ashamed about going to a psychological clinic. Even though similar studies have been conducted to extend the professional help seeking knowledge in Arab-Muslim countries (e.g., Abolfotouh et al., 2019; Alhabeeb et al., 2019; Alsubaie et al., 2020; Mahsoon et al., 2020), it is relatively unknown whether the findings reflect Arabian sport participants’ attitudes toward interacting with sport psychology professionals. However, in a recent small-scaled survey study, Abdulshakur (2022) examined Saudi Arabian male athletes’ attitudes toward seeking professional help in general using the Arabic version of ATSPPH-SF (Rayan et al., 2020) while also examining their attitudes toward seeking psychological assistance in sport using the Arabic version of SPA-R. Results of this study supported past research indicating that athletes’ nationality, culture, age, type of sport, sport experience, and previous experience with sport psychology influence attitudes toward seeking sport psychology and mental health services (Anderson et al., 2004; Checa et al., 2021; Lavallee et al., 2005; Martin, 2005; Martin et al., 2004; Ong & Harwood, 2018). Only a few of the Saudi male athletes indicated previous interactions with a mental health or sport psychology professional and their mean response scores on the stigma scale of the SPA-R form was similar to athletes from other countries who had limited experiences with mental health or sport psychology services (Abdulshakur, 2022). In addition, similar to the Checa et al. (2021) study, Saudi male athletes prefer to engage with sport psychology professionals who are from the same cultural background. This also seems consistent with other studies where religion may play a significant role (Rayan et al., 2020). Abdulshakur’s (2022) study indicated that the Saudi male athletes primary coping strategy was through prayer regardless of whether the issue was personal or performance related (>90% and >79%, respectively). These examples illustrate how religion and culture may influence athletes’ attitudes toward seeking help from others and whether they would be willing to use mental skills and sport psychology consulting services, especially if the person offering the skills or services was not familiar or similar to them. Familiarity of the mental health professional themselves is likely to be important across all cultures. For example, an Australian study also identified this as a critical factor influencing whether young elite athletes would seek help for mental health issues (Gulliver, 2012a).

Important Others’ Stigma Toward Seeking Service Provision While much more is known about athletes’ attitudes toward help-seeking, some researchers have focused on understanding coaches’ and personnel/support staffs’ (e.g., administrators, athletic trainers) perceptions about sport psychology consulting, especially in Western societies. For instance, coaches are considered important individuals in competitive sport settings who play a fundamental role in athletes’ lives (Jowett, 2003; Jowett & Cockerill, 2003). Therefore, in 2007 the SPA-R was modified to examine coaches’ attitudes toward working with sport psychology practitioners (Zakrajsek & Zizzi, 2007, 2008). This 274

Stigmatisation of Mental Illness

resulted in the development of the Sport Psychology Attitudes Revised Coaches – 2 (SPARC-2; Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2007, 2008), which also includes the original four factors that exist in the SPA-R (i.e., stigma tolerance, confidence in sport psychology consultation, personal openness, and cultural preference). The SPARC-2 questionnaire was used to assess coaches’ attitudes toward sport psychology skills and services (Adviento, 2018; Allen, 2013; Neelis et al., 2012; Nelson, 2008; Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2007, 2008). Findings indicated that coaches who had previous experience working with sport psychology professionals and had sport psychology knowledge reported less stigma and were more open and confident to seeking assistance from sport psychology professionals compared to those who did not have previous experience and knowledge in sport psychology (Allen, 2013; Neelis et al., 2012; Nelson, 2008; Zakrajsek & Zizzi, 2007). In addition, female coaches were more positive and open to have sport psychology professionals working with their athletes, compared to male coaches (Allen, 2013; Neelis et al., 2012; Wrisberg et al., 2010; Zakrajsek & Zizzi, 2007). Coaches in physical contact and male-dominated sport (e.g., American football) demonstrated greater stigma, lower confidence, and less openness to sport psychology services compared to coaches in sport that are not as maledominated or masculine oriented (e.g., swimming, track and field; Zakrajsek et al., 2011; Zakrajsek & Zizzi, 2007, 2008). Coaches’ education level, years of experience, and age were also found to influence their perceptions of working with sport psychology consultants. In fact, coaches who have a graduate degree, are more experienced, and are older than 29 years old, were found to be more open to engage with sport psychology consultants, compared to those who have a high school diploma or bachelor’s degree, are less experienced, and are aged between 20–29 years old (Zakrajsek et al., 2011). Coaches’ attitudes toward mental health and help-seeking has been identified as an important factor in how comfortable athletes feel in seeking help (Gulliver, 2012a). Consequently, programme to improve coaches and other elite sport staff attitudes, mental health literacy, and ability to appropriately respond to athletes with mental health problems have been developed and found to be useful in enhancing the critical role of coaches as gatekeepers (Sebbens, et al., 2016). Similarly, researchers from Western cultures have assessed athletic administrators’ and support staff members’ sport psychology knowledge and attitudes toward sport psychology consultants (e.g., Pain & Harwood, 2004; Wilson et al., 2009, Zakrajsek et al., 2016). Because of their position to influence the employment of sport psychology professionals, knowing administrators’ (e.g., academy directors, athletic directors) attitudes regarding the value of sport psychology services is beneficial. The limited research available suggests that misconceptions and contradictory attitudes about sport psychology services exist among this population. Using items adapted from the SPA-R, Wilson and colleagues (2009) found that athletic administrators in the United States believed mental training would enhance athletes’ performance yet also believed that athletes should be able to cope with conflicts on their own. Understanding the personal and situational characteristics that influence administrators’ stigma toward sport psychology services is extremely limited. What is available suggests that knowledge and exposure to sport psychology consultants may impact administrators’ attitudes toward services. In the United Kingdom, youth academy directors’ lack of sport psychology knowledge underpinned the stigma attached to sport psychology (e.g., sport psychology is for problem players and would not benefit strong players; Pain & Harwood, 2004). In the United States, administrators with a sport psychology consultant employed in the athletic department generally reported higher benefits of services compared to their counterparts (Wrisberg et al., 2012). Support staff members such as sport medicine professionals (e.g., athletic trainers, physiotherapists) form trusting relationship with athletes and are often viewed as mentors or friends (Moulton et al., 1997; Tracey, 2008). Due to sport medicine professionals’ nurturing approach, athletes often share details about their experiences and challenges. Therefore, they are in a critical gatekeeper position from which to initiate conversations about the benefits of sport psychology services and influence athletes’ stigma and receptivity to mental training (Zakrajsek et al., 2017, 2018). In fact, athletic trainers in the United States 275

Rebecca A. Zakrajsek et al.

and physiotherapists in the United Kingdom have reported encouraging or referring athletes to seek mental health and sport psychology services (Arvinen-Barrow et al., 2007; Clement et al., 2013; Zakrajsek et al., 2015, 2016, 2018). Some of the situational and personal characteristics that influence athletic trainers’ receptivity to sport psychology services appear to be similar to what has been found with athletes and coaches. For example, female athletic trainers reported greater perceptions of the benefits of sport psychology services and were more supportive of including a sport psychology consultant as part of the athletic department support staff compared to male athletic trainers (Zakrajsek et al., 2015, 2016). Athletic trainers with previous experience and professional interactions with sport psychology consultants also perceived the benefits of services to be higher than those without previous experience or interaction (Zakrajsek et al., 2015). Of important consideration is the quality of the experience and interaction, as athletic trainers with past positive experiences and interactions with sport psychology consultants reported the services as highly beneficial, were more open to using services, and were more supportive of including sport psychology consultants as part of the support staff compared to those with negative past experiences and interactions (Zakrajsek et al., 2015, 2016). Lastly, athletic trainers who were graduate students or interns perceived greater benefits of having a sport psychology consultant as part of the support staff compared to part-time or full-time athletic trainers. Findings from these studies indicate that addressing attitudes toward sport psychology consultation of personnel/support staff, such as administrators and sport medicine professionals, may be just as important to consider as athletes’ and coaches’ attitudes when attempting to gain access to an athletic setting.

Intra and Interpersonal Strategies to Decrease Stigma and Enhance Personal Openness The types of strategies, or evidence-based interventions, to decrease stigma and promote more positive attitudes toward help-seeking include education and interpersonal contact (Corrigan, 2004; Zakrajsek et al., 2015, 2016). These types of interventions are primarily geared toward self-stigma (intrapersonal) and social stigma (interpersonal; see Figure 17.1). Education should focus on information to enhance confidence in the benefits of services and decrease the negative impact of stigma on help seeking (Corrigan, 2004; Martin et al., 2012). Those designing educational programme or workshops should consider imparting general knowledge about sport psychology and mental skills training, normalising the integration of sport psychology services, demystifying the process of sport psychology consulting, and providing information about access to sport psychology services. Knowledge-based mental health awareness programme should also target stigma reduction by increasing mental health literacy (e.g., knowledge and beliefs about mental health disorders), conceptualising mental health in a positive direction (e.g., wellbeing), and enhancing understanding about the process of working with a mental health service provider (Breslin et al., 2019). The goal of such education is to help create positive shifts in athletes, coaches, and personnel/support staffs’ attitudes and beliefs about mental health and sport psychology services. That is because the less obvious shifts that occur with cognitions and attitudes/beliefs are precursors to more obvious changes such as behaviours (e.g., use of sport psychology services). In fact, even a one-time educational workshop has found to produce benefits. For example, a sport psychology workshop has been found to create positive shifts in athletes’ and coaches’ beliefs and attitudes about sport psychology (Zakrajsek & Zizzi, 2008; Zizzi & Perna, 2003); such as an increase in confidence in the benefits of services, openness to sport psychology, control beliefs (e.g., ability to access services and self-efficacy in contacting a sport psychology consultant), and a decrease in perceived barriers. These shifts in attitudes and beliefs were also related to an increase in readiness and intentions to use services as well as actual behaviours related to sport psychology service use. A sport psychology workshop with athletic trainers has also been found to increase sport psychology related behaviours, including speaking with a sport psychology consultant (Clement & Shannon, 2009). Furthermore, as mentioned above, a Mental Health in Sport workshop with coaches and support staff working with elite athletes improved mental health literacy 276

Stigmatisation of Mental Illness

(knowledge of the signs and symptoms of mental illness) and confidence in helping (e.g., referring to a mental health professional; Sebbens et al., 2016). Increases in knowledge and confidence through mental health literacy education have led to enhanced helping behaviours (Hadlaczkky et al., 2014; Kitchener & Jorm, 2006). Digital approaches have also been successful in this group, an online health help-seeking intervention with elite athletes was found to improve mental health literacy and reduce mental health stigma (Gulliver et al., 2012b). While sport psychology researchers have primarily focused efforts on educational interventions, interpersonal contact has generally been found to be more influential in decreasing stigma in the general population (Corrigan et al., 2012). Contact interventions include exposing athletes, coaches, and personnel/support staff to others who have had positive experiences with mental health and sport psychology services. Contact however should also include familiarising athletes, coaches, and personnel/support staff with qualified mental health and sport psychology providers. This is an important consideration since interactions, especially positive ones, with sport psychology professionals has been found to be related to higher perceptions of the benefits of and greater willingness to use services (Zakrajsek et al., 2015, 2016). In addition, more frequent contact with sport psychology professionals has been found to be related to greater willingness to use sport psychology services (Wrisberg et al., 2010). Therefore, actively facilitating positive and on-going interactions between sport psychology/mental health professionals and important others (i.e., athletes, coaches, and personnel/support staff) may be a powerful approach to enhancing confidence, decreasing stigma, and increasing receptivity to service use. Professional interactions can be informal (e.g., lunches) or formal (e.g., meeting); however, more organic interactions that occur in hallways or other spaces (e.g., on the field) can be just as beneficial. The point of these interactions is to foster the establishment of a positive relationship through open, two-way communication that allows each party to get to know each other’s experiences, aspirations, and goals (Zakrajsek et al., 2016). New methods of facilitating connections between athletes and sport psychology/mental health professionals may also involve technology, such as the use of apps such as Timeout (thetimeoutapp.com). Apps or websites such as this can easily provide accessible information, including health care professional profiles, plus the ability to actively connect and make appointments with health professionals seamlessly. In addition to increasing familiarity with sport psychology and mental health professionals, removing barriers such as having to make a phone call to make an appointment, or seek help face to face, may also lead to greater help-seeking, increasing access to care. During informal and formal interactions, experiences related to mental factors and performance can be explored. Sport psychology and mental health practitioners should engage in evidence-based and theoryinformed interactions, in which the discussion is focused on learning about and addressing the specific needs of the population and context. Recent research with elite level athletes, coaches, and personnel/ support staff (e.g., administrators, athletic trainers) suggest that they are interested in, and open to, some sport psychology services more than others (Wrisberg et al., 2009, 2010, 2012; Zakrajsek et al., 2015, 2016). While preferences varied by personal (e.g., population, gender) and situational (e.g., context) characteristics (see Figure 17.2, M2SP2-R), the results of studies with U.S. populations generally demonstrate a greater interest in and openness to performance-related services as compared to life-related services. In the performance context (i.e., practice and competition) athletes, coaches, and personnel/ support staff (administrators, athletic trainers) were most interested in services related to building confidence, managing anxiety and emotions, improving focus, and dealing with pressure (Wrisberg et al., 2009, 2010, 2012; Zakrajsek, 2015). Increasing enjoyment, communicating with coaches and teammates, and preventing burnout were among the services these populations were least interested in. However, female athletes and athletic trainers rated the benefits of services related to communicating with teammates and coaches as higher than male athletes and athletic trainers. In the injury and rehabilitation context, managing anxiety and emotions, improving coping techniques, achieving confidence in returning to sport, and dealing with pressure were the services athletic trainers perceived as most beneficial (Zakrajsek 277

Rebecca A. Zakrajsek et al.

et al, 2016). The injury context also appears to be one where addressing personal and mental health concerns is desired, as athletic trainers rated dealing with personal issues as the second most beneficial service (Zakrajsek et al., 2016). There are some differences globally with what specific issues sport psychology and mental health professionals are expected to assist. In the United Kingdom, youth coaches reported a preference for “sport psychology” services to be primarily geared toward enhancing athletes’ sport performance and abilities to use psychological techniques (Barker & Winter, 2014). Coaches identified confidence as a psychological skill their athletes need to develop. However, these coaches believed that sport psychology services should also focus on personal development including athletes’ mental health. A limited amount of research is available related to the type of topics athletes are willing to discuss or seek help. When provided a list with various personal and performance related concerns, American and Japanese athletes reported they were most willing to discuss or seek help for performance issues (i.e., dealing with pressure/stress, concentration/focus, confidence). Personal and mental health concerns were ranked at the bottom. However, American athletes were more likely to talk about academic concerns and burnout/overtraining than Japanese athletes. When athletes in the United States were presented with a list of only personal concerns, they reported that they were most willing to discuss drug problems, depression, and excessive alcohol use (Hilliard et al., 2020). Sexuality, difficulty with friends, and body image were among the lowest-rated topics athletes were willing to discuss. However, it is possible this willingness also relates to what they are expected to discuss. As above, if their sport psychology service is primarily geared toward performance and is promoted as such, then athletes may feel uncomfortable or discouraged to discuss anything that is not related to sport (Gulliver, 2012a). Clarity for coaches and athletes in the roles of sport psychology and all related mental health professionals is needed to ensure that athletes understand exactly what services are being provided. In addition to this, to ensure optimal athlete mental health, which is also likely to improve performance, sport organisations should explicitly provide services that clearly promote their role in the targeting of “personal” problems and mental health issues. Overall, gaining an understanding of services that are of most interest to a population and context can help to improve outreach efforts and lead to more positive interactions between sport psychology professionals and important others (e.g., athletes, coaches, and personnel/support staff). A rather high percentage, approximately 20–32% of athletic trainers have reported negative experiences and interactions with sport psychology professionals (Zakrajsek et al., 2015, 2016). Negative experiences included the perception of sharing information as one-sided in which sport psychology professionals wanted information about athletes, yet they did not reciprocate professional information (Zakrajsek et al., 2015). In addition, 26% of coaches who worked with a sport psychology professional perceived their effectiveness to be low to moderate (Wrisberg et al., 2010). This indicates a potential mismatch between what is desired from a sport psychology professional compared to what is actually being delivered. Perhaps there may be different expectations related to confidentiality. There could be a lack of clarity in the services that sport psychology and mental health professionals provide, and the differences related to confidentiality between these types of services, which may also be contributing to this dissatisfaction. This demonstrates a clear need for sport psychology and mental health professionals to make explicit what services they offer and continue to work on building a positive and trusting relationship in order to enhance coaches and support staff receptivity to integrating their services. When interacting with coaches and support staff, such as athletic trainers, sport psychology and mental health professionals should try to complement existing efforts to enhance athletes’ performances and their overall wellbeing. For example, athletic trainers reported that sport psychology professionals could assist with their efforts by teaching athletes self-talk, imagery, and relaxation techniques to help with managing anxiety, coping with pain, building confidence, remaining focused, and mentally preparing to return to play (Zakrajsek et al., 2018). Athletic trainers have reported limited knowledge and understanding of these specific techniques; therefore, athletic trainers may feel 278

Stigmatisation of Mental Illness

empowered to integrate sport psychology and mental health professionals when they can work together and provide mutual support toward a shared purpose.

Structural Efforts to Reduce Stigma While efforts to decrease stigma has occurred on the interpersonal and intrapersonal levels, there are also examples of structural impediments that lead to mental health and illness stigmas (e.g., geographical accessibility, see Figure 17.1). Although intrapersonal and interpersonal efforts identify ways individuals and those around them can reduce stigma, structural efforts that permeate through government policy and practices of social institutions are needed (Ahmedani, 2011; Javed et al., 2021). With elite athletes, such as Osaka, publicly speaking about their challenges with poor mental health and the need for structural organisational change, it is encouraging that many organisations around the world are responding to this by striving to reduce mental health stigma and raising awareness of the services that are available. A multipronged approach is needed to make a meaningful and long-lasting impact on reducing mental health stigma and promoting service provision (Liddle et al., 2017). In Australia, Liddle et al. (2017) systematically screened 62 national sport organisation websites to gain an understanding of the current approaches to mental health promotion, prevention, and intervention. All 56 sports in the Olympic Games as well as national organisations for key team sports such as cricket, rugby league (National Rugby League; NRL), netball, touch football, Oztag and Australian Rules football (Australian Football League; AFL) were represented. Of the 18 (26%) national sporting bodies websites that mentioned mental health or psychological factors, 13 (21%) referenced mental strategies for performance. Results revealed that only seven (11.3%) national sport organisations acknowledged mental health as important and made efforts to address it. One example is the NRL State of Mind campaign established in 2011 and re-launched in 2014 (see https://www.nrl.com/community/state-of-mind/). Ambassadors of the campaign visited local rugby clubs and connected through social media and online videos to talk about their mental health experiences. They partnered with local communities, non-governmental organisations, and state and territory government in the area to enhance mental health literacy and reduce stigma toward mental health within the NRL. Another example is the Good Sports + Healthy Minds programme (Good Sports, n.d. see https://goodsports.com.au/mental-health/), which is an accredited programme that covers every state and territory of Australia with over 6,500 clubs enrolled. This programme aims to reduce mental health stigmas by providing support networks that encourage open and inclusive conversations around mental health, connecting local mental health services to the needs of each club and encouraging early help-seeking behaviours. While these programmes are one of a small number making specific efforts to reduce stigma toward mental health, there is little evidence that demonstrate the programmes are effective. Nevertheless, those that are making an effort are gaining nation-wide support and have potential to have a broad impact. In the United Kingdom, there are reports of anti-stigma efforts on a national and elite level. The U.K. government presented a mental health in sport initiative in which several sport associations signed a contract pledging to support the elimination of stigma surrounding mental health and encourage helpseeking behaviours. One such example is the English Institute of Sport (EIS, 2021), funded by UK Sport, which is an organisation that is solely invested by the U.K. government and National Lottery. Since its inception, the EIS is now the largest single provider of sport science, medicine, performance psychology, engineering, and technology services that work with both elite athletes and support staff (sport medics and scientists) across the United Kingdom. The EIS is unique in that all professional staff collaborate to provide athletes with the best quality of care. According to the M2SP2-R (see Figure 17.2), an important antecedent to receptivity to sport psychology service provision is the proximity of available services. For example, a physiotherapist who has regular contact with an athlete can be more involved with services of a sport psychology or mental health practitioner when they are readily available. One recent example is that the EIS established a Mental Health Expert Panel for the Tokyo 2020 Olympic cycle that sought to better 279

Rebecca A. Zakrajsek et al.

support the mental health of athletes and performance staff (Cumming & Ranson, 2021). As a result, there was a significant increase in mental health service usage. For example, the number of claims for mental health services increased. Cumming and Ranson (2021) speculated that there was a possible correlation between increased awareness and earlier intervention. In the United States, similar efforts are seen on a national and elite level. The USA Olympic Committee and the USA Olympic Governing Bodies have provided athletes, coaches, and support staff with increased access to mental health and sport psychology services. In 2019, the U.S. Olympic & Paralympic Committee (USOPC) created the athlete services division that provides mental health, wellness, and education to athletes. The division also raises awareness through education of mental health in the broader community (USOPC, 2022; see https://www.teamusa.org/Team-USA-Athlete-Services/ Mental-Health). Since 2019, the USOPC has invested more than $11.5 million, trained over one million people in safety prevention and awareness and received 2,770 reports of physical and emotional misconducts (TeamUSA, 2019; see https://2019impactreport.teamusa.org/foundational-programs.html). At the colligate level, The National Collegiate Athletic Association (NCAA) in 2018 required that studentathletes have access to mental health services. The NCAA created a new mental health initiative called the Mental Health Best Practices. The initiative advocates for the importance of mental health across all three NCAA divisions by increasing awareness and addressing individual needs. The Sport Science Institute with the NCAA now emphasises the importance “to promote and develop safety, excellence and wellness in college student-athletes, and to foster lifelong physical and mental development” (NCAA, 2022; see https://www.ncaa.org/sports/2021/5/24/sport-science-institute.aspx). While several countries have focused their efforts on creating structural changes within sporting organisations, in the Middle East there has recently been a media-based awareness campaign approach. That is, media-based companies in the Middle East highlighted the extent of mental health problems among the region’s Arab-Muslim youth and the importance of seeking professional help for mental health and illness issues (Bell, 2019; see https://www.arabnews.com/node/1496661/middle-east). An Arab Youth Survey identified 54% of young Arabs that feel mental health care is difficult to access (Bell, 2019). Media campaigns such as these are advocating that governments fund mental health programmes, community outreach programmes, annual screening for depression and mental health awareness in schools and communities. These mental health campaigns may help improve athletes’ and coaches’ abilities to navigate uncertainty and improve mental and physical health. Influential leaders (religious, etc.), professionals (sport medicine doctors, teachers, etc.), and athletes (e.g., Olympic, professional) may also be advocates for increasing interest and use of sport psychology and mental health services. Overall, while these efforts to reduce stigma toward mental health are fairly recent, it is encouraging to recognise that there is a global effort to increase the availability and access to services. Other countries and their organisations such as Sport Northern Ireland, the European Federation of Sport Psychology, and the Varsity Sport Speak Up programme in Southern Africa have all begun to promote anti-stigma efforts toward mental health. Whether the effort is on an intrapersonal/interpersonal or structural level, all are equally important in creating changes at individual, national, and global levels. As Liddle et al. (2017) recognised, “to realize the potential of organized sport to promote mental health at a national level, a multilevel, integrated and evidence-based approach to mental health promotion may be needed” (p. 94). Consequently, for an organisation to achieve its potential, organisational or structural policy changes may be needed at all levels.

Evaluation and Assessment For individuals and organisational policies to change, regular evaluation and assessment of mental health and sport psychology services is necessary. For example, prior to delivering mental skills training interventions, professionals should assess athletes’, coaches’, and personnel/support staffs’ attitudes, perceptions, 280

Stigmatisation of Mental Illness

and expectations about sport psychology and mental health services and mental skills training use. These assessments could provide strategies to improve awareness of athletes’, coaches’, and personnel/support staffs’ needs, increase geographical availability and accessibility, decrease fear of stigmatization, and increase financial support for mental health and sport psychology services. Continual assessment over time would also provide information regarding impact and satisfaction with services, in other words, how and what athletes’, coaches’, and personnel/support staffs’ attitudes and perceptions are changing and improving (or not). If sport psychology organizations are not open to assessing attitudes, expectations, and past experiences through an external evaluation process, then the growth of the field and sport participants’ use will be limited. An example of a working model of a process that may meet these criteria can be viewed at the Australian Institute of Sport (AIS), who partnered with Orygen at the University of Melbourne to create a world-leading programme to annually evaluate the mental health of athletes and staff via an online audit survey. This survey provides important information on the mental health needs of these groups and can be used to inform the creation and delivery of specialist services and support (https://www.ais.gov.au/ mhrn/audit). In addition, the AIS has also evaluated via interviews and an online survey, the delivery of their mental health services, via the Mental Health Referral Network, to determine whether these services are performing optimally and to allow continuous improvement of services for both athletes and elite sport staff.

Future Directions Future research is recommended that further examines the intersectionality or interconnected nature of social categorisations (e.g., race, ethnicity, class, and gender) associated with creating overlapping and interdependent systems of discrimination or disadvantage (Crenshaw, 1991), which likely influences stigma toward seeking assistance for mental illness (Hermaszewska et al., 2022). Social categorisations within sport, like the military and law enforcement, may be greatly impacted by the ingrained culture of developing mental toughness, grit, and resiliency. This “no pain, no gain” outcome-oriented focus, which is often emphasised in sport, places tremendous stress and pressure on athletes, emotionally and physically. Consequently, researchers examining attitudes toward mental illness in sport should likely consider the influence of intersectionality, geopolitical issues, mass media (e.g., print, broadcast, and digital media), and social media (e.g., social computer-based networks, where the public can be both the audience and content creators) because these factors likely contribute to athletes’ interest, willingness, and ability to seek mental and physical healthcare services. A more robust view of mental illness stigma would also likely lead to improved interventions and increased interest in mental skills services.

References Abdulshakur, A. (2022). Saudi male athletes’ experience using mental skills and attitudes toward seeking psychological assistance in sport (Unpublished Master’s Thesis), University of North Texas, Denton Texas. Abolfotouh, M.A., Almutairi, A.F., Almutairi, Z., Salam, M., Alhashem, A., Adlan, A.A., & Modayfer, O. (2019). Attitudes toward mental illness, mentally ill persons, and help-seeking among the Saudi public and sociodemographic correlates. Psychology Research and Behavior Management, 12, 45–54. 10.2147/PRBM.S191676 Adviento, M.L.G. (2018). Filipino coaches’ attitudes toward sports psychology. ASPASP-JPASPEX Special Edition, 1(1), 30–38. Ahmedani, B.K. (2011). Mental health stigma: Society, individuals, and the profession. Journal of Social Work Values and Ethics, 8(2), 4–1-16. Akesdotter, C., Kentta, G., Eloranta, S., & Frank, J. (2020). The prevalence of mental health problems in elite athletes. Journal of Science and Medicine, in Sport, 23, 329–335. 10.1016/j.jsams.2019.10.022 Alhabeeb, A., Alasmari, S., Alduraihem, R., & Qureshi, N. (2019). Mental health awareness phone polling survey: Focus on community knowledge, attitude and practice, Saudi Arabia. International Neuropsychiatric Disease Journal, 13(2), 1–14. 10.9734/indj/2019/v13i230106

281

Rebecca A. Zakrajsek et al. Allen, P.G. (2013). NCAA DIII coaches’ attitudes and receptivity toward sports psychology consulting services (Unpublished Master’s Thesis), University of Tennessee, Knoxville Tennessee. Alsubaie, S., Almathami, M., Alkhalaf, H., Aboulyazid, A., & Abuhegazy, H. (2020). A survey on public attitudes toward mental illness and mental health services among four cities in Saudi Arabia. Neuropsychiatric Disease and Treatment, 16, 2467–2477. 10.2147/NDT.S265872 Anderson, A.G., Hodge, K.P., Lavallee, D., & Martin, S.B. (2004). New Zealand athletes’ attitudes towards seeking sports psychology consultation. New Zealand Journal of Psychology, 33, 129–136. Arnold, R., & Fletcher, D. (2012). A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. Journal of Sport & Exercise Psychology, 34, 397–429. 10.1123/jsep.34.3.397 Arvinen-Barrow, M., Hemmings, B., Weigand, D., Becker, C., & Booth, L. (2007). Views of chartered physiotherapists on the psychological content of their practice: A follow-up survey in the UK. Journal of Sport Rehabilitation, 16, 111–121. 10.1123/jsr.16.2.111 Ayala, E., Nelson, L., Bartholomew, M., & Plummer, D. (2022). A conceptual model for mental health and performance of North American athletes: A mixed methods study. Psychology of Sport and Exercise, 61, 102176. 10.1016/ j.psychsport.2022.102176 Barker, S., & Winter, S. (2014). The practice of sports psychology: A youth coaches’ perspective. International Journal of Sports Science & Coaching, 9(2), 379–392. 10.1260/1747-9541.9.2.379 Bauman, N.J. (2016). The stigma of mental health in athletes: Are mental toughness and mental health seen as contradictory in elite sport? British Journal of Sports Medicine, 50, 135–136. 10.1136/bjsports-2015-095570 Bell, J. (2019, May 14). The hidden face of mental illness in the Middle East. ARAB NEWS. https://www.arabnews.com/ node/1496661/middle-east. Bell, A.F., Knight, C.J., Lovett, V.E., & Shearer, C. (2022). Understanding elite youth athletes’ knowledge and perceptions of sports psychology. Journal of Applied Sport Psychology, 34(1), 155–177. 10.1080/10413200.2020. 1719556 Biggin, I.J.R., Burns, J.H., & Uphill, M. (2017). An investigation of athletes’ and coaches’ perceptions of mental illhealth in elite athletes. Journal of Clinical Sport Psychology, 11, 126–147. 10.1123/JCSP.2016-0017 Bird, M.D., Chow, G.M., & Yang, Y. (2020). College students’ attitudes, stigma, and intentions toward seeking online and face-to-face counseling. Journal of Clinical Psychology, 76, 1775–1790. 10.1002/jclp.22956 Breslin, G., Shannon, S., Ferguson, K., Devlin, S., Haughey, T., & Prentice, G. (2019). Predicing athlete mental health stigma using the theory of reasoned action framework. Journal of Clinical Sport Psychology, 13, 103–115. 10.1123/jcsp.2017-0055 Brown, G.T. (Ed.) (2014). Mind, body and sport: Understanding and supporting student-athlete mental wellness. Indianapolis, IN: National Collegiate Athletic Association. http://www.ncaa.org/sport-science-institute/introduction-mindbody-and-sport. Castaldelli-Maia, J.M., Gallinaro, J.G.M.E., Falcão, R.S., Gouttebarge, V., Hitchcock, M.E., Hainline, B., Reardon, C.L., & Stull, T. (2019). Mental health symptoms and disorders in elite athletes: A systematic review on cultural influencers and barriers to athletes seeking treatment. British Journal of Sports Medicine, 53(11), 707–721. 10.1136/ bjsports-2019-100710 Checa, I., Bohórquez, M.R., Arnau, V.M., & Tomás, J.M. (2021). Factor structure and Measurement invariance across gender, age and sports psychology experience of the SPA-R in Spanish athletes. Current Psychology, 1–9. 10.1007/s12144-021-01447-7 Clement, S., Scauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., Morgan, C., Rüsch, N., Brown, J.S.L., & Thornicroft, G. (2015). What is the impact of mental health-related stigma on help seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45, 11–27. 10.1017/S0033291714 000129 Clement, D., Granquist, M.D., & Arvinen-Barrow, M.M. (2013). Psychological aspects of athletic injuries as perceived by athletic trainers. Journal of Athletic Training, 48(4), 512–521. 10.4085/1062-6050-48.3.21 Clement, D., & Shannon, V. (2009). The impact of a workshop on athletic training students’ sports psychology behaviors. The Sport Psychologist, 23, 504–522. 10.1123/tsp.23.4.504 Connaughton, D., Hanton, S., & Jones, G. (2010). The development and maintenance of mental toughness in the world’s best performers. The Sport Psychologists, 24, 168–193. 10.1123/tsp.24.2.168 Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. 10.1037/ 0003-066X.59.7.614 Corrigan, P.W., Morris, S.B., Michaels, P.J., Rafacz, J.D., & Rüsch, N. (2012). Challenging the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatric Services, 63(10), 963–973. 10.1176/appi.ps.2011 00529

282

Stigmatisation of Mental Illness Costa, P.T., Jr., & McCrae, R.R. (1992). Revised NEO personality inventory (NEO-PI-R) and NEO five-factor inventory (NEO-FFI) professional manual. Crenshaw, K.W. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241–1299. 10.2307/1229039 Cumming, S., & Ranson, C. (2021). 380 The English institute of sport’s mental health journey, 55, 144–145. 10.1136/ bjsports-2021-IOC.347 English Institute of Sport. (2021). Who We Are. Retrieved April 27, 2022, from https://eis2win.co.uk/who-we-are/. Fenker, R.M., & Lambiotte, J.G. (1987). A performance enhancement program for a college football team: One incredible season. The Sport Psychologist, 1(3), 224–236. 10.1123/tsp.1.3.224. Fischer, E.H., & Turner, J.L. (1970). Orientations to seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35, 79–90. 10.1037/h0020198 Fishbein, M. & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. New York: Psychology Press. 10.4324/9780203838020 Foskett, R.L., & Lognstaff, F. (2018). The mental health of elite athletes in the United Kingdom. Journal of Science and Medicine in Sport, 21, 765–770. 10.1016/j.jsams.2017.11.016 Good Sports. (n.d.). Mental Health. Retrieved April 27, 2022, from https://goodsports.com.au/mental-health/. Gould, D., Murphy, S., Tammen, V., & May, J. (1991). An evaluation of U.S. Olympic sports psychology consultant effectiveness. The Sport Psychologist, 5(2), 111–127. 10.1123/tsp.5.2.111 Gould, D., Petlichkoff, L., Hodge, K., & Simons, J. (1990). Evaluating the effectiveness of a psychological skills educational workshop. The Sport Psychologist, 4(3), 249–260. 10.1123/tsp.4.3.249 Gould, D., Tammen, V., Murphy, S., & May, J. (1989). An examination of U.S. Olympic sports psychology consultants and the services they provide. The Sport Psychologist, 3(4), 300–312. 10.1123/tsp.3.4.300 Gould, D., & Maynard, I. (2009). Psychological preparation for the Olympic Games. Journal of Sports Sciences, 27, 1393–140810.1080/02640410903081845. Greenleaf, C., Gould, D., & Dieffenbach, K. (2001). Factors influencing Olympic performance: Interviews with Atlanta and Nagano US Olympians, Journal of Applied Sport Psychology, 13, 154–184. 10.1080/104132001753149874 Grove, J.R., & Hanrahan, S.J. (1988). Perceptions of mental training needs by elite field hockey players and their coaches. The Sport Psychologist, 2(3), 222–230. 10.1123/tsp.2.3.222 Gucciardi, D.F., Hanton, S., & Fleming, S. (2017). Are mental toughness and mental health contradictory concepts in elite sport? A narrative review of theory and evidence. Journal of Science and Medicine in Sport, 20(3), 307–311. 10.1016/j.jsams.2016.08.006 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Gulliver, A., Griffiths, K.M. & Christensen, H. (2012a). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12, 157. 10.1186/1471-244X-12-157 Gulliver, A., Griffiths, K.M., Christensen, H., Mackinnon, A., Calear, A.L., Parsons, A., & Stanimirovic, R. (2012b). Internet-based interventions to promote mental health help-seeking in elite athletes: An exploratory randomized controlled trial. Journal of Medical Internet Research, 14(3), e1864. 10.2196/jmir.1864 Hadlaczky, G., Hokby, S., Mkrtchian, A., Carli, V., & Wasserman, D. (2014). Mental health first aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: A meta-analysis. International Review of Psychiatry, 26, 467–475. 10.3109/09540261.2014.924910 Hassan, J. (2021, June 1). Naomi Osaka hailed for bravery, pilloried for ‘diva behavior’ amid French Open withdrawal. The Washington Post. https://www.washingtonpost.com/world/2021/06/01/naomi-osaka-world-reacts-mental-health/. Hellstedt, J.C. (1987). Sport psychology at a ski academy: Teaching mental skills to young athletes. The Sport Psychologist, 2(1), 222–230. 10.1123/tsp.1.1.56 Hermaszewska, S., Sweeney, A., & Sin, J. (2022). Time to change course in stigma research? Journal of Mental Health, 31(1), 1–4. 10.1080/09638237.2021.2022636 Hilliard, R.C., Watson, J.C., & Zizzi, S.J. (2020). Stigma, attitudes, and intentions to seek mental health services in college student-athletes. Journal of American College Health, 70(5), 1476–1485. 10.1080/07448481.2020.1806851 Javed, A., Lee, C., Zakaria, H., Buenaventura, R.D., Cetkovich-Bakmas, M., Duailibi, K., Ng, B., Ramy, H., Saha, G., Arifeen, S., Elorza, M.P., Ratnasingham, P., Azeem, W.M. (2021). Reducing the stigma of mental health disorders with a focus on low- and middle-income countries. Asian Journal of Psychiatry, 58. 10.1016/j.ajp.2021. 102601 Jowett, S. (2003). When the “honeymoon” is over. A case study of a coach-athlete dyad in crisis. The Sport Psychologist, 17, 444–460. 10.1123/tsp.17.4.444 Jowett, S., & Cockerill, I. (2003). Olympic medalists’ perspective of the athlete-coach relationship. Psychology of Sport and Exercise, 4, 313–331. 10.1016/S1469-0292(02)00011-0

283

Rebecca A. Zakrajsek et al. Kuettel, A., & Larsen, C.H. (2020). Risk and protective factors for mental health in elite athletes: A scoping review, International Review of Sport and Exercise Psychology, 13(1), 231–265. 10.1080/1750984X.2019.1689574 Kuettel, A., Pedersen, A.K., & Larsen, C.H. (2021). To flourish or languish, that is the question: Exploring the profiles of Danish elite athletes. Psychology of Sport & Exercise, 52, 101837. 10.1016/j.psychsport.2020.101837 Kitchener, B.A., & Jorm, A.F. (2006). Mental health first aid training: Review of evaluation studies. Australian & New Zealand Journal of Psychiatry. 40, 6–8. 10.1080/j.1440-1614.2006.01735.x Lavallee, D., Jennings, D., Anderson, A.G., & Martin, S.B. (2005). Irish athletes’ attitudes toward seeking sports psychology consultation. The Irish Journal of Psychology, 26, 115–121. 10.1080/03033910.2005.10446214 Liddle, S.K., Deane, F.P., & Vella, S.A. (2017). Addressing mental health through sport: A review of sporting organizations’ websites. Early Intervention in Psychiatry, 11(2), 93–103. 10.1111/eip.12337 Liddle, S.K., Vella, S.A., & Deane, F.P. (2021). Attitudes about mental illness and help seeking among adolescent males. Psychiatry Research, 301. 10.1016/j.psychres.2021.113965 Mahmoud, M.A. (2018). Knowledge and awareness regarding mental health and barriers to seeking psychiatric consultation in Saudi Arabia. Asian Journal of Pharmaceutical Research and Health Care, 10(4), 109–116. 10.18311/ ajprhc/2018/23359 Mahmoud, M.A., Sadeghi-Bahmani, D., Zarei, S., Zandi, H.G., & Brand, S. (2022). Examining the effects of Mindfulness–Acceptance–Commitment training on self-compassion and grit among elite female athletes. International Journal of Environmental Research and Public Health, 19(1), 134. 10.3390/ijerph19010134 Mahsoon, A., Sharif, L., Banakhar, M., Alasmee, N., Almowallad, E., Jabali, R., Bahamil, A. & Assur, S. (2020). Parental support, beliefs about mental illness, and mental help-seeking among young adults in Saudi Arabia. International Journal of Environmental Research and Public Health, 17(15), 1–11. 10.3390/ijerph17155615 Martin, S.B. (2005). High school and college athletes’ attitudes toward sports psychology consulting. Journal of Applied Sport Psychology, 17, 127–139. 10.1080/10413200590932434 Martin, S.B., Kellmann, M. Lavallee, D., & Page, S.J. (2002). Development and psychometric evaluation of the sports psychology attitudes-Revised form: A multiple group investigation. The Sport Psychologist, 16, 272–290. 10.1123/ tsp.16.3.272 Martin, S.B., Lavallee, D., Kellmann, M., & Page, S.J. (2004). Attitudes toward sports psychology consulting of adult athletes from the United States, United Kingdom, and Germany. International Journal of Sport and Exercise Psychology, 2, 146–160. 10.1080/1612197X.2004.9671738 Martin, S.B., Wrisberg, C.A., Beitel, P.A., & Lounsbury, J. (1997). NCAA Division I athletes’ attitudes toward seeking sports psychology consultation: The development of an objective instrument. The Sport Psychologist, 11, 201–218. 10.1123/tsp.11.2.201 Martin, S.B., Zakrajsek, R.A., & Wrisberg, C.A. (2012). Attitudes toward sports psychology and seeking assistance: Key factors and a proposed model. In C.D. Logan & M.I. Hodges (Eds.), Psychology of attitudes (pp. 1–33). Hauppauge, NY: Nova Science Publishers, Inc. Moulton, M. A., Molstad, S. , & Turner, A. (1997). The role of athletic trainers in counseling collegiate athletes. Journal of Athletic Training, 32(2), 148. National Rugby League. (n.d.). State of Mind. Retrieved April 27, 2022, from https://www.nrl.com/community/ state-of-mind/. NCAA. (2022). Sport Science Institute. Retrieved April 27, 2022 from https://www.ncaa.org/sports/2021/5/24/ sport-science-institute.aspx. Neelis, L.A., Blom, L.C., Drane, D., Speed, N., & Phillip, D. (2012). NCAA Division I head softball coaches’ confidence, openness and stigma tolerance toward sports psychology consultants. Journal of Contemporary Athletics, 6(1), 51–68. Nelson, D.J. (2008). The attitudes of coaches toward sports psychology consultation (Unpublished doctoral dissertation), Capella University. Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7, 313–326. 10.1123/jcsp.7.4.313 Orlick, T., & Partington, J. (1987). The sports psychology consultant: Analysis of critical components as viewed by Canadian Olympic athletes. The Sport Psychologist, 1, 4–17. 10.1123/tsp.1.1.4 Ong, N.C.H., & Harwood, C. (2018). Attitudes toward sports psychology consulting in athletes: Understanding the role of culture and personality. Sport, Exercise, and Performance Psychology, 7(1), 46–59. 10.1037/spy0000103 Osaka, N. [@naomiosaka]. (2021, May 31). Hey everyone, this isn’t a situation I ever imagined or intended when I posted a few days ago. [Tweet]. Twitter. https://twitter.com/naomiosaka/status/1399422304854188037?s=20& t=emIgS06zFaMpnULsOty1Ug. Pain, M.A., & Harwood, C.G. (2004). Knowledge and perceptions of sports psychology within English soccer. Journal of Sports Sciences, 22, 813–826. 10.1080/02640410410001716670

284

Stigmatisation of Mental Illness Partington, J., & Orlick, T. (1987). The sports psychology consultant: Olympic coaches’ views. The Sport Psychologist, 1, 95–102. Parrott, S., Billings, A.C., Buzzelli, N., & Towery, N. (2021). “We all go through it”: Media depictions of mental illness disclosures from star athletes DeMar DeRozan and Kevin Love. Communication & Sport, 9(1), 33–54. 10.1177/ 2167479519852605 Pensgaard, A.M., Oevreboe, T.H., & Ivarsson, A. (2021). Mental health among elite athletes in Norway during a selected period of the COVID-19 pandemic. BMJ Open Sport & Exercise Medicine, 7, e001025. 10.1136/bmjsem2020-001025 Porter, R. (2002). Madness: A brief history. Oxford Press. Poucher, Z.A., Tamminen, K.A., Sabiston, C.M., Cairney, J., & Kerr, G. (2021). Prevalence of symptoms of common mental disorders among elite athletes. Psychology of Sport & Exercise, 57, 102018. 10.1016/j.psychsport.2021.102018 Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. 10.1037/0022-006X.51.3.390 Rayan, A., Baker, O., & Fawaz, M. (2020). The psychometric properties of attitudes toward seeking professional psychological help scale-short form in Jordanian university students. Journal of Muslim Mental Health, 14(1). 10. 3998/jmmh.10381607.0014.102 Rayan, A., & Fawaz, M. (2018). Cultural misconceptions and public stigma against mental illness among Lebanese university students. Perspectives in Psychiatric Care, 54(2), 258–265. 10.1111/ppc.12232 Rayan, A., & Jaradat, A. (2016). Stigma of mental illness and attitudes toward psychological help-seeking in Jordanian university students. Research in Psychology and Behavioral Sciences, 4(1), 7–14. 10.12691/rpbs-4-1-2 Reardon, C.L., Hainline, B., Aron, C.M., Baron, D., Baum, A.L., Bindra, A., Budgett, R., Campriani, N., Castaldelli-Maia, J.M., Currie, A., Derevensky, J.L., Glick, I.D., Gorczynski, P., Gouttebarge, V., Grandner, M.A., Han, D.H., McDuff, D., Mountjoy, M., Polat, A., Purcell, R., … Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine, 53(11), 667–699. 10.1136/bjsports-2019-100715 Rössler, W. (2016). The stigma of mental disorders: A millennia-long history of social exclusion and prejudices. EMBO Reports, 17(9), 1250–1253. 10.15252/embr.201643041 Sebbens, J., Hassmén, P., Crisp, D., & Wensley, K. (2016). Mental health in sport (MHS): Improving the early intervention knowledge and confidence of elite sport staff. Frontiers in Psychology, 7, 911. 10.3389/fpsyg.2016.00911 Strong, S. (1968). Counselling: An interpersonal influence process. Journal of Counseling Psychology, 15(3), 215–224. 10.1037/h0020229 TeamUSA. (2019). 2019 Impact Report. https://2019impactreport.teamusa.org/foundational-programs.html. Tracey, J. (2008). Inside the clinic: Health professionals’ role in their clients’ psychological rehabilitation. Journal of Sport Rehabilitation, 17, 413–431. 10.1123/jsr.17.4.413. U.S. Olympic & Paralympic Committee. (2022). Mental Health. https://www.teamusa.org/Team-USA-AthleteServices/Mental-Health. Van Raalte, J.L., Brewer, B.W., Brewer, D.D., & Linder, D.E. (1992). NCAA division II college football players’ perceptions of an athlete who consults a sport psychologist. Journal of Sport & Exercise Psychology, 14, 273–282. Van Raalte, J.L., Brewer, D.D., Matheson, H., & Brewer, B.W. (1996). British athletes’ perceptions of sport and mental health practitioners. Journal of Applied Sport Psychology, 8, 102–108. 10.1080/10413209608406311 Van Slingerland, K.J., Durand-Bush, N., Bradley, L., Goldfield, G., Archambault, R., Smith, D., Edwards, C., Delenardo, S. Taylor, S., Werthner, P., Kenttä, G. (2019). Canadian Centre for Mental Health and Sport (CCMHS) position statement: Principles of mental health in competitive and high-performance sport. Clinical Journal of Sport Medicine, 29(3), 173–180. 10.1097/JSM.0000000000000665 Wilson, K.A., Gilbert, J.N., Gilbert, W.D., & Sailor, S.R. (2009). College athletic directors’ perceptions of sports psychology consulting. The Sport Psychologist, 23, 405–424. 10.1123/tsp.23.3.405 Wrisberg, C.A., Loberg, L.A., Simpson, D., Withycombe, J.L., & Reed, A. (2010). An exploratory investigation of NCAA Division-I coaches’ support of sports psychology consultants and willingness to seek mental training services. The Sport Psychologist, 24, 489–503. Wrisberg, C.A., Simpson, D., Loberg, L.A., Withycombe, J.L., & Reed, A. (2009). NCAA Division-I studentathletes’ receptivity to mental skills training by sports psychology consultants. The Sport Psychologist, 23, 470–486. 10.1123/tsp.23.4.470 Wrisberg, C.A., Withycombe, J.L., Simpson, D., Loberg, L.A., & Reed, A. (2012). NCAA Division-I administrators’ perceptions of the benefits of sports psychology services and possible role for a consultant. The Sport Psychologist, 26, 16–28. 10.1123/tsp.26.1.16 Zakrajsek, R.A., Fisher, L.A., & Martin, S.B. (2018). Certified athletic trainers’ experiences with and perceptions of sports psychology services for student-athletes. The Sport Psychologist, 32, 300–310. 10.1123/tsp.2017-0119

285

Rebecca A. Zakrajsek et al. Zakrajsek, R.A., Fisher, L.A., & Martin, S.B., (2017). Certified athletic trainers’ understanding and use of sports psychology in their practice. Journal of Applied Sport Psychology, 29(2), 215–233. 10.1080/10413200.2016.1231722 Zakrajsek, R.A., & Martin, S.B., (in press). Gaining entry. In J. Shaprio (Ed.), Routledge Encyclopedia of Psychology in the Real World – Sport Section. Zakrajsek, R.A., Martin, S.B., & Wrisberg, C.A. (2015). Sport psychology services in performance settings: NCAA D-I certified athletic trainers’ perceptions. Sport, Exercise, and Performance Psychology, 4, 280–292. 10.1037/ spy0000042 Zakrajsek, R.A., Martin, S.B., & Wrisberg, C.A. (2016). National collegiate athletic association division-I certified athletic trainers’ perceptions of the benefits of sports psychology services. Journal of Athletic Training, 51, 398–405. http://natajournals.org/doi/pdf/10.4085/1062-6050-51.5.13 Zakrajsek, R.A., Martin, S.B. & Zizzi, S.J. (2011). American high school football coaches’ attitudes toward sports psychology consultation and intentions to use sports psychology services. International Journal of Sport Science & Coaching, 6, 461–478. 10.1260/1747-9541.6.3.461 Zakrajsek, R.A., & Zizzi, S.J. (2007). Factors influencing track and swimming coaches’ intentions to use sports psychology services. Athletic Insight: The Online Journal of Sport Psychology, 9(2). Retrieved from https:// researchrepository.wvu.edu/faculty_publications/2922/ Zakrajsek, R.A., & Zizzi, S.J. (2008). How do coaches’ attitudes change when exposed to a sports psychology workshop? Journal of Coaching Education, 1(1), Retrieved from http://www.aahperd.org/naspe/jce/pdf_files/ Zakrajsek_Zizzi_JCE_2008.pdf. 10.1123/jce.1.1.66 Zizzi, S.J., & Perna, F.M. (2003). Impact of a brief workshop on stages of change profiles in athletes. Athletic Insight: The Online Journal of Sport Psychology, 5(4). Retrieved from https://researchrepository.wvu.edu/faculty_ publications/2924/

286

18 CAREER TRANSITIONS IN SPORT Robert Morris, Pete Coffee, Hee Jung Hong, Chris Hartley, and Nina Verma

Introduction A transition is defined in counselling psychology as an event that requires “a change in assumptions about oneself and the world and requires a corresponding change in one’s behaviour and relationships” (Schlossberg, 1981, p. 5). Transitions in sport can include, amongst others, the youth-to-senior transition (i.e., the move from age grouped sport to senior level sport without age restrictions; see Drew et al., 2019) and retirement from sport (i.e., retirement at the end of a sport career; see Wylleman & Lavallee, 2004). This shift to a new phase often results in athletes experiencing a different set of demands and commitments which they need to cope with to successfully manage their athletic careers and other domains of their lives (e.g., personal life; Alfermann & Stambulova, 2007). As a result, transitions can be extremely challenging for athletes. To contextualise, the youth-to-senior transition is often considered as the most difficult transition athletes may undertake – it can lead to them experiencing poor psychological health and well-being, and, ultimately, mental health issues (Drew et al., 2019). Additionally, according to Cosh et al. (2020), up to 20% of retiring athletes experience crisis transitions, characterised by a lack of adjustment, ongoing psychological distress, depression, and low self-esteem. In recent years, there have been several high-profile examples of when athletes have suffered mental health issues because of the challenges of undergoing career transitions. The cases of retired athletes such as Clarke Carlisle, Gary Speed, Kelly Holmes, and John Kirwan, who all suffered from varying degrees of mental health issues post-retirement, are just some of these. In this chapter, we are going to outline the link between career transitions and mental health and well-being by providing an overview of the research and examples pertaining to this issue. We will also outline a contemporary approach to understanding career transitions and mental health in sport, via the social identity approach. In addition, there are several key antecedents, risk, and protective factors such as athletic identity and social support, which can influence athletes’ mental health and well-being through transition that will be outlined. We will conclude this chapter by providing an overview of unanswered questions, controversies, and future directions in the topic area.

What Are the Different Career Transitions Athletes Might Experience? As indicated, there are several transitions which athletes may face throughout the course of their athletic career. These transitions can be categorised as either normative (expected/voluntary) or non-normative DOI: 10.4324/9781003099345-24

287

Robert Morris et al.

(unexpected/involuntary; Stambulova, 2000). Normative transitions include progressing to a higher/senior level of sport and the transition out of sport, caused by, for instance, age or for athletes’ personal or social reasons (Wylleman & Lavallee, 2004; Taylor et al., 2005). Contrastingly, non-normative transitions may include injury, deselection, or doping sanctions (Pummell et al., 2008; Hong et al., 2020). Research on sport career transitions initially focused on the normative transition, athletes’ retirement, with research suggesting that this process can be extremely challenging for some, with variables such as voluntariness of the retirement decision, injuries and health problems, and balance of life all having an impact on the quality of the transition (Park et al., 2013). To contextualise, athletes who do not voluntarily retire, have injury or health problems, or do not have a balanced life are more likely to suffer a more challenging transition. Research has suggested that athletes who do have a more difficult transition and are not able to manage the challenges they are experiencing through, for instance, appropriate psychosocial support can suffer from mental health issues such as depression, with some even taking their own lives (e.g., Coverdale, 2020; Hong, 2018). In this respect, since athletes inevitably face the transition out of sport as part of their athletic career, they are exposed to an increased likelihood of suffering from mental health issues or Experiencing psychological distress if they are not prepared for the transition and do not have adequate resources to cope with difficulties and challenges this presents. As the research in sport career transitions has shifted from career termination and retirement to athletes’ holistic development (Park et al., 2012), other types of career transitions have been investigated, including normative within-career (i.e., they occur during the athletic career) transitions. Considering that the span of athletic career can be 15–35+ years (Sosniak, 2006; Wylleman et al., 1993), it is crucial for sport psychologists to have in-depth knowledge on transitional challenges and barriers experienced by elite athletes throughout their sport career (Wylleman & Rosier, 2016). In this respect, Wylleman and colleagues (see Wylleman & Lavallee, 2004; Wylleman et al., 2013; Wylleman, 2019) developed a conceptual model outlining the typical career pathway of athletes and the types and timings of transitions that athletes might experience during this pathway. The model represents the whole sport career pathway, from initiation to discontinuation, along with the transitions that may occur across the pathway. The model, in addition to outlining the sport career pathway, also highlights stages and transitions that occur at the psychological level (childhood to adulthood), psycho-social level (parents, siblings, peers to family (coach), peers), academic and vocational level (primary education to post-sport career), financial level (family to family, employer), and legal level (minor to adult). One specific within-career transition which has been subject to considerable research more recently is the transition from junior-to-senior level (Wylleman & Lavallee, 2004). The junior-to-senior transition is considered as the most difficult within-career transition across the athletic career (Stambulova, 2009). Morris (2013) pointed out that such transitions can be especially difficult as young athletes may experience difficulties and challenges in their non-athletic domain as well as their athletic one. As outlined by Wylleman and colleagues (e.g., Wylleman & Lavallee, 2004; Wylleman et al., 2013; Wylleman, 2019), the transition to senior sport, which occurs at the age of approximately 18–19 years old, occurs alongside the transition from puberty/adolescence to adulthood at the psychological level; the transition from support being provided by peers, coach, and parents to partner, family, coach, support staff, teammates, and student athletes at the psycho-social level; the transition from primary to secondary education at the academic and vocational level; the transition from family and sport governing body to sport governing body/NOC/sponsor and family at the financial level; and from minor to adult at the legal level. In this respect, elite athletes can simultaneously face transitions across various domains, with each transition having unique challenges associated with it (Wylleman & Rosier, 2016). Combined, therefore, because the junior-to-senior transition can include a series of differing demands that athletes need to cope with, along with other challenges such as establishing themselves in the senior squad, maintaining motivation for 288

Career Transitions in Sport

the transition, a lack of social support, and increased pressure to perform (see Drew et al., 2019), it is reported that only one-third of junior athletes succeed in the process (Australian Sports Commission, 2003; Bussmann & Alfermann, 1994; Vanden Auweele et al., 2004).

How Do Transitions Relate to Mental Health? From a holistic life span perspective, athletes’ mental health is considered to develop from the athletic, psychological, psychosocial, academic-vocational, financial, and legal domains throughout their life and career (see Wylleman & Lavallee, 2004; Wylleman et al., 2013; Wylleman, 2019). In this respect, career transitions are critical phases where athletes may experience changes in these life and career domains and may perceive a misbalance between the demands posed by the transition versus their resources to cope (Stambulova et al., 2009). For example, during junior-to-senior transitions and retirement transitions, athletes might have to deal with notable transition events such as advancement to a national team, career decline, deselection, or dealing with temporary (potentially career-ending) injuries (Henriksen et al., 2020). Due to the demanding nature of these transitional events, subsequent fluctuations in mental health are commonplace for athletes whether they are transitioning into, through or out of high-performance sport (e.g., Keuttel et al., 2017; Pummell & Lavallee, 2019). While there are noticeable challenges associated with transitions, research and empirical data outlining the prevalence of mental health issues in sport because of transition are generally lacking (Stambulova & Wylleman, 2019). At the most critical phases of transitioning from junior-to-senior levels of performance (e.g., Pummell & Lavallee, 2019) and transitioning out of elite sport (e.g., Kuettel et al., 2017), it is estimated that between 15–20% of athletes may encounter adjustment difficulties characterised by feelings of loss, identity crises, and distress (Park et al., 2013). Amongst current and retired football players, up to 39% of retired athletes face mental health problems such as poor nutrition and drinking behaviour (Gouttebarge et al., 2015, 2016), with a more recent survey of 800 retired athletes reporting that about half of the respondents had concerns about their mental or emotional well-being since retiring (State of Sport, 2018). These levels of mental health issues within current and retired athletes can have tragic consequences. Recent tragic incidents include reports of athletes who have suffered from mental health issues as a result of being released from their sport committing suicide (see Carroll & Hong, 2020). There are several reasons why transitions can result in mental health issues. To conceptualise, it has been outlined that upwards and lateral transition events into elite sport may be accompanied with notable changes to training demands, resulting in physical and psychological exhaustion which may contribute to maladaptive outcomes such as symptoms of burnout (Hartley & Coffee, 2019; see Chapter 12). Additionally, an inability to effectively cope with the multiple demands of a dual career may lead to elevated stress, compromised mental health, burnout, and sport dropout (Stambulova et al., 2020). Compared to athletes with weaker and less exclusive athletic identities, retired athletes with a strong, exclusive athletic identities are more susceptible to a range of mental health problems such as feelings of loss, depression, and hopelessness (Carless & Douglas, 2009; Lavallee & Robinson, 2007). Strong athletic identities can also result in more negative psychological responses to transition experiences such injury and de-selection (Brewer et al., 1993; Brown & Potrac, 2009), including maladaptive coping strategies and emotional disturbances (Brown & Potrac, 2009). Ultimately, failure to cope with the demands posed by transitions can result in premature dropout from sport, neuroses, depression, and substance abuse (Stambulova, 2009; Stambulova & Wylleman, 2014).

A Social Identity Approach to Career Transitions and Mental Health For a contemporary perspective on the impact of career transitions on mental health, we turn to the social identity approach. Informed by social identity theory (Tajfel & Turner, 1979) and self-categorisation 289

Robert Morris et al.

theory (Turner et al., 1987), the social identity approach has gained considerable recent attention in the field of sport and exercise psychology (Haslam et al., 2020). The approach offers a novel perspective by moving beyond an individualistic understanding of career transitions and mental health to considering how such processes are bound up in group life. Here then, we argue that elite athletes’ sense of identity as group members could shape their experiences of career transitions and mental health. Broadly, the social identity approach refers to the capacity for groups to be internalised into our sense of self (Haslam, 2004). As such, the psychology of career transitions is not that of an elite athlete as an individual but the psychology of an elite athlete as a group member. Group life structures how elite athletes (a) perceive the world and events, including career transitions, in their lives, and (b) behave as group members rather than individuals when negotiating career transitions (Turner, 1982). As such, career transitions, as with all life transitions, involve negotiating identity change, and how this process unfolds determines experiences of both identity continuity and gain, and identity loss (O’Halloran & Haslam, 2020). Speaking to the latter, elite athletes can be prone to identity foreclosure where a high (and sometimes singular) investment in elite sport can lead to little exploration of alternative identities outside of being an athlete (also termed athletic identity; e.g., Brewer et al., 1993). Presented in a summative statement by Ronkainen and colleagues (2016): “athletic identity can be a positive source of meaning and self-esteem, but also highly problematic for well-being when sport is not going well or the career is abruptly terminated” (Ronkainen et al., 2016, p. 57). While evidence exists to suggest that athletic identity generally declines towards retirement (Martin et al., 2014), those facing involuntary retirement (e.g., through injury) with a high athletic identity are more likely to experience negative emotional and psychological well-being (e.g., loss, depression, loneliness, decreased life satisfaction; Carless & Douglas, 2009; Sanders & Stevinson, 2017). Thus, coupled with the increased tendency of identity foreclosure amongst athletes (Brewer & Petitpas, 2017), negative associations have been highlighted in relation to athletes’ quality of career transitions (Park et al., 2013). While ample evidence has explored the psychological toll of personal identity loss (i.e., athletic identity) during career transition, there is much reason to believe that the loss of social identity (i.e., team identity) may be just as significant to understand. By drawing upon literature outside of the sporting domain, we consider how social identities can be harnessed (Jetten et al., 2012) to foster positive career transitions through, for example, identity continuity (i.e., maintaining current social identities) and identity gains (i.e., generating new social identities) which can lead to protecting (i.e., against the inevitable loss of being an elite athlete), or even enhancing mental health (O’Halloran & Haslam, 2020). Consolidating the ideas above, we turn to O’Halloran and Haslam (2020) who have argued for the relevance of the Social Identity Model of Identity Change (SIMIC: e.g., Haslam et al., 2008) to career transitions in sport. A core proposition of SIMIC is that an individual’s capacity to cope with a life transition, and thereby experience positive health and well-being, can be enhanced through belonging to multiple social groups (Cruwys et al., 2020). As such, belonging to multiple social groups prior to retirement or during career transition may help to reduce or negate the effects of both personal identity loss (i.e., athletic identity) and the loss of social identity (i.e., team identity). Memberships of social groups are important because these memberships provide resources that individuals can draw upon to facilitate coping behaviours (Jetten et al., 2009, 2014; O’Halloran & Haslam, 2020). As such, throughout career transitions, having access to multiple identities increases the number and range of resources upon which elite athletes can draw. One key resource that social identities provide access to is social support (Hartley et al., 2020). Evidence in sport has demonstrated that social support is an effective resource towards a functional adaptation to higher stress such that individuals may be protected from burnout (Hartley & Coffee, 2019). Further, social support is a critical resource to facilitate successful career transitions in elite sport (e.g., Brown et al., 2018). SIMIC points to the importance of negotiating identity change during career transitions in elite sport. This is achieved through (a) maintaining existing identities, (b) gaining new ones, and (c) ensuring that 290

Career Transitions in Sport

maintained and new identities are compatible. These concepts are represented in the model through the pathways of social identity continuity and social identity gain. The model predicts that having multiple group memberships (a) increases the chances of maintaining at least some of one’s old networks during the life transition (social identity continuity), and (b) provides individuals with greater opportunities to gain memberships of new social groups (social identity gain through social scaffolding; Williams et al., 2019). SIMIC predicts that, when managing change, such as career transitions, both maintaining group memberships and acquiring compatible new group memberships results in positive effects upon mental health (Cruwys et al., 2020; Haslam et al., 2018). To assess the propositions of SIMIC to career transitions and mental health of athletes in elite sport, researchers and practitioners could draw upon the method of Social Identity Mapping (SIM: Bentley et al., 2020; Cruwys, et al., 2016). Completed in hardcopy (Cruwys et al., 2016) or through an online tool (Bentley et al., 2020), SIM would provide researchers and practitioners with a visual representation of an elite athlete’s network and social group memberships. The method could be repeated across time to depict changes in elite athlete’s social group memberships while they are progressing through a career transition. This approach would capture where an elite athlete maintains existing identities (SIMIC pathway of social identity continuity) and where an athlete gains new social identities (SIMIC pathway of social identity gain), and would help identify whether or not new social identities are compatible with existing social identities. Such analysis would help researchers and practitioners to identity aspects in elite athlete’s networks and social group memberships that might be improved. Such intervention may well improve elite athletes’ experiences of transition in their career and their mental health. We have drawn upon the social identity approach to provide a contemporary perspective on the impact of career transitions on mental health. The relevance of propositions from SIMIC, informed by a large body of evidence across several life changes (Cruwys et al., 2020; O’Halloran & Haslam, 2020), is compelling to career transitions and mental health in elite sport. Nevertheless, it is important to acknowledge that the propositions of SIMIC have yet to be tested in the context of sporting career transitions and associated impact for mental health of elite athletes. As such, this is a call for researchers to take up the charge and explore these propositions with elite athletes.

Guidelines for Practitioners There is a recognition that elite sport need to have mechanisms to not only respond to the crisis transition experiences of athletes, but also have ways of fortifying mental health in proactive, preventative ways (e.g., Breslin et al., 2017; Rice et al., 2016). Indeed, emerging research trends in athlete transitions and career research emphasises athlete mental health as a resource throughout the athlete’s career development and also as a target outcome of career development (Henriksen et al., 2020). Therefore, we present three hypothetical case studies, each employing differing degrees of responsive versus preventative and athletecentred versus holistic approaches to navigating career transitions for good mental health, which can be considered in addition to the use of social identity approach to career transitions and mental health. Thereafter, we present overall recommendations that are crucial in supporting athletes pre-, during, and post-transition.

Case Studies Case study 1 – Responsive approach to a crises-coping transition In the below case (Box 18.1), the transition is initiated through an unplanned injury which results in deselection. Rehabilitation of the injury is an obvious focal area in this case (for further information on injury prevention, see Chapter 23). For instance, receiving close and well-coordinated support from 291

Robert Morris et al.

Box 18.1

Case Study 1 – Injured Rugby Player

A rugby player has narrowly missed out on national team selection due to an unplanned injury. To complicate matters further, the athlete now discloses the additional strain that training has been placing on her relationships, finances, and studying. She feels she is unable to cope.

medical staff may provide effective problem-focused coping resources (e.g., for dealing with the controllable aspects of treating the injury such as establishing a rehabilitation plan; Cutrona & Russell, 1990; Mitchell et al., 2014). However, there is a range of other factors (relationship issues, finances, studying) that complicate this crisis transition further, necessitating the additional inclusion of psychological support in the injury rehabilitation and crisis transition coping process. This may help to establish effective problem- and emotion-focused coping for this athlete. In these types of cases, responsive crisis-coping interventions may also require the application of counselling and psychotherapeutic frameworks aimed at reducing athletes’ experience of anxiety, promoting adaptive coping behaviours, and managing the psychosocial stressors imposed by the transition (Wylleman, 2018). Indeed, there are a range of social forces (e.g., stigmatisation, approach-avoidance dilemmas, fear of deselection; Butler et al., 2018; Sarkar & Fletcher, 2014) that might contribute towards athletes keeping the personal stressors posed by transitions private or intentionally hidden from their support network (e.g., straining of relationships, identity struggles, financial stressors), sometimes to the point of exacerbating a crisis transition (Henriksen et al., 2020). This extends to the need for sport practitioners to be competently trained in a broad range of areas to signpost and (in some cases) support clinical issues when they do emerge. With the challenges of doing so abound (e.g., competency and role boundaries), regular collaboration with clinical experts and having multiple supervisors of varying experience both within the sport and clinical domains is advocated (Sly et al., 2020). To bridge the competency gap between sport and clinical practitioners, it has been suggested that a more holistic systems approach could be adopted where sport practitioners are given (or proactively cultivate) opportunities to work closely with clinical colleagues in order to develop experience of initiating, monitoring, and evaluating support provisions to athlete populations (Eubank, 2016; Rotheram et al., 2016).

Case study 2 – Crisis-prevention approach using an athlete-centred perspective In the below case (Box 18.2), practitioners take a proactive crises-prevention and athlete-centred perspective and a hands-on approach that assists athletes in identifying, planning, and mobilising their coping resources for any pre- and post-transitional experiences that may be either anticipated or unanticipated in their career, would be one possible approach (Bouchetal-Pellegri et al., 2006). This might involve a paperand-pencil reflective planning task (e.g., the ‘5-Step Career Planning Strategy’; Stambulova, 2010), where athletes are guided through past, present, and future potential transition scenarios, the implications thereof for their mental health and well-being, how this might impact upon different life domains, and what this means for their coping resources and goal setting in the future. Sport practitioners might also be involved in assisting athletes to develop their social support network, establish monitoring systems, mobilise current coping resources, and to buffer the experience of transitional stress (Morris et al., 2017). It is worthwhile raising a cautionary tale regarding the unintentional ill side-effects of athlete-centred support provision for transitions. Athletes may express reliance on support from sport personnel (Poucher et al., 2018), and it is important to consider the effects of support discontinuation following a transition – as this has been demonstrated to contribute to negative outcomes as the level of support decreases abruptly 292

Career Transitions in Sport

Box 18.2 Case Study 2 – Junior Badminton Player An elite junior badminton player currently situated within a performance pathway system is 12–24 months away from senior national team selection. Due to the athlete’s fledgling tier on the performance-pathway, they have been offered 20 hours of support from a sport practitioner in the area of performance lifestyle or psychology.

(Park et al., 2013). As such, athlete-centred support should be provided by trained personnel who can be readily available to the athlete pre-, during, and post-transition as this will provide some degree of familiarity and support for ongoing daily sport processes (Henriksen et al., 2020). For example, it has been advised that a dedicated mental health officer trained in clinical expertise should be a central figure throughout athletes’ careers as they can monitor, educate, consult, network, and refer throughout any transition experiences (Henriksen et al., 2020).

Case study 3: Preventative approach using a holistic perspective Taking a holistic perspective to managing the below case (Box 18.3) would be one possibility for practitioners working with this athlete. This could be done through the adoption of a preventative and multidisciplinary career transition support programme. In line with its use in research (e.g., Debois et al., 2015) and athlete career support guidelines (European Commission, 2012), this type of programme is based on Wylleman and colleagues work, which stresses how the developmental contexts outside of the sport domain will influence transition experiences within sport (see Wylleman & Lavallee, 2004; Wylleman et al., 2013; Wylleman, 2019). In working in this way, sport practitioners are encouraged to take a holistic career and whole-person perspective when approaching transitional challenges. This is because, as mentioned earlier, transitions pose multiple challenges to athletes across life domains, and therefore optimal preventative support will generally require multidisciplinary input that is integrated with the sport domain (Morris et al., 2016). In more concrete terms, Stambulova (2010) proposed the adoption of a career transitions assistance frameworks to help athletes plan for career transitions, which encourages stakeholders and practitioners to collect holistic information about the athlete, consider their sport and non-sporting context, and situate their interventions within a continuum of preventative, educational, and coping perspectives (Stambulova & Wylleman, 2014). These may take the form of formalised career assistance programmes (over 60 are currently in existence across different countries; Stambulova & Ryba, 2013; 2014), which aim to help athletes navigate transitional challenges by supporting sport, education, work, and personal growth, thereby often directly or indirectly supporting mental health issues (Stambulova, 2010). Working in this way, if sport practitioners are to help athletes navigate transitions effectively, they need knowledge of intervention skills, and should strive for continual investment in multidisciplinary collaboration, competence, reflection and influence before, during, and following a transition. If these actions

Box 18.3 Case Study 3 – Collegiate Football Player A football club is considering signing a new player – a college student aged 17 – from their academy system into the reserves for their senior team within the next 6 months. The club’s performance directors, managers, and multidisciplinary team of sport practitioners are considering how best to navigate the likely transition this athlete might face.

293

Robert Morris et al.

are to effectively support good mental health during transitions, they should also be done with an intricate knowledge of the structural, organisational, and policy aspects of elite sport and the impact of these on athletes’ life domains. For example, understanding the selection processes athletes need to go through, along with the organisational requirements of joining the programme (e.g., reality of training versus social life), the nature of interpersonal relationships, along with the reality of managing a dual career and the financial strains thereof, might be important information sport practitioners can use when supporting athletes in this way (Stambulova & Wylleman, 2015; Wylleman, 2018).

Overall Recommendations Recommendation 1: It is Important to Use All of Athletes’ Available Resources When Supporting Their Transition Key coping resources may include athletes’ internal and external coping resources (parental support, use of social and dual career competencies, financial support, pre-retirement planning and preparations; Stambulova et al., 2020; Stephan & Demulier, 2008). Rather than just using internal or external resources, or singular resources when supporting athletes, understanding their full repertoire and any gaps in their coping resources in order to prevent mental health issues is important. This can be something that is done prior to transition to support the process.

Recommendation 2: Social Support Is One of the Most Crucial Coping Mechanisms That Can Be Called Upon by Athletes and This Is Something That Should Be Mobilised During Transition Social support is generally considered to play a preventative and proactive role against negative career transitions (Park et al., 2013; Willard & Lavallee, 2016). Case studies conducted with Scandinavian cultures identified that developing psychosocial skills, supportive relationships, and having proximal role models are conducive to helping young athletes successfully navigate transitions while mainlining high levels of mental health and well-being (Henriksen et al., 2010). In this respect, social support can prevent athletes experiencing mental health issues when going through these processes. Therefore, practitioners should assist athletes in mobilising this support prior to transition, perhaps by helping them understand who can help them with their transition and the support they can provide (e.g., technical, tangible, social, emotional support).

Recommendation 3: Help Athletes Find Alternative Scope to Their Lives Being able to work productively and fruitfully, contribute to ones’ community, and finding meaning in life following elite sport are considered to be protective factors for mental health following a retirement transition (World Health Organisation, 2014). Indeed, amongst retired footballers, employment status and having working hours were considered to be protective factors against poor mental health following a transition (Gouttebarge et al., 2016). Practitioners should, therefore, help athletes to identify alternative foci in their lives that help them achieve their goal of positive transition.

Recommendation 4: Support for Transition Should Be Long not Short Term To contextualise, in the event of a retirement transition out of sport, for example, it is imperative and recognised that this presents a critical time for ongoing mental health support through and after the transition (e.g., a minimum of 12 months’ ongoing mental health screening and services are recommended following completion of an Olympic cycle; Henriksen et al., 2020). Athletes may need to come to terms 294

Career Transitions in Sport

with performance outcomes and experiences, physiological changes, physical relocations out of training centres or housing systems, and the time spent away from loved ones. Athletes may also need to adapt to managing new and multiple life commitments, such as transitioning into the ‘bottom rung’ of education or work – all of which may exacerbate existing mental health challenges (Henriksen et al., 2020). In other transitions, such as the junior-to-senior transition, similar challenges may be experienced, including physiological challenges, performance outcomes, and spending time away from loved ones. Ultimately, these challenges can manifest in both the short and longer term (see Drew et al., 2020) and, as a result, support should be reflective of this.

Conclusion To summarise, career transitions can have an influence on athlete mental health and well-being. There are several challenges, as have been outlined here, which athletes need to overcome during transitions in order that they successfully cope with the process and maintain positive mental health and well-being. In this chapter, we have offered several ways of explaining these challenges and how practitioners could look to support athletes with these. Specifically, social identity theory has been purported as a vehicle for explaining transitions and the challenges and potential mechanisms for overcoming these. Additionally, we also offer additional case studies and applied recommendations that should be considered when working to support athletes in this way. In outlining these aspects in this chapter, several unanswered questions, controversies, and future directions have emerged, which could be areas for practitioners, researchers, and others to consider. Firstly, while there is initial evidence to support the notion that career transitions can lead to mental health issues and the fact we have conceptualised the relationship in this chapter, there is a lack of empirical data which identifies, specifically, what percentage of athletes experience these issues as a result of transition. This is particularly prevalent for transitions such as the junior-to-senior transition. We would encourage researchers to consider conceptualising more clearly the underpinning connection between the two variables and identify more clearly the number of athletes who do suffer from mental health and well-being challenges as a result of transition. Second, while we have proposed the social identity approach as a way of explaining the connection between career transitions and mental health and well-being, we have not empirically tested this connection. In other words, we have, at this stage, just proposed that social identity helps explain the process of transition and the mental health and well-being consequences, without testing this in the context of sporting career transitions and associated impact for mental health of elite athletes. As mentioned earlier, this is a call for researchers to take up the charge and explore these propositions with elite athletes. We would also encourage more work to unpick the transitional experiences of disabled athletes and the influence this has on their mental health. Perhaps controversially, much of the transition work in sport has focused on understanding the experiences of able-bodied athletes, with this work then translated to disabled sport contexts, which may negate the specific challenges this group experience. To elaborate, the manner in which athletes are recruited to disability sport (e.g., from the military) means that athletes can go through numerous group and identity transitions (e.g., able-bodied to disabled) within a short space of time (Sparkes, 2018). Additionally, the classification structure of disability sport means that athletes face constant evaluation and stress relating to their events (Howe, 2017). For example, not meeting minimum impairment standards means athletes are ineligible to compete and hence they may be removed from governing body funded programmes with immediate effect and have to transition away from their sport. Such novel challenges mean that disabled athletes may experience heightened demands which can, consequently, result in poorer health and well-being outcomes over time. Understanding the unique context of disability sport, therefore, will mean that the additional challenges which disabled athletes

295

Robert Morris et al.

experience can be understood and additional support can be put in place to ensure that the health and well-being of disabled athletes can be protected and maintained. Finally, we would also encourage practitioners to explore how their support programmes support athletes going through transition, not just from a performance perspective, but also from a mental health perspective. Athletes transitioning typically experience one of four outcomes when transitioning – positive mental health and positive performance, poor mental health and positive performance, positive mental health and poor performance, or poor mental health and poor performance outcomes. In this respect, consideration in support programmes needs to account for all eventualities (and everything in between!). Ensuring coverage across the range of potential outcomes can mean that athletes are better supported to avoid and manage mental ill health as and when it arises. To conclude, the relationship between sport transitions and mental health should not be underestimated. In this chapter, we have tried to outline possible reasons for this link, using the social identity approach to do so. In doing so, we hope to open up new avenues for future work in this area and for the implementation of new and improved interventions to support athletes going through transition.

References Alfermann, D., & Stambulova, N. (2007). Career transitions and career termination. In G. Tenenbaum & R.C. Eklund (Eds.), Handbook of sport psychology (3rd ed., pp. 712–736). Wiley. 10.1002/9781118270011.ch32 Australian Sports Commission. (2003). How do elite athletes develop? A look through the “rearview mirror.” A preliminary report from the National Athlete Development Survey (NADS). Australian Sports Commission. Bentley, S.V., Greenaway, K.H., Haslam, S.A., Cruwys, T., Steffens, N.K., Haslam, C., & Cull, B. (2020). Social identity mapping online. Journal of Personality and Social Psychology, 118, 213–241. 10.1037/pspa0000174 Bouchetal-Pellegri, F., Leseur, V., & Debois, N. (2006). Carriere sportive. Projet de vie. INSEP-Publications. Breslin, G., Shannon, S., Haughey, T., Donnelly, P., & Leavey, G. (2017). A systematic review of interventions to increase awareness of mental health and well-being in athletes, coaches and officials. Systematic reviews, 6(1), 1–15. 10.1186/s13643-017-0568-6 Brewer, B.W., & Petitpas, A.J. (2017). Athletic identity foreclosure. Current Opinion in Psychology, 16, 118–122. 10. 1016/j.copsyc.2017.05.004 Brewer, B.W., Van Raalte, J.L., & Linder, D.E. (1993). Athletic identity: Hercules’ muscles or Achilles heel? International Journal of Sport Psychology, 24, 237–254. Brown, G., & Potrac, P. (2009). ‘You’ve not made the grade, son’: De‐selection and identity disruption in elite level youth football. Soccer & Society, 10(2), 143–159. 10.1080/14660970802601613 Brown, C.J., Webb, T.L., Robinson, M.A., Cotgreave, R. (2018). Athletes’ experiences of social support during their transition out of elite sport: An interpretive phenomenological analysis. Psychology of Sport and Exercise, 36, 71–80. 10.1016/j.psychsport.2018.01.003 Bussmann, G., & Alfermann, D. (1994). Drop-out and the female athlete: A study with trackand- field athletes. In D. Hackfort (Ed.), Psycho-social issues and interventions in elite sport (pp. 89–128). Lang. Butler, T.L., Mckimmie, B.M., & Haslam, S.A. (2018). The approach-avoidance dilemma at the heart of group-based support: Evidence that group identification increases willingness to seek support at the same time that identitybased support threat reduces it. European Journal of Social Psychology, 49(1), 31–46. 10.1002/ejsp.2384 Carless, D., & Douglas, K. (2009). ‘We haven’t got a seat on the bus for you’ or ‘All the seats are mine’: Narratives and career transition in professional golf. Qualitative Research in Sport and Exercise, 1, 51–66. 10.1080/193984408025 67949 Carroll, M., & Hong, H.J. (2020, December 9). How football’s youth academy culture is failing youngsters who don’t make the grade. The Conversation. https://theconversation.com/how-footballs-youth-academy-culture-is-failing-youngsterswho-dont-make-the-grade-151781 Cosh, S.M., McNeil, D.G., & Tully, P.J. (2020). Poor mental health outcomes in crisis transitions: An examination of retired athletes accounting of crisis transition experiences in a cultural context. Qualitative Research in Sport, Exercise and Health, 13(4), 604–623. 10.1080/2159676x.2020.1765852 Coverdale, D. (2020, February 13). SPECIAL REPORT: ’We are chewed up and spat out … where’s the duty of care?’ - Many of our retired Olympic medal winners are plagued by mental health issues … and much of it stems from a lack of support. Daily mail. https://www.dailymail.co.uk/sport/olympics-2020/article-8001263/ManyBritish-Olympic-medallists-plagued-mental-health-issues-stemmed-lack-aftercare.html

296

Career Transitions in Sport Cruwys, T., Steffens, N.K., Haslam, S.A., Haslam, C., Jetten, J., Dingle, G.A. (2016). Social identity mapping: A procedure for visual representation and assessment of subjective multiple group memberships. British Journal of Social Psychology, 55, 613–642. 10.1111/bjso.12155 Cruwys, T., Stevens, M., Haslam, C., Haslam, S.A., & Olive, L. (2020). Mental health and resilience. In S.A. Haslam, K. Fransen, & F. Boen (Eds.), The new psychology of sport and exercise: The social identity approach (pp. 265–284). SAGE. Cutrona, C.E., & Russell, D.W. (1990). Type of social support and specific stress: Toward a theory of optimal matching. In B.R. Sarason, I.G. Sarason, & G.R. Pierce (Eds.), Social support: An interactional view (pp. 319–336). Wiley. Debois, N., Ledon, A., & Wylleman, P. (2015). A lifespan perspective on the dual career of elite male athletes. Psychology of sport and exercise, 21, 15–26. 10.1016/j.psychsport.2014.07.011 Drew, K., Morris, R., Tod, D., & Eubank, M. (2019). A meta-study of qualitative research on the junior-to-senior transition in sport. Psychology of Sport and Exercise, 45, 101556. 10.1016/j.psychsport.2019.101556 Eubank, M. (2016). Commentary: Blurred lines: Performance enhancement, common mental disorders and referral in the U.K. athletic population. Frontiers in Psychology, 7, 1709. 10.3389/fpsyg.2016.01709 European Commission. (2012). Guidelines on dual careers of athletes recommended policy actions in support of dual careers in high- performance sport. Retrieved from http://ec.europa.eu/sport/news/20130123-eu-guidelinesdualcareers_en.htm Gouttebarge, V., Kerkhoffs, G., & Lambert, M. (2016). Prevalence and determinants of symptoms of common mental disorders in retired professional Rugby Union players. European Journal of Sport Science, 16(5), 595–602. 10.1080/ 17461391.2015.1086819 Gouttebarge, V., Frings-Dresen, M.H., & Sluiter, J.K. (2015). Mental and psychosocial health among current and former professional footballers. Occupational Medicine, 65(3), 190–196. 10.1093/occmed/kqu202 Hartley, C., & Coffee, P. (2019). Perceived and received dimensional support: Main and stress buffering effects on dimensions of burnout. Frontiers in Psychology, 10, 1724. 10.3389%2Ffpsyg.2019.01724 Hartley, C., Haslam, S.A., Coffee, P., & Rees, T. (2020). Social support. In S.A. Haslam, K. Fransen, & F. Boen (Eds.), The new psychology of sport and exercise: The social identity approach (pp. 245–264). SAGE. Haslam, C., Holme, A., Haslam, S.A., Iyer, A., Jetten, J., & Williams, W.H. (2008). Maintaining group membership: Identity continuity and well-being after stroke. Neuropsychological Rehabilitation, 18, 671–691. 10.1080/0960201 0701643449 Haslam, C., Jetten, J., Cruwys, T., Dingle, G., & Haslam, S.A. (2018). The new psychology of health: Unlocking the social cure. Routledge. Haslam, S.A. (2004). Psychology in organizations: The social identity approach. SAGE. Haslam, S.A., Fransen, K., & Boen, F. (2020). The new psychology of sport and exercise: The social identity approach. SAGE. Henriksen, K., Schinke, R., Moesch, K., McCann, S., Parham, W.D., Larsen, C.H., & Terry, P. (2020). Consensus statement on improving the mental health of high performance athletes. International Journal of Sport and Exercise Psychology, 18(5), 553–560. 10.1080/1612197X.2019.1570473 Henriksen, K., Stambulova, N., & Roessler, K.K. (2010). Holistic approach to athletic talent development environments: A successful sailing milieu. Psychology of Sport and Exercise, 11(3), 212–222. 10.1016/j.psychsport. 2009.10.005 Hong, H.J. (2018, May 1). Top athletes struggle to adjust away from limelight – more should be done for them. The Conversation. https://theconversation.com/top-athletes-struggle-to-adjust-away-from-limelight-more-shouldbe-done-for-them-95796 Hong, H.J., Henning, A. & Dimeo, P. (2020). Life after doping: A cross-country analysis of organisational support for sanctioned athletes. Performance Enhancement & Health, 8(1), 100161. 10.1016/j.peh.2020.100161 Howe, D. (2017). (Dis)abled bodies. In M. Silk, D. Andrews & H. Thorpe (Eds.), Routledge handbook of physical cultural studies (pp. 159–166). Routledge. 10.4324/9781315745664-17 Jetten, J., Haslam, C., & Haslam, S.A. (2012). The social cure: Identity, health and wellbeing. Psychology Press. 10.4324/ 9780203813195 Jetten, J., Haslam, C., Haslam, S.A., Dingle, G., & Jones, J.M. (2014). How groups affect our health and well-being: The path from theory to policy. Social Issues and Policy Review, 8, 103–130. 10.1111/sipr.12003 Jetten, J., Haslam, S.A., Iyer, A., & Haslam, C. (2009). Turning to others in times of change: Shared identity and coping with stress. In S. Stürmer & M. Snyder (Eds.), New directions in the study of helping: Group-level perspectives on motivations, consequences and interventions (pp. 139–156). Wiley-Blackwell. 10.1002/9781444307948.ch7 Kuettel, A., Boyle, E., & Schmid, J. (2017). Factors contributing to the quality of the transition out of elite sports in Swiss, Danish, and Polish athletes. Psychology of Sport and Exercise, 29, 27–39. 10.1016/j.psychsport.2016.11.008 Lavallee, D., & Robinson, H.K. (2007). In pursuit of an identity: A qualitative exploration of retirement from women’s artistic gymnastics. Psychology of Sport and Exercise, 8(1), 119–141. 10.1016/j.psychsport.2006.05.003

297

Robert Morris et al. Martin, L., Fogarty, G., & Albion, M. (2014). Changes in athletic identity and life satisfaction of elite athletes as a function of retirement status. Journal of Applied Sport Psychology, 26, 96–110. 10.1080/10413200.2013.798371 Mitchell, I., Evans, L., Rees. T., & Hardy, L. (2014). Stressors, social support and the buffering hypothesis: Effects on psychological responses of injured athletes. British Journal of Health Psychology, 19, 486–508. 10.1111/bjhp.12046 Morris, R. (2013). Investigating the youth to senior transition in sport: From theory to practice. (Doctoral dissertation) Aberystwyth University, Aberystwyth, United Kingdom. Morris, R., Tod, D., & Eubank, M. (2017). From youth team to first team: An investigation into the transition experiences of young professional athletes in soccer. International Journal of Sport and Exercise Psychology, 15(5), 523–539. 10.1080/1612197X.2016.1152992 Morris, R., Tod, D., & Oliver, E. (2016). An investigation into stakeholders’ perceptions of the youth-to-senior transition in professional soccer in the United Kingdom. Journal of Applied Sport Psychology, 28(4), 375–391. 10. 1080/10413200.2016.1162222 O’Halloran, L., & Haslam, C. (2020). Career transitions. In A.S. Haslam, K. Fransen, & F. Boen (Eds.), The new psychology of sport and exercise: The social identity approach. Sage. Park, S., Lavallee, D., & Tod, D. (2012). The development of an athlete career transition programme: A case study. Qualitative Methods in Psychology Bulletin, 13, 11–19. Park, S., Lavallee, D., & Tod, D. (2013). Athletes’ career transition out of sport: A systematic review. International Review of Sport and Exercise Psychology, 6, 22–53. 10.1080/1750984X.2012.687053 Poucher, Z.A., Tamminen, K.A., & Kerr, G. (2018). Providing social support to female Olympic athletes. Journal of Sport and Exercise Psychology, 40(4), 217–228. 10.1123/jsep.2018-0008 Pummell, B., Harwood, C., & Lavallee, D. (2008). Jumping to the next level: A qualitative examination of withincareer transition in adolescent event riders. Psychology of Sport and Exercise, 9, 427–447. 10.1016/j.psychsport. 2007.07.004 Pummell, B., & Lavallee, D. (2019). Preparing UK tennis academy players for the junior-to-senior transition: Development, implementation, and evaluation of an intervention program. Psychology of Sport and Exercise, 40, 156–164. 10.1016/j.psychsport.2018.07.007 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Ronkainen, N.J., Kavoura, A., & Ryba, T.V. (2016). A meta-study of athletic identity research in sport psychology: Current status and future directions. International Review of Sport and Exercise Psychology, 9, 45–64. 10.1080/175 0984X.2015.1096414 Rotheram, M., Maynard, I., & Rogers, A. (2016). Using an integrated sport/clinical psychology approach to reduce anxiety and facilitate training adherence. Sport and Exercise Psychology Review, 12, 74–80. Sanders, G., & Stevinson, C. (2017). Associations between retirement reasons, chronic pain, athletic identity, and depressive symptoms among former professional footballers. European Journal of Sport Science, 17, 1311–1318. 10. 1080/17461391.2017.1371795 Sarkar, M., & Fletcher, D. (2014). Psychological resilience in sport performers: A review of stressors and protective factors. Journal of Sports Sciences, 32, 1419–1434. 10.1080/02640414.2014.901551 Schlossberg, N. (1981). A model for analyzing human adaptation. The Counseling Psychologist, 9(2), 2–18. 10.1177%2 F001100008100900202 Sly, D., Wagstaff, C., & Mellalieu, S. (2020). “It’s psychology Jim, but not as we know it!": the changing face of applied sport psychology practice. Sport, Exercise, and Performance Psychology, 9(1), 87–101. https://psycnet.apa.org/ doi/10.1037/spy0000163 Sosniak, A. (2006). Retrospective interviews in the study of expertise and expert performance. In K.A. Ericsson, N. Charness, P.J. Feltovich, & R.R. Hoffman (Eds.), The Cambridge handbook of expertise and expert performance (pp. 287–302). Cambridge University Press. Stambulova, N. (2000). Athletes’ crises: A developmental perspective. International Journal of Sport Psychology, 31, 582–601. Stambulova, N. (2009). Talent development in sport: A career transitions perspective. In E. Tsung-Min Hung, R. Lidor, & D. Hackfort (Eds.). Psychology of sport excellence (pp. 63–74). Fitness Information Technology. Stambulova, N. (2010). Counseling athletes in career transitions: The five-step career planning strategy. Journal of Sport Psychology in Action, 1(2), 95–105. 10.1080/21520704.2010.528829 Stambulova, N., Alfermann, D., Statler, T., & Côté, J. (2009). ISSP Position stand: Career development and transitions of athletes. International Journal of Sport and Exercise Psychology, 7(4), 395–412. 10.1080/1612197x.2009.9671916 Stambulova, N.B., & Ryba, T.V. (Eds.). (2013). Athletes’ careers across cultures. Routledge. 10.4324/9780203545683 Stambulova, N.B., & Ryba, T.V. (2014). A critical review of career research and assistance through the cultural lens: Towards cultural praxis of athletes’ careers. International Review of Sport and Exercise Psychology, 7(1), 1–17. 10. 1080/1750984X.2013.851727

298

Career Transitions in Sport Stambulova, N.B., Ryba, T.V., & Henriksen, K. (2020). Career development and transitions of athletes: The international society of sport psychology position stand revisited. International Journal of Sport and Exercise Psychology, 19(4), 524–550. 10.1080/1612197X.2020.1737836 Stambulova, N., & Wylleman, P. (2014). Athletes’ career development and transitions. In Routledge Companion to Sport and Exercise Psychology (pp. 629–644). Routledge. Stambulova, N.B., & Wylleman, P. (2015). Dual career development and transitions. Psychology of Sport and Exercise, 21, 1–134. 10.1016/j.psychsport.2015.05.003 Stambulova, N.B., & Wylleman, P. (2019). Psychology of athletes’ dual careers: A state-of-the-art critical review of the European discourse. Psychology of Sport and Exercise, 42, 74–88. 10.1016/j.psychsport.2018.11.013 State of Sport 2018: Half of retired sportspeople have concerns over mental and emotional wellbeing. (2018, February 5). BBC Sport. https://www.bbc.co.uk/sport/42871491 Stephan, Y., & Demulier, V. (2008). Transition out of elite sport: A dynamic, multi- dimensional and complex phenomenon. In M. Simmons & L. Foster (Eds.), Sport and exercise psychology research advances (pp. 175–190). Nova Science Publishers Inc. Sparkes, A.C. (2018). Autoethnography comes of age: Consequences, comforts, and concerns. In D. Beach, C. Bagley, & S.M. da Silva (Eds.), The wiley handbook of ethnography of education (pp. 479–499). Wiley. 10.1002/ 9781118933732.ch21 Tajfel, H., & Turner J.C. (1979). An integrative theory of intergroup conflict. In W.G. Austin & S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33–48). Brooks/Cole. Taylor, J., Ogilvie, B., & Lavallee, D. (2005). Career transition among elite athletes: Is there life after sports? In J.M. Williams (Ed.), Applied sport psychology: Personal growth to peak performance (pp. 595–615). McGraw-Hill. Turner, J.C. (1982). Towards a cognitive redefinition of the social group. In H. Tajfel (Ed.), Social identity and intergroup noakesrelations (pp. 15–40). Cambridge University Press. Turner, J.C., Hogg, M.A., Oakes, P.J., Reicher, S.D., & Wetherell, M.S. (1987). Rediscovering the social group: A selfcategorization theory. Blackwell. Vanden Auweele, Y., De Martelaer, K., Rzewnicki, R., De Knop, P., & Wylleman, P. (2004). Parents and coaches: A help or harm? Affective outcomes for children in sport. In Y. Vanden Auweele (Ed.), Ethics in youth sport. Lannoocampus. Williams, R., Kemp, V., Haslam, S.A., Haslam, C., Bhui, K.S., & Bailey, S. (2019). Social scaffolding: Applying the lessons of contemporary social science to health and healthcare. Cambridge University Press. 10.1017/9781911623069 Willard, V.C., & Lavallee, D. (2016). Retirement experiences of elite ballet dancers: Impact of self-identity and social support. Sport, Exercise, and Performance Psychology, 5(3), 266. https://psycnet.apa.org/doi/10.1037/spy0000057 World Health Organization (WHO) (2014). Mental health: A state of well-being. World Health Organization. Wylleman, P. (2018). Sport psychologists assisting young talented athletes face with career transitions. In C.J. Knight, C.G. Harwood, & D. Gould (Eds.), Sport psychology for young athletes (pp. 141–152). Routledge. 10.4324/ 9781315545202-13 Wylleman, P. (2019). An organizational perspective on applied sport psychology in elite sport. Psychology of Sport and Exercise, 42, 89–99. 10.1016/j.psychsport.2019.01.008 Wylleman, P., De Knop, P., Menkehorst, H., Theeboom, M., & Annerel, J. (1993). Van topsporternaar extopsporter. De noodzaak tot het optimaliseren van het beëindigen van de topsportcarrière [From elite athlete to former elite athlete. The need to optimize the discontinuation of the elite sport career]. In K. Rijsdorp et al. (Ed.), Handboek voor lichamelijke opvoeding en sportbegeleiding [Handbook for physical education and sport support] (p. IV.3.Wyll.1– IV.3.Wyll.24). Van Loghum Slaterus. Wylleman, P., & Lavallee, D. (2004). A developmental perspective on transitions faced by athletes. In M. Weiss (Ed.), Developmental sport psychology. Fitness Information Technology. Wylleman, P., Reints, A., & De Knop, P. (2013). A developmental and holistic perspective on athletic career development. In P. Sotiaradou, & V. De Bosscher (Eds.), Managing high performance sport (pp. 159–182). Routledge. Wylleman, P., & Rosier, N. (2016). Holistic perspective on the development of elite athletes. In M. Raab, P. Wylleman, R. Seiler, A.M. Elbe, & A. Hatzigeorgiadis (Eds.), Sport and exercise psychology research: From theory to practice (pp. 269–288). Elsevier. 10.1016/B978-0-12-803634-1.00013-3

299

19 DOPING AND DRUG MISUSE IN ELITE SPORT Claudia L. Reardon and Ryan Benoy

Introduction Athletes face significant pressures to perform at the top of their abilities. It is thus not surprising that use of substances or certain prohibited strategies for performance-enhancement (doping) occurs at most levels of competition and in most age groups (Reardon & Creado, 2014). While cycling has perhaps had the most high-profile doping allegations, few if any sport are immune to this problem (Reardon & Creado, 2014). Performance-enhancing substances include some illegal drugs, prescription medications, and over-the counter dietary supplements and compounds that are available online, in health foods stores, and grocery stores (Reardon & Creado, 2014). Doping goes back to ancient times, even before the development of organised sport, with many modern-day “advances” in performance-enhancement strategies driven by improved drug testing detection methods. Consequently, athletes who wish to dope have been forced to develop new ways of evading detection (Teale et al., 2012). Substances and strategies utilised have variable evidence for their efficacy as performance-enhancing agents, and medical risks come with most such activities. Doping is a complex biopsychosocial problem that calls for thoughtful preventive measures and management strategies.

Sport Organisation Policies At higher levels of competition, most sport organisations have policies delineating the types of substances and strategies that are prohibited. These organisations include high schools and their governing bodies; universities and their governing bodies; professional sport; and national, international, and Olympic sport. These policies are ever-changing, and thus, it is critical for athletes and the members of their entourage to stay updated on current prohibited lists, as ignorance of current policy is rarely accepted as an excuse for adverse analytical findings (“testing positive”) on drug tests. For the highest levels of competition, the World Anti-Doping Agency (WADA) publishes an annual World Anti-Doping Code, which is the document harmonising anti-doping policies in all sport and all countries (World Anti-Doping Agency, 2020c). The Code sets forth specific anti-doping rules and principles that are to be followed by the anti-doping organisations responsible for adopting, implementing, or enforcing anti-doping rules within their authority, including the International Olympic Committee, International Paralympic Committee, international sport federations (for example, the International Cycling Union), major event organisations, and national anti-doping organisations (for example, the U.S. 300

DOI: 10.4324/9781003099345-25

Doping and Drug Misuse in Elite Sport

Anti-Doping Agency; World Anti-Doping Agency, 2020c). It specifies those prohibited substances and methods that are prohibited at all times (both in-competition and out-of-competition), and those substances and methods that are prohibited in-competition only (defined as spanning from 11:59 p.m. the day before a competition in which the athlete is scheduled to participate until the end of the competition and the sample collection process) (World Anti-Doping Agency, 2020c). The list may be expanded by WADA for a particular sport. WADA does not generally specify reasons for prohibiting particular substances/methods. Rather, WADA generally notes that substances/methods are included based on one or more of the following characteristics: may provide performance enhancement, may negatively impact athlete health, or may negatively impact the spirit of sport. High school and collegiate sport organisations and various professional sport leagues have their own published lists of prohibited agents and associated testing and penalty protocols, which may or may not be drawn substantially from the WADA Code. WADA has also led the development of the athlete biological passport concept (World Anti-Doping Agency, 2020a). The athlete biological passport is based on the monitoring of selected parameters over time that indirectly reveal the effect of doping, as opposed to the traditional direct detection of doping by analytical means. An athlete’s passport purports to establish individual baseline hormone and blood levels, which are tracked over time for significant changes. This approach is intended to protect athletes from false-positive tests resulting from naturally occurring high levels of endogenous substances, while catching those attempting to cheat by using naturally occurring substances (World Anti-Doping Agency, 2020a). In order to enforce the prohibited lists within various sport jurisdictions, athletes competing at national and international levels of competition are typically subject to standard drug testing programmes and penalties for adverse analytical findings. Depending on the sport and league or level of competition, penalties may include temporary or permanent periods of ineligibility in sport, disqualification of results from competition with revocation of medals or awards, forfeited prize money, publication of sanctions, and fines. At many national and international levels of competition, athletes may apply for therapeutic use exemptions (TUEs) if they have medical reasons for wanting or needing to take otherwise prohibited medication and their physician attests that it is medically necessary for them to do so (World Anti-Doping Agency, 2020b). Similarly, National Collegiate Athletic Association collegiate sports in the United States (National Collegiate Athletic Association, 2020) and many professional sport leagues have procedures by which athletes can apply for TUEs or be excused for taking certain otherwise prohibited but medically necessary substances. In considering medications with performance-enhancing effects, it is important to distinguish between therapeutic performance-enhancement and non-therapeutic (i.e., ergogenic) performance enhancement (Reardon et al., 2019); organisations that develop doping policies and lists of prohibited medications attempt to make this discernment. For example, an athlete who is performing poorly because of uncontrolled depression may gain a therapeutic performance enhancing effect by taking a selective serotonin reuptake inhibitor (SSRI). However, there is no evidence that an SSRI provides non-therapeutic (ergogenic) performance enhancement, and thus they are not prohibited substances in elite sport. Conversely, medications for which research suggests performance enhancement beyond a pharmacological therapeutic effect are typically prohibited.

General Prevalence and Risk Factors for Use of Performance-Enhancing Substances It is difficult to ascertain with certainty the prevalence of the use of performance-enhancing measures. The lifetime or current prevalence of doping varies greatly (1–70%) depending on the sport, substance, detection method, and definition used (McDuff et al., 2019). For example, self-reports likely yield under-reporting (Uvacsek et al., 2011) but are the most common method of determining use. Each year, 1–2% of WADA urine and blood tests result in adverse analytical findings for prohibited substances, with 48% of these 301

Claudia L. Reardon and Ryan Benoy

violations being for androgens (de Hon et al., 2015). Some argue that standard methods of testing likely fail to detect many “cutting-edge” doping techniques. Thus, one study (Ulrich et al., 2018) attempted to account for this via utilisation of a “randomized response technique” so as to guarantee anonymity for individuals when answering a sensitive question. They found a prevalence of past-year doping as reported by elite athletes (n = 2167) at two major sporting events of 43.6%–57.1%. Athletes may turn to performance-enhancing measures for a number of reasons. These include pressure to perform related to a desire or need to maintain a scholarship, paycheck, or sponsorship or coping with pain from injury. Sometimes, but not always, a substance use disorder (“addiction”) might develop in response to regular use of a given substance, and thus the athlete will have a physiological or psychological drive to continue to use the substance to avoid withdrawal (Reardon & Creado, 2014). This is explained in greater detail in Chapter 8. Importantly, increasing financial rewards in high-level sport are not felt to be solely responsible for any increases in doping, given the long-standing history of doping well before organised sport brought pay checks (Baron et al., 2013).

Specific Performance-Enhancing Substances/Methods and Their Impact on Performance and Side Effects Androgens Androgens include exogenous testosterone, synthetic androgens (e.g., nandrolone, danazol), androgen precursors (e.g., dehydroepiandrosterone, androstenedione), selective androgen receptor modulators (SARMs), and other forms of androgen stimulation. Athletes may use the latter categories to increase endogenous testosterone while circumventing the prohibition of natural or synthetic androgens by many sport organisations (Reardon & Creado, 2014). Studies have demonstrated that amounts of testosterone above those normally found in the human body can increase muscle strength and mass (Bhasin et al., 1996; Bhasin et al., 2001; Storer et al., 2003). However, androgens in various forms have not been found to improve endurance (Basaria et al., 2010). Moreover, there is only minimal evidence that androgen precursors increase muscle strength (Wallace et al., 1999). For example, the precursor dehydroepiandrosterone (DHEA) is available as a nutritional supplement that is widely advertised in body building magazines as a substance that will improve strength, but results from studies of DHEA in males have been mixed (Wallace et al., 1999; Morales et al., 1998). SARMs are not approved for use in humans, but athletes are able to obtain these substances on the Internet (Kohler et al., 2010). Studies demonstrating increased muscle mass or strength in humans using SARMs are minimal. One randomised control study reported a dose-related increase in lean body mass, but found no statistically significant difference in muscle power or strength. (Basaria et al., 2013). Another randomised control trial reported increased lean body mass and power in elderly men and postmenopausal women but was not specific to the athlete context (Dalton et al., 2011). Other forms of androgen stimulation include exogenous human chorionic gonadotropin, antiestrogens such as tamoxifen, clomiphene, and raloxifene, and aromatase inhibitors such as testolactone, letrozole, and anastrozole. These substances may result in increased serum testosterone (Handelsman et al., 2006). However, there is minimal research demonstrating an effect on muscle strength (Handelsman et al., 2008). Most doping agents, including androgens, are presumed to have potential short- and or long-term side effects. However, it is difficult to do the necessary studies to confirm these findings, as it would be unethical to give dosages as high as those used by athletes for performance enhancement to participants in research studies (Baron et al., 2013). Thus, information on side effects is typically obtained from empirical observation, reports of known users, and effects in patients prescribed such agents for medical conditions (Reardon & Creado, 2014), which may or may not be the same effects that occur in athletes without those same underlying medical conditions. 302

Doping and Drug Misuse in Elite Sport

Potential side effects of androgens cross many organ systems: reproductive (decreased spermatogenesis and gynecomastia in males, decreased fertility, decreased testicular size, possible benign prostatic hypertrophy or prostate cancer); cardiovascular (dyslipidemia); hepatic (hepatotoxicity); psychiatric (depression, mania, psychosis, aggression); and other various systems (e.g., via premature growth plate closure in adolescents, acne, hirsutism, male pattern baldness, clitoromegaly, voice depending, diminished menstrual functioning in females, tendon rupture, and infections from injecting the agents) (Baron et al., 2013).

Growth Hormone and Growth Factors Recombinant human growth hormone has been demonstrated to increase muscle mass, decrease adipose tissue, and improve sprint capacity in males and females (Meinhardt et al., 2010). Growth factors include insulin-like growth factor (IGF) and insulin. They may have similar effects to growth hormone and are used by athletes because of apparent anabolic effects on muscle but have received little study in athletes (Holt et al., 2008). One randomised, controlled study comparing the effects of Recombinant Human Insulin-Like Growth Factor to placebo found no changes in body mass composition, but did demonstrate increased maximal oxygen consumption, suggesting a possible improvement in aerobic fitness (Guha et al., 2015). Side effects of growth hormone and growth factors may include insulin resistance, hyperglycemia, diabetes mellitis, cardiomegaly, premature growth plate closure in adolescents, myopathy, hypertension, edema, and carpal tunnel syndrome (Baron et al., 2013).

Stimulants Stimulants include amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, dimethylamylamine, cocaine, fenfluramine, pemoline, selegiline, sibutramine, strychnine, and modafinil (Reardon & Creado, 2014). Research has demonstrated that stimulants improve endurance, increase anaerobic performance, decrease feelings of fatigue, improve reaction time, increase alertness, and cause weight loss (Eicher et al., 2008). They specifically seem to allow exercise to higher core body temperature without the athlete perceiving as great of an effort as they otherwise would, which could be both performance-enhancing and dangerous (Reardon et al., 2019). While WADA prohibits stimulants as a class, caffeine is currently allowed (World Anti-Doping Agency, 2020c). Energy drinks and supplements often contain large amounts of caffeine (up to 500 mg per can or bottle). Caffeine may be performanceenhancing up to a certain amount, but larger doses do not appear to increase performance and are more likely to cause side effects (McDuff et al., 2019). Side effects of stimulants may include hypertension, tachycardia, myocardial infarction, stroke, heat illness, weight loss (which can be a side effect as opposed to a desired effect depending on sport), rhabdomyolysis, headache, nausea, and tremor. Mental health side effects specifically may include insomnia, anxiety, agitation, and psychosis (Baron et al., 2013).

Beta Agonists Beta agonists include albuterol, formoterol, and salmeterol. Anecdotal evidence demonstrates improvements in swimmers who use these agents prior to competing and increased skeletal muscle, inhibited breakdown of protein, and decreased body fat in athletes (Davis et al., 2008). However, swimmers may have a relatively high prevalence of airway hyperresponsiveness due to hours spent breathing chlorine by-products, such that these substances may be needed to restore normal, not enhanced, lung function (Davis et al., 2008). Beta agonists may mimic the fight-or-flight response and side effects thus may include tachycardia, anxiety, and tremor, as well as arrhythmias, hypokalemia, and hyperglycemia (Baron et al., 2013). 303

Claudia L. Reardon and Ryan Benoy

Beta Blockers Beta blockers are blood pressure-lowering medications that include propranolol, metoprolol, atenolol, and others. They result in decreased heart rate, reduced hand tremor, and decreased anxiety, all of which may be performance-enhancing in certain sport where it is beneficial to have increased steadiness, such as in archery, shooting, billiards, and several others (McDuff et al., 2019). They are prohibited in-competition in these types of sport by WADA, and out-of-competition as well in a subset of these sport (World Anti-Doping Agency, 2020c). While decreased heart rate may be ergogenic in certain sport, it may be a side effect in others and may be associated with decreased maximum cardiopulmonary capacity. It may also increase airway resistance (hence, these medications are typically contraindicated in people with lung disease such as asthma) (Baron et al., 2013).

Methods to Increase Oxygen Transport Methods to increase oxygen transport include blood transfusions, erythropoiesis-stimulating substances such as recombinant human erythropoietin and darbepoetin alfa, hypoxia mimetics that stimulate endogenous erythropoietin production such as deferoxamine and cobalt, and artificial oxygen carriers (Reardon & Creado, 2014). Studies have shown transfusions and erythropoiesis-stimulating substances to increase aerobic capacity, but the ergogenic effects of the other methods are not proven (Elliott et al., 2008; Reardon & Creado, 2014). Potential side effects of these methods include myocardial infarction, stroke, deep vein thrombosis/ pulmonary embolism, hypertension, and antibody-mediated anemia (Baron et al., 2013).

Nutritional Supplements Nutritional supplements include vitamins, minerals, herbs, extracts, and metabolites (Higgins et al., 2010). Even if the supplements themselves are not outright prohibited, they may be knowingly or unknowingly laced with substances that are prohibited. In fact, studies demonstrate this to not uncommonly be the case, especially with regards to lacing with steroids and stimulants (Judkins et al., 2012). Unintentional ingestion of prohibited substances in this manner is not a justifiable excuse for adverse analytical findings on drug testing (McDuff et al., 2019). Creatine is one of the most popular supplements among athletes (Reardon & Creado, 2014). Some studies have demonstrated increased maximum power output and lean body mass from this substance (Kendall et al., 2009; Branch et al., 2003), but evidence apparently is not to the level of it being included on most prohibited lists. Side effects of nutritional supplements of course depend on the components. For creatinine, they include kidney disease (i.e., acute interstitial nephritis and more rapid progression of chronic kidney disease) (Baron et al., 2013).

Other Prescription Drugs Diuretics and other masking agents may be used as doping agents themselves. For example, diuretics may be used to achieve rapid weight loss in sport with weight classes, such as wrestling (Botre et al., 2009). Masking agents such as diuretics are also used to conceal other prohibited substances by hastening urinary excretion of the other prohibited agents (Botre et al., 2009). Other masking agents, such as epitestosterone (to normalise urine testosterone to epitestosterone ratios), probenecid, 5-alpha reductase inhibitors, and plasma expanders (e.g., glycerol intravenous administration of albumin, dextra, and mannitol) are used to conceal prohibited substances in urine or other body samples (Reardon & Creado, 2014). 304

Doping and Drug Misuse in Elite Sport

Glucocorticoids may be used by athletes to try to enhance performance via their anti-inflammatory and analgesic properties (Botre et al., 2009), but minimal research shows any performance benefits of this class of drugs. Similarly, little research demonstrates ergogenesis from phosphodiesterase-5 inhibitors, but athletes may attempt to use them to increase oxygenation and exercise capacity, given vasodilatory effects (Petroczi et al., 2010). Psychiatric medications beyond stimulants, such as antidepressants, anxiolytics, antipsychotics, and anticonvulsants, are generally not on prohibited lists. Bupropion is an antidepressant that has remained in the WADA Monitoring Program for several years, meaning WADA is monitoring for any concerning trends of inappropriate use (World Anti-Doping Agency, 2020c). One small study suggested that bupropion, when used acutely in warm environments, may allow athletes to push themselves to higher body temperature and heart rates without perceiving as great of effort as they otherwise would (Watson et al., 2005). Otherwise, there is minimal to no evidence that any of these classes of psychiatric medications enhance performance (Reardon et al., 2019). Side effects of these various prescription medications of course are highly variable depending on the agent. Diuretics may cause dizziness (as they can contribute to dehydration), muscle cramps (as they can cause electrolyte disturbances that contribute to this), rash, gout, renal insufficiency, and specific to spironolactone, gynecomastia (Baron et al., 2013). Glucocorticoids may cause hyperglycemia and fluid retention, and chronic use may cause reduced muscle mass/weakness, osteoporosis, diabetes mellitus, hypertension, weight gain, central obesity, and cataracts; psychiatric impacts of glucocorticoids may include depression, mania, and psychosis (Baron et al., 2013).

Recreational Drugs Recreational drugs not yet covered in other categories above that may be used to try to improve performance include alcohol, cannabinoids, opioids, and nicotine. Previously, WADA had prohibited alcohol in certain sport in-competition but no longer does so (World Anti-Doping Agency, 2020c). However, some sport leagues and teams still prohibit alcohol in certain contexts, e.g., on planes or bus rides after competitions and in team facilities so as to limit the risk of dangerous intoxication during times of celebrating wins or consoling losses and the risk of driving while intoxicated (McDuff et al., 2019). WADA currently prohibits cannabinoids (cannabidiol an exception) and opioids. Nicotine is in the WADA Monitoring Program (World Anti-Doping Agency, 2020c). Little research exists to confirm significant performance enhancement from these substances, though athletes may use them for such a purpose (McDuff et al., 2019; Reardon& Creado, 2014). Specifically, athletes may use alcohol before competition to try to reduce anxiety or tremor and boost self-esteem or confidence, and after competition to improve team cohesion and strengthen athletic identity, especially in team sport. They may use cannabinoids to try to improve sleep and reduce pain or anxiety. They may use opioids to try to decrease pain during sport. Finally, they may use nicotine to try to improve alertness and concentration, increase energy and focus, increase muscular strength, improve concentration and memory, enhance endurance, induce relaxation, control weight, or reduce boredom (McDuff et al., 2019). Side effects of these recreational drugs are quite variable but potentially prominent depending on the agent (Baron et al., 2013; McDuff et al., 2019). Alcohol may cause sedation, decreased concentration and coordination, dehydration, insomnia (even if it helps an athlete to initially fall asleep), reduced metabolic recovery/glycogen re-synthesis, slower injury healing and higher injury rates, weight gain, and academic underperformance that can threaten athletic eligibility at some levels of competition (McDuff, et al., 2019). Cannabinoids can reduce alertness, impair short-term memory, and cause psychomotor retardation, dysphoria, anxiety, psychosis, and weight gain (McDuff, et al., 2019). Opioids are particularly apt to cause physical dependence, and can also cause nausea/vomiting, constipation, decreased concentration and coordination, and sedation (Hainline, et al., 2017). Nicotine in the short term may increase blood 305

Claudia L. Reardon and Ryan Benoy

pressure, cause anxiety and insomnia, or contribute to respiratory infections. Chronic nicotine use is associated with cardiovascular disease, lung disease, and many forms of cancer (McDuff, et al., 2019).

Other Non-Drug Performance-Enhancing Measures Gene doping is a potential method of non-drug performance enhancement that is prohibited by WADA. In theory, every known gene could be used, with the most likely targets for athletes being the genes that play a role in promoting endurance, muscle strength and power, recovery after injury, pain tolerance, psychological well-being, and motivation (Birzniece, 2015). Studies on laboratory mice that have undergone gene manipulation have shown improved strength and endurance, but human athletes thus far have not been reported to be using this method and have not been studied (Baron et al., 2013). Potential side effects of gene doping are largely unproven or unknown. However, prolonged overexpression of relevant gene targets such as IGF has presumed potential to induce unwanted side effects such as cardiac hypertrophy, systolic dysfunction, and cancer. Liver damage, autoimmune disease, and permanent changes to cells that could be transmitted to future generations are also thought to be possible side effects (Birzniece, 2015). Athletes may not uncommonly attempt to improve performance in other non-prohibited, non-drug ways, including via hypoxia induction techniques (Reardon & Creado, 2014). For example, endurance athletes may train at high altitudes to induce erythrocytosis. Dietary changes are also used to increase hemoglobin levels.

Doping and Mental Health Doping is closely intertwined with mental health in a variety of ways. Mental health symptoms and disorders may be the drivers that lead to substance use including doping and recreational drug use. For example, athletes who have a paucity of coping strategies to deal with the pressure of high-level sport may turn to doping to deal with performance anxiety. They may also find that any of a number of substances used for doping or recreational purposes lead to temporary relief of depression or anxiety. Athletes with eating disorders may use certain substances to suppress their appetite in sport where a low body mass index is seen as desirable or to increase it in sport where a higher body mass index is demanded. While the short-term impact of substances on mental health may be the driver that leads to their use in the first place, or that perpetuates their continued use, ultimately the impact of substances on mental health is quite often negative. The cycle of addiction leads to the need for the continued use of substances, often in greater quantities or frequencies, in order to feel “normal” or to avoid withdrawal. This cycle may lead to depression and/or anxiety. Even if an athlete experiences relief of anxiety in the moment, for example, when using marijuana, they may not appreciate the risk for development of rebound anxiety, wherein their perception is the need for even more use of the substance to quell the even higher levels of anxiety that occur when marijuana blood levels dip. Psychotic and hypomanic or manic symptoms are particularly concerning possible developments that can occur with use of a variety of substances.

Prevention Given the not uncommon use of substances by athletes as a coping strategy, there may be a preventative role for mental health clinicians who can help athletes pre-emptively develop coping strategies for their high intensity world of competitive sport. Didactic education aims to inform athletes about the potential medical and sport consequences of doping while ultimately hopefully changing attitudes about such activities (Reardon & Creado, 2014). 306

Doping and Drug Misuse in Elite Sport

Additionally, drug testing is a primary aspect of prevention of doping. It is used to deter athletes from using drugs, as well as to punish and offer opportunities for rehabilitation to those who are found to have been doing so. Frequent, accurate, very closely observed, truly random urine drug testing is touted as perhaps the most effective prevention strategy (Harcourt et al., 2012).

Management Treatment of athletes who use doping techniques has not received robust study. However, motivational interviewing is one purported strategy. This relies on the Transtheoretical Model (also called the Stages of Change Model), developed by Prochaska and DiClemente (Prochaska et al., 1983). According to the model, patients may present and progress through six stages of change as they work through substance use concerns. These stages are: precontemplation (no intention of making a change in the foreseeable future); contemplation (intending to start the healthy behaviour in the foreseeable future); preparation (ready to take action within the next month); action (recently changed their behaviour and intend to keep moving forward with that behaviour change); maintenance (have sustained their behaviour change for months and intend to keep moving forward with it); and termination (no desire to return to the unhealthy behaviour and feel certain relapse will not happen). Athletes often present to clinical attention because of an adverse analytical finding in the precontemplation stage of change (Reardon & Creado, 2014). Thus, they are not yet ready to make a change in behaviour nor convinced of the merits of doing so. Motivational interviewing attempts to move them from precontemplative to contemplative and ultimately action toward changing behaviour. Important elements of motivational interviewing include (Johnson et al., 2010): 1 2 3 4

Clinician empathy Developing discrepancies between where the athlete wants to go in life within sport or outside or after sport and the impact that continued doping might have on those goals Rolling with resistance (i.e., avoidance of arguing with athletes, and instead “agreeing to disagree” or proposing or “wondering about” certain alternative viewpoints but not insisting upon them) Encouragement of self-efficacy (without the need for ergogenic aids)

Beyond motivational interviewing, other therapeutic approaches that may help athletes who are participating in doping may include 12-step groups (e.g., Alcoholics Anonymous, Narcotics Anonymous), cognitive behavioural therapy, and network therapy (Reardon & Creado, 2014). However, these modalities have not been well studied for the purposes of treatment of doping in athletes. If an athlete is physically dependent on a drug (e.g., opioids, alcohol), then pharmacologic intervention may be warranted. These are addressed more fully in Chapter 8 on addiction disorders in athletes. Moreover, providers should always assess for comorbid mental health symptoms and disorders, such as depression or anxiety, since comorbidity is common (Reardon & Creado, 2014). Any such comorbidities should be addressed through appropriate treatment such as psychotherapy, pharmacologic treatments, or both.

Practical Implications A number of practical implications for professionals flow from the information presented. Specifically: • •

Regularly update athletes on any prohibitions (e.g., by WADA, professional sport leagues, high school or collegiate sport associations, etc.) against use of certain substances or strategies. Healthcare providers should clinically screen all athletes they see for (i.e., ask about) use of performance-enhancing strategies. 307

Claudia L. Reardon and Ryan Benoy

•

• •

•

• •

If a provider is seeing an athlete known to have been participating in doping, they should educate the athletes about the potential risks of continued use and explicitly encourage discontinuation of the method(s). Brief motivational interviewing strategies should be incorporated into clinical encounters with athletes known to be participating in doping. All members of the athlete entourage, including physicians, other mental health professionals, athletic trainers/physios, coaches, parents, and athletes themselves, should be educated on the risks of doping, reasons not to participate in it, and how to recognise it. Mental health professionals with skill and comfort in addressing doping and substance use should be included in the network of providers readily available to athletes and should have a year-round presence with athletes/teams so as to build trust. Strong drug prevention policies should include frequent, accurate, very closely observed, truly random urine drug testing and should emphasise education and treatment and not just sanctions. Coaches, athletic trainers/physios, and healthcare providers should provide evidence-based, safe, non-prohibited alternatives to doping, including optimal nutrition, weight-training strategies, psychological approaches to improving performance, and optimal recovery methods, all of which may help with athletes’ confidence in their natural abilities.

Summary Athletes face many temptations to participating in doping. If they do so, they risk significant negative ramifications for sport participation as well as potentially severe short- and/or long-term health consequences. Such health effects include worsening mental and other aspects of physical health. Strong prevention policies, educational programmes, and accessibility of knowledgeable multidisciplinary teams of staff and other supports within the athlete entourage are important. Several questions remain unanswered, providing directions for future study (McDuff et al., 2019; Reardon & Creado, 2014). More thorough and reliable epidemiology on doping in athletes is needed, with attention to cross cultural differences. The efficacy of education about doping as a preventative measure needs further study. Early integration of well-designed prevention curricula into sport programmes may be beneficial. Additional prevention strategies for doping in athletes are needed. For example, more highquality, prospective, randomised trials should be undertaken to determine the deterrent efficacy of various types of drug testing programmes, and changes should be made to those types of programmes found to be ineffective. Timing of drug testing must be carefully considered, given that risks may increase at various times throughout a season and during an athlete’s career. Finally, additional research is needed on treatments, especially psychotherapeutic ones, for motivation of behavioural change when it comes to doping in athletes.

References Baron, D.A., Reardon, C.L., & Baron, S.H. (2013). Doping in sport. In D.A. Baron, C.L. Reardon, & S.H. Baron (Eds.), Clinical sports psychiatry: An international perspective. Wiley. 10.1002/9781118404904 Basaria, S., Collins, L., Dillon, E.L., Orwoll, K., Storer, T.W., Miciek, R., Ulloor, J., Zhang, A., Eder, R., Zientek, H., Gordon, G., Kazmi, S., Sheffield-Moore, M., & Bhasin, S. (2013). The safety, pharmacokinetics, and effects of LGD4033, a novel nonsteroidal oral, selective androgen receptor modulator, in healthy young men. Journal of Gerontology: Medical Sciences, 68(1), 87–95. 10.1093/gerona/gls078 Basaria, S. (2010). Androgen abuse in athletes: Detection and consequences. The Journal of Clinical Endocrinology & Metabolism, 95, 1533–1543. 10.1210/jc.2009-1579 Bhasin, S., Storer, T.W., Berman, N., Callegari, C., Clevenger, B., Phillips, J., Bunnell, T.J., Tricker, R., Shizari, A., & Casaburi, R. (1996). The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. New England Journal of Medicine, 335, 1–7. 10.1056/NEJM199607043350101

308

Doping and Drug Misuse in Elite Sport Bhasin, S., Woodhouse, L., Casaburi, R., Singh, A.B., Bhasin, D., Berman, N., Chen, X., Yarasheski, K.E., Magliano, L., Dzekov, C., Dzekov, J., Bross, R., Phillips, J., Sinha-Hikim, I. Shen, R., & Storer, T.W. (2001). Testosterone dose-response relationships in healthy young men. The American Journal of Physiology-Endocrinology and Metabolism, 281, E1172–E1181. 10.1152/ajpendo.2001.281.6.E1172 Birzniece, V. (2015). Doping in sport: Effects, harm and misconceptions. Internal Medicine Journal, 45, 239–248. 10.1111/imj.12629 Botre, F., & Pavan, A. (2009). Enhancement drugs and the athlete. Physical Medicine and Rehabilitation Clinics of North America, 20, 133–148. 10.1016/j.pmr.2008.10.010 Branch, J.D. (2003). Effect of creatinine supplementation on body composition and performance: A meta-analysis. International Journal of Sport Nutrition and Exercise Metabolism, 13, 198–226. 10.1123/ijsnem.13.2.198 Dalton, J.T., Barnette, K.G., Bohl, C.E., Hancock, M.L., Rodriguez, D., Dodson, S.T., Morton, R.A., & Steiner, M.S. (2011). The selective androgen receptor modulator GTx-024 (enobosarm) improves lean body mass and physical function in healthy elderly men and postmenopausal women: Results of a double-blind, placebocontrolled phase II trial. Journal of Cachexia, Sarcopenia and Muscle, 2(3), 153–161. 10.1007/s13539-011-0034-6 Davis, E., Loiacono, R., & Summers, R.J. (2008). The rush to adrenaline: Drugs in sport acting on the betaadrenergic system. British Journal of Pharmacology, 154, 584–597. 10.1038/bjp.2008.164 de Hon, O., Kuipers, H., & van Bottenburg, M. (2015). Prevalence of doping use in elite sports: A review of numbers and methods. Sports Medicine, 45, 57–69. 10.1007/s40279-014-0247-x Eicher, E.R. (2008). Stimulants in sports. Current Sports Medicine Reports, 7, 244–245. 10.1249/JSR.0b013e3181 86bf44 Elliot, S. (2008). Erythropoiesis-stimulating agents and other methods to enhance oxygen transport. British Journal of Pharmacolology, 154, 529–541. 10.1038/bjp.2008.89 Guha, N., Nevitt, S.P., Francis, M., Woodland, J.A., Böhning, D., Sönksen, P.H., & Holt, R.I. (2015). The effects of recombinant human insulin-like growth factor-I/insulin-like growth factor binding protein-3 administration on body composition and physical fitness in recreational athletes. The Journal of Clinical Endocrinology and Metabolism, 100(8), 3126–3131. 10.1210/jc.2015-1996 Hainline, B., Derman, W., Vernec, A., Budgett, R., Deie, M., Dvořák, J., … Engebretsen, L. (2017). International olympic committee consensus statement on pain management in elite athletes. British Journal of Sports Medicine, 51(17), 1245–1258. 10.1136/bjsports-2017-097884 Handelsman, D.J. (2006). Clinical review: The rationale for banning human chorionic gonadotropin and estrogen blockers in sport. The Journal of Clinical Endocrinology & Metabolism, 91, 1646–1653. 10.1210/jc.2005-2569 Handelsman, D.J. (2008). Indirect androgen doping by oestrogen blockage in sports. British Journal of Pharmacology, 154, 598–605. 10.1038/bjp.2008.150 Harcourt, P.R., Unglik, H., & Cook, J.L. (2012). A strategy to reduce illicit drug use is effective in elite Australian football. British Journal of Sports Medicine, 46, 943–945. 10.1136/bjsports-2012-091329 Higgins, P., Tuttle, T.D., & Higgins, C.L. (2010). Energy beverages: content and safety. Mayo Clinic Proceedings, 85, 1033–1041. 10.4065/mcp.2010.0381 Holt, R.I., & Sonksen, P.H. (2008). Growth hormone, IGF-I and insulin and their abuse in sport. British Journal of Pharmacology, 154, 542–556. 10.1038/bjp.2008.99 Johnson, M.B., Sacks, D.N., & Edmonds, W.A. (2010). Counseling athletes who use performance-enhancing drugs: A new conceptual framework linked to clinical practice. The Journal of Social, Behavioral, and Health Sciences, 4, 1–29. Judkins, C. & Prock, P. (2012). Supplements and inadvertent doping-how big is the risk to athletes. Medicine and Sport Science, 59, 143–152. 10.1159/000341970 Kendall, K.L., Smith, A.E., Graef, J.L., Fukuda, D.H., Moon, J.R., Beck, T.W., Cramer, J.T., & Stout, J.R. (2009). Effects of four weeks of high-intensity interval training and creatinine supplementation on critical power and anaerobic working capacity in college-aged men. The Journal of Strength & Conditioning Research, 23, 1663–1669. 10.1519/JSC.0b013e3181b1fd1f Kohler, M., Thomas, A., Geyer, H., Petrou, M., Schanzer, W., & Thevis, M. (2010). Confiscated black market products and nutritional supplements with non-approved ingredients analyzed in the Cologne Doping Control Laboratory 2009. Drug Testing and Analysis, 2, 533–537. 10.1002/dta.186 McDuff, D., Stull, T., Castaldelli-Maia, J., Hitchcock, M.E., Hainline, B., & Reardon, C.L. (2019). Recreational and ergogenic substance use and substance use disorders in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 754–760. 10.1136/bjsports-2019-100669 Meinhardt, U., Nelson, A.E., Hansen, J.L., Birzniece, V., Clifford, D., Leung, K.C., Graham, K., & Ho, K.K. (2010). The effects of growth hormone on body composition and physical performance in recreational athletes: A randomized trial. Annals of Internal Medicine, 152, 568–577. 10.7326/0003-4819-152-9-201005040-00007

309

Claudia L. Reardon and Ryan Benoy Morales, A.J., Haubrich, R.H., Hwang, J.Y., Asakura, H., & Yen, S.S. (1998). The effect of six months treatment with a 100 mg daily dose of dehydroepiandrosterone (DHEA) on circulating sex steroids, body composition and muscle strength in age-advanced men and women. Clinical Endocrinology, 49, 421–432. 10.1046/j.1365-2265. 1998.00507.x National Collegiate Athletic Association. (2020). Medical Exceptions Procedures. http://www.ncaa.org/sport-scienceinstitute/medical-exceptions-procedures Petroczi, A., & Naughton, D.P. (2010). Potentially fatal new trend in performance enhancement: A cautionary note on nitrate. Journal of the International Society of Sports Nutrition, 7, 25. 10.1186/1550-2783-7-25 Prochaska, J.O., DiClemente, C.C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. 10.1037/0022-006X.51.3.390 Reardon, C.L., Hainline, B., Aron, C.M., Baron, D., Baum, A.L., Bindra, A., Budgett, R., Campriani, N., Castaldelli-Maia, J.M., Currie, A., Derevensky, J.L., Glick, I.D., Gorczynski, P., Gouttebarge, V., Grandner, M.A., Han, D.H., McDuff, D., Mountjoy, M., … Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine, 53, 667–699. 10.1136/bjsports-2019-100715 Reardon, C.L., & Creado, S. (2014). Drug abuse in athletes. Substance Abuse and Rehabilitation, 5, 95–105. 10.2147/ SAR.S53784 Storer, T.W., Magliano, L., Woodhouse, L., Lee, M.L., Dzekov, C., Dzekov, J., Casaburi, R., Bhasin, S. (2003). Testosterone dose-dependently increases maximal voluntary strength and leg power but does not affect fatigability or specific tension. The Journal of Clinical Endocrinology & Metabolism, 88, 1478–1485. 10.1210/jc.2002-021231 Teale, P., & Judson, S. (2012). Impact of the emergence of designer drugs upon sports doping testing. Bioanalysis, 4, 71–88. 10.4155/bio.11.291 Ulrich, R., Pope, H.G., Cléret, L., Petróczi, A., Nepusz, T., Schaffer, J., Kanayama, G., Comstock, R.D., & Simon, P. (2018). Doping in two elite athletics competitions assessed by randomized-response surveys. Sports Medicine, 48(1), 211–219. 10.1007/s40279-017-0765-4 Uvacsek, M., Nepusc, T., Naughton, D.P., Mazanov, J., Ranky, M.Z., & Petroczi, A. (2011). Self-admitted behavior and perceived use of performance-enhancing vs psychoactive drugs among competitive athletes. Scandinavian Journal of Medicine & Science in Sports, 21, 224–234. 10.1111/j.1600-0838.2009.01041.x Wallace, M.B., Lim, J., Cutler, A., & Bucci, L. (1999). Effects of dehydroepiandrosterone vs androstenedione supplementation in men. Medicine & Science in Sports & Exercise, 31, 1788–1792. 10.1097/00005768-19991200000014 Watson, P., Hasegawa, H., Roelands, B., Piacentini, M.F., Looverie, R., & Meeusen, R. (2005). Acute dopamine/ noradrenaline reuptake inhibition enhances human exercise performance in warm, but not temperate conditions. The Journal of Physiology, 565(3), 873–883. 10.1113/jphysiol.2004.079202 World Anti-Doping Agency (2020a). Athlete Biological Passport. https://www.wada-ama.org/en/athlete-biologicalpassport World Anti-Doping Agency (2020b). Therapeutic Use Exemptions. https://www.wada-ama.org/en/what-we-do/ science-medical/therapeutic-use-exemptions World Anti-Doping Agency (2020c). World Anti-Doping Code International Standard Prohibited List 2021. https:// www.wada-ama.org/sites/default/files/resources/files/2021list_en.pdf

310

SECTION D

Application and Care

INTRODUCTION TO THE SECTION Jürgen Beckmann

In this final section of this book, the general conditions, possibilities, and procedures for putting the topics addressed in the previous chapters into practice are discussed. The authors of the chapters in this section address a broad range of professional considerations from basic demands and conditions of the application of mental health care in the sport context and intervention approaches to specific needs of particular groups. Specifically, the chapters focus on professional considerations for the clinician, psychotherapeutic applications in elite sport, the role of recovery for mental health promotion in elite athletes, prevention of injuries, nature-based interventions in elite sport, and young athletes’ mental health and well-being. Chapter 20 by Watson, Gonzalaez, Harris, and Wayda addresses important issues in in mental health service provision in elite sport including relevant legal aspects of this work, as well as ethical standards and principles. Stillman, Farmer, and Glick emphasise in Chapter 21 that even though psychotherapeutic interventions are similar to those with non-athletes, elite athletes can present unique challenges, including diagnostic ambiguity, barriers to help-seeking behaviours, and altered expectations about services. They present a broad array of psychotherapeutic approaches in elite sport, along with empirical evidence regarding their effectiveness. When Heidari and Kellmann consider recovery as a centrepiece for mental health promotion in elite athletes, they do not understand recovery simply as regeneration or cure of a disease but rather from a much broader perspective as building and replenishing resources increasing athletes’ resilience. Zakrajsek, Bianco, Casey, Hayden, and Martin highlight the importance of preventing injuries. Building on the biopsychosocial model, two case studies and practical guideline for various professions within sport to support athletes are provided. Another relatively new approach to promote athletes’ mental health and well-being is addressed in Chapter 24 by MacIntyre, Nigg, Murphy, and Oblinger-Peters. Increasing evidence suggests that athletes’ optimal functioning, health, and well-being can benefit from exposure to or interaction with nature. Purcell, Campbell Walton, Currie, and Rice specify how competitive youth sport generate an elevated risk for mental health issues. Their comprehensive narrative review of the extant literature on the mental health and well-being of young athletes in competitive elite sport points out deficits in relevant research and the development of programmes for young athletes.

312

DOI: 10.4324/9781003099345-27

20 PROFESSIONAL CONSIDERATIONS FOR THE CLINICIAN Jack C. Watson II, Matthew Gonzalez, Brandonn Harris, and Valerie Wayda

Introduction For the purpose of this chapter, the authors will consider athletes to be elite if they are participating at the highest echelons of their sport (e.g., professional, Division I collegiate athletes, youth specifically training within international development programmes). Elite athletes across sport may experience many similarities in relation to such factors as training regimen, coaching, travel schedules, competition schedules, and financial stability. Some of the factors associated with their athletic status make elite athletes’ lives and experiences different from others. Additional stressors specific to elite sport are one reason that athletes may experience more mental health risk factors than non-athletes (Schinke et al., 2018). Research has shown that a high percentage of elite athletes experience mental health related problems associated with issues such as depression and anxiety (Gouttebarge et al., 2016; Hammond et al., 2013) and overall mental disorders (Gulliver et al., 2015). Therefore, it is important that clinical services be made available to these athletes and their coaches, and that practitioners are trained to understand the issues and challenges unique to this setting. Even though performance and mental health services have been provided to elite athletes for many years, these services appear to have become more prevalent in recent years. Most elite sport programmes now have clinical mental health and/or sport and performance psychology (SPP) focused professionals embedded with teams to help athletes and coaches achieve and maintain a level of positive mental wellness that is necessary for peak performance. Given the importance of clinical mental health services within elite sport, it is essential that clinicians are cognizant of the professional considerations that should guide service delivery. Therefore, the focus of this chapter is on the ethical and legal issues that impact the mental health services provided to elite athletes and others within their organisations. These services take many different forms and can be provided by clinicians from different training backgrounds. No matter the training background and experiences of the clinician, it is important that they are competent to provide their services and do so in an ethical and legal manner thus ensuring that the client’s well-being remains at the forefront of the relationship. Because of differences between professional organisations and jurisdictional licensing/certifying boards that regulate clinical mental health service provision across the world, it is not possible for this chapter to provide specific guidance for all practitioners. Instead, we discuss several important areas of consideration for clinicians to be aware of when practicing. The primary issues highlighted in this chapter are competence and appropriate use of referrals, multicultural and diversity issues, confidentiality and informed DOI: 10.4324/9781003099345-28

313

Jack C. Watson II et al.

consent, teleconsulting, multiple role relationships, and the provision or receiving of supervision for one’s applied work. The authors can also not overstate the importance of clinicians reading and understanding the ethical guidelines and legal statutes that govern the provision of services within their jurisdiction. We also strongly encourage all clinicians to practice within their areas of competence based upon their education, training, supervision, consultation, study, and professional experience (APA, 2017).

Competence and Appropriate Use of Referrals Competency can be described as the knowledge, skills, behaviours, and abilities that define the scope of effective professional practice (von Treuer & Reynolds, 2017). Defining what professional competency means for clinicians who work in the realm of sport has been challenging. Only recently have scholars attempted to clearly delineate the boundaries of practice for clinicians who work in sport (Portenga et al., 2017). To begin this discussion, we first need to identify the different training and practice models that exist in the profession. Clinically trained professionals are often psychologists, counsellors, or therapists who have received training and licensure to provide clinical mental health services. These professionals provide services through a primary modality of psychotherapy. Non-clinical, mental performance consultants are often trained and/or certified to teach psychoeducational skills (e.g., imagery, self-talk, goal setting, breathing) with the goal of increasing sport performance but not addressing clinical concerns (Watson, Harris, & Baillie, 2020). Competence for SPP clinicians/practitioners greatly depends on which of these two camps a professional is located as competencies are often set by the professional association/board that oversees the services provided. Unless stated otherwise, this chapter will focus on those who are trained and licensed/certified to provide clinical services. In the United States, sport psychologists and athletic counsellors are governed by the American Psychological Association (APA) and the American Counseling Association (ACA), respectively. While it is beyond the scope of this chapter to fully list the competencies of psychologists and counsellors alike, APA’s Division 47 has published a list of specialised knowledge and skills for its members that work with athletic populations which are based upon their sport proficiency (APA, 2005). This comprehensive checklist serves as an example of the wider scope of mental health services that clinically trained sport psychology professionals can provide. For example, the skills portion of this checklist simultaneously identifies psychological performance enhancement skills (e.g., goal setting, attentional control, visualisation) and well as clinical skills (e.g., substance abuse, depression, sexual identity) as necessary competencies. The British Association of Sport and Exercise Sciences (BASES, n.d.) has published a list of 65 competencies necessary to qualify through their Sport and Exercise Psychology Accreditation Route (SEPAR). By meeting these competencies, among other things, one can use the protected professional title sport and exercise psychologist. These competencies are broken into four categories: knowledge, skills, self, and experience. Efforts to define competence in mental performance consulting have only been undertaken recently. In a joint position stand of four leading applied sport psychology organisations, the importance and centrality of competencies was noted in the process of accreditation (Schinke, Si, et al., 2018). They wrote, “These competencies must tie to theoretical knowledge, sound scientific approaches, assessment skills, intervention techniques, personal skills, and a deep knowledge of professional ethics and suitable cultural sport psychology/diversity skills training” (p. 114). A thorough attempt to fully delineate the scope of mental performance consulting was addressed through the job task analysis (JTA) published by the Association for Applied Sport Psychology (AASP) in 2016; the final product of which delineated 6 domains, spanning 21 tasks, and 38 individual knowledge statements (Rosen & Lipkins, 2016). Note that this JTA was not administered with the purpose of detailing competencies it was administered to understand the scope of the profession to help design the structure and content of the certification examination for the later established Certified Mental Performance Consultant certification. 314

Professional Considerations for the Clinician

Critical writings about the shortcomings of competencies associated with the provision of services within sport settings are sparse. Fletcher and Maher (2013) identified limitations in the various professional organisations by collating the competencies identified by AASP, the International Society of Sport Psychology (ISSP), the American Psychological Association (APA) Division 47, and a set of athletic counseling competencies published in The Sport Psychologist (Ward et al., 2005). Fletcher and Maher (2013) were critical of the state of outlined competencies and listed six different limitations including: outright missing competencies, poorly described competencies, poorly broken-down competencies, poorly defined competencies, a lack of focus on the development of competencies, and an over-reliance of self-assessment. There is much more work to be done in defining what exactly competencies mean in the provision of services within sport settings.

Multicultural Competencies in Sport Psychology The process of integrating cultural competencies into clinical work within sport has been specifically complicated. Evidence suggests that many sport clinicians may not be entirely sure how to integrate cultural considerations into their existing practice (Quartiroli, Harris et al., 2021) and may not even be aware of the impact their own cultural identity has on their work (Lee et al., 2020). These shortcomings are not without significant clinical consequences. There is data suggesting that clients who identify as racial/ethnic minorities tend to terminate mental health care after the first session at a higher rate than clients of the majority (Kilmer et al., 2019). A possible explanation of this pattern is there may be microaggressions communicated from the clinician to the client (Capodilupo, 2019). Given these complications, we have chosen to briefly draw attention to this particular set of competencies. Fletcher and Maher’s (2013) previously mentioned criticisms of general competencies associated with professionals who work in sport are likewise reflected in multicultural competencies. Of specific importance is their criticism of poorly defined or poorly described competencies. Despite at least three decades of scholarship, there seems to be an issue translating cultural sport psychology scholarship into tangible, culturally informed applied practices. It is possible that the current state of multicultural education and training is insufficient. Martens, Mobley, & Zizzi (2000) suggested that the most impactful model of multicultural education would integrate multicultural considerations across all coursework. Despite this recommendation, few graduate programmes offer a course in this area (Lee, 2015) let alone integrate it across the curriculum. In addition, Quartiroli et al. (2020) reported limited effectiveness of cultural competency specific trainings in SPP related programmes. Quartiroli and colleagues (2020) also identified a small, positive correlation between cultural experiences (e.g., research projects or work with diverse clients) and scores on cultural competency assessments. From these results we can draw two possible conclusions. First, the current model of cultural competency training is insufficient for generating culturally competent clinicians. Second, we need to re-think the model entirely and aim for exposure to culture over rote training about culture. Clearly, there is work to be done to better understand, educate, and train SPP professionals about multicultural competencies. The current understanding of cultural competence in the profession of sport psychology has been greatly informed by a combination of the Sue et al. (1992) tripartite model of cultural competency, and Ryba et al. (2013) position statement. Sue et al.’s work (1992) provided a foundation of cultural competency for the last several decades in psychology and counselling and includes a consideration of three cultural competency factors including knowledge, awareness, and skills. Ryba and colleagues (2013) authored a sport psychology specific position statement pertaining to cultural competency and emphasised culturally competent communication. There have also been supplemental factors of cultural competency forwarded in the past decade, such as cultural humility, which is loosely defined as a general openness to the impact and importance that culture has in a client’s life (Hook et al., 2013). As the profession continues to grapple with cultural competency guidelines, a student or professional looking to further their 315

Jack C. Watson II et al.

own development would be well-served to read the ISSP position statement (Ryba et al., 2013) and standard two of the ISSP-R Ethical Code (Quartiroli, Harris, et al., 2021) to start.

Becoming an Effective Professional Neophyte clinicians can and must eventually become competent and effective practitioners. Cropley et al. (2010) defined effective practice as follows: Effective practice is therefore a process where, (a) a working alliance is developed between client(s) and practitioner, (b) clients’ goals are clear and agreed by all stakeholders, (c) appropriate evidence-based interventions are undertaken to achieve goals, and (d) goals are achieved or reformulated. Honest evaluation and reflection on the process then occurs to inform future practice, which requires the consultant to pro-actively seek sincere feedback. (p. 527) A hallmark of this transition from inexperience to experience is a transition from a rigid, problem-solving oriented trainee to a professional who is flexible and acts in the role of a facilitator (Tod et al., 2017). Tod (2010) delineates four specific ways in which SPP trainees can grow as professionals: through the supervisory experience, personal counselling/therapy, a purposeful reflective practice, and the process of building a reliable and knowledgeable network. We will contextualise these general recommendations in an elite sporting space. There is evidence to suggest multiple benefits of lifelong, formal (i.e., from a designated mentor) and informal (i.e., peer-to-peer) supervision over the span of one’s entire career (Sharp et al., 2021). Some of these benefits include better monitoring the boundary of applied practices, facilitating the development of self-awareness, and using the supervisory space acting as a social support system (Sharp et al., 2021). Since supervision does not necessarily need to be formal, this further supports Tod’s (2010) call for a robust professional network as a source of peer-to-peer supervision. This supervisory process also meets Cropley and colleagues’ (2010) advocacy of feedback-seeking by the professional. An ethical consideration to make in these elite spaces, however, might arise depending on if the issues identified while working for an elite organisation are permitted to be discussed in supervision outside the organisation itself, or needs to be kept internal to the organisation. Anderson et al. (2004) defined reflective practice as, “an approach to training and practice that can help practitioners explore their decisions and experiences in order to increase their understanding of and manage themselves and their practice” (p. 189). There are multiple types of reflection which have been described in the literature including journaling and supervision (Anderson et al., 2004; Tod, 2010), and informal peer-to-peer reflection (Sharp et al., 2021). A reflective practice can be simple and straightforward, such as asking a simple series of three questions: What went well? What could have been done better? What will I do to get better next time? Reflective practice can also assist in the process of developing cultural competency by engaging in a practice called reflexivity. Reflexivity is a reflective practice borrowed from cultural praxis research whereby there is purposeful consideration of the dynamic of power and privilege between the professional and the client (Schinke et al., 2012). A reflexive question might ask, “How does my identity and social position bring me to assess and understand client presentations in a particular way?”

Referrals At the outer edge of one’s professional competency lies a professional and ethical responsibility to refer a client to a more suitable professional in service of the client’s well-being. Referrals are made when there is 316

Professional Considerations for the Clinician

an ethical complication that cannot be met by the primary service provider; and can include: not having enough time to appropriately serve the client, not having the appropriate training and licensure to meet the presenting concern of the clients, or not having developed enough multicultural competency to adequately meet the needs of a client (Van Raalte, 2010). Van Raalte (2010) identified several primary reasons why sport psychology clinicians may not seek referrals, even when needed. These reasons might include: a lack of awareness by the professional that a referral is needed, lack of know-how on the way to make a referral, a want to help a client that lies just outside the boundaries of their competencies, or a poorly developed referral network. Given the inherent “blurry” nature of modern service provision with athletes (Roberts, Faull, & Tod, 2016), the development of effective referral skills is a necessary competency for the profession. Perhaps the most common referral necessary in the field is when a non-clinically trained consultant recognises that their client requires the attention of a clinically trained professional. In some cases, the line between what a non-clinically trained professional can adequately address can and should be clear; for example, in the case of clear and present risk factors such as suicidality and homicidality. However, there are some presentations that lie between sport and general life that need to be attended to with great care to determine if a clinically trained professional is necessary. Tod, McEwan, and Andersen (2021) identified the following eight such presentations: identity issues, matters of sexual orientation, abusive environments, sex and health related concerns, eating disorders, alcohol and substance use issues, anger and aggression control, and romantic and family relationship issues. For all possible cases of referral, the authors suggest a multistep decision-making process. These steps include determining the time and scope of the issue, how these issues interact with factors of life, recognising abnormal patterns of emotion when the issue arises, understanding the effectiveness of the athlete’s current patterns of coping, and lastly being reflective of one’s own competencies with respect to the presentation. Given the above information, we provide the following recommendations pertaining to making referrals in elite sport settings. First, it has been suggested that referring out might not be as effective as referring in (Tod, 2010). In other words, there might be a higher rate of success if the referred-to professional meets the client in the existing working environment. Second, it is essential that SPP service providers, both nonclinical and clinical, should maintain a healthy and current referral network. This is best if the service provider has personally met those in their referral network as they could then more authentically vouch for those individuals. In elite sport settings, the referral may occur within the organisation as some organisations house mental performance operations separate from mental health offices.

Confidentiality and Informed Consent Confidentiality is “a general standard of professional conduct that obliges a professional not to discuss information about a client with anyone” (Koocher & Keith-Spiegel, 2016, p. 151). This differs from privacy which is defined as, “… the basic entitlement of people to decide how much of their property, thoughts, feelings, or personal data to share with others” (Koocher & Keith-Spiegel, 2016, p. 150). The legal and ethical governance of confidentiality in SPP depends largely on the type of services provided. Those in the United States receiving care in a clinical setting have their records classified as protected health information (Health Insurance Portability and Accountability Act [HIPAA], 1996). In comparison, there is no legal oversight of records associated with mental performance services. However, there are clearly defined ethical considerations in mental performance services that do govern these services (e.g., AASP, 1996, Standard 18). There are a few specific confidentiality considerations that merit further discussion in elite sporting spaces. These extra considerations relate to parents, coaches, and allied health staff. Elite sport training can begin at an early age. In these instances, the parents of these budding elite athletes are well within their rights to be fully informed about all services their child is receiving. Returning to the example of HIPAA (Health Insurance Portability and Accountability Act, 1996) regulations in the United States, guardians of 317

Jack C. Watson II et al.

minors are considered to be a “personal representative” of the athlete and are therefore entitled to be privy to all protected health information generated about their child (U.S. Department of Health and Human Services, n.d.). In this case, an extra step, called “assent” should be added to the informed consent procedure (Quartiroli, Harris, et al., 2021). In many states, minors cannot legally consent to any medical service. The assent process, when added to the intake procedure, gives the minor a semblance of agency whereby they can either agree (assent) or decline (dissent) to care. A particularly complex ethical dilemma native to many elite sporting spaces is the navigation of confidentiality between athlete, clinician, coaching staff, and organisation. Whereas confidentiality is relatively straightforward in independent practice, practice within an elite sporting organisation can be anything but. Moore (2003, p. 602) wrote: … Many sport psychology practitioners are hired by a sport organization, and thus the professional cannot assume that typical confidentiality parameters apply when working with athletes who are under the jurisdiction of a sport organization. This is especially important when considering that the sport psychologist cannot solely focus on the individual within the system that desires services but must place primary consideration on the fulfillment of the organization’s broader mission, intent, and goals. In essence, confidentiality may be limited in these spaces as the professional is hired by the organisation to serve the athlete in order to help the organisation meet its goals (i.e., enhance competitiveness). In general, the suggestions to SPP clinicians to help navigate this dilemma are three-fold (Moore, 2003). First, upon being hired, familiarise oneself with the expectations of information sharing pertaining to the athlete between the organisation and clinician. Second, the clinician should clearly outline and communicate the limits of confidentiality and nature of information sharing during the informed consent process. Lastly, once an information exchange has been requested by the organisation, the clinician should exercise professional judgment in sharing the minimum necessary information to meet the request of the organisation. The nature of elite sport may also endanger client privacy/confidentiality given the often-public environment. Indeed, service provision with athletes may not be as effective when applied in the traditional mental health manner (Aoyagi & Portenga, 2010) due to the dynamic nature of elite sport. This could require the clinician to provide services outside of normal office hours when athletes have free time, and wherever the opportunity presents itself which can be in very public environments including practicing spaces, during travel, lobbies, or over a shared team meal (Watson et al., 2020). This does not necessarily mean that these services should be limited, however, these limitations of privacy and confidentiality must be clearly delineated and agreed to during the informed consent process. It is an ethical necessity to include an informed consent procedure at the outset of practice with a new client. Further, informed consent should continue throughout treatment and be expanded as necessary. The purpose of informed consent is to educate the client about the scope of care (including risks and benefits) before service provision begins. In no particular order of importance, a thorough informed consent procedure will discuss: confidentiality, services, billing/fees, release of information to third parties, the nature of typical intervention, expected benefits and risks, that services are voluntary and can be terminated at any time, how records are used and kept secure, and the nature of any supervision (Quartiroli, Harris, et al., 2021). Once discussed, a record of the client’s consent must be retained by the professional and updated as necessary.

Telepsychology The term “telepsychology” can be defined as “the provision of psychological services using telecommunication technologies” (APA, 2013, Para. 1). Although the term telepsychology relates to the 318

Professional Considerations for the Clinician

provision of therapeutic services to a client, it also applies to a variety of other interactions such as case management, appointment scheduling, and other information transmitted using telecommunications. While video conferencing may be the most common method for delivering telepsychology, the process may also include telephone calls, instant messaging, email, texts, discussion boards, and social media (McCord et al., 2020). The most commonly cited reasons for utilising telepsychology for service provision are increased accessibility, improved convenience, decreased stigma, and cost effectiveness (Luxton et al., 2015). Telepsychology can make psychological services available to those who may not otherwise receive these services because of geographic, financial, medical, anonymity, stigma, convenience, time, and/or scheduling constraints (Hancock et al., 2016). Research has generally supported the effectiveness of telepsychology (Abrams, 2020). The reason clinicians have embraced the use of telepsychology in athletics likely stems from some of the common characteristics associated with elite athletes. Elite athletes spend a lot of time training, they travel frequently for training and competitions, tend to be younger, meaning that they grew up as digital natives and carry cell phones that give them access to many communication platforms, are comfortable using technology in their daily lives, and may also enjoy the anonymity associated with its use (Watson et al., 2020). The use of telepsychology by clinicians working with elite athletes was further solidified during the COVID-19 pandemic. Organisations such as the International Society of Sport Psychology offered editorials and/or commentaries about the impact of the pandemic on athletes and their mental and emotional health (Henriksen et al., 2020, Schinke, Papaioannou, Henriksen et al., 2020, Schinke, Papaioannou, Maher et al., 2020). To further understand the impact of the COVID-19 pandemic on athletes’ mental health, Schinke, Papaioannou, Henriksen et al. (2020) stated that Never has there been a more important moment for mental performance consultants to be accessible to their clients, and to validate the multitude of mixed thoughts and emotions experienced by Olympic aspirants. Access needed to transcend availability; to the type of encouragement that could best serve each high-performance athlete. For these reasons, authors have identified the need to use or consider utilising telepsychology strategies (Schinke, Papaioannou, Maher et al., 2020) to work with elite athletes to improve upon their mental health and well-being. Because of the impact of the COVID-19 pandemic on the psychological well-being of all individuals and the need to provide safe opportunities for service delivery, many jurisdictions and organisations relaxed rules associated with the practice of telepsychology to increase the pool of available providers and to allow clinicians to meet with their clients (APA, n.d.). Nearly all psychologists utilised some form of telepsychology during the COVID-19 pandemic (Sampaio et al., 2021). This increased use of telepsychology resulted in clinicians developing new competencies and skills in this area, the development of new training materials, and likely helped to change perspectives associated with its future use. It is likely that regulations associated with telepsychology may change post-COVID (Maheu, 2021). It is extremely important that clinicians educate themselves on the legal and ethical issues surrounding the practice of telepsychology before providing such services. The major legal issues associated with telepsychology are the practice laws within the jurisdictions where the clinician and client are located, the definition of where the practice of psychology takes place, and associated liability issues. Although many ethical issues are associated with the practice of telepsychology, those most often discussed include competency, confidentiality, and informed consent.

319

Jack C. Watson II et al.

Legal Issues Associated with Telepsychology Laws surrounding the provision of psychological services are generally set by territorial or federal regulatory agencies with the goals of protecting citizens and the livelihoods of clinicians. These laws often define the scope of practice and regulate the professional requirements necessary to practice in that jurisdiction (Zur, 2021). In the United States, these laws were commonly written in the 1950s, which was before current technologies were developed (Maheu, 2018) or even imagined. Therefore, these laws often don’t account for telepsychology as a service delivery option. Because practice laws for clinicians are specific to jurisdictions, most professionals practicing with clients located outside their jurisdiction are likely practicing illegally if they are not licensed or registered in both jurisdictions. Additionally, when a client is located in a jurisdiction different than the clinician, the clinician should be meeting all criteria established by the practice laws in both jurisdictions (Zur, 2021). Important steps have been taken to provide opportunities for clinicians to practice with clients interjurisdictionally. In the United States, the Psychology Interjurisdictional Compact (PSYPACT) was created to provide a way for psychologists licensed in one state to legally work with clients located in other states that have also adopted PSYPACT legislation (PSYPACT, n.d.). Under this compact, psychologists can use telepsychology or in-person face-to-face practices on a temporary basis (APA, 2019) to work with clients in a state where they are not licensed. To be eligible to provide these services, the practitioner must obtain an E.Passport Certificate. Those psychologists practicing across jurisdictions via PSYPACT are subject to the scope of practice laws in the receiving state. As of January 1, 2023 there are 32 PSYPACT participating states and two participating districts/territories, with others in the process of writing or passing legislation (PSYPACT, n.d.). The authors are unaware of similar legislation in other countries or regions.

Ethical Issues Associated with Telepsychology It is important that clinicians desiring to practice telepsychology be aware of the associated risks and challenges. The best way to familiarise oneself with these factors is to review telepsychology guidelines, such as those published by the American Psychological Association (2013). These aspirational guidelines were written to help practitioners develop the knowledge and competency to ethically practice telepsychology. These telepsychology guidelines cover eight specific areas of concern (APA, 2013) that include competence, standards of care in the delivery of telepsychology, informed consent, confidentiality of data and information, security of transmission of data and information, disposal of data and information and technologies, testing and assessment, and interjurisdictional practice. Although these areas are all extremely important to consider, the most commonly cited risks are associated with standards of care, competency, confidentiality, and informed consent. When practicing telepsychology, it is essential that clinicians utilise the same standards of care they would if they were meeting with a client in-person (APA, 2013). Therefore, clinicians should deliberately consider the core virtue of “Beneficience and Nonmaleficence” and seek to evaluate the appropriateness (i.e., potential benefits and risks) of utilising telepsychology with each specific client before providing such services and continue to do so throughout treatment (Harris & Younggren, 2011). It is clear that some clients may be better suited for receiving telepsychology services than others. Factors that may impact a client’s appropriateness for telepsychology include the presenting problem for which the client is requesting treatment, their comfort, competence, and/or trust with technology, therapeutic needs, mental status and stability (APA, 2013), and amount of personal contact and relationship development required by the type of therapy that would likely be used (Harris & Younggren, 2011). Therefore, clients who might be considered to be of high risk in any clinical setting (e.g., experiencing high levels of distress, have a diagnosis that requires either intensive care or team treatments, are at risk for self-harm or noncompliance) may not be suitable candidates for telepsychology (Harris & Younggren, 2011). 320

Professional Considerations for the Clinician

The issue of risk is of common concern when providing services via telepsychology. As is also true of clinicians who work with clients in person, it is important for clinicians using telepsychology to have a safety plan in place for clients who may present a risk to themselves or others (Luxton et al., 2014). While not able to cover all aspects of a safety plan in detail within this section, such plans should include having alternative contact information for the client, having local emergency contact information (e.g., EMS) on file, having contact information for a local collaborator (e.g., family member, clinician, secondary staff), and obtaining authorisation to release information (Luxton et al., 2014). In addition to this information included in an emergency plan, it is also important to continually assess the client’s environment for any potential issues related to privacy and safety, stay aware of any local news that could cause a change in functioning, and assess symptom levels and progress to see if telepsychology is being effective. The issue of competency is multifaceted. Telepsychology service providers must ensure that they are both professionally and technically competent to practice (APA, 2013). Clinicians must ensure that they have the appropriate training to provide quality telepsychology services based upon best practices as developed through their education, training, and supervision. However, since accreditation standards for educational programmes do not often require training in the provision of remote services as part of the curriculum (Maheu, 2018) most programmes do not provide training in telepsychology. Therefore, most clinicians must learn these skills elsewhere if they are to develop competency to deliver such services. Beyond one’s competency related to the delivery of services using telepsychology, it is also important to consider that assessment and diagnosis may be different in a virtual environment, leading to an increased risk of misdiagnosis or lack of diagnosis which are both potentially harmful to the client and could lead to improper treatment (Kelley, 2019). From a technical perspective, clinicians must also ensure that they have the knowledge and skills to effectively utilise the specific technologies associated with service provision (APA, 2013). This means that they must understand the technology they use, how to troubleshoot problems associated with its use, and the associated risks of using it in practice. Clinicians are also responsible for making reasonable efforts to protect electronic client information and maintain confidentiality through transmission and storage of that information (APA, 2013). Before engaging in telepsychology, clinicians should be aware of and inform clients about the increased risks to confidentiality and should take appropriate steps to minimise these risks and follow all laws associated with the storage of information and the disposal of data, information and technologies. Additionally, practitioners should discuss with clients the implications of the location they choose to take consulting calls, as the setting can impact the client’s privacy and confidentiality (McCord et al., 2020). The process of obtaining informed consent is extremely important when it relates to the practice of telepsychology and must take into consideration the applicable laws and regulations (APA, 2013). Beyond the topics previously cited to be covered as part of the informed consent process, clinicians utilising telepsychology must be clear and comprehensive when describing services and share with clients the processes for communicating with each other, dealing with technological issues or handling emergencies that may arise (McCord et al., 2020). Informed consent must be presented in a manner that is understandable to the client and clearly address and provide information about safeguards against potential risks associated with telepsychology. Important issues to discuss include confidentiality and security issues with information transmission, storage, access, and deletion. The use of telepsychology provides many opportunities to expand upon and improve the provision of clinical mental health services to elite athletes. However, the practice of telepsychology brings with it several legal and ethical issues of which clinicians must be aware. It is essential that clinicians take appropriate action and follow risk management suggestions to make themselves competent to provide these services in a safe, effective, and legal manner (Martin, Millán, & Campbell, 2020). 321

Jack C. Watson II et al.

Multiple Role Relationships A multiple role relationship (MRR) exists when a clinician assumes two or more professional relationships with a person (e.g., athlete) at the same time. Clinicians should be cautious about entering into MRRs with clients. The nature of their background, training, and employment may lead SPP clinicians to serve in multiple roles such as a clinician, educator, researcher, and/or coach (Etzel & Watson, 2011). As the number of roles increases, the likelihood of MRRs occurring also increases (Watson et al., 2006). MRRs may be more problematic in sport settings where they appear to be more common and accepted as compared to traditional psychology service settings (Etzel & Watson, 2016). Within an elite sport setting, the two most common MRRs are likely those involving the clinician who also serves as either a coach or instructor for one or more of the athletes with whom they consult. Given this chapter’s focus on clinical mental health and sport psychology, the MRR consisting of an educator-clinician will be addressed.

Teacher-Clinician Multiple Role Relationships Within clinical sport psychology settings, likely one of the most common examples of MRRs is that of a SPP clinician who also teaches classes with their athlete-client(s) enrolled. Although this type of relationship is more common among clinicians working on college campuses, it can occur in professional sport settings as well. Those professionals employed in academia are often likely expected to meet the mission areas of teaching, scholarship, and service. Clinicians who are employed as either full-time or part-time educators will therefore deliver courses to students who may also be clients. Additionally, clinicians working within academic settings are often expected to conduct research and to provide service to their institution. To meet the service requirement, clinicians may seek to provide services to individual athletes or teams, even if their primary responsibilities are within those teaching and scholarship realms. Alternatively, part of one’s appointment may be assigned to the athletic department or university counselling centre. In each of these roles (e.g., educator, researcher, SPP service provider, counsellor/psychologist), there is the potential to work with athletes across different capacities (Etzel & Watson, 2016).

Ethical Considerations Associated with Multiple Role Relationships Mental health clinicians who work with athletes can find themselves facing a variety of ethical considerations associated with MRRs (Etzel & Watson, 2007; 2011). Multiple psychology-based professional associations [e.g., American Psychological Association (APA), Association for Applied Sport Psychology (AASP), British Association of Sport and Exercise Sciences (BASES), International Society of Sport Psychology (ISSP)] have adopted codes of ethics to protect the safety of those being served and promote the highest standards of professional conduct within their members. While MRRs are not inherently unethical, SPP clinicians need to carefully evaluate each relationship to ensure it is not causing unintentional harm to the client or service provider (Watson & Clement, 2009). It is vital for the clinician to be aware of where one role ends, and the other role begins. It is also essential for the clinician to identify MRRs, the potential hazards associated with them, and to clarify the roles to all involved individuals (Etzel & Watson, 2016). An open line of dialogue between the involved parties will help deal with any potential problems and concerns before they arise. The primary concern associated with MRRs is that the clinician could have undue power and influence over the client and could use this influence to harm or exploit the client (Etzel & Watson, 2011; O’Connor Slimp & Burian, 1994). Further, interactions between the clinician and client in one relationship may impact their interactions/expectations in another relationship. For example, a client may find themselves as a student in a class taught by an adjunct faculty member who is also the clinician they meet with regularly for mental health services. This client may believe that their clinical relationship could 322

Professional Considerations for the Clinician

impact their treatment and grade in class as dictated by their teacher-clinician. Additionally, there might be a concern from the student/client that their teacher-clinician would ask questions of them in class that illustrate the presence of a clinical relationship within the academic classroom setting. Again, open lines of communication and clear delineation of roles will help to avoid such issues. As previously mentioned, services are often delivered to athletes in non-traditional environments such as training tables, training facilities (e.g., pool deck, ski lift, inside a track, on the sidelines of a field), shared housing accommodations, and on various forms of transportations (Stapleton, Hankes, Hays, & Parham, 2010). The non-traditional service delivery settings provide for more access to athletes but can also impact confidentiality (Etzel & Watson, 2007). The provision of services in these settings can also give the impression of the clinician serving multiple roles, as there are likely to be times when they are interacting with the client in social settings. It is also important for clinicians who are engaged in MRRs to evaluate their objectivity. Information learned in one role can impact the objectivity of the professional in other roles (Watson & Clement, 2009). Further, SPP clinicians need to develop “professional alertness” to the shifting roles within conversations so as not to violate professional boundaries (Stapleton et al., 2010).

Ethical Issues Regarding Supervision The provision of supervision and/or mentorship represents one of many activities in which SPP professionals are engaged. Indeed, Fogaca, Zizzi, and Andersen (2018) have suggested that supervision represents a pivotal component to the professional growth of both current and future SPP professionals (e.g., trainees, students). Although the terms supervision and mentorship often appear to be used interchangeably, it should be noted that Andersen, Van Raalte, and Brewer (1994) differentiated the terms supervisor/ supervision and mentor/mentorship as they imply different types of relationships in terms of purpose and content. More specifically, they suggested that supervisors oversee trainees in their applied work, while a mentor can be considered a more general identity that may include supervision and advising roles. Supervision also includes additional legal and ethical responsibilities as it pertains to regulatory and licensing laws. Within relevant ethics codes for both clinical and non-clinical SPP professionals, (e.g., AASP, APA, ACA, ISSP), the process of supervision is often addressed, which informs both the profession and public that this area of the field remains an important facet of our profession’s activity. For example, the AASP Ethics Code (AASP, 1996) highlights professionals’ obligation to ensure students/trainees engaged only in activities they can competently and ethically perform (see Standard 13 of the AASP Ethics Code). The APA (2017) also addresses supervision in terms of relationships between supervisors and supervisees, as well as the assessment of supervisee and student performance (see Sections 7.05 and 7.06 of the APA Code of Ethics). Additionally, the ISSP recently adopted a new Code of Ethics for its Registry of Practitioners (ISSP-R, 2020). Within this organisation, Standard 13 specifically addresses supervision in professional practice. In this standard, appropriate training in supervision is underscored to provide appropriate and competent oversight of trainees’ work in SPP; it is also worth noting that specific training is required by the ISSP to become registered supervisors within their organisation. It has been suggested that supervision and mentorship can serve several purposes which include not only the personal and professional development of clinicians and mentees, but also the welfare of athleteclients through the provision of ethical and legally sound services (Andersen et al., 1994; Foltz et al., 2015; Watson, Zizzi, Etzel, & Lubker, 2004). To help guide such work, models of supervision have been developed and adopted within helping professions. Although a thorough discussion of these is beyond the scope of this chapter, clinicians are encouraged to review those models within SPP and related disciplines, all of which are designed to provide a structured and effective process for supervision to take place (see Andersen & Williams-Rice, 1996; Lubker & Andersen, 2014; Silva, Metzler, & Lerner, 2007). 323

Jack C. Watson II et al.

Supervision Implications for Client Welfare, Supervisors, and Trainees Researchers have previously identified common ethical dilemmas and challenges worthy of attention as it pertains to mitigating harm and managing the quality of service provision to athlete-clients, particularly as it pertains to the role of the supervisor. Although most research has been conducted outside of the sport setting, areas of interest have included (a) multicultural and diversity-related factors influencing relationships among the trainee and supervisor, as well as the trainee and client(s), (b) the maintenance of inadequate case notes, (c) failing to seek supervision prior to integrating interventions, (d) the introduction of biases into sessions with clients, (e) trainee competence and performance evaluation, (f) the presence of transference and countertransference in service provision, (g) the impairment of trainees, and (h) the maintenance of confidentiality of clients and the supervisee (Andersen, Van Raalte, & Brewer, 2000; Barnett Cornish, Goodyear, & Lichtenberg, 2007; Lubker & Andersen, 2014; Pakdaman, Shafranske, & Falender, 2015). Research has also acknowledged the importance of the relationship between the supervisor and supervisee for this process to be effective and ultimately benefit the emerging clinician and their clientele. Interpersonal and intrapersonal communication and the establishment of one’s professional or professional practice philosophy have been noted to be of particular importance (see Watson et al., 2004). Supervisor training is another factor that affects this professional relationship and the services delivered to clients. As previously mentioned, the ISSP-R requires specific training for those on the Registry who would be providing supervision to trainees. The Certified Mental Performance Consultant (CMPC) credential, as administered by AASP and the Canadian Sport Psychology Association, also requires continuing education in mentorship for individuals to provide this service to those in training working towards their own CMPC (AASP, 2021). A great deal of variety may exist in the experiences and manner by which the applied work of graduate students is supervised or mentored. As such, measures could be integrated into this process to enhance the necessary competencies associated with providing effective supervision to trainees. For example, an appropriate ratio of supervisors-to-supervisees is encouraged, as is modeling prosocial and ethical behaviour during supervision, including performance feedback to trainees, and the awareness of multiple role relationships within supervision (e.g., teacher-student/supervisor-supervisee) so as to maintain appropriate professional boundaries (see Barnett et al., 2007; Lubker & Andersen, 2014).

Conclusion Although their lives may at times appear glamorous, the experiences of elite athletes vary greatly, and they often include many stresses and challenges that are unique to their pursuits. For many elite athletes, this means that they have celebrity status and live their lives under the scrutinising gaze of others. Because of the uniqueness of their experiences, elite athletes can benefit from mental health and performance enhancement service providers who are knowledgeable about and competent to help with the challenges associated with high level athletic performance. Throughout this chapter, the authors have focused on several legal and ethical issues that may be important for clinicians to consider when working with elite athletes. While not a comprehensive list of the legal and ethical challenges faced by service providers, the authors have attempted to provide background on the more important issues faced by practitioners working in this space. Clinicians working with elite athletes are strongly encouraged to regularly review the ethics codes of appropriate organisations that govern their work and the relevant practice laws in the jurisdiction(s) in which they work. Additionally, practitioners are encouraged to develop a strong network of clinician peers for the purpose of professional development and mentoring, consider receiving supervision throughout their careers, utilise ethical decision-making models to help make decisions about the issues they may face, and take part in continuing education courses to help maintain their competencies. 324

Professional Considerations for the Clinician

References Abrams, Z. (2020, July 1). How well is telepsychology working? Monitor on Psychology, 51(5), from https://www.apa. org/monitor/2020/07/cover-telepsychology American Psychological Association (APA). (n.d.). Telehealth guidance by state during COVID-19. Retrieved October 5, 2021 from https://www.apaservices.org/practice/clinic/covid-19-telehealth-state-summary American Psychological Association (2005). Sport psychology: Knowledge and skills checklist. Retrieved from https:// www.apadivisions.org/division-47/about/resources/checklist.pdf American Psychological Association (2013). Guidelines for the practice of telepsychology. American Psychologist, 68, 791–800. Retrieved October 7, 2021 from https://www.apa.org/practice/guidelines/telepsychology American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. Retrieved November 5, 2021, from https://www.apa.org/ethics/code American Psychological Association (2019, April 24). Agreement allowing licensed psychologists to practice across certain state borders a step toward care for those who most need it, APA says. American Psychological Association. Retrieved September 21, 2021 from https://www.apa.org/news/press/releases/2019/04/psychologists-stateborders Anderson, A.G., Knowles, Z., & Gilbourne, D. (2004). Reflective practice for sport psychologists: Concepts, models, practical implications, and thoughts on dissemination. The Sport Psychologist, 18(2), 188–203. 10.1123/tsp.18.2.188 Andersen, M.B., Van Raalte, J.L., & Brewer, B.W. (1994). Assessing the skills of sport psychology supervisors. The Sport Psychologist, 8, 238–247. 10.1123/tsp.8.3.238 Andersen, M.B., Van Raalte, J.L., & Brewer, B.W. (2000). When sport psychology consultants and graduate students are impaired: Ethical and legal issues in training and supervision. Journal of Applied Sport Psychology, 12, 134–150. 10.1080/10413200008404219 Andersen, M.B., & Williams-Rice, B.T. (1996). Supervision in the education and training of sport psychology service providers. The Sport Psychologist, 10, 278–290. 10.1123/tsp.10.3.278 Aoyagi, M.W., & Portenga, S.T. (2010). The role of positive ethics and virtues in the context of sport and performance psychology service delivery. Professional Psychology: Research and Practice, 41, 253–259. 10.1037/a0019483 Association for Applied Sport Psychology. (1996). AASP code of ethical principles and standards. Retrieved June 5th, 2021 from http://www.appliedsportpsych.org/ethics/code2002.html Association for Applied Sport Psychology (2021). Certification candidate handbook. Retrieved December 12, 2021 from https://appliedsportpsych.org/certification/certification-program-candidate-handbook/ Barnett, J.E., Cornish, J.A.E., Goodyear, R.K., & Lichtenberg, J.W. (2007). Commentaries on the ethical and effective practice of clinical supervision. Professional Psychology: Research and Practice, 38, 268–275. 10.1037/0735-7028. 38.3.268 British Association of Sport and Exercise Sciences (BASES). (n.d.). Sport and exercise psychology accreditation route. Retrieved December 12, 2021 from: https://www.bases.org.uk/spage-professional_development-separ.html Capodilupo, C.M. (2019). Microaggressions in counseling and psychotherapy. In D.W. Sue, D. Sue, H.A. Neville, & L. Smith (Eds.). Counseling the culturally diverse (pp. 119–141). Wiley. Cropley, B., Hanton, S., Miles, A., & Niven, A. (2010). Exploring the relationship between effective and reflective practice in applied sport psychology. The Sport Psychologist, 24(4), 521–541. 10.1123/tsp.24.4.521 Etzel, E.F., & Watson II, J.C. (2007). Ethical challenges for psychological consultations in intercollegiate athletics. Journal of Clinical Sport Psychology, 1, 304–317. 10.1123/jcsp.1.3.304 Etzel, E.F., & Watson II, J.C. (2011). Ethics. In T. Morris & P. Terr (Eds.). The new sport and exercise psychology companion (pp. 425–439). Fitness Information Technology. Etzel, E., & Watson II, J. (2016). Psychology in professional sports and the performing arts: Challenges and strategies. In R. Schinke & D. Hackfort (Eds), The routledge companion of professional sport and performance psychology (pp. 63–74). Routledge. Fletcher, D., & Maher, J. (2013). Toward a competency-based understanding of the training and development of applied sport psychologists. Sport, Exercise, and Performance Psychology, 2(4), 265–280. 10.1037/a0031976. Fogaca, J.L., Zizzi, S.J., & Andersen, M.B. (2018). Walking multiple paths of supervision in American sport psychology: A qualitative tale of novice supervisees’ development. The Sport Psychologist, 32(2), 156–165. 10.1123/ tsp.2017-0048 Foltz, B.D., Fisher, A.R., Denton, L.K., Campbell, W.L., Speight, Q.L., & Steinfeldt, J. (2015). Applied sport psychology supervision experience: A qualitative analysis. Journal of Applied Sport Psychology, 27, 449–463. 10. 1080/10413200.2015.1043162

325

Jack C. Watson II et al. Gouttebarge, V., Jonkers, R., Moen, M., Verhagen, E., Wylleman, P., & Kerkhoffs, G. (2016). The prevalence and risk indicators of symptoms of common mental disorders among current and former Dutch elite athletes. Journal of Sports Sciences, 35, 2148–2156. 10.1080/02640414.2016.1258485 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18, 255–261. 10.1016/j.jsams.2014.04.006 Hammond, T., Gialloreto, C., Kubas, H., & Hap Davis 4th, H. (2013). The prevalence of failure-based depression among elite athletes. Clinical Journal of Sport Medicine, 23, 273–277. 10.1097/JSM.0b013e318287b870 Hancock, S.L., Stark, K.S., & Kreiner, D.S. (2016, December 14). A brief look at telepsychology in the age of the internet. The Amplifier Magazine. Retrieved November 1, 2021, from https://div46amplifier.com/2016/12/14/a-brieflook-at-telepsychology-in-the-age-of-the-internet/ Harris, E., & Younggren, J.N. (2011). Risk management in the digital world. Professional Psychology: Research and Practice, 42(6), 412–418. 10.1037/a0025139 Health Insurance Portability and Accountability Act. Pub. L. No. 104-191, § 264, 110 Stat.1936. (1996). Henriksen, K., Schinke, R.J., Noce, F., Poczwardowski, A., & Si, G. (2020, Apr 3). Working with athletes during a pandemic and social distancing: International society of sport psychology corona challenges and recommendations. The International Society of Sport Psychology (ISSP). Retrieved September 15, 2021, from https://www.issponline. org/index.php/component/k2/item/49-issp-corona-challenges-and-recommendations Hook, J.N., Davis, D.E., Owen, J., Worthington, E.L., & Utsey, S.O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60, 353–366. 10.1037/a0032595 International Society of Sport Psychology (ISSP). (2020). Ethical code for sport psychology practice. Retrieved November 27, 2021, from https://www.issponline.org/index.php/issp-r-ethics-code Kelley, K. (2019). Is telepsychology putting our most vulnerable patients at risk? Journal of Health & Biomedical Law, 15(1), 55–59. Kilmer, E.D., Villarreal, C., Janis, B.M., Callahan, J.L., Ruggero, C.J., Kilmer, J.N., Love, P.K., & Cox, R.J. (2019). Differential early termination is tied to client race/ethnicity status. Practice Innovations, 4(2), 88–98. Koocher, G.P. & Keith-Spiegel, P. (2016). Ethics in psychology and the mental health professionals (4th ed.). Oxford University Press. Lee, S.M. (2015). Cultural competence development in sport and exercise psychology graduate programs. Athletic Insight, 7(3), 269–289. Lee, S.M., Quartiroli, A., Baumann, D., Harris, B.S., Watson, J.C., & Schinke, R.J. (2020). Cultural competence in applied sport psychology: A survey of students and professionals. International Journal of Sport Psychology, 51, 1–22. 10.1123/tsp.2019-0075 Lubker, J.R., & Andersen, M.B. (2014). Ethical issues in supervision: Client welfare, practitioner development, and professional gatekeeping. In E. Etzel, & J. Watson II (Eds.), Ethical issues in sport, exercise and performance psychology (pp. 151–162). Fitness Information Technology. Luxton, D., Nelson, E., & Maheu, M. (2015). A practitioner’s guide to telemental health: How to conduct legal, ethical and evidence-based telepractice. American Psychological Association. Luxton, D.D., O’Brien, K., Pruitt, L.D., Johnson, K., & Kramer, G. (2014). Suicide risk management during clinical telepractice. International Journal of Psychiatry in Medicine, 48(1), 19–31. 10.2190/PM.48.1.c Maheu, M. (2018, October 30). Is it legal to practice across state lines with online therapy, telemental health & telebehavioral health? Retrieved October 15, 2021, from https://telehealth.org/practice-across-state-lines/?utm_medium= adwords&utm_campaign=&utm_source=&gclid=CjwKCAjwzt6LBhBeEiwAbPGOgZCggpgEqKvodmTmD6i0 WhQ4i2osE6SvMQa0ODw4J49yfDBGW9dEKRoCQDgQAvD_BwE Maheu, M. (2021, March 13). Update: Telemedicine across state lines post pandemic. Telehealth.org. Retrieved September 15, 2021, from https://telehealth.org/telemedicine-across-state-lines/ Martens, M.P., Mobley, M., & Zizzi. S.J. (2000). Multicultural training in applied sport psychology. The Sport Psychologist, 14, 81–97. 10.1123/tsp.14.1.81 Martin, J.N., Millán, F., & Campbell, L.F. (2020). Telepsychology practice: Primer and first steps. Practice Innovations, 5, 114–127. 10.1037/pri0000111 McCord, C., Bernhard, P., Walsh, M., Rosner, C., & Console, K. (2020). A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76, 1060–1082. 10.1002/jclp.22954 Moore, Z. (2003). Ethical dilemmas in sport psychology: Discussion and recommendations for practice. Professional Psychology: Research and Practice, 34, 601–610. 10.1037/a0017976 O’Connor Slimp, P.A., & Burian, B.K. (1994). Multiple role relationships during internship: Consequences and recommendations. Professional Psychology: Research and Practice, 25(1), 39–45.

326

Professional Considerations for the Clinician Pakdaman, S., Shafranske, E., & Falender, C. (2015). Ethics in supervision: Consideration of the supervisory alliance and countertransference management of psychology doctoral students. Ethics & Behavior, 25, 427–441. 10.1080/ 10508422.2014.947415 Portenga, S.T., Aoyagi, M.W., & Cohen, A.B. (2017). Helping to build a profession: A working definition of sport and performance psychology. Journal of Sport Psychology in Action, 8, 47–59. 10.1080/21520704.2016.1227413 Psychology Interjurisdictional Compact (n.d.). About Us. Retrieved October 23, 2021, from https://psypact.site-ym. com/page/About Quartiroli, A., Harris, B.S., Brückner, S., Chow, G.M., Connole, I.J., Cropley, B., & Zito, M. (2021). The International Society of Sport Psychology Registry (ISSP-R) ethical code for sport psychology practice. International Journal of Sport and Exercise Psychology, 19, 907–928. 10.1080/1612197X.2020.1789317 Quartiroli, A., Vosloo, J., Fisher, L., & Schinke, R. (2020). Culturally competent sport psychology: A survey of sport psychology professionals’ perception of cultural competence. The Sport Psychologist, 34, 242–253. 10.1123/tsp. 2019-0075. Quartiroli, A., Vosloo, J., Schinke, R.J., Anderson, S.N., Fisher, L.A., Giffin, C.E. (2021). Sport psychology professionals’ perceptions of the roadblocks to cultural sport psychology. Sport, Exercise, and Performance Psychology. Advance online publication. 10.1037/spy0000256. Roberts, C.M., Faull, A.L., & Tod, D. (2016). Blurred lines: Performance enhancement, common mental disorders, and referral in the U.K. athletic population. Frontiers in Psychology, 7, 1–13. 10.3389/fpsyg.2016.01067 Rosen, G.A., & Lipkins, R.H. (2016). Sport psychology certification job task analysis and validation. Indianapolis, IN: Association for Applied Sport Psychology. Retrieved October 25, 2021 from https://appliedsportpsych.org/site/ assets/files/30082/jtareport-finalfull012116.pdf Ryba, T.V., Stambulova, N.B., Si, G., & Schinke, R.J. (Eds.). (2013). ISSP position stand: Culturally competent research and practice in sport and exercise psychology. International Journal of Sport and Exercise Psychology, 11(2), 123–142. 10.1080/1612197X.2013.779812 Sampaio, M., Haro, M.V.N., De Sousa, B., Melo, W.V., & Hoffman, H.G. (2021). Thereapists make the switch to telepsychology to safely continue treating their patients during COVID-19 Pandemic. Virtual reality telepsychology may be next. Frontiers in Virtual Reality. 10.3389/frvir.2020.576421 Schinke, R.J., McGannon, K.R., Parham, W.D., & Lane, A.M. (2012). Toward cultural praxis and cultural sensitivity: Strategies for self-reflective sport psychology practice. QUEST, 64, 34–46. 10.1080/00336297.2012. 653264 Schinke, R., Papaioannou, A., Henriksen, K., Si, G., Zhang, L., & Haberl, P. (2020). Sport psychology services to high performance athletes during COVID-19. International Journal of Sport and Exercise Psychology, 18, 269–272. 10.1080/1612197X.2020.1754616 Schinke, R., Papaioannou, A., Maher, C., Parham, W.D., Larsen, C.H., Gordin, R., & Coterrill, S. (2020). Sport psychology services to professional athletes: Working through COVID-19. International Journal of Sport and Exercise Psychology, 18, 409–413. 10.1080/1612197X.2020.1766182 Schinke, R.J., Si, G., Zhang, L., Elbe, A., Watson, J., Harwood, C., & Terry, P. (2018). Joint position stand of the ISSP, FEPSAC, ASPASP, and AASP on professional accreditation. Psychology of Sport and Exercise, 38, 107–115. 10.1016/j.psychsport.2018.06.005 Schinke, R.J., Stambulova, N.B., Si, G., & Moore, Z. (2018). International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16, 622–639. 10.1080/1612197X.2017.1295557 Sharp, L.A., Hodge, K., & Danish, S. (2021). “I wouldn’t want to operate without it”: The ethical challenges faced by experienced sport psychology consultant’s and their engagement with supervision. Journal of Applied Sport Psychology, 33, 259–279. 10.1080/10413200.2019.1646838 Silva III, J.M., Metzler, J.N., & Lerner, B. (2007). Training professionals in the practice of sport psychology. Fitness Information Technology. Stapleton, A.B., Hankes, D.M., Hays, K.F., & Parham, W.D. (2010). Ethical dilemmas in sport psychology: A dialogue on the unique aspects impacting practice. Professional Psychology: Research and Practice, 41(2), 143–152. 10.1037/a0017976 Sue, D.W., Arredondo, P., & McDavis, R.J. (1992). Multi-cultural competences/standards: A call to the profession. Journal of Counseling and Development, 70, 477–486. 10.1002/j.1556-6676.1992.tb01642.x Tod, D. (2010). Training and professional development in applied sport psychology. In S.J. Hanrahan & M.B. Andersen (Eds.), Routledge handbook of applied sport psychology (pp. 21–29). Routledge. Tod, D., Hutter, R.V., & Eubank, M. (2017). Professional development for sport psychology practice. Current Opinion in Psychology, 16, 134–137. 10.1016/j.copsyc.2017.05.007

327

Jack C. Watson II et al. Tod, D., McEwan, H.E., & Andersen, M.B. (2021). When to refer athletes to other helping professionals. In J.M. Williams & V. Krane (Eds.), Applied sport psychology: Personal growth to peak performance. (pp. 433–450). McGraw Hill. U.S. Department of Health and Human Services. (n.d.). Personal representatives and minors. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/faq/personal-representatives-and-minors/ index.html Van Raalte, J.L. (2010). Referring clients to other professionals. In S.J. Hanrahan & M.B. Andersen (Eds.), Routledge handbook of applied sport psychology. (pp. 205–213). Routledge. von Treuer, K.M., & Reynolds, N. (2017). A competency model of psychology practice: Articulating complex skills and practices. Frontiers in Education, 2, 1–7. 10.3389/feduc.2017.00054 Ward, D.G., Sandstedt, S.D., Cox, R.H., & Beck, N.C. (2005). Athlete-counseling competencies for U.S. psychologists working with athletes. The Sport Psychologist, 19, 318–334. 10.1123/tsp.19.3.318 Watson II, J.C., & Clement, D. (2009). Ethical and practical issues related to multiple role relationships in sport psychology. Athletic Insight, 10(4). Retrieved from http://www.athleticinsight.com/Vol10Iss4/Multiple.htm Watson II, J.C., Clement, D. Harris, B., Leffingwell, T., & Hurst, J. (2006). Teacher-practitioner role issues in sport psychology. Ethics and Behavior, 16(1), 41–59. 10.1207/s15327019eb1601_5 Watson II, J.C., Harris, B.S., & Baillie, P. (2020). Ethical issues impacting the profession of sport psychology. In G. Tenenbaum & R.C. Eklund (Eds.), Handbook of sport psychology (4th ed., pp. 751–772). John Wiley & Sons Inc. Watson II, J.C., Zizzi, S.J., Etzel, E.F., & Lubker, J.R. (2004). Applied sport psychology supervision: A survey of students and professionals. The Sport Psychologist, 18, 415–429. Zur, O. (2021). TeleMental health services across state lines. Zur Institute. Retrieved October 7, 2021, from https:// www.zurinstitute.com/telehealth-across-state-lines/

328

21 PSYCHOTHERAPEUTIC APPLICATIONS IN ELITE SPORT: PROMOTING MENTAL HEALTH AMONG ATHLETES Mark A. Stillman, Hudson Farmer, and Ira D. Glick

Introduction When it comes to being susceptible to clinical and subclinical mental health symptoms and psychiatric disorders, elite athletes are no exception. They are prone to having their overall functioning impacted by these types of symptoms and disorders just as much as the general population. A 2014 study found that just under half of the sample of 224 elite athletes met criteria for at least one mental health “problem” including psychological distress (16.5% of the sample), depression (27.2%), general anxiety (7.1%), or social anxiety as a symptom (14.7%) – and panic disorder (4.5%) and eating disorders (22.8%) (Gulliver et al., 2014). Eating disorders are present in up to 60% of female athletes that participate in sport or events which require individuals to maintain a lean physique (Glick et al., 2012). College athletes binge drink and display binge drinking behaviours more frequently than non-athletes at the same universities (Ford, 2007). Additionally, 15% of college athletes reported that they had previously participated in pathological gambling behaviour (McDuff & Baron, 2005). As for older athletes, those in the 30–50-year-old range have a 2–4 times higher risk of death by suicide than the general population in the same age range (Lindqvist et al., 2014). Within the population of elite athletes, individuals who sustain physical injuries experience more depressive and anxiety symptoms, and lower self-esteem immediately following the injury and during recovery than uninjured athletes (Leddy et al., 1994). With elite athletes, these symptoms and disorders can negatively affect athletic performance (Chang et al., 2020). This, in turn, could negatively affect overall well-being even more in conjunction with the direct effects of the symptoms and disorders as their livelihood is negatively impacted.

Psychotherapy In general, psychotherapy has been found to be helpful and effective to the treatment and management of clinical and subclinical mental health symptoms and disorders, either by itself or in combination with other nonpharmacological and pharmacological treatments. This holds true for elite athletes as well, but we argue that the psychotherapy may need to be modified to best suit their needs in order to be most effective. For this to happen, psychotherapy for athletes should address athlete-specific issues while also being validated as a “normal” or standard treatment for mental health symptoms by the athletes and their DOI: 10.4324/9781003099345-29

329

Mark A. Stillman et al.

core stakeholders and influencers (partners, family, coaches, teammates, agents, etc.). By addressing stigma and misconceptions held by individuals within the athlete’s support system, a mental healthcare provider can hope to increase the athlete’s likelihood of seeking and adhering to treatment (Glick et al., 2013). In the event of reluctance by the athlete to seek or receive treatment for mental health issues, the concept of psychotherapy can be reframed as “performance help” (Stillman et al., 2013). This is an accurate description of psychotherapy with athletes, as the goal is to improve athletic performance by way of improving overall functioning. This may also help reduce the long-standing stigma associated with seeking and receiving mental health services, especially within the elite athlete population (Glick & Horsfall, 2001). Several forms of psychotherapy have been found to be particularly successful and useful in the treatment of mental health symptoms and disorders in athletes. These are individual psychotherapy, couples/family psychotherapy, and group therapy.

Individual Psychotherapy Individual psychotherapy takes the form of a one-on-one interaction between a patient and a trained mental health professional. Frequently individual psychotherapy as a sole treatment is sufficient in treating less severe mental health issues such as mild depression, anxiety, and sport related adjustment issues (relocating, dealing with injuries, etc.) (Stillman et al., 2016). Not only can it be used to treat mental disorders, but individual psychotherapy provided by a psychiatrist, psychologist, or other counsellor who specialises in the treatment of athletes can help improve adherence to medication and other prescribed treatments. Common healing factors between cognitive behavioural therapy, motivational enhancement therapy, supportive therapy, and psychodynamic therapy (Markowitz, 2014): • • • • • • •

Affective arousal Feeling understood by the therapist Offering a framework for understanding the problem/solution Therapist expertise Therapeutic structure/procedures Optimism regarding improvement Experiences/histories of successful outcomes

Some of the most commonly used individual psychotherapies for young adults, college students, and collegiate athletes are cognitive behavioural therapy, motivational enhancement therapy, supportive therapy, and psychodynamic therapy. These four specific therapies appear to have common healing factors which include affective arousal, feeling understood by the therapist, offering a framework for understanding a problem/solution, therapist expertise, therapeutic structure/procedures, optimism regarding improvement, and experiences/histories of successful outcomes (Markowitz, 2014). Cognitive behavioural therapy (CBT) has received the most empirical support of the above therapies (Butler et al., 2006). The goal of CBT is to improve functioning by helping patients understand how dysfunctional thoughts can lead to negative emotional activation and maladaptive actions or inactions (Barth et al., 2013). In other words, it helps individuals identify and change thought patterns that negatively influence emotions and behaviour. The process of CBT involves several elements that are comparable to physical training such as structure, direction, and practice (Hayes, 1999). These factors along with others make CBT a practical option for athletes that they ought to be relatively comfortable with. This may be the case especially for athletes who perform in individual sport as they are already familiar with individual goal setting and self-reliance (Stillman et al., 2016). Symptoms and disorders that

330

Psychotherapeutic Applications in Elite Sport

CBT appears to be most helpful and effective for include depression, anxiety, substance use disorder, anger/aggression, insomnia, somatisation, chronic pain, and general stress (Hofmann et al., 2012). As with the general population, an athlete’s opinions and feelings on certain topics can be strongly influenced by the people around them. Information or advice that athletes are given on legal and illegal substance use can come from coaches, teammates, peers, agents, trainers, family members, and friends. These sources people may help determine how an athlete feels about substances. If a coach points out that their athlete has been gaining weight or appears to be more sluggish since beginning a new prescription, that athlete may begin taking less than the prescribed dose or completely quit taking the medication all together. If a trainer or teammate is using a substance that they believe has greatly improved their performance, then an athlete may become interested or feel pressured into trying it even if that substance is illegal by law or in their league/association/organisation. Motivational enhancement therapy (MET) draws from motivational interviewing to help patients understand their conflicting feelings and opinions towards substance use. Instances where MET appears to be most helpful include risky drinking and adverse alcohol behaviours, cannabis use, tobacco cessation, and medication adherence difficulties (Stillman et al., 2019; Walker et al., 2006). One of the more common mental health disorders that is experienced by athletes is what has been labelled as “adjustment disorder” (Stillman et al., 2016). Adjustment disorder looks like an excessive emotional or behavioural reaction to a major event or change in a person’s life. It has a relatively short course but can have a significant impact on overall functioning for its duration. Potentially stressful events that athletes often face, that could bring about an adjustment disorder, include being cut from a team, moving to a new part of the country/world, joining a new team, or receiving an injury diagnosis. Adjustment disorders may also arise after events that are more common to the general population including separating from a partner, losing a close family member or friend, being in an accident, or retiring. Again, as duration is relatively short compared to other mental health issues, adjustment disorders are most effectively treated by psychotherapies that are short-term and problem-solving focused (Carta et al., 2009).

Couples/Family Psychotherapy Oftentimes, involving an athlete’s family can help the athlete to understand how personal and family stress can impact their overall performance (Stillman et al., 2019). Spouses/partners and other family members can play a significant role in maintaining or impacting the mental health of an athlete. One side of that role can be assisting the athlete in maintaining or improving good mental health. Specifically, this may include dissemination of mental health awareness material to key support people, including partners, friends, family, coaching staff, and administrative staff. Such efforts have been shown to help ensure early detection and prompt access to high-quality, evidence-based intervention (Rice, et al. 2016). By involving family members in the assessment of an athlete, with the athlete’s permission of course, a clinician is able to obtain a better and more well-rounded understanding of the patient/symptoms. These family members may provide key supplemental information that the athlete may leave out (intentionally or unintentionally) or they can be helpful if the athlete appears to have low or no insight into their condition (Stillman et al., 2013). Additionally, family members can be vital to ensuring adherence to treatment by making sure that the athlete is attending therapy, taking their prescribed medications, etc. (Stillman et al., 2013). Many clinicians hold the belief that not only patients but also their partner/family member(s) should receive psychoeducation before the patient is allowed to begin taking a prescribed psychotropic medication (Stillman et al., 2013). And of course, the family/significant others are crucial for being supportive to their family member-athlete as they provide guidance, fulfilment, and affirmation. If the athlete is open to it, coaches, trainers (especially since they often work the athlete daily), agents, teammates, and other close individuals can also be useful in the assessment stages by providing supplemental information as well as during treatment stages by helping to ensure and increase adherence to 331

Mark A. Stillman et al.

treatment throughout the athlete’s daily activities. Oftentimes, these individuals and family members are the people who encourage the athlete to seek treatment in the first place – and to stay in therapy. While they can be crucial in the assessment and treatment of an athlete, family members and other close individuals can also be a source of stress or suffer from the consequences of stress in an athlete’s life. Stress from familial issues can be the presenting problem or the underlying source of the presenting problem for an athlete who is seeking treatment (Stillman et al., 2016). Hussey and colleagues found that family problems in a collegiate athlete’s life may predispose them to mental health distress and could even be used as a screening method to assist referrals (Hussey et al., 2019). Some issues that are not exclusive to but may occur more frequently in the family settings of athletes include substance use; domestic violence; time spent away from home; jealousy; and especially with male elite athletes, extramarital affairs (Stillman et al., 2019). Again, these issues may be the presenting problem when an athlete seeks treatment, or they may be the underlying causes of other psychiatric symptoms and disorders. In order to treat these, a clinician must be competent in implementing marriage/couple’s psychotherapy which can be difficult if both parties are not committed to seeking/participating in treatment (Stillman et al., 2016). For example, a couple that is working through issues of jealousy that stem from the athlete often being away from home for days at a time due to sporting events would likely have great difficulty working through this issue if the spouse wants to participate in marriage therapy, but the athlete does not view being away from home as a problem. When performing this form of psychotherapy, the mental health clinician must be able to address not only the influence of the family but also the influence from other interlocking systems including teammates, coaching/training staffs, and the overall organisation.

Group Psychotherapy A third form of psychotherapy that has may be particularly appropriate for athletes is group psychotherapy (Stillman, et al., 2016). Group psychotherapy involves a mental health clinician providing psychoeducation and psychotherapy to patients in a group setting. Patients are able to hear from and interact with each other during portions of the session and are able to learn from and encourage one another. Finding shared experiences between patients may lead to greater change than what can be provided by therapy and medication alone (Khantzian & Mack 1994). Group psychotherapy is a common treatment for individuals with substance abuse issues. More wellknown examples of this include groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). It is often used in conjunction with medication, especially for substance use disorders, and can be led by a qualified mental health clinician (Stillman et al., 2016). Another reason that group psychotherapy may be more effective, specifically for athletes that participate in team sport, is that it reflects a team structure. The group consists of individuals that make up a “team” which is led by a mental healthcare provider who takes on the role of the “coach” (Stillman et al., 2016). This approach may provide an added layer of comfort for team sport athletes (Stillman et al., 2013). An athlete is more likely to take part in this form of therapy if confidentiality can be guaranteed, if they have had positive experiences with it in the past, and if it can be well integrated into their life (Putukian, 2016).

Unique Challenges Although the previously discussed psychotherapeutic interventions are the same for elite athletes and the general population, there are several factors that mental health clinicians must consider when providing services to athletes. Because of lifestyle differences (training regimens, financial situations, celebrity status, etc.), among other factors, several challenges may present themselves, including diagnostic ambiguity, barriers to help-seeking behaviours, and altered expectations about services and personality factors. 332

Psychotherapeutic Applications in Elite Sport

Diagnostic Ambiguity Mental health clinicians must carefully consider all aspects of each case when attempting to diagnose athletes as patient presentations may be better explained by unique lifestyle factors and behaviours that are more common to athletes than non-athlete clients. Many athletes may display signs and symptoms that mirror mental health disorders, but they are caused by entirely different reasons. Fatigue, appetite loss, weight change, cognitive deficits, and general lack of energy and motivation are symptoms of clinical depressive disorders as well as over-training syndrome (Bar & Markser, 2013). These two issues may present with the same or similar symptoms, but the course of treatment will need to be different in order to effectively treat the true condition that is causing the symptoms. Athletes may also display signs of obsessive-compulsive disorder (OCD) as evidenced by ritualistic behaviour during competitions or practice. Examples of this look like unique free-throw warm-ups in basketball, pre-game/event rituals, and superstitious behaviours. A diagnosis of OCD would be incorrect as the behaviours are limited exclusively to competitive settings and result in no overall day-to-day functional impairment (Reardon & Factor, 2010). These behaviours are performed by athletes simply to reduce anxiety during athletic performance (Broch & Kristiansen, 2014). A diagnosis of an eating disorder should not be given to an Olympic ski jumper with an extremely low body mass index (BMI) without first considering other factors and symptoms. A low BMI gives them a competitive edge in their sport and is a common characteristic among this specific group of athletes. During case conceptualisation, all signs and symptoms must be considered within the context of athletic performance and what is “common” or “typical” among athletes of the same or a similar sport or position as some behaviours become “functional requirements” for participation in their sport. Not only do athletes display signs and symptoms that may appear to be due to mental health issues, but they also face unique triggers and stressors that are not common to the general population. The symptoms or disorders that they face may be common in the general population, but they are brought on by circumstances that are unique to their lifestyle. Overtraining, poor performance, and retirement from their sport can all be sources of hopelessness leading to depression or depressive symptoms (Glick et al., 2012, Reardon & Factor, 2010). Severe injury, which athletes in contact and non-contact sport are frequently exposed to, can bring about mood disturbance, tension, and anger (Quinn & Fallon, 1999). Elite athletes also have greater prevalence rates of performance anxiety and jetlag induced insomnia compared to the general population (Glick et al., 2010). Even within the population of elite athletes there are different risks for mental health symptoms and disorders based on the sport or type of sport in which the athlete participates. For example, athletes that participate in individual sport may be at a greater risk for depressive symptoms than athletes that participate in team sport (Nixdorf et al., 2016; Wolanin, Hong et al., 2016). Due to varying sources of symptoms, uncommon stressors, and differences in individual circumstances, mental health clinicians must carefully consider all factors in each case when determining diagnoses and creating treatment plans.

Barriers and Resistances to Help-Seeking Behaviours Stigma associated with seeking and receiving mental health services is one of the most common barriers to treatment within the elite athlete population (Glick et al., 2020). Based on their own personal experiences or what other people have told them, athletes may believe that receiving mental health services is a sign of “weakness” or evidence of being “crazy” and therefore untrustworthy (Glick et al., 2012). Also related to stigma, responses from Australian student athletes in a 2012 study showed that poor understanding of mental health and past negative experiences in help seeking were also barriers to seeking treatment (Gulliver et al., 2012). Because of these misconceptions and misperceptions that they hold and have heard from others (family, peers, coaches, etc.), athletes may choose to not seek out mental health treatment 333

Mark A. Stillman et al.

even though they need it. Research has shown that coaches are more likely to refer their athletes to therapy for issues regarding mental health if the coach views mental health as less stigmatising, if they have greater confidence in positive outcomes from consolation, if receiving therapy is a cultural preference over other forms of treatment or no treatment for them, and if they have higher levels of openness (Stillman et al., 2016). Another barrier to help-seeking is when athletes view certain behaviours, specifically ones that would be considered by healthcare professionals as problematic, as having a positive impact on their performance in their sport. An athlete who competes in a sport that uses weight classes, such as a wrestler or a boxer, may justify negative behaviours such as restricting food consumption, purging, and overexercising as they help to maintain and cut weight leading up to contests (Bar & Markser, 2013). These same behaviours are also criteria for anorexia nervosa and bulimia nervosa. Athletes who participate in sport that emphasise strength (American football, rugby, baseball, weightlifting, etc.) may choose to deal with the side effects of anabolic steroids such as mood disturbances and inter-personal difficulties if they perceive that the steroids are helping them to build muscle and perform at a higher level (McDuff & Baron, 2005). These types of beliefs can cause strains and ruptures in the therapeutic alliance when the mental health clinician points out the negative effects of the behaviours that the athlete views as beneficial and useful (Stillman et al., 2016). Confidentiality and anonymity are key factors for clinicians to consider with high profile athletes, especially when considering group therapy as a form of treatment (Stillman et al., 2016). If these cannot be guaranteed, a more well-known athlete may be reluctant to seek this form of psychotherapy or may avoid it altogether even though it could be most effective in treating their specific mental health symptoms/disorder. It can be difficult to ensure or maintain confidentiality, for an athlete with a level of fame or recognition within their city, region, state, or country. Fear of being recognised while attending or traveling to and from treatment may be a deterrent for athletes who are more well known in their city, state, or country. Athletes that fall into this category may prefer that the clinician meets them at their home, hotel, or team facilities to participate in treatment in order to avoid potential exposure (Glick et al., 2020). This is permissible, but mental health professionals must consider the pros and cons of providing services outside of the clinical setting before agreeing to this type of arrangement (Stillman et al., 2016). This is where issues of being fully present during sessions could come in to play as the clinician may not be fully comfortable in an unfamiliar setting, or the athlete may be attempting to focus on multiple or other things such as practice, family, housework, etc. A few psychosomatic clinics in Germany have found a way to work around this issue by installing secluded or protected areas for elite athletes who are even able to check in under an alias. Some athletes may even prefer confidentiality from other close individuals that are involved in their personal lives. Individuals such as coaches, agents, trainers, and family that are accustomed to being involved in day-to-day activities in the athlete’s life may wish to be a part of the athlete’s psychoeducation and psychotherapy, but this can create complications with confidentiality if it is against the athlete’s wishes (Glick et al., 2012). Clinicians ought to be aware of barriers to help-seeking behaviours, and they should be prepared to address and discuss as well as work with the patient to reduce them.

Altered Expectations About Services Many elite athletes are used to and expect preferential treatment and accommodations that are not given to the general population such as not having to pay for meals and other services and having other people do certain daily tasks like cooking, cleaning, organising, planning, etc. for them. An athlete may have either a personal assistant or someone within their organisation that is available to them to plan their schedule, organise travel accommodations, and make other arrangements (Glick et al., 2020). A problem that clinicians can run into is when they need to speak directly with the athlete but are passed off to an assistant or other individual instead. Because of the potential of this issue occurring, we recommend direct 334

Psychotherapeutic Applications in Elite Sport

contact with the athlete in order to set the expectation that you will be working directly with the athlete and to avoid possible breakdowns in communication. Some athletes prefer that mental health providers meet them outside of the clinic for confidentiality purposes, but other athletes request this because it is what they are accustomed to. Athletes may expect this as they may have other healthcare professionals, these individuals may even work within the athlete’s organisation, provide services and consultations at team facilities or in their home. Again, mental health clinicians must weigh the advantages and disadvantages of providing services outside of the clinical setting (Stillman et al., 2016). Busy schedules and frequent traveling combined with repeated accommodations made by others may give athletes a sense that they can expect a clinician to be available to provide services to them whenever they want. This mindset can make it difficult for the clinician to work to establish and maintain boundaries if they attempt to meet an athlete’s preferences by constantly traveling to the athlete’s location and scheduling based on when it is convenient for them (Glick et al., 2020). The best arrangement is on-site employment of the team with mental health professionals (Glick et al, 2018). Many elite athletes may be financially well-off, but they are not accustomed to paying for various services (Glick et al., 2012). For example, an athlete or agent may attempt to give the clinician tickets or merchandise that is equivalent to the cost of services (Glick et al., 2012). Accepting these as an alternative to monetary payment is unethical and could lead to future issues with boundaries if both parties begin to view the relationship as more personal than professional (Glick et al., 2012). Not every athlete will expect a mental health professional to wait on them hand and foot, but there may be a tendency to anticipate general preferential treatment due to their lifestyle and day-to-day interactions with others. Regardless of the circumstance, the goal of the clinician should be to balance “flexibility with appropriate boundaries” (Glick et al., 2012). This can be accomplished by balancing the unique needs of the athlete with providing appropriate treatment based on the athlete’s diagnosis, their specific circumstances, and the context in their sport (Glick & Horsfall, 2001).

Personality Factors The elite athlete population has higher rates of narcissism and aggression as personality traits than the general population (Stillman et al., 2013). Clinicians may encounter or notice these personality traits while providing mental health services to athletes, or these personality traits may be the presenting problem for the patient who is seeking or receiving treatment. The most elite performers in their respective sport may achieve great fame and wealth during and beyond their careers as athletes. This often leads them to be held in high esteem by fans, teammates, coaches, family, and others. They are admired for their accomplishments and abilities, and people want to follow not only their sport performances but also their personal lives. With the emergence of social media, this is now easier than ever, and athletes receive even more attention and praise in addition to what they experience in-person. This can lead to ingrained narcissism and feelings of superiority as they are the centre of attention and in the spotlight both on and off the field, court, pitch, etc. (Stillman et al., 2016). Further, this could lead to feelings of invincibility as they are constantly receiving praise and adoration. They may feel that they do not need help, or they may develop unrealistic expectations about therapy (Glick et al., 2012). For example, an athlete may decide that therapy is not worth their time or effort if they are not able to see immediate results or if the therapeutic process does not feel as natural as practicing their sport or event. In more extreme cases, athletes may develop grandiose beliefs, lose their ability to empathise, and respond to real and imagined slights with fury (Stillman et al., 2016). In many ways even more importantly, is to address the problems these ‘admired and courted’ athletes experience after the end of the careers, and nobody is interested in them anymore. The task for the treating professional is to prompt them that they need not only to work on their athletic careers, but it is necessary/mandatory to develop meaningful relationships (as in friends and family) plus career interests before, during and after 335

Mark A. Stillman et al.

their athletic careers. For example, some players go into sport careers like broadcasting or coaching, while others go outside of sport into politics (Hershel Walker) or finance, business etc. Not only that, but the Guttridge study shows an increase in mental health problems in retired footballers; the implication is that brain-mind problems need to be addressed early on, before career-ending illnesses strike and leave them sick, dependent, desperate, and alone during retirement. A positive relationship has been discovered between anger, aggressiveness, general aggressive behaviour, antisocial behaviour toward opponents and teammates, and the experience and expression of anger (Sofia & Cruz, 2017). This relationship supports the previous findings that antisocial traits can often lead to outbursts of anger, especially within training, practices, and games (Stillman et al., 2016). With much of their pride being built on the praise and adoration of others, many athletes maybe successful but still have fragile and frail egos (DeFife, 2009). When that ego is threatened, whether real or imagined, it can lead to rage and aggression (Stillman et al., 2013). These threats can come from loss of praise or increase in criticism from others as athletes are subject to a cycle of praise and criticism that is uncommon in other populations (DeFife, 2009). As the ego is “injured” during the low parts of the cycle, individuals may respond with “impulsive and explosive rage” when they perceive to be threatened (DeFife, 2009). Naturally, these could occur during or after events such as a slump, mediocre performance, key mistake, defeat, or unwise decision. If not the presenting issue, clinicians should be aware that these personality traits may arise during assessment or treatment and should be prepared to work on them with the patient.

Conclusion As with any population, athletes are a unique group and have their own unique “culture” that must be considered when it comes to treatment of psychiatric symptoms and disorders. There are challenges that come with working with this population, but there are also unique factors present that make them good candidates for treatment when the clinician focuses on their strengths and circumstances. The goal of treatment always is to help improve patient functioning and in the case of athletes, help them to perform at peak levels by addressing mental health issues. Psychotherapy is a proven and commonly used method for treating these types of issues, and individual, marriage/family, and group psychotherapy are forms that have been shown to be particularly effective with elite athletes. In working with and providing mental health services to athletes, clinicians may run into various challenges that are unique to this population such as diagnostic ambiguity, barriers to help-seeking behaviours, altered expectations about services, and personality factors. Moving forward, mental health clinicians must work to find ways to reduce barriers to treatment that are unique to athletes. This begins with reducing the stigma associated with diagnosis and treatment of psychiatric symptoms and disorders and normalising the process of seeking and receiving mental health services.

References Bar, K.J., & Markser, V.Z. (2013). Sport specificity of mental disorders: The issue of sport psychiatry. European Archive of Psychiatry and Clinical Neuroscience, 263, 205–210. 10.1007/s00406-013-0458-4 Barth, J., Munder, T., Gerger, H., Nuesch, E., Trelle, S., Znoj, H., Juni, P., & Cuijpers, P. (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: A network meta-analysis. PLOS Medicine, 10(5), e1001454. 10.1371/journal.pmed.1001454 Broch, T.B., & Kristiansen, E. (2014). “The margin for error”: Ritual coping with cultural pressures. Scandinavian Journal of Medicine and Science in Sports, 24, 837–845. 10.1111/sms.12077 Butler, C.A., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. 10.1016/j.cpr.2005.07.003 Carta, M.G., Balestrieri, M., Murru, A., & Hardoy, M.C. (2009). Adjustment disorder: Epidemiology, diagnosis, and treatment. Clinical Practice and Epidemiology in Mental Health, 5, 1–15. 10.1186/1745-0179-5-15

336

Psychotherapeutic Applications in Elite Sport Chang, C.J., Putukian, M., Aerni, G., Diamond, A.B., Hong, E.S., Ingram, Y.M., Reardon, C.L., & Wolanin, A.T. (2020). American medical society for sports medicine position statement: Mental health issues and psychological factors in athletes: Detection, management, effect on performance, and prevention. Clinical Journal of Sport Medicine, 30(2), 91–95. 10.1097/JSM.0000000000000799 DeFife, J. (2009). Aggressive athletes: Out of control and unapologetic. Why do athletes lash out? And are they really sorry? The Shrink Tank, November 19. http://www.psychologytoday.com/blog/the-shrinktank/200911/aggressive-athletesout-control-and-unapologetic. Ford, J.A. (2007). Alcohol use among college students: A comparison of athletes and nonathletes. Substance Use & Misuse, 42, 1367–1377. 10.1080/10826080701212402 Glick, I.D., & Horsfall, J.L. (2001). Psychiatric conditions in sports: Diagnosis, treatment, and quality of life. The Physician and Sportsmedicine, 29, 45–55. 10.3810/psm.2001.08.913 Glick, I.D., Kamis, D., & Stull, T. (2018). The ISSP manual of sports psychiatry. Routledge Press. 10.4324/9781315211 664. Glick, I.D., Morse, E., Reardon, C.L., & Newmark, T. (2010). Sport psychiatry: A new frontier in a challenging world. Die Psychiatrie, 7, 249–253. 10.1055/s-0038-1673460 Glick, I.D., Newmark, T., & Reardon, C.L. (2013). Sports psychiatry: Current status and challenges. In D. Baron, S. Baron, & C.L. Reardon, (Eds.), Clinical sports psychiatry: An international perspective (pp. 215–218). John Wiley & Sons. 10.1002/9781118404904.ch20 Glick, I., Stillman, M., & McDuff, D. (2020). Update on integrative treatment of psychiatric symptoms and disorders in athletes. The Physician and Sportsmedicine, 48(4), 385–391. 10.1080/00913847.2020.1757370 Glick, I.D., Stillman, M.A., Reardon, C.L., & Ritvo, E. (2012). Managing psychiatric issues in elite athletes. Journal of Clinical Psychiatry, 73, 640–644. 10.4088/JCP.11r07381 Gulliver, A., Griffiths, K., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12(1), 157. 10.1186/1471-244X-12-157 Gulliver, A., Griffiths, K., Mackinnon, A., Batterham, P., & Stanimirovic, R. (2014). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Hays, K.F. (1999). Working it out: Using exercise in psychotherapy (pp. 177–187). American Psychological Association, xxi, 281. 10.1037/10333-017 Hofmann, S.G., Asnaani, A., Vonk, I.J.J., Sawyer, A.T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427–440. 10.1007/s10608-012-9476-1 Hussey, J., Donohue, B., Barchard, K., & Allen, D. (2019). Family contributions to sport performance and their utility in predicting appropriate referrals to mental health optimization programmes. European Journal of Sport Science, 19(7), 972–982. 10.1080/17461391.2019.1574906 Khantzian, E.J., & Mack, J.E. (1994). How AA works and why it’s important for clinicians to understand. Journal of Substance Abuse Treatment, 11, 77–92. 10.1016/0740-5472(94)90021-3 Leddy M.H., Lambert M.J., & Ogles B.M. (1994). Psychological consequences of athletic injury among high-level competitors. Research Quarterly for Exercise Sport, 65, 347–354. 10.1080/02701367.1994.10607639 Lindqvist, A.-S., Moberg, T., Ehrnborg, B.O., Eriksson, C., Fahlke, C., & Rosen, T. (2014). Increased mortality rate and suicide in Swedish former elite male athletes in power sports. Scandinavian Journal of Medicine and Science in Sports, 24, 1000–1005. 10.1111/sms.12122 Markowitz, J.C. (2014). What is supportive psychotherapy? Focus, 12, 285–289. 10.1176/appi.focus.12.3.285 McDuff, D.R., & Baron, D. (2005). Substance use in athletes: A sports psychiatry perspective. Clinics in Sports Medicine, 24, 885–897. 10.1016/j.csm.2005.06.004 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893 Putukian, M. (2016) The psychological response to injury in student athletes: A narrative review with a focus on mental health. British Journal of Sports Medicine, 50, 145–148. 10.1136/bjsports-2015-095586 Quinn, A.M., & Fallon, B.J. (1999). The changes in psychological characteristics and reactions of elite athletes from injury onset until full recovery. Journal of Applied Sport Psychology, 11, 210–229. 10.1080/10413209908404201 Reardon, C.L., & Factor R.M. (2010). Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Medicine, 40, 961–980. 10.2165/11536580-000000000-00000 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Sofia, R. & Cruz, J.F.A. (2017). Unveiling anger and aggression in sports: The effects of type of sport, competitive category, and success level. Revista de Psicología Del Deporte, 26(2), 21–28.

337

Mark A. Stillman et al. Stillman, M.A., Brown, T., Ritvo, E.C., & Glick, I.D. (2016). Sport psychiatry and psychotherapeutic intervention, circa 2016. International Review of Psychiatry, 28(6), 614–622. 10.1080/09540261.2016.1202812 Stillman, M., Glick, I., McDuff, D., Reardon, C., Hitchcock, M., Fitch, V., & Hainline, B. (2019). Psychotherapy for mental health symptoms and disorders in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 767–771. 10.1136/bjsports-2019-100654 Stillman, M.A., Ritvo, E., & Glick, I.D. (2013). Psychotherapeutic treatment of athletes and their significant others. In D. Baron, S. Baron, & C.L. Reardon (Eds.), Clinical sports psychiatry: An international perspective (pp. 115–123). John Wiley & Sons, UK. 10.1002/9781118404904.ch11 Walker, D.D., Roffman, R.A., Stephens, R.S., Berghuis, J., & Kim, W. (2006). Motivational enhancement therapy for adolescent marijuana users: A preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 628–632. 10.1037/0022-006X.74.3.628 Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50(3), 167–171. 10.1136/bjsports-2015-095756

338

22 RECOVERY AS THE CENTREPIECE FOR MENTAL HEALTH PROMOTION IN ELITE ATHLETES Jahan Heidari and Michael Kellmann

Introduction Many young athletes dream about being a professional elite athlete in their sport discipline at some point during their sporting career. The status of an elite athlete is often associated with a number of benefits such as financial incentives, great athletic accomplishments, media presence, or the possibility to travel all around the world to participate in various competitions (Lee, 2014). Undoubtedly, these amenities are present among elite athletes and contribute to an exciting and multi-faceted life. On the downside, these aspects are only reflecting the reality for a selected cohort of athletes who range among the absolute best within their profession. And even for them, the path to the top is accompanied by a lot of blood, sweat, and tears with numerous challenges and setbacks (Kliethermes et al., 2020; Sabato et al., 2016). The majority of promising talents drop out of a career in sport due to an overload of physical and psychological demands in the professional sport environment. Injuries, the incompatibility of sport and school/ profession, or a growing loss of motivation can be considered as factors contributing to a termination of a sporting career (Baron-Thiene & Alfermann, 2015; Isoard-Gautheur et al., 2016; Stambulova et al., 2007). Athletes are confronted with a myriad of demands resulting from severe and extensive training regimes, a high-pressure competitive environment, and constant media coverage with frequent and often critical evaluations (Hayes et al., 2020; Reardon et al., 2019; Sabato et al., 2016). As a whole, these unfavourable influences accumulate, unbalance the organism, and contribute to the deterioration of the mental well-being of athletes. Rice et al. (2016) conducted a narrative systematic review on the topic of mental health in elite athletes and found that the prevalence of mental disorders such as anxiety disorders or depression is comparable to the general population.

The Impact of COVID-19 on Athletes In addition to the existing plethora of diverse challenges for elite athletes, unforeseen significant and extensive global changes stemming from the recent emergence and spread of the coronavirus disease (COVID-19) have arisen. The outbreak of COVID-19 has led to a worldwide health crisis influencing individuals all over the world from an emotional, economical, and social perspective. Since the first appearance of COVID-19, several recommendations for the containment of the disease and the prevention of infections have been developed which have been destabilising people’s perception of control and have limited regular social functioning in a meaningful manner (World Health Organization, 2020). The implemented safety measures DOI: 10.4324/9781003099345-30

339

Jahan Heidari and Michael Kellmann

all aim at reducing physical contacts through the prohibition of mass gatherings, periods of confinement, maintaining at least a 1-meter distance between yourself and others, and wearing a mask in order to avoid a collapse of health systems in countries all across the world (Steinacker et al., 2020). Given these notable restrictions in everyday life, the pandemic can be considered as a significant additional stressor affecting athletes on all performance levels in various regards. Training and competition schedules have been altered as a result of the cancellation and postponement of important and global competitions such as the Olympic Games in Tokyo 2020. The world of sport was basically shut down for about two months in April and May of the year 2020 until hygiene concepts and measures without on-site audiences were developed and put into practice (Garcia-Garcia et al., 2020). As detrimental consequences, issues of social isolation have risen among athletes and career transitions have been complicated considerably, especially in contact sports (Schinke et al., 2020; Toresdahl & Asif, 2020). Many athletes were left without a clear perspective and felt irritated by uncertainty and unpredictability (di Fronso et al., 2020; Samuel et al., 2020). According to Rice et al. (2016), the occurrence of significant negative life events such as COVID-19 may increase the prevalence of mental illness and may aggravate the course of the diseases.

Mental Health in Athletes Mental disorders encompass a wide range of different conditions such as affective disorders, substance abuse disorders, eating disorders, or somatic symptom disorders (Steel et al., 2014; Wittchen et al., 2011). Prevalence data, costs, and consequences associated with mental disorders are varying depending on the target population and study design used in the respective mental health survey or systematic review. However, they all have in common that mental disorders represent a global problem among all age groups and gender which warrants the universal promotion of mental health (Merikangas et al., 2010; Substance Abuse and Mental Health Services Administration, 2020; Wittchen et al., 2011). According to the Global Burden of Disease Study (Whiteford et al., 2015), mental disorders are responsible for the largest proportion of disability-adjusted life years (56.7%) while approximately 971 million people worldwide are affected by mental disorders (James et al., 2018). While the evidence for an considerable increase in mental health problems in the recent years is mixed (Baxter et al., 2014), the current situation concerning the COVID-19 pandemic might function as a catalyst for mental health issues (Czeisler et al., 2020). While a significant body of research has emerged focusing on the examination of mental health in the general population, there is room for improvement when it comes to the demographic of (elite) athletes. However, there is a number of studies that have investigated mental health in athletes from an epidemiological and interventional point of view (Foskett & Longstaff, 2018; Nixdorf et al., 2013; Rice et al., 2016). Reardon et al. (2019) provided an overview of mental health in elite athletes using a combination of an expert-driven and literature-based approach. The authors noted that the comparability of the studies remains an issue due to limiting factors such as the heterogeneity of the assessment or the lack of consideration of cultural differences. However, for many psychiatric disorders such as anxiety disorders or sleep disorders, Reardon et al. (2019) delineate background information on the development of these conditions and suggest potential interventions. Other studies allude to the prevalence of mental disorders in relation to variables such as type of sport (i.e., team vs. individual sport) as well as gender. Nixdorf et al. (2013) reported an overall prevalence of 15% for depression in German elite athletes, with individual athletes showing more depressive symptoms than team sport athletes (Nixdorf et al., 2016). These results align with findings for the athletic population in other countries such as France, Australia, and the United Kingdom (UK). Anxiety disorders, eating disorders, and depressive disorders are consistently registered among the most prevalent conditions for athletes in these three countries, while differences are reported between male and female athletes as well as type of sport (Foskett & Longstaff, 2018; Gulliver et al., 2015; Schaal et al., 2011). For example, Schaal et al. (2011) stated that female athletes displayed a higher prevalence for the above-mentioned disorders and that the category of sport was associated with certain 340

Mental Health Promotion in Elite Athletes

patterns of psychiatric disorders (e.g., eating disorders in racing sport). Taking all these different influences together, it can be summarised that mental health is a highly relevant topic for athletes, both in terms of performance and well-being which deserves even more attention from a research point of view (Rice et al., 2016; Schinke et al., 2018). While the majority of studies focuses on the identification of potential risk factors for mental health issues and subsequent interventions, this chapter aims to integrate a pro-active approach which might serve as a meaningful perspective to preventively manage mental health in (elite) athletes. The interrelatedness of stress and recovery should be discussed regarding mental health with a focus on preventing detrimental developments through adequate monitoring and timely interventions.

The Relationship Between Recovery, Stress, and Well-Being Physical and psychological well-being is the foundation of long-term health and elite performance in athletes (Heidari et al., 2019; Reardon et al., 2019). In order to allow comprehensive well-being for athletes, it is pivotal to map out risk and protective factors that either threaten or promote well-being and mental health in athletes. One of the most prevalent and influential factor to ensure healthy athletes is recovery (Heidari et al., 2019; Kuettel & Larsen, 2020; Nixdorf et al., 2013). Recovery is characterised as an inter- and intraindividual multilevel (e.g., psychological, physiological, social) process in time for the re-establishment of personal resources and their full functional capacity. Recovery includes a broad range of physiological processes like sleep, motivated behavior (like eating and drinking) and goal-oriented components (like relaxation or meeting friends). Recovery activities can be passive or active and in many instances recovery is achieved indirectly by activities, which stimulate recovery processes like active sports. (Kallus, 2016, p. 42) Normally, the human organism is in a state of homeostasis in which recovery and stress are keeping a balance. Especially in elite sport, this equilibrium rarely remains for long since stressors such as training schedules, appointments with the media or competitions affect the homeostasis. Taking the current NBA schedule as an example, teams are facing each other roughly every two days as a result of the of the postponed season due to the COVID-19 pandemic. Apart from the physical stressors in terms of intense games against elite opponents, psychological stressors such as constant travel or pressure to perform also place a burden on the players. In order to maintain a high level of performance, it is pivotal for athletes to regain their resources through adequate recovery activities. Kellmann (2002) delineates that this continuing and cumulative process can consist of a change of, a reduction of, or a break from stress (e.g., sitting out a game). The relationship between stress and recovery can be best described as intertwined and mutually dependent. The interplay of these factors in terms of ensuring the right amounts of stress and the respective compensation through recovery can best be achieved when contemplating all influences that potentially impact performance (Heidari et al., 2019). For athletes, these encompass lifestyle (e.g., recreational activities, sleeping habits, diet, fluid balance), health status (e.g., cold, infections, ailments), training (e.g., intensity, frequency, volume), and the environment (e.g., team members, coaching staff). A lack of understanding the importance of the recovery-stress balance may result in detrimental consequences such as sleep disturbances, inadequate time management, or wrong training priorities. In case sufficient recovery cannot be ensured, the constant exposition to this myriad of demands will ultimately exceed the resources and coping mechanisms of athletes. At the end of the chain, both the physical and mental health of athletes is threatened through injuries, underrecovery, the overtraining syndrome, or even the burnout syndrome (Gustafsson et al., 2017; Heidari et al., 2019; Heidari et al., 2022; Kellmann et al., 2018). 341

Jahan Heidari and Michael Kellmann

Recovery and Stress Monitoring for Mental Health Prevention in Athletes The procedures in modern elite sport encompass a variety of different elements such as meticulous planning of training sessions or detailed video analyses before and after competitions. Another integral part of performance enhancement in many sport disciplines consists of the collection of data as a means of identifying patterns in behaviour and health. These monitoring methods aim at the evaluation of training and competition loads and individual responses to the concomitants of being an athlete. On a methodological level, both objective and subjective tools are used for monitoring and ideally complement each other in order to gather a thorough picture of athletic performance as well as physical and mental health (Heidari et al., 2019; Kellmann et al., 2018; Saw et al., 2017). While the monitoring of recovery and stress is predominantly aiming at the assessment of performancerelated developments, its usefulness as a supportive strategy for mental health promotion through gathering subjective data should be elaborated. Therefore, the focus lies on subjective monitoring instruments through self-report rather than objective measures such as creatine kinase or urea (Lee et al., 2017). The indisputable value of such objective measures in athletic contexts should not be discarded. Rather, it should be noted that the usage of such measures plays only a secondary role in mental health assessment, which traditionally relies on self-report via screening instruments such as the Patient Health Questionnaire 9 (PHQ-9; Kroenke et al., 2001) and clinical interviews such as the Structured Clinical Interview for DSM Disorders (SCID; First et al., 2016) to assess important markers of mental health such as the type of symptoms or symptom duration (Sommers-Flanagan et al., 2020; Zimmerman, 2019). Independent of the context, the assessment of subjective conditions should be based on scientifically validated psychometric questionnaires which fulfil the criteria of scientific rigor and practicability in sport contexts. To clarify, the presented questionnaires for the assessment of recovery and stress in athletic populations cannot be employed as diagnostic instruments for mental health for two reasons. First, the personnel having the required professional competence to diagnose mental health disorders is rarely present and available in sport contexts. Second, these instruments were not designed and developed to diagnose and evaluate mental health. Preferably, they should be used as indicators and auxiliaries for detecting detrimental developments of well-being using recovery-stress values. As such, these instruments can exhibit a benefit and should be used and considered as a puzzle piece for mental health prevention in sport. The selection of the self-report measures to be presented was based on two reasons: a) most commonly used across studies in sport settings, and b) underlying potential for mental health prevention (Jeffries et al., 2020; McGuigan et al., 2020; Saw et al., 2016). The Recovery-Stress Questionnaire for Athletes (RESTQ-Sport; Kellmann & Kallus, 2016) can be implemented to measure the recovery-stress balance of athletes from various perspectives. This psychometric instrument provides an overview of sport-specific as well as external factors (e.g., social interactions) in relation to well-being, resulting in a profound evaluation of potential resources and stressors of the respondent. All statements in the questionnaire are introduced with the phrase “In the past (3) days/nights …” and responses can be marked on a 7-point Likert scale ranging from 0 (never) to 6 (always). The RESTQSport encompasses 19 scales including overall recovery (Success, Social Recovery, Physical Recovery, General Well-being, Sleep Quality) and overall stress (General Stress, Emotional Stress, Social Stress, Conflicts/Pressure, Fatigue, Lack of Energy, Physical Complaints) as well as sport-specific recovery (Being in Shape, Personal Accomplishment, Self-Efficacy, Self-Regulation) and sport-specific stress (Disturbed Breaks, Emotional Exhaustion, Injury). All scales can be illustrated visibly in a profile indicating the recovery-stress balance. Considering the length of the original version of the RESTQ-Sport with 76 items, a highly frequent monitoring (e.g., daily) is not advised and does not correspond to the core idea of the instrument. The usage rate should be decided on in consultation with the entire coaching staff and together with the athletes in order to achieve compliance. A higher degree of compliance can be realised using the abbreviated version consisting of only 36 items with 12 scales. This consideration is of particular interest from a mental health standpoint, where honest and self-reflective responses become even more important 342

Mental Health Promotion in Elite Athletes

(Kellmann & Kallus, 2016). The applicability of the RESTQ-Sport as monitoring instrument for recovery and stress as well as a gauge of a deterioration of mental health and well-being has been outlined in several publications (Fagundes et al., 2019; Laux et al., 2015; Nicolas et al., 2019). Kellmann and Kallus (2016) also report a number of psychometric quality criteria regarding objectivity, reliability, and validity. Next, the Acute Recovery and Stress Scale (ARSS; Kellmann & Kölling, 2019; Kellmann et al., 2016; Kölling et al., 2019) was developed to assess the acute recovery-stress states of athletes in a valid, sportspecific, and economical way. The ARSS consists of a list of 32 adjectives which are assigned to eight scales of physical, mental, emotional, and overall recovery and stress. Although the ARSS represents a relatively new tool for recovery and stress monitoring, recent studies came to the conclusion that the ARSS could serve as a sensitive instrument to indicate acute fluctuations in recovery and stress in various settings (Hagen et al., 2020; Travis et al., 2020). Coaches who use the ARSS with their athletes will obtain valuable information about the recovery-stress state of athletes as a response to training or competion. This data can be utilised to adapt the training schedule on both an individual or team level. By regularly measuring the athlete’s individual developments of the recovery-stress state, overload symptoms as precursors of negative long-term developments of mental health can be identified at an early stage. Based on these monitoring results, appropriate intervention plans can be initiated. Additionally, Kellmann et al. (2016) report good internal consistencies and internal validity indicators in their manual for the German as well as for the English version (Kellmann & Kölling, 2019). The Short Recovery and Stress Scale (SRSS; Kellmann & Kölling, 2019; Kellmann et al., 2016; Kölling et al., 2020) was developed as a modified short version of the ARSS and is comprised of eight items (Short Recovery Scale: Physical Performance Capability, Mental Performance Capability, Emotional Balance, Overall Recovery; Short Stress Scale: Muscular Stress, Lack of Activation, Negative Emotional State, Overall Stress). The short completion time makes the SRSS an ideal tool for practical settings especially for repeated measurements within short intervals (e.g., multiple times a week; Pelka et al., 2018) while the SRSS also fulfills psychometric requirements such as good internal consistency values (Kellmann et al., 2016). In the sportscientific practice, the SRSS offers a nuanced picture of the individual recovery-stress state of athletes. This can be used for training modifications and to prevent overload and overtraining. It should be noted that the usage of the SRSS is best combined with occasional data collection using the ARSS, since the ARSS provides a more in-depth picture of the current balance between recovery and stress. A combined implementation of both instruments can be considered as a feasible way of documenting changes in recovery and stress in athletic populations in an applicable manner (Heidari et al., 2019; Kellmann & Kölling, 2019). Over the last decades of training monitoring research, the Profile of Mood States (POMS; McNair et al., 1992) has been used in many studies in athletic and non-athletic populations (McGuigan et al., 2020; Nässi et al., 2017). The POMS allows the assessment of six mood dimensions (i.e., Tension, Depression, Anger, Vigour, Fatigue, Confusion), which can be portrayed as an ‘iceberg-profile’. A neat characteristic of the POMS is the adaptability of the instruction via four different versions, namely How have you been feeling during the past week including today – generally – right now depending on the scope and purpose of usage (Nässi et al., 2017). Mood disturbances can be detected as a result of training or competition which makes the POMS a useful tool to implement for mental health monitoring (Jeffries et al., 2020). It provides a multi-dimensional view on mood, fulfils psychometric requirements for validity and reliability, and can therefore serve as a complement to monitoring instruments such as the RESTQ-Sport or the ARSS which genuinely focus on recovery and stress. It also has to be noted critically that the POMS was originally designed for the clinical setting. Additionally, the original version consists of 65 items which represents a problem in time-efficient sport settings (Nässi et al., 2017). Finally, the Daily Analysis of Life Demands for Athletes (DALDA; Rushall, 1990) is a two-part self-report measure which focuses on athlete’s stress state and its influenceability by internal and external stressors. Part A assesses nine sources of stress (e.g., training and exercise, health). Part B surveys 25 symptoms of stress (e.g., recovery time). The scoring mode for both the sources and symptoms of stress range from worse 343

Jahan Heidari and Michael Kellmann

than normal, to normal to better than normal. The evaluation is done graphically on a timeline which facilitates an intuitive comparison of the results with previous data. The meaningfulness of the results can be increased through repeated measurements. Three consecutive days with ’worse than normal’ responses regarding certain stressors might indicate a deteriorating condition that needs an intervention. The DALDA remains a feasible instrument in sport settings due to its sensitivity to sport-specific and general changes in stress (Jeffries et al., 2020; Saw et al., 2016). Another strength of the DALDA consists in its ability to detect sources of stress and stressors that are related to both sport and non-sport settings. In their overview on self-report measures in sport, Nässi et al. (2017) report that the DALDA covers a wide range of influences on athletes, represents an intuitive tool which is easy to use in sport, and can be considered as a psychometrically sound questionnaire.

Practical Implications Mental health has long been considered a taboo topic in the general population and particularly in sport. Due to a shift towards more openness to mental health in sport, a significant body of research on prevalence, potential risk factors, and preventive measures has accumulated. Athletes across a variety of sports have started to talk about their mental health related to their status as elite athletes, paving the way for mental health data to be collected. A couple of review articles (Reardon et al., 2019; Rice et al., 2016; Schinke et al., 2018) are now available which provide a comprehensive overview of mental health in sport and elaborate on specific characteristics such as sport discipline, age group, or gender. This positive development even leads to books, such as the present, which entirely focus on mental health in athletes, thereby examining the topic from different perspectives. With regard to the contribution of recovery and stress for mental health promotion in athletes, its importance for prevention in terms of regular monitoring should be noted (Heidari et al., 2019). While the previously described subjective, psychometric questionnaires are not suited for mental health diagnostics, they do have potential in the context of mental health in athletic populations. Using these instruments in a systematic and thought-out manner, they can draw the attention to detrimental changes in recovery and stress. Both concepts have been linked to health-related outcomes such as underrecovery, overtraining, or burnout (Gustafsson et al., 2017; Kellmann & Beckmann, 2022; Kellmann et al., 2018). From a practical perspective, this means that a monitoring system should ideally be implemented in teams, academies, and institutions in applied sport environments. Such a monitoring programme needs to be established and maintained by qualified personnel (i.e., sport psychologists, sport scientists with psychological training) and should be complemented by mental health screening instruments (e.g., PHQ-9) having a scientific foundation in non-athlete populations. This combination allows the integration and observation of both sport-specific and general factors impacting mental health in the demographic of athletes. For more detailed considerations on how to establish a functioning and effective monitoring system, see Table 22.1. Another aspect which has been addressed in the context of mental health promotion among athletes is the implementation of educational workshops (Moesch et al., 2018). Such workshops with the overriding topic mental health can be facilitated through knowledge dissemination regarding stress management and recovery enhancement as protective factors for mental health. For example, recovery and stress monitoring data can be extracted and analysed collectively with athletes. Based on this collaborative evaluation, strategies to improve recovery and mental health can be discussed and taught (e.g., relaxation techniques) (Heidari et al., 2018; Purcell et al., 2019). The final piece of the puzzle related to recovery and stress monitoring and mental health in sport settings is connected to dealing with possible cases of clinically relevant mental health issues. A well-functioning monitoring system should not only serve as a tool for performance improvement, but also as an auxiliary to identify potential detrimental mental health developments, especially by adding mental health screening questionnaires (Moesch et al., 2018). The affected athletes should have the possibility to receive adequate and 344

Mental Health Promotion in Elite Athletes Table 22.1 Guidelines for the Establishment of a Monitoring System in the Context of Sport Topic

Considerations

Type of monitoring data Collection of monitoring data

• • • • • • • • •

Usage of monitoring data

Responsibility for the monitoring data

Communication and status of monitoring data

• • • • •

subjective (e.g., questionnaires) vs. objective (e.g., urea) paper-pencil vs. digitally (e.g., app-based) frequency (e.g., daily, weekly) time of day (e.g., in the morning) data privacy individual (i.e., each player) vs. collective (i.e., entire team) evaluations type of feedback (e.g., reports, personal meeting, visual presentation) accessibility (e.g., sport psychologist, athletic trainer, head coach) “head of monitoring” vs. individual assignments (e.g., sport psychologist for subjective data) implementation of the data collection analysis of the data illustration of the importance and benefits of the monitoring data acceptance of monitoring system among stakeholders (e.g., coaches) acceptance of monitoring approach among target group (i.e., athletes)

qualified help without long delays. Partnerships with mental health professionals, hospitals, or outpatient facilities should be organised to guarantee a straightforward referral to clinically trained psychologists or psychiatrists. Ideally, these mental health professionals should have knowledge on the specific circumstances of athletes (see Stillman et al., this volume). Such collaborations result in a comprehensive mental health care for athletes and reduce the psychological barriers for seeking help among athletes. In a youth sport setting, collaborations should be established with specialised institutions accordingly.

Summary and Future Directions An atmosphere of trust and transparency in the respective setting serves as basis for all of the abovementioned steps to ensure the promotion, maintenance, and adequate handling of mental health. It should be enshrined in the core values of each institution that mental health is of paramount importance and that all individuals involved in the organisation are considering well-being as priority and prerequisite for performance. More importantly, active athletes need to experience in their daily athletic routine that mental health is not only an issue of significance on paper but is authentically entrenched in all processes. If such a development is advanced in (elite) sport, research and practice are continuing to benefit equally. Trust and openness from all parties in sport will most likely lead to increased possibilities to gather more mental health data in sport settings. This should result in a better understanding of mental health issues and its ramifications in sport, a higher presence of the topic in the media, and ultimately in more effective ways to promote mental health in athletes and design tailored interventions for that demographic group (Breslin et al., 2017; Kuettel & Larsen, 2020; Purcell et al., 2019).

References Baron-Thiene, A., & Alfermann, D. (2015). Personal characteristics as predictors for dual career dropout versus continuation – A prospective study of adolescent athletes from German elite sport schools. Psychology of Sport and Exercise, 21, 42–49. 10.1016/j.psychsport.2015.04.006 Baxter, A.J., Scott, K.M., Ferrari, A.J., Norman, R.E., Vos, T., & Whiteford, H.A. (2014). Challenging the myth of an “epidemic” of common mental disorders: Trends in the global prevalence of anxiety and depression between 1990 and 2010. Depression & Anxiety, 31(6), 506–516. 10.1002/da.22230

345

Jahan Heidari and Michael Kellmann Breslin, G., Shannon, S., Haughey, T., Donnelly, P., & Leavey, G. (2017). A systematic review of interventions to increase awareness of mental health and well-being in athletes, coaches and officials. Systematic Reviews, 6(1), 177. 10.1186/s13643-017-0568-6 Czeisler, M. É., Lane, R.I., Petrosky, E., Wiley, J.F., Christensen, A., Njai, R., … Rajaratnam, S.M.W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049–1057. 10.15585/mmwr.mm6932a1 di Fronso, S., Costa, S., Montesano, C., Di Gruttola, F., Ciofi, E.G., Morgilli, L., … Bertollo, M. (2020). The effects of COVID-19 pandemic on perceived stress and psychobiosocial states in Italian athletes. International Journal of Sport and Exercise Psychology, 20(1), 1–13. 10.1080/1612197X.2020.1802612 Fagundes, L.H.S., Noce, F., Albuquerque, M.R., de Andrade, A.G.P., & Teoldo da Costa, V. (2019). Can motivation and overtraining predict burnout in professional soccer athletes in different periods of the season? International Journal of Sport and Exercise Psychology, 19(2). 10.1080/1612197X.2019.1655778 First, M.B., Williams, J.B.W., Karg, R.S., & Spitzer, R.L. (2016). User’s guide for the SCID-5-CV Structured Clinical Interview for DSM-5® disorders: Clinical version. American Psychiatric Association. Foskett, R.L., & Longstaff, F. (2018). The mental health of elite athletes in the United Kingdom. Journal of Science and Medicine in Sport, 21(8), 765–770. 10.1016/j.jsams.2017.11.016 Garcia-Garcia, B., James, M., Koller, D., Lindholm, J., Mavromati, D., Parrish, R., & Rodenberg, R. (2020). The impact of Covid-19 on sports: A mid-way assessment. The International Sports Law Journal, 20(3), 115–119. 10.1 007/s40318-020-00174-8 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18, 255–261. 10.1016/j.jsams.2014.04.006 Gustafsson, H., DeFreese, J.D., & Madigan, D.J. (2017). Athlete burnout: Review and recommendations. Current Opinion in Psychology, 16, 109–113. 10.1016/j.copsyc.2017.05.002 Hagen, J., Stone, J.D., Hornsby, W.G., Stephenson, M., Mangine, R., Joseph, M., & Galster, S. (2020). COVID-19 surveillance and competition in sport: Utilizing sport science to protect athletes and staff during and after the pandemic. Journal of Functional Morphology and Kinesiology, 5(3), 69. 10.3390/jfmk5030069 Hayes, M., Filo, K., Geurin, A., & Riot, C. (2020). An exploration of the distractions inherent to social media use among athletes. Sport Management Review, 23(5), 852–868. 10.1016/j.smr.2019.12.006 Heidari, J., Beckmann, J., Bertollo, M., Brink, M., Kallus, K.W., Robazza, C., & Kellmann, M. (2019). Multidimensional monitoring of recovery status and implications for performance. International Journal of Sports Physiology and Performance, 14(1), 2–8. 10.1123/ijspp.2017-0669 Heidari, J., Jakowski, S., & Kellmann, M. (2022). The value of recovery-stress monitoring for athletes’ well-being. In M. Kellmann & J. Beckmann (Eds.), Recovery and well-being in sport and exercise (pp. 3–16). Routledge. Heidari, J., Kölling, S., Pelka, M., & Kellmann, M. (2018). Monitoring the recovery-stress state in athletes. In M. Kellmann & J. Beckmann (Eds.), Sport, recovery and performance: Interdisciplinary insights (pp. 3–18). Routledge. Isoard-Gautheur, S., Guillet-Descas, E., & Gustafsson, H. (2016). Athlete burnout and the risk of dropout among young elite handball players. The Sport Psychologist, 30(2), 123–130. 10.1123/tsp.2014-014010.1123 James, S.L., Abate, D., Abate, K.H., Abay, S.M., Abbafati, C., Abbasi, N., … Murray, C.J.L. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. The Lancet, 392(10159), 1789–1858. 10.1016/S0140-6736(18)32279-7 Jeffries, A.C., Wallace, L., Coutts, A.J., McLaren, S.J., McCall, A., & Impellizzeri, F.M. (2020). Athlete-reported outcome measures for monitoring training responses: A systematic review of risk of bias and measurement property quality according to the COSMIN guidelines. International Journal of Sports Physiology and Performance, 15(9), 1203–1215. 10.1123/ijspp.2020-0386 Kallus, K.W. (2016). Stress and recovery: An overview. In K.W. Kallus & M. Kellmann (Eds.), The Recovery-Stress Questionnaires: User manual (pp. 27–48). Pearson Assessment & Information GmbH. Kellmann, M. (2002). Underrecovery and overtraining: Different concepts - similar impact? In M. Kellmann (Ed.), Enhancing recovery: Preventing underperformance in athletes (pp. 3–24). Human Kinetics. Kellmann, M., & Beckmann, J. (Eds.). (2022). Recovery and well-being in sport and exercise (Series: Advances in recovery and stress research: Multi-disciplinary approaches. Edited by M. Kellmann & J. Beckmann, Vol. 1. Routledge. Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A.J., Duffield, R., … Beckmann, J. (2018). Recovery and performance in sport: Consensus statement. International Journal of Sports Physiology and Performance, 13, 240–245. 10.1123/ijspp.2017-0759 Kellmann, M., & Kallus, K.W. (2016). Recovery-stress questionnaire for athletes. In K.W. Kallus & M. Kellmann (Eds.), The Recovery-Stress Questionnaires: User manual (pp. 86–131). Pearson Assessment.

346

Mental Health Promotion in Elite Athletes Kellmann, M., & Kölling, S. (2019). Recovery and stress in sport: A manual for testing and assessment. Routledge. 10.4324/ 9780429423857 Kellmann, M., Kölling, S., & Hitzschke, B. (2016). Das Akutmaß und die Kurzskala zur Erfassung von Erholung und Beanspruchung im Sport. Sportverlag Strauß Kölling, S., Schaffran, P., Bibbey, A., Drew, M., Raysmith, B., Nässi, A., & Kellmann, M. (2019). Validation of the acute recovery and stress scale (ARSS) and the short recovery and stress scale (SRSS) in three English-speaking regions. Journal of Sports Sciences, 38, 130–13910.1080/02640414.2019.1684790. Kliethermes, S.A., Nagle, K., Côté, J., Malina, R.M., Faigenbaum, A., Watson, A., … Jayanthi, N. (2020). Impact of youth sports specialisation on career and task-specific athletic performance: A systematic review following the American Medical Society for Sports Medicine (AMSSM) collaborative research network’s 2019 youth early sport specialisation summit. British Journal of Sports Medicine, 54(4), 221. 10.1136/bjsports-2019-101365 Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x Kuettel, A., & Larsen, C.H. (2020). Risk and protective factors for mental health in elite athletes: A scoping review. International Review of Sport and Exercise Psychology, 13(1), 231–265. 10.1080/1750984X.2019.1689574 Laux, P., Krumm, B., Diers, M., & Flor, H. (2015). Recovery-stress balance and injury risk in professional football players: A prospective study. Journal of Sports Sciences, 33(20), 2140–2148. 10.1080/02640414.2015.1064538 Lee, A. (2014). 20 cool perks of being a pro athlete. Bleacher Report. Retrieved November 13, 2020, from https:// bleacherreport.com/articles/1963776-20-cool-perks-of-being-a-pro-athlete Lee, E.C., Fragala, M.S., Kavouras, S.A., Queen, R.M., Pryor, J.L., & Casa, D.J. (2017). Biomarkers in sports and exercise: Tracking health, performance, and recovery in athletes. The Journal of Strength and Conditioning Research, 31(10), 2920–2937. 10.1519/JSC.0000000000002122 McGuigan, H., Hassmén, P., Rosic, N., & Stevens, C.J. (2020). Training monitoring methods used in the field by coaches and practitioners: A systematic review. International Journal of Sports Science and Coaching, 15(3), 439–451. 10.1177/1747954120913172 McNair, D.M., Lorr, M., & Droppleman, L.F. (1992). Revised manual for the Profile of Mood States. Educational and Industrial Testing Service. Merikangas, K.R., He, J.P., Burstein, M., Swanson, S.A., Avenevoli, S., Cui, L., … Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989. 10.1016/j.jaac.2010.05.017 Moesch, K., Kenttä, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Nässi, A., Ferrauti, A., Meyer, T., Pfeiffer, M., & Kellmann, M. (2017). Psychological tools used for monitoring training responses of athletes. Performance Enhancement & Health, 5(4), 125–133. 10.1016/j.peh.2017.05.001 Nicolas, M., Vacher, P., Martinent, G., & Mourot, L. (2019). Monitoring stress and recovery states: Structural and external stages of the short version of the RESTQ sport in elite swimmers before championships. Journal of Sport and Health Science, 8(1), 77–88. 10.1016/j.jshs.2016.03.007 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893 Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. 10.1123/jcsp.7.4.313 Pelka, M., Schneider, P., & Kellmann, M. (2018). Development of pre- and post-match morning recovery-stress states during in-season weeks in elite youth football. Science and Medicine in Football, 2(2), 127–132. 10.1080/24733 938.2017.1384560 Purcell, R., Gwyther, K., & Rice, S.M. (2019). Mental health in elite athletes: Increased awareness requires an early intervention framework to respond to athlete needs. Sports Medicine - Open, 5(1), 46. 10.1186/s40798-019-0220-1 Reardon, C.L., Hainline, B., Aron, C.M., Baron, D., Baum, A.L., Bindra, A., … Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement. British Journal of Sports Medicine, 53(11), 667–699. 10.1136/bjsports-2019-100715 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Rushall, B.S. (1990). A tool for measuring stress tolerance in elite athletes. Journal of Applied Sport Psychology, 2(1), 51–66. 10.1080/10413209008406420.

347

Jahan Heidari and Michael Kellmann Sabato, T.M., Walch, T.J., & Caine, D.J. (2016). The elite young athlete: Strategies to ensure physical and emotional health. Open Access Journal of Sports Medicine, 7, 99–113. 10.2147/OAJSM.S96821 Samuel, R.D., Tenenbaum, G., & Galily, Y. (2020). The 2020 Coronavirus pandemic as a change-event in sport performers’ careers: Conceptual and applied practice considerations. Frontiers in Psychology, 11(2522). 10.3389/ fpsyg.2020.567966 Saw, A.E., Kellmann, M., Main, L.C., & Gastin, P.B. (2017). Athlete self-report measures in research and practice: Considerations for the discerning reader and fastidious practitioner. International Journal of Sports Physiology and Performance, 12(Suppl 2), S2127–S2135. 10.1123/ijspp.2016-0395 Saw, A.E., Main, L.C., & Gastin, P.B. (2016). Monitoring the athlete training response: Subjective self-reported measures trump commonly used objective measures: A systematic review. British Journal of Sports Medicine, 50(5), 281–291. 10.1136/bjsports-2015-094758 Schaal, K., Tafflet, M., Nassif, H., Thibault, V., Pichard, C., Alcotte, M., … Toussaint, J.-F. (2011). Psychological balance in high level athletes: Gender-based differences and sport-specific patterns. PLoS ONE, 6(5), e19007. 10.1371/journal.pone.0019007 Schinke, R., Papaioannou, A., Henriksen, K., Si, G., Zhang, L., & Haberl, P. (2020). Sport psychology services to high performance athletes during COVID-19. International Journal of Sport and Exercise Psychology, 18(3), 269–272. 10.1080/1612197X.2020.1754616 Schinke, R.J., Stambulova, N.B., Si, G., & Moore, Z. (2018). International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622–639. 10.1080/1612197X.2017.1295557 Sommers-Flanagan, J., Johnson, V.I., & Rides At The Door, M. (2020). Clinical interviewing. In M. Sellbom & J.A. Suhr (Eds.), The Cambridge handbook of clinical assessment and diagnosis (pp. 113–122). Cambridge University Press. Stambulova, N., Stephan, Y., & Japhag, U. (2007). Athletic retirement: A cross-national comparison of elite French and Swedish athletes. Psychology of Sport & Exercise, 8(1), 101–118. 10.1016/j.psychsport.2006.05.002 Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J.W., Patel, V., & Silove, D. (2014). The global prevalence of common mental disorders: A systematic review and meta-analysis 1980–2013. International Journal of Epidemiology, 43(2), 476–493. 10.1093/ije/dyu038 Steinacker, J.M., Bloch, W., Halle, M., Mayer, F., Meyer, T., Hirschmüller, A., … Sports Medicine Commission of FISA. (2020). Fact sheet: Health situation for athletes in the current Coronavirus pandemic (SARS-CoV-2 / COVID-19). German Journal of Sports Medicine, 71(4), 85–86. 10.5960/dzsm.2020.431 Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality. https://www.samhsa.gov/data/ Toresdahl, B.G., & Asif, I.M. (2020). Coronavirus disease 2019 (COVID-19): Considerations for the competitive athlete. Sports Health, 12(3), 221–224. 10.1177/1941738120918876 Travis, S.K., Mizuguchi, S., Stone, M.H., Sands, W.A., & Bazyler, C.D. (2020). Preparing for a national weightlifting championship: A case series. Journal of Strength and Conditioning Research, 34(7), 1842–1850. 10.1519/ jsc.0000000000003312 Whiteford, H.A., Ferrari, A.J., Degenhardt, L., Feigin, V., & Vos, T. (2015). The global burden of mental, neurological and substance use disorders: An analysis from the Global Burden of Disease Study 2010. PLoS ONE, 10(2), e0116820. 10.1371/journal.pone.0116820 Wittchen, H.U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jönsson, B., … Steinhausen, H.C. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21(9), 655–679. 10.1016/j.euroneuro.2011.07.018 World Health Organization. (2020). Coronavirus disease (COVID-19) advice for the public. Retrieved November 13, 2020, from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Zimmerman, M. (2019). Using the 9-item patient health questionnaire to screen for and monitor depression. Journal of the American Medical Association, 322(21), 2125–2126. 10.1001/jama.2019.15883

348

23 INJURY PREVENTION AND REHABILITATION Rebecca A. Zakrajsek, Alexander G. Bianco, Taylor B. Casey, Keely N. Hayden, and Scott B. Martin

Introduction Unfortunately, mental health concerns are a common occurrence among high-level athletes. In the United States, Edwards et al. (2021) found that between 2011 and 2019 the rate at which varsity-level collegiate athletes were diagnosed with a mental health disorder increased from roughly 15% to 25%. These same trends are seen internationally as well (Brandt et al., 2017; Poucher et al., 2021; Shahoseini & VaezMousavi, 2021). For instance, Å kesdotter and colleagues (2020) found that, out of 333 elite Swedish athletes, 51.7% had experienced mental health problems at some point in their lives, and 50% of these problems emerged between ages 17 and 21. Furthermore, prior to the 2016 Olympic Games, 17% out of 176 athletes reported symptoms of depression and 19% reported symptoms of anxiety (Drew et al., 2017). In sport, clear relationships exist between injury and mental health challenges (Appaneal et al., 2009; Gulliver et al., 2015). However, Haugen (2022) argued that injury and mental health have a bidirectional relationship, suggesting that it is difficult to determine whether injuries cause mental health disorders or visa versa. That said, injured athletes regularly report experiencing mental health challenges during the rehabilitation process (Bejar et al., 2017; Bianco, 2001; Clement et al. 2015). Furthermore, it is possible that the stress athletes experience from injury can “trigger” dormant mental health disorders (Putukian, 2016, p. 145). Despite the known benefits of physical activity and sport participation, athletes of all ages, especially those in highly competitive environments, risk injury every time they train, practice, and compete (Smyth et al., 2019). Injuries can cause physical and mental distress and may reduce the chance of future successful sport performance and progression (Drew, Raysmith, & Charlton, 2017). Although advances in medicine, technology, protective equipment, and environment safety have improved injury prevention and the effectiveness of injury rehabilitation, sport-related injuries are quite common (Sheu et al., 2016; Insurance Information Institute, 2019; National Safety Council, n.d.) and remain a major reason for premature involuntary retirement from organised sport (Chan & Hagger, 2012; Gervis et al., 2019; Knowles et al., 2006; Pitcho-Prelorentzos & Mahat-Shamir, 2019). According to the Youth Sports Safety Alliance (2013), 90% of interscholastic athletes report some sort of sport-related injury, with 62% of them taking place during practice. Major risk factors that influence the occurrence and severity of sport injuries and the resultant recovery from them include biological (genetic, biochemical, physical, neurological, etc.), psychological (behaviours, thoughts, emotions, personality, etc.), and socio-cultural (cultural and social norms, familial and societal burdens, socioeconomic, etc.) components (see Martin et al., 2020). Understanding injury risk factors, methods to prevent injuries from occurring, and strategies for DOI: 10.4324/9781003099345-31

349

Rebecca A. Zakrajsek et al.

improving recovery and quality of life are important for professionals who are regularly involved with elite athletes’ sport performance and progression (e.g., coaches, athletic administrators, athletic trainers, orthopedic physical therapists, mental performance consultants, and mental health providers). To effectively address elite athletes’ biopsychosocial needs, it is important that these professionals do not operate on their own, in individual “silos,” but combine their expertise to form a synergistic interprofessional care team. Therefore, this chapter describes the holistic biopsychosocial intervention and observation interprofessional care team approach to injury prevention and rehabilitation for successful outcomes.

Biopsychosocial Approach to Injury Prevention and Rehabilitation The biopsychosocial model developed by Engel (1977) illustrates the importance of the interconnection between biological, psychological, and socio-cultural components. Several theoretical models have been advanced that consider the biopsychosocial factors associated with injury prevention and the recovery process (see McGlashan & Finch, 2010), such as the stress-injury model (Williams & Andersen, 1988), integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998), and biopsychosocial model of sport injury rehabilitation (Brewer et al., 2002). For example, Williams and Andersen’s (1988) stress-injury model suggests that athletes experiencing major life events, who have high competitive anxiety, low problem-focused and emotion-focused coping resources, and limited social support may, when placed in a highly competitive and stressful athletic situation, be at increased risk of injury. Consequently, disturbance of attention, too high or low arousal, and lack of muscle coordination can increase the likelihood of an injury (Andersen & Williams, 1988; Johnson & Ivarsson, 2011; Maddison & Prapavessis, 2005; Patterson et al., 1998). The integrated model of psychological response indicates that if internal and external risk factors and their interaction as co-determinants are present, vulnerability is increased (Bahr & Krosshaug, 2005; Meeuwisse et al., 2007). For instance, as often seen in gymnastics, early athletic maturation and sport specialisation may increase the risk of unhealthy behaviour, pushing young athletes beyond their body’s physical and psychological limits (DiFiori et al., 2014), resulting in a high injury risk (Moller et al., 2012; von Rosen, Flostrom et al., 2017; von Rosen, Olofsson, et al., 2019). Professionals working in sport settings, especially individuals who are regularly involved in helping individuals achieve their full athletic potential, need to take into consideration the interconnections between biopsychosocial factors. The Biopsychosocial Intervention and Observation Team Approach (BIOTA, see Figure 23.1) illustrates components that may influence injury prevention and rehabilitation. Specifically, this model demonstrates how biology (e.g., immune functioning), fitness (e.g., muscular endurance and strength), use of mental skills and strategies (e.g., self-confidence, effective self-talk), demographics (e.g., socioeconomic status), socio-cultural considerations (e.g., social network), and psychology (e.g., personality) interact to influence sport related injury prevention and recovery. For instance, Tom Brady, a seven-time Super Bowl champion, has had the unique ability to avoid major injuries throughout his career. An interaction of biopsychosocial factors has helped Brady, who is now 40 years of age, adjust to varying conditions to prolong his football career. In addition to maintaining his health and performance through rigorous physical conditioning, healthy sleep habits, and proper nutrition, Brady regularly uses mental strategies to maintain awareness and focus on the field (Brady, 2017). The BIOTA also demonstrates how the interaction of biopsychosocial factors can affect athletic injury rehabilitation outcomes (e.g., quality of life, readiness to return to activity). Similar to Tom Brady, the interplay between biopsychosocial factors can be observed in other elite athletes, such as Serena Williams, who at age 39, continues to be ranked inside the top 10 of the Women’s Tennis Association rankings. Williams credits several biopsychosocial components for her longevity in the game despite suffering from numerous injuries during her career. Like Tom Brady, proper nutrition, hydration, and training have been critical; however, Williams also believes frequent meditation and a reliable social support network have been essential for her ability to overcome injuries and sustain continued success in tennis (Mulumba, n.d.; Scipioni, 2020). In a similar fashion, 350

Injury Prevention and Rehabilitation

Figure 23.1

Biopsychosocial Intervention and Observation Team Approach (BIOTA)

Lionel Messi, winner of 47 individual awards and 36 major trophies with club and country teams, considers proper nutrition, hydration, and training instrumental in his enduring success. However, Messi has indicated that his physical conditioning and training over the years has involved adapting mentally to compensate, not only for the aging process, but also his lack of size and strength compared to some of his rivals (e.g., Cristiano Ronaldo), and as a result of various injuries (Messi vows to listen to his body, 2019). Throughout his career, Messi has been able to display his speed, ball control, and striking ability. As he indicated: My brain thinks Messi is 25 years old and I can continue doing the same things at that age. But the body rules and there are circumstances in which I have to be more careful than before. Adapting to it requires a process and preparing differently for training and matches. (Messi, 2019, para. 3)

351

Rebecca A. Zakrajsek et al.

A biopsychosocial (i.e., biological, psychological, and socio-cultural) approach to health and well-being, such as BIOTA, strives to address various factors that influence any given injury prevention or injury rehabilitation situation. Therefore, professionals who are involved with athletic injury prevention and rehabilitation will need knowledge of the BIOTA and associated models (e.g., related to stress, performance, illness and injury recovery, communication, psychosocial educational skills and techniques) to increase the likelihood that the best possible injury prevention and recovery outcomes are achieved (Martin et al., 2020).

iTeam for Injury Prevention and Rehabilitation Athletes may prevent injuries from occurring or positively influence injury rehabilitation outcomes, when the biopsychosocial factors, represented in the BIOTA model, are addressed by an interprofessional care team (iTeam; see Martin et al., 2020). The “spoke of the wheel” ecological model (see Figure 23.2, modified from Bader & Martin, 2019) provides an organisational approach to understanding the various iTeam members who work together to address elite athletes’ biopsychosocial needs related to injury prevention and rehabilitation. The elite athlete is located at the centre of the wheel, which is the hub or focal point. Surrounding the athlete are the “spokes” of the wheel or primary iTeam members. This includes orthopedic specialists (e.g., athletic trainers, physical therapist, physiotherapist), physicians, mental performance consultants (MPCs), mental health specialists (e.g., clinical psychologist, mental health counselor, social worker), nutritionists and dietitians, and other sport-related professionals (e.g., coaches).

Figure 23.2 Ecological Model: Inter-professional Team – Spokes of the Wheel. (Adapted from Bader & Martin, 2019.)

352

Injury Prevention and Rehabilitation

Members of the iTeam ought to represent a cohesive and synergistic group, meaning they should not only refer athletes to one another because of their individual expertise, but trust one another enough to integrate their personal and professional competencies to best support injury prevention and rehabilitation (Bridges et al., 2011). The gaps between each of the “spokes” represent potential social support providers who are not directly a part of the iTeam (e.g., spouse, children, fans), but can still have an effect on an elite athlete’s injury prevention and rehabilitation. Although the primary support comes from the iTeam members (i.e., “spokes of the wheel”) and their ability to work together, social support from individuals and groups, represented by the spaces between the spokes, may “flow” in and out of importance during various stages of athletic development or phases of injury rehabilitation. For instance, seeking social support from significant others (e.g., family) has been reported by athletes as the most common behavioural response following an injury (Clement et al., 2015). Social support from friends and family may increase in importance when athletes attempt to maintain health and well-being or try to overcome injuries (Bianco, 2001). Finally, surrounding the wheel are various external support groups, ranging from those in the immediate athletic environment to those in the global community, that can also influence injury prevention and rehabilitation (e.g., felt pressure through changes in rules). Within the “spoke of the wheel” organisational approach, interprofessional education is strongly valued and reinforces effective collaboration (Martin et al., 2020). There are four elements that nurture an effective collaborative environment (Samuelson, 2012). These four elements can help iTeam members develop trust to support one another in meeting elite athletes’ biopsychosocial needs. The first element is uniting around a shared vision and common goal, which allows iTeam members to work together to find solutions and provide mutual support for one another. For example, this common goal might include an optimal rehabilitation period to ensure a safe return to pre-injury (or better) health and performance status. A shared vision provides the foundation for the second element, internalisation, which is a common understanding that each iTeam member is integral to the accomplishment of the team’s goal(s). Internalisation can also be viewed as a recognition and acceptance that no single individual has the necessary expertise to ensure the holistic health of the athlete. The third element is formalisation, or the methods and plan for how iTeam members will communicate and share information. While information sharing has traditionally occurred through formal meetings (White et al., 2013), technological advances have provided additional ways for iTeams to effectively communicate (e.g., file sharing software; Setiadi et al., 2017). The fourth element is governance, which refers to there being some central leadership that oversees and supports the iTeam with the necessary resources to function effectively. As an iTeam member, knowing the competencies and responsibilities of other professionals is important in managing the various biopsychosocial components involved in injury prevention and rehabilitation (Bondevik et al., 2015). Learning from and about each other nurtures respect and trust among group members (Samuelson et al., 2012; Yalom & Leszcz, 2005). Understanding how iTeam members align with one another when addressing complex challenges empowers them to collaborate and work within their own boundaries of competence without feeling the need to protect their jurisdiction. Consequently, the ecological model includes MPCs and mental health specialists as separate, but complementary, “spokes of the wheel.” Even though there are often similarities in educational training and credentials of interprofessional care professionals, differences exist, and these differences may influence their observations, evaluations, and focus of service delivery. For example, MPCs are trained to assist with the mental and emotional demands of injury prevention and rehabilitation. The types of services MPCs provide include teaching a variety of psychological strategies (e.g., imagery, self-talk) that athletes can use to bolster their mental skills and facilitate optimal involvement, performance, and enjoyment (Association for Applied Sport Psychology, n.d.). Whereas, licensed mental health specialists, which may include psychologists, counselors, and social workers; are trained to diagnose and treat personal and emotional concerns that are clinical in nature (e.g., depression, anxiety, eating disorders, substance abuse; Weinberg & Williams, 2015). In addition, licensed social workers receive specific education regarding how the environment and surrounding social issues can impact the 353

Rebecca A. Zakrajsek et al.

mental health of individuals (National Association of Social Workers, n.d.). It can be advantageous to involve MPCs and mental health specialists with different licensures (e.g., psychologist, counselor, social worker) as each serves a unique and specialised role in the biopsychosocial care of elite athletes. Early interaction between iTeam members with unique and specialised training may result in valuable discussions and observations that provide greater comprehensive information and insight, leading to enhanced well-being and improved performance success.

iTeam Checklist In order for an iTeam to function properly members need to communicate effectively and efficiently by sharing essential information on a wide range of biopsychosocial factors that may influence injury prevention and rehabilitation outcomes (Martin et al., 2020). The iTeam Checklist (Figure 23.3) is a tool that can enhance communication, awareness, and the development of a treatment plan (see Figure 23.4, ITEAM process). The iTeam Checklist incorporates information from sources such as the Biopsychosocial Intake and Observation form (Martin et al., 2020), Emotional Responses of Athletes to Injury Questionnaire (Smith, 1996), Psychological Distress Checklist (Taylor & Taylor, 1997), and Sport Mental Health Assessment Tool 1 (Gouttebarge et al., 2020). The iTeam Checklist should be considered a fluid instrument that evolves over the course of athletic injury prevention and rehabilitation. This may mean that there is a “master” iTeam Checklist that is reviewed and modified at different developmental stages or phases of injury rehabilitation (i.e., reaction to injury, reaction to rehabilitation, and reaction to return to play [see case vignette 2]). The universality of this checklist throughout injury prevention and rehabilitation can help iTeam members literally be on the “same page” with one another, to identify progress or areas for improvement. By using a checklist that is adaptable, the iTeam members’ roles and responsibilities may be adjusted as challenges arise, regarding injury prevention or as injury rehabilitation progresses. As with group therapy (e.g., Yalom & Leszcz, 2005), iTeam members gain personal insight about their interpersonal impact through feedback provided from other members and during group meetings (i.e., interpersonal learning-input). In addition, a customizable checklist and regular group meetings provides an environment that allows iTeam members the opportunity to interact in an adaptive and, hopefully, positive manner (i.e., interpersonal learning-output). Consequently, during intake and diagnosis (see Figure 23.4, I-TEAM process), members of the iTeam should not focus solely on the section of the checklist that is reflective of their specific expertise. For instance, a MPC should not just review the Mental Skills and Strategies section. The purpose of such a checklist is to help members of the iTeam gain a holistic view of the biopsychosocial factors that put athletes at risk for injury or get in the way of a reasonable and timely recovery. An important consideration with the I-TEAM process is confidentiality, especially as it influences the rapport and trust between iTeam members and the elite athlete. Athletes should be fully aware of who composes the iTeam and the type of information that is shared among the members (e.g., iTeam Checklist, prevention and recovery plan). Information gathered using the checklist is best shared at formal confidential meetings that include all members of the iTeam. Regular meetings provide iTeam members with an opportunity to discuss the comprehensive biopsychosocial factors involved. On the other hand, poor communication amongst professionals, role confusion, and uncooperative leadership have been identified as barriers to interprofessional team effectiveness (Breitbach et al., 2015; Morin et al., 2018). Guided by the checklist, these group discussions allow for successful interprofessional learning and interaction to occur (Setiadi et al., 2017; van Dongen et al., 2016; Washington et al., 2017). Confidentiality among the iTeam members during these meetings should be assured and ascertained. Utilising an interactive interdisciplinary checklist can provide iTeam members an opportunity to clearly delineate their roles and responsibilities in managing specific challenges (e.g., record keeping, drug misuse, harm to self or others, overload training, organisation requirements). 354

Injury Prevention and Rehabilitation

Figure 23.3

iTeam Checklist (continued)

355

Rebecca A. Zakrajsek et al.

Figure 23.3

(continued)

356

Injury Prevention and Rehabilitation

Figure 23.3

(continued)

357

Rebecca A. Zakrajsek et al.

Figure 23.3

(continued)

358

Injury Prevention and Rehabilitation

Figure 23.3

(continued)

359

Rebecca A. Zakrajsek et al.

Figure 23.3

(continued)

360

Injury Prevention and Rehabilitation

Figure 23.3

(continued)

Part of the I-TEAM process is advocating for what is best for elite athletes to prevent injuries or progress through rehabilitation; this may indicate the need for re-evaluation, referral, and/or release. For example, on the iTeam Checklist, if an area seems to be of particular concern, it can be brought to the attention of the professional whose competencies best match. Evidence exists that integrating other professionals into injury prevention and rehabilitation is beneficial (Arvinen-Barrow & Clement, 2017; Zakrajsek et al., 2018). For example, if the orthopedic specialist views a checklist and, under the Biological Wellness Factors, learns that the athlete recently reported changes in her eating habits and/or body weight, it would be important to communicate with the iTeam dietician for further assessment. From there, the dietician can help the athlete address potential concerns while the rest of the iTeam assists however they can (e.g., reminders, goal setting exercises, support). The iTeam Checklist also includes items that may indicate a need for psychosocial interventions, such as the Socio-Cultural Factors, Psychological Factors, and Mental Skills and Strategies sections. Some items included 361

Rebecca A. Zakrajsek et al.

Figure 23.4 Interprofessional – Therapeutic, Evaluation, Appraisal, & Management (I-TEAM) Process

in the section on Biological Wellness Factors may also signify the need for psychosocial interventions (e.g., substance use). The use of a checklist and follow-up meetings encourages iTeam members, such as orthopedic specialists, to recognise the influence of psychosocial factors on injury prevention and recovery. Utilising a holistic biopsychosocial approach (e.g., BIOTA) that incorporates assessments, such as the iTeam Checklist (Figure 23.3), may help guide positive and productive interactions between iTeam members that result in valuable early information and insight on injury prevention and the injury rehabilitation process (Figure 23.4, I-TEAM), as well as lead to enhanced athlete well-being and improved performance outcomes.

Biopsychosocial and Interprofessional iTeam Considerations for Injury Prevention Case Vignette 1: Achieving the Olympic Dream during a Pandemic Ajani is a track and field long-distance runner from Jamaica. He competed in the 5,000- and 10,000-meter run on a college track and field team and qualified for the Southeastern Conference and the National Collegiate Athletic Association Division I Outdoor Championships in three out of his five years, placing in the top three in two of those years. During his sophomore and junior years, he was unable to attend the championships and the remaining two months of his competitive season due to a severe medial tibial stress syndrome. Throughout his time in college, primarily during his injuries, Ajani worked with the iTeam (e.g., nutritionist, physical therapist, athletic trainers, MPC). He primarily worked with them on managing his anxiety, practicing mindfulness, journaling, and setting goals to be positive when dealing with adversity. Upon graduating in 2019, with the emotional and financial support of his family, Ajani signed with Adidas and trained to compete for the Jamaican Olympic team in the 5,000- and 10,000-meter run. Due to COVID-19, the competition season was postponed indefinitely and Olympic qualifiers were placed on hold until late spring, or possibly early summer of 2021, which drastically changed Ajani’s training regime and financial stability. Support from Adidas shifted to a virtual format only, limiting access to the 362

Injury Prevention and Rehabilitation

community of fellow athletes and available athletic training facilities, equipment, and iTeam services (e.g., strength and conditioning coaching, physical therapy, mental training, nutritional support). Additionally, support from his parents was limited, since both work in resort hospitality. Therefore, the impact of COVID-19 left him struggling to support his athletic career and family. Due to the lack of readily available support and Jamaica travel restrictions from COVID-19, Ajani is trying to adjust his training regiments during this pandemic while helping support his family. Recently, the Jamaican government stated that athletes who qualified, or are on the brink of qualifying, for the Olympics will receive a monthly stipend, which Ajani is eager to receive. The government stipend includes assistance for athletes to offset costs relating to coaching and training, transportation, physiotherapy and massage therapy, nutrition, and other associated needs. This opportunity would allow Ajani to allocate more time (physically and mentally) to training for the Olympics instead of working to support himself and his family and relieve some stress. In addition, the Jamaica Athletes Insurance Plan is available to assist with medical treatments that athletes require. All of this would be very beneficial to Ajani as he pursues his running career and Olympic dream. Ajani continues to try to be proactive in moving forward as he navigates these unexpected, difficult, and ever-changing circumstances.

Case Summary and Guidelines for Practice The importance of Case Vignette 1 is to illustrate the biopsychosocial factors associated with elite athletes’ lifestyles and their needed support to prevent injuries. The biopsychosocial model highlights the importance of the interconnection between biological, psychological, and socio-cultural factors that influence overall health and well-being (Martin et al., 2020). Specifically, this vignette highlights the importance of understanding the multidimensional nature of athletes inside and outside of their athletic pursuits that may influence their ability to pursue sport and remain physically and mentally healthy. Understanding the biopsychosocial model, along with having a strong working alliance with professionals from various disciplines, increases the likelihood that the best possible health outcomes are provided to the athlete by the iTeam (Martin et al., 2020). Ajani is at a critical point in his career, transitioning from collegiate athletics to a professional running career in hopes of achieving his Olympic dream. Trying to achieve athletic goals, while training for the Olympics is already a challenging endeavor. Adding the uncertainty of the pandemic creates additional stress for Ajani. These stressors stem from several important associated biopsychosocial factors (e.g., family, financial support, COVID-19, relocation, change in training regiment, lack of resources and social support from fellow teammates, postponement of goals, pursuit of Olympic stipend, lack of clarity of future events). Increased life event stress, lack of control, and a shift in arousal increase the likelihood of an injury occurring (Anderson & Williams, 1988; Johnson & Ivarsson, 2011). A chain of shifting circumstances can lead to injury. Therefore, if the iTeam understands and is aware of the predecessors of injury, and how the athlete is coping with them, effective preventative measures can be put in place to mitigate the risk (Meeuwisse et al., 2007). Understanding Ajani’s previous experiences with athletics (e.g., injuries, accomplishments, dealing with adversity) will aid the iTeam in assessing current biological, psychological, and socio-cultural factors. These factors can be assessed by the iTeam (such as the iTeam Checklist) to create and maintain an effective plan to help ensure optimal functioning for achieving success, while also preventing injury. The iTeam Checklist allows for the iTeam to assess several factors related to Ajani’s previous and current physical and mental state. Based on the iTeam Checklist, a preventative plan that benefits Ajani as he navigates his current circumstances can be discussed. Depending on Ajani’s needs regarding his training regimen and other life stressors, iTeam members will rely on the expertise of one another to prevent injury and increase performance success. The iTeam can work effectively with one another to address

363

Rebecca A. Zakrajsek et al.

Ajani’s emotional and physical demands, while implementing strategies which promote a supportive and holistic environment. For example, Ajani endured severe medial tibial stress syndrome when competing at the collegiate level, which is a common injury occurring among long-distance runners (Gallo et al., 2012). Previous injuries may bring about feelings of anxiety and stress about maintaining health during competition, as well as possibly leading to inappropriate training and nutritional supplement choices. These factors are important to consider in preventing injury, particularly when Ajani is adjusting his current training regimen. Likewise, information about his previous experiences with other iTeam staff members may be helpful in determining what was effective. The iTeam needs to be aware of the various circumstances Ajani has previously and is currently experiencing to understand his perspective and beliefs about moving forward to achieve his Olympic dream. Early detection of changes in biopsychosocial indicators help guide check-ins and possible adjustments to the injury prevention plan. Changes in physical responses, mood states, emotions, and behaviours are potential indicators for reassessment (Martin et al., 2020). Therefore, in the case study, as Ajani progresses and begins to manage various life events, iTeam members should reassess and discuss any necessary changes that need to be made. The iTeam Checklist will then serve as a fluid and evolving resource that can be adapted to best suit Ajani’s needs. The iTeam should become familiar with typical responses and behaviours of the athlete, making adjustments as needed. Implementing preventative measures (e.g., physical measures, self-report surveys, and semi-structured or structured interviews) as a team and using them in conjunction with one another, will likely reduce the risk of future injury from occurring (Bahr & Krosshaug, 2005; Martin et al., 2020). Using an integrated, holistic approach that relies on each iTeam member’s area of specialty is important to help prevent injuries and achieve performance success.

Biopsychosocial and Interprofessional iTeam Considerations for Injury Rehabilitation Case Vignette 2: A Professional Cyclist’s Recovery and Return to Racing Natalia, a 25-year-old professional cyclist from Colombia, has been racing professionally for five years. During a “sprinter” stage of a five-stage race, she was clipped from behind by a competitor, resulting in a severe crash in which she flipped over the front of her bike. As she hit the ground, the full weight of her body was pushed into her elbow. The area around the elbow instantly became swollen and discolored, indicating that it was likely broken. Her soigneur immediately ran to the scene and removed Natalia from the track until the ambulance arrived. X-rays confirmed that there was a type II radial head fracture in Natalia’s elbow. While surgery was not deemed necessary, her elbow required at least three weeks in a cast. This was her first serious injury. In the days following her crash, Natalia was naturally upset and felt a good deal of pain in her elbow. However, Natalia also reported that she has a natural mental toughness that has helped her deal effectively with adversity, which she credits to her mother and Colombian culture. Additionally, Natalia had already been working with a MPC before the crash. At their next session, the two discussed breathing and imagery strategies that Natalia could use to help manage any pain and irritation experienced in her elbow. While initially disheartened, using these techniques helped Natalia feel more in control and she was able to quickly shift toward a more optimistic mindset. Natalia was motivated to meet this new challenge headon, so she could get back on her bike as soon as possible. A week following the crash the pain and swelling in Natalia’s elbow began to subside, signifying that she had entered the second phase of injury rehabilitation (i.e., reaction to rehabilitation). With permission from the team physician, Natalia began a training routine developed by her physical therapist and road coach. This routine helped Natalia maintain her cardiovascular fitness and strength in her lower body while her elbow healed. Her training regularly involved using a stationary bike. While exercising on the 364

Injury Prevention and Rehabilitation

stationary bike, Natalia’s physical therapist had her use several breathing and imagery strategies. These mental training techniques were previously created by Natalia’s MPC for cycling. Guided imagery was used to help simulate a race environment, despite Natalia being on a stationary bike and not able to steer the handlebars. Outside of her training, Natalia reported that she was getting optimal amounts of quality sleep to help her body heal. Additionally, she adhered to a nutrition plan that was crafted by the team dietician to reflect her reduced activity level as well as promote healing. After three weeks the cast was removed; however, her physician recommended an additional two weeks for her elbow to continue healing before any full training was attempted. Now that her elbow was no longer in a cast, Natalia’s physical therapy sessions included range of motion and elbow strengthening procedures. Additionally, Natalia’s soigneur began to implement massage therapy, which was meant to stimulate blood flow to the recovering area. With the help of Natalia’s road coach and soigneur, her physical therapist created many exercises that mimicked important cycling movements such as putting weight forward on the handlebars and turning. Being able to complete these sport-specific movements without pain signified that Natalia had entered the third phase of her rehabilitation, reaction to return to play. Five weeks after the crash, Natalia was cleared for full activity and felt healthy, confident, and motivated over the following month of training. Perhaps most important is that despite the time off Natalia noticed little drop off from her pre-injury performance. Only two months after the injury, Natalia placed in the top ten at her next road race. During the race, Natalia was able to stay in the present and focused on the race without thinking about her elbow or the crash that caused her injury.

Case Vignette 2 Summary and Guidelines for Practice This case vignette demonstrates how the management of biopsychosocial factors by an iTeam can help produce optimal injury rehabilitation outcomes. Having experiential knowledge of the BIOTA and iTeam Checklist can help sport performance professionals recognise the interconnectedness between the various factors that influence injury rehabilitation and return to sport. Additionally, positive interaction between professionals from various disciplines can ensure that biopsychosocial factors are sufficiently addressed at each phase of athletic injury rehabilitation. The psychological challenges athletes face during each phase of rehabilitation—reaction to injury, reaction to rehabilitation, and reaction to return to play—vary and often coincide with the physical challenges experienced at the time. The reaction to injury phase of rehabilitation occurs immediately after the injury and the experience of swelling and pain are at their highest (Kamphoff et al., 2013). Using the iTeam Checklist, iTeam members were fully aware that this was Natalia’s first serious injury and there were no changes noted prior to the onset of the injury (e.g., level of training or competition, cognitive, social interaction). During initial iTeam meetings, the MPC emphasised that Natalia needs to feel a sense of familiarity, predictability, and controllability related to the rehabilitation process, especially since it was her first serious injury (see Taylor & Taylor, 1997). Information provides an individual the power to overcome obstacles. Providing Natalia knowledge and education can help her: (a) become familiar with the different phases of rehabilitation, (b) anticipate the recovery process by knowing what the rehabilitation programme involves (e.g., predictability), and (c) develop a sense of control over rehabilitation by learning tools (e.g., mental strategies) to actively participate and contribute to her recovery (Taylor & Taylor, 1997). During this initial phase, Natalia’s personality and cultural upbringing (e.g., family and perseverance are extremely important in Colombian culture) played a role in her cognitive appraisal of the injury and recovery process. In other words, these psychosocial factors caused Natalia to view her injury as a challenge to overcome (i.e., opportunity for self-growth) instead of a threat (i.e., perceived as leading to failure). Her use of mental techniques (e.g., breathing, imagery), also helped Natalia manage pain during this phase, creating the opportunity for rehabilitation success. While the use of breathing and imagery may not completely alleviate the feeling of pain, these techniques have been found to reduce adverse emotions 365

Rebecca A. Zakrajsek et al.

and serve to provide a sense of personal control over the pain (Cupal & Brewer, 2001). Although initially used to reduce pain, the iTeam continued to integrate these mental techniques into the next two phases of rehabilitation to maintain motivation, enhance focus, and build confidence. In phase two, reaction to rehabilitation, symptoms of swelling and pain improve (Kamphoff et al., 2013). This phase is typically the longest part of the rehabilitation process where interventions are focused on enhancing strength, balance, and coordination. Motivation and focus are considered critical mental skills, as they influence optimal adherence and successful execution of rehabilitation exercises during sessions (Chan et al., 2009). Early in this phase Natalia was highly motivated to have a successful rehabilitation period and get back to sport as soon as possible. Although Natalia’ motivation was enhanced by her initial cognitive appraisal of the injury, it was also further amplified by her previous use of imagery outside of rehabilitation sessions. These mental techniques were reinforced when the physical therapist integrated them directly into rehabilitation sessions. In the final phase, reaction to return to play, athletes engage in sport specific movements (Kamphoff et al., 2013). Returning to the sporting environment often cause a mixture of positive and negative emotions, especially for elite athletes where much is at risk. That is, while return to competition may be accompanied by feelings of excitement, athletes may also fear re-injury or have concerns about reaching their goals (Podlog & Eklund, 2006). Managing fears related to re-injury, while continuing to build confidence in their ability to return to sport can help athletes perform sport skills safely, especially in dynamic environments (Clement et al., 2015). Natalia’s positive reaction to return to play was likely facilitated by the iTeam members’ deliberate attention to biopsychosocial factors during the reaction to injury and reaction to rehabilitation phases. Attending to biopsychosocial factors early served to increased Natalia’s confidence that her elbow was fully healed and reduced the potential that fear of re-injury would impede her future performance. Several other factors identified by the BIOTA and iTeam Checklist played an important role in Natalia having a successful rehabilitation process. For instance, Natalia’s young age likely aided her ability to quickly recover from a fracture without a significant drop off in athletic performance (Clark et al., 2017). Furthermore, important biological factors (i.e., sleep and diet) were successfully managed in all three phases of her rehabilitation which helped promote her body’s ability to heal (Adam & Oswald, 1984; Smith-Ryan et al., 2020). Additionally, the type of injury that Natalia experienced resulted in her ability to maintain a strong overall fitness level (i.e., muscular endurance, muscular strength, aerobic capacity) while her elbow was in a cast. Lastly, setting effective goals that addressed Natalia’s biopsychosocial factors, and modifying these goals during and between each phase of rehabilitation, likely led to optimal adherence and increased self-efficacy (Evans & Hardy, 2002; Scherzer et al., 2001). For example, with the help of the MPC, Natalia set goals to perform breathing and imagery exercises during the reaction to injury phase, which helped her manage pain. While Natalia’s injury did not require surgery, specific biopsychosocial goals can also be created to reflect the pre and post-operative periods. For instance, a preoperative goal may involve managing stress and anxiety related to surgery. Following surgery, goals related to optimal sleep and diet may be particularly effective in promoting healing. Once Natalia entered the next phase, reaction to rehabilitation, her goals shifted to improving her cardiovascular fitness and strengthening her lower body. Natalia’s goals also included simulating a race environment with guided imagery. Finally, in the reaction to return to play phase, Natalia set goals related to maintaining a safe activity level which helped to prevent her from pushing too hard too early as she reentered cycling. Together, these factors enabled Natalia to reenter cycling without experiencing any significant decline in performance and reduced the risk of reinjury. Several professionals included in the “spokes of the wheel” ecological model (e.g., physical therapist, MPC, dietician, physician) were critical in Natalia successfully progressing from the initial phase of her injury recovery to her return to sport. However, instead of these professionals operating individually, they worked together as iTeam members, which allowed for the best possible rehabilitation outcomes. The 366

Injury Prevention and Rehabilitation

iTeam met several times throughout the five weeks of Natalia’s injury rehabilitation, using the iTeam Checklist to assist with her recovery. At their first meeting, the iTeam Checklist aided in developing an initial treatment plan. During each subsequent meeting they reviewed the iTeam Checklist to ensure that (a) they were all on the “same page” and (b) there were no unaddressed biopsychosocial factors that could impede Natalia’s recovery. The iTeam frequently combined their expertise to ensure the treatment plan was as effective as possible. For instance, Natalia’s physical therapist, road coach, and physician worked together to ensure that her physical therapy programme was safe and promoted healing but was still specific to cycling. Furthermore, her physical therapist worked with the MPC to incorporate mental strategies (e.g., breathing, imagery) into her rehabilitation exercises. Other iTeam members (e.g., dietician, soigneur) utilised their own expertise throughout Natalia’s rehabilitation and assisted when needed. Throughout iTeam meetings, the checklist was used to answer important questions related to Natalia’s biopsychosocial factors. For example, the iTeam members checked in with one another to determine if Natalia: (a) was motivated in sessions; (b) exhibited any symptoms of depression; (c) had changes in her sleep, eating habits (e.g., daily fluid uptake), or physical wellness; or (d) experienced any other major life events. Asking questions related to these biopsychosocial factors throughout rehabilitation helps iTeam members learn from and about each other to assure elite athletes’ holistic recovery.

Conclusion The purpose of this chapter was to discuss how a biopsychosocial approach to injury prevention and rehabilitation can lead to improved health and well-being outcomes for elite athletes. Throughout the stages of injury prevention and injury rehabilitation, iTeam members should strive to recognise and address critical biopsychosocial factors that influence elite athletes’ health and well-being. Table 23.1 provides a summary and quick reference guide of the key biopsychosocial determinants, potential iTeam members, and optimal health and well-being outcomes for each stage of injury prevention and rehabilitation. This table and the case vignettes can serve as a guide in identifying the biopsychosocial determinants and iTeams members that may help produce optimal outcomes for injury prevention and at each phase of injury rehabilitation. For example, the story of Ajani (Case vignette 1) reflects the pre-injury phase. In this case, Ajani’s iTeam members helped him successfully manage his fitness and anxiety related to external events (e.g., COVID). This allowed Ajani to have the necessary physical fitness, focus, and environment to enhance health and well-being outcomes. Alternatively, Natalia’s story (Case vignette 2) demonstrates how these same principles apply when an elite athlete is recovering from an injury. In the reaction to injury phase, and immediately following Natalia’s crash, she was taken to a safe location in order to prevent further injury. As she continued in phase one, and following her diagnosis, management of biopsychosocial determinants (e.g., emotions, mental skills and strategies, sensation) by iTeam members allowed her to successfully manage any stress, anxiety, and pain that she was experiencing. Note that the reaction to injury phase may also include preoperative and postoperative considerations if surgery is required. Throughout the reaction to rehabilitation phase, Natalia’s iTeam intervened with fitness skills and mental strategies to help her maintain motivation and prime her body for optimal recovery. Finally, as Natalia reentered cycling (reaction to return to play), her iTeam continued to address her fitness and use of mental skills and strategies. This created an environment that reduced her concerns of re-injury and cultivated confidence in her rehabilitation process. Research into how interprofessional care can be best implemented into sport injury prevention and injury rehabilitation is in its infancy (Washmuth et al., 2019). While there are no known studies that directly compare the efficacy of interprofessional care teams across nations, research exists that indicates iTeams are universally effective in traditional medicine. For instance, a common component of successful traditional medicine interprofessional teams across the world involves scheduling regular meetings to help members 367

Emotions Family and Social Burdens Mental Skills and Strategies Perception Personality Sensation Social Network

Biological Health-Related Fitness Mental Skills and Strategies Social Network

Postoperative Care (if applicable)

Immediate Safety

Sport and Injury History Biological Health-Related Fitness Major Sport and Life Events Mental Skills and Strategies Situational Life Characteristics

Key Biopsychosocial Determinants

Diagnosis and Preoperative Care (if applicable)

Reaction to Injury (Phase I) Immediately Post-Injury

Pre-Injury

Injury Prevention and Rehabilitation

368

Physician Orthopedic Specialist Mental Performance Consultant Nutritionist or Dietician Social Support Provider

Physician Orthopedic Specialist Mental Performance Consultant Mental Health Specialist Social Support Providers

First Responders Orthopedic Specialist

Head and Assistant Coaches Nutritionist or Dietician Mental Performance Consultant Performance Coaches Social Support Providers

Potential iTeam Members

• • •

•

• •

•

• • •

•

•

• • •

•

Limit severity of injury (e.g., transfer to safe location) Facilitate calm internal and external environment Accept that the injury happened Navigate mobility challenges Cope positively with distractions and daily hassles Understand the rehabilitation and recovery process Manage stress, anxiety, and pain Imagine successful recovery and return to sport Understand the post-surgery recovery process Promote sleep and diet for healing Manage stress, anxiety, and pain Imagine successful recovery and return to sport

Maintain focus and physical fitness to reduce incidence of injury Manage life stress and daily hassles Build social network and team culture Advocate for safe environments and equipment

Optimal Athlete Outcomes

Table 23.1 Key Biopsychosocial Determinants, Potential iTeam Members, and Optimal Athlete Outcomes Pre- and Post-Injury

Rebecca A. Zakrajsek et al.

Reaction to Return to Sport (Phase III) Fitness Factors Mental Skills and Strategies

Reaction to Rehabilitation (Phase II) Biological Demographic Health-Related Fitness Mental Skills and Strategies Social Network

Coaches Orthopedic Specialist Performance Coaches Mental Performance Consultant

Orthopedic Specialist Physician Mental Performance Consultant Mental Health Specialist Social Support Provider

• •

•

• •

• • •

•

Limit worries and fears of re-injury Reinforce quality of effort and rehabilitation Cultivate confidence in post-injury performance Recognise mental and physical readiness Focus on desired long term goals

Maintain motivation and adhere to rehabilitation Obtain adequate rest for recovery Cope positively with distractions Imagine successful recovery and return to sport

Injury Prevention and Rehabilitation

369

Rebecca A. Zakrajsek et al.

become informed about the biopsychosocial needs of patients and their roles and responsibilities for improved health and well-being outcomes (Setiadi et al., 2017; van Dongen et al., 2016; Washington et al., 2017). Conversely, barriers to effective interprofessional collaboration such as poor communication amongst members, role confusion, and uncooperative leadership are universally consistent (Breitbach et al., 2015; Morin et al., 2018). However, additional empirical evidence is needed regarding best iTeam practices regarding sport injury prevention and rehabilitation. Although interprofessional education and care are promoted by international entities such as the World Health Organization (2010), it appears that they are primarily utilised by wealthy nations (Herath et al., 2017). In order for elite athletes around the globe to benefit from interprofessional care teams, it is essential to further understand and overcome the barriers that may prevent them from being utilised.

Acknowledgment We greatly appreciate Natalia Franco, MS for her feedback with Case study vignette 2.

References Adam, K., & Oswald, I. (1984). Sleep helps healing. British Medical Journal, 289, 1400–1401. 10.1136/bmj.289.6456. 1400 Å kesdotter, C., Kentta, G., Eloranta, S., & Frank, J. (2020). The prevalence of mental health problems in elite athletes. Journal of Science and Medicine, in Sport, 23, 329–335. 10.1016/j.jsams.2019.10.022. Andersen, M.B., & Williams, J.M. (1988). A model of stress and athletic injury: Prediction and prevention. Journal of Sport and Exercise Psychology, 10(3), 294–306. 10.1123/jsep.10.3.294 Appaneal, R.N., Levine, B.R., Perna, F.M., & Roh, J.L. (2009). Measuring postinjury depression among male and female competitive athletes. Journal of Sport and Exercise Psychology, 31(1), 60–76. 10.1123/jsep.31.1.60 Arvinen-Barrow, M., & Clement, D. (2017). Preliminary investigation into sport and exercise psychology consultants’ views and experiences of an interprofessional care team approach to sport injury rehabilitation. Journal of Interprofessional Care, 31(1), 66–74. 10.1080/13561820.2016.1235019 Association for Applied Sport Psychology. (n.d.). What is a Certified Mental Performance Consultant (CMPC)? https:// appliedsportpsych.org/site/assets/files/1016/cmpc-onepage.pdf Bader, C.M., & Martin, S.B. (2019). Sport psychology considerations in intercollegiate athletics in the United States. In E.O. Acevedo (Ed.), The Oxford encyclopedia of sport, exercise, and performance psychology. Oxford University Press. 10.1093/acrefore/9780190236557.013.179 Bahr, R., & Krosshaug, T. (2005). Understanding injury mechanisms: A key component of preventing injuries in sport. British Journal of Sports Medicine, 39(6), 324–329. 10.1136/bjsm.2005.018341 Bejar, M.P., Fisher, L.A., Nam, B.H., Larsen, L.K., Fynes, J.M., & Zakrajsek, R.A. (2017). High-level South Korean Athletes’ experiences of injury and rehabilitation. The Sport Psychologist, 31(1), 16–29. 10.1123/tsp.2015-0060 Bianco, T. (2001). Social support and recovery from sport injury: Elite skiers share their experiences. Research Quarterly for Exercise and Sport, 72(4), 376–388. 10.1080/02701367.2001.10608974 Bondevik, G.T., Holst, L., Haugland, M., Baerheim, A., & Raaheim, A. (2015). Interprofessional workplace learning in primary care: Students from different health professions work in teams in real-life settings. International Journal of Teaching and Learning in Higher Education, 27(2), 175–182. Brady, T. (2017). The TB12 method: How to achieve a lifetime of sustained peak performance. Simon and Schuster. Brandt, R., Bevilacqua, G.G., & Andrade, A. (2017). Perceived sleep quality, mood states, and their relationship with performance among Brazilian elite athletes during a competitive period. Journal of Strength and Conditioning Research, 31(4), 1033–1039. 10.1519/JSC.0000000000001551 Brewer, B.W., Andersen, M.B., & Van Raalte, J.L. (2002). Psychological aspects of sport injury rehabilitation: Toward a biopsychosocial approach. In D.L. Mostofsky & L.D. Zaichkowsky (Eds.), Medical and psychological aspects of sport and exercise (pp. 41–54). Fitness Information Technology. Breitbach, A.P., & Richardson, R. (2015). Interprofessional education and practice in athletic training. Athletic Training Education Journal, 10(2), 170–182. 10.4085/1002170 Bridges, D., Davidson, R.A., Soule Odegard, P., Maki, I.V., & Tomkowiak, J. (2011). Interprofessional collaboration: Three best practice models of interprofessional education. Medical Education Online, 16(1), 6035. 10.3402/meo.v1 6i0.6035

370

Injury Prevention and Rehabilitation Chan, D.K., & Hagger, M.S. (2012). Self-determined forms of motivation predict sport injury prevention and rehabilitation intentions. Journal of Science and Medicine in Sport, 15(5), 398–406. 10.1016/j.jsams.2012.03.016 Chan, D.K., Lonsdale, C., Ho, P.Y., Yung, P.S., & Chan, K.M. (2009). Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: The influence of physiotherapists’ autonomy-supportive behaviors. Archives of Physical Medicine and Rehabilitation, 90(12), 1977–1982. 10.1016/j.apmr.2009.05.024 Clark, D., Nakamura, M., Miclau, T., & Marcucio, R. (2017). Effects of aging on fracture healing. Current Osteoporosis Reports, 15(6), 601–608. 10.1007/s11914-017-0413-9 Clement, D., Arvinen-Barrow, M., & Fetty, T. (2015). Psychosocial responses during different phases of sport-injury rehabilitation: A qualitative study. Journal of Athletic Training, 50(1), 95–104. 10.4085/1062-6050-49.3.52 Cupal, D.D., & Brewer, B.W. (2001). Effects of relaxation and guided imagery on knee strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction. Rehabilitation Psychology, 46(1), 28. 10.1037/0090-5550.4 6.1.28 DiFiori, J.P., Benjamin, H.J., Brenner, J.S., Gregory, A., Jayanthi, N., Landry, G.L., & Luke, A. (2014). Overuse injuries and burnout in youth sports: A position statement from the American Medical Society for Sports Medicine. British Journal of Sports Medicine, 48(4), 287–288. 10.1136/bjsports-2013-093299 Drew, M.K., Raysmith, B.P., & Charlton, P.C. (2017). Injuries impair the chance of successful performance by sportspeople: A systematic review. British Journal of Sports Medicine, 51(16), 1209–1214. 10.1136/bjsports-2016096731 Drew, M.K., Vlahovich, N., Hughes, D., Appaneal, R., Peterson, K., Burke, L., Lundy, B., Toomey, M., Watts, D., Lovell, G., Praet, S., Halson, S., Colbey, C., Manzanero, S., Welvaert, M., West, N., Pyne, D.B., & Waddington, G. (2017). A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games. Journal of Science and Medicine in Sport, 20(8), 745–750. 10.1016/j.jsams.2017.02.010 Edwards, B., Froehle, A. W. & Fagan, S.E. (2021). Trends in college student‐athlete mental health in the National College Health Assessment (NCHA), 2011–2019. Journal of Athlete Training. 10.4085/1062‐6050‐586‐21. Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. 10.1126/science.847460 Evans, L., & Hardy, L. (2002). Injury rehabilitation: A goal-setting intervention study. Research Quarterly for Exercise and Sport, 73, 310–319. 10.1080/02701367.2002.10609025 Gallo, R.A., Plakke, M., & Silvis, M.L. (2012). Common leg injuries of long-distance runners: Anatomical and biomechanical approach. Sports Health, 4(6), 485–495. 10.1177/1941738112445871 Gervis, M., Pickford, H., & Hau, T. (2019). Professional footballers’ association counselors’ perceptions of the role long-term injury plays in mental health issues presented by current and former players. Journal of Clinical Sport Psychology, 13(3), 451–468. 10.1123/jcsp.2018-0049 Gouttebarge, V., Bindra, A., Blauwet, C., Campriani, N., Currie, A., Engebretsen, L., Hainline, B., Kroshus, E., McDuff, D., Mountjoy, M., Purcell, R., Putukian, M., Reardon, C.L., Rice, S.M., & Budgett, R. (2020). International Olympic committee (IOC) sport mental health assessment tool 1 (SMHAT-1) and sport mental health recognition tool (SMHRT-1): Toward better support athletes’ mental health. British Journal of Sports Medicine, 1(9), 1–20. 10.1136/bjsports-2020-102411 Gulliver, A., Griffiths, K.M., Mackinnon, A., Batterham, P.J., & Stanimirovic, R. (2015). The mental health of Australian elite athletes. Journal of Science and Medicine in Sport, 18(3), 255–261. 10.1016/j.jsams.2014.04.006 Haugen, E. (2022). Athlete mental health & psychological impact of sport injury. Operative Techniques in Sports Medicine, 30(1), e150898. 10.1016/j.otsm.2022.150898 Herath, C., Zhou, Y., Gan, Y., Nakandawire, N., Gong, Y., & Lu, Z. (2017). A comparative study of interprofessional education in global health care: A systematic review. Medicine, 96(38). 10.1097/MD.0000000000007336 Insurance Information Institute. (2019). Facts + statistics: Sport injuries. https://www.iii.org/fact-statistic/factsstatistics-sports-injuries Johnson, U., & Ivarsson, A. (2011). Psychological predictors of sport injuries among junior soccer players. Scandinavian Journal of Medicine & Science in Sports, 21(1), 129–136. 10.1111/j.1600-0838.2009.01057.x Kamphoff, C.S., Thomae, J., & Hamson-Utley, J.J. (2013). Integrating the psychological and physiological aspects of sport injury rehabilitation: Rehabilitation profiling and phases of rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), The psychology of sport injury and rehabilitation (pp. 134–155). Routledge. Knowles, Z., Tyler, G., Gilbourne, D., & Eubank, M. (2006). Reflecting on reflection: Exploring the practice of sports coaching graduates. Reflective Practice, 7(2), 163–179. 10.1080/14623940600688423 Maddison, R., & Prapavessis, H. (2005). A psychological approach to the prediction and prevention of athletic injury. Journal of Sport and Exercise Psychology, 27(3), 289–310. 10.1123/jsep.27.3.289

371

Rebecca A. Zakrajsek et al. Martin, S.B., Zakrajsek, R.A., Casey, T., & Bianco, A.G. (2020). Mental techniques for performance. (Independent Course, ISC 30.3.4). In C. Hughes (Ed.), Special topics: Enhancing performance using a mind, body, metric approach. Academy of Orthopedic Physical Therapy, American Physical Therapy Association. McGlashan, A.J., & Finch, C.F. (2010). The extent to which behavioural and social sciences theories and models are used in sport injury prevention research. Sports Medicine, 40(10), 841–858. Meeuwisse, W.H., Tyreman, H., Hagel, B., & Emery, C. (2007). A dynamic model of etiology in sport injury: The recursive nature of risk and causation. Clinical Journal of Sport Medicine, 17(3), 215–219. 10.2165/11534960000000000-00000 Messi Vows to listen to his body to prolong Barcelona career. (2019, October 17). BeSoccer. https://www.besoccer.com/ new/messi-vows-to-listen-to-his-body-to-prolong-barcelona-career-728087 Moller, M., Attermann, J., Myklebust, G., & Wedderkopp, N. (2012). Injury risk in Danish youth and senior elite handball using a new SMS text messages approach. British Journal of Sports Medicine, 46(7), 531–537. 10.1136/ bjsports-2012-091022 Morin, C., Desrosiers, J., & Gaboury, I. (2018). Enablers and barriers to the development of interprofessional collaboration between physicians and osteopaths: A mixed methods study. Journal of Interprofessional Care, 32(4), 463–472. 10.1080/13561820.2018.1435515 Mulumba, P. (n.d.). Serena Williams: How the Tennis Legend stays healthy. Longevity Live. https://longevitylive.com/ anti-aging/serena-williams-how-the-tennis-legend-stays-ealthy/ National Association of Social Workers. (n.d.). Practice. https://www.socialworkers.org/Practice National Safety Council. (n.d.). Concussion Care Should Top Every Youth Sports Playbook. https://www.nsc.org/homesafety/safety-topics/child-safety/concussions Patterson, E.L., Smith, R.E., Everett, J.J., & Ptacek, J.T. (1998). Psychosocial factors as predictors of ballet injuries: Interactive effects of life stress and social support. Journal of Sport Behavior, 21(1), 101. Pitcho-Prelorentzos, S., & Mahat-Shamir, M. (2019). A shattered dream: Meaning construction in response to retirement from professional sport due to career-ending injury. The Sport Psychologist, 33(2), 110–118. 10.1123/tsp.2 018-0069 Podlog, L., & Eklund, R.C. (2006). A longitudinal investigation of competitive athletes’ return to sport following serious injury. Journal of Applied Sport Psychology, 18(1), 44–68. 10.1080/10413200500471319 Poucher, Z.A., Tamminen, K.A., Sabiston, C.M., Cairney, J., & Kerr, G. (2021). Prevalence of symptoms of common mental disorders among elite Canadian athletes. Psychology of Sport and Exercise, 57, e102018. 10.1016/ j.psychsport.2021.102018 Putukian, M. (2016). The psychological response to injury in student athletes: A narrative review with a focus on mental health. British Journal of Sports Medicine, 50(3), 145–148. 10.1136/bjsports-2015-095586 Samuelson, M., Tedeschi, P., Aarendonk, D., de la Cuesta, C., & Groenewegen, P. (2012) Improving interprofessional collaboration in primary care: Position paper of the European Forum for Primary Care. Quality Primary Care, 20(4), 303–312. Scipioni, J. (2020, February 19). Two things Serena Williams does every day to be productive. CNBC. https://www.cnbc. com/2020/02/19/what-serena-williams-does-every-day-to-be-productive.html Setiadi, A.P., Wibowo, Y., Herawati, F., Irawati, S., Setiawan, E., Presley, B., Arif Zaidi, M. & Sunderland, B. (2017). Factors contributing to interprofessional collaboration in Indonesian health centres: A focus group study. Journal of Interprofessional Education & Practice, 8, 69–74. 10.1016/j.xjep.2017.06.002 Shahoseini, M., & VaezMousavi, M. (2021). Mental health in Iranian elite athletes: A 14 year retrospective study. Journal of Humanistic Approach to Sport and Exercise Studies, 1(1), 30–39. 10.52547/hases.1.1.30 Sheu, Y., Chen, L.H., & Hedegaard, H. (2016). Sports-and Recreation-related Injury Episodes in the United States, 2011–2014. National Health Statistics Reports, (99), 1–12. Sherzer, C.B., Brewer, B.W., Cornelius, A.E., Van Raalte, J.L., Petipas, A.J., Sklar, J.H., Pholman, M.H., Krushell, R.J., & Ditmar, T.D. (2001). Psychological skills and adherence to rehabilitation after reconstruction of the anterior cruciate ligament. Journal of Sport Rehabilitation, 10(3), 165–172. 10.1123/jsr.10.3.165 Smith, A.M. (1996). Psychological impact of injuries in athletes. Sports Medicine, 22(6), 391–405. 10.2165/0000725 6-199622060-00006 Smith-Ryan, A.E., Hirsch, K.R., Saylor, H.E., Gould, L.M., & Blue, M.N. (2020). Nutritional considerations and strategies to facilitate injury recovery and rehabilitation. Journal of Athletic Training, 55(9), 918–930. 10.4085/10626050-550-19 Smyth, E.A., Newman, P., Waddington, G., Weissensteiner, J.R., & Drew, M.K. (2019). Injury prevention strategies specific to pre-elite athletes competing in Olympic and professional sports—A systematic review. Journal of Science and Medicine in Sport, 22(8), 887–901. 10.1016/j.jsams.2019.03.002

372

Injury Prevention and Rehabilitation Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Aspen. van Dongen, J.J.J., Lenzen, S.A., van Bokhoven, M.A., Daniëls, R., van der Weijden, T., & Beurskens, A. (2016). Interprofessional collaboration regarding patients’ care plans in primary care: A focus group study into influential factors. BioMed Central Family Practice, 17(1), 1–10. 10.1186/s12875-016-0456-5 von Rosen, P., Floström, F., Frohm, A., & Heijne, A. (2017). Injury patterns in adolescent elite endurance athletes participating in running, orienteering, and cross-country skiing. International Journal of Sports Physical Therapy, 12(5), 822. 10.26603/ijspt20170822 von Rosen, P., Olofsson, O., Väsbom, S., & Heijne, A. (2019). Correlates of health in adolescent elite athletes and adolescents: A cross-sectional study of 1016 adolescents. European Journal of Sport Science, 19(5), 707–716. 10.1 080/17461391.2018.1552721 Washmuth, N.B., Sepich, J.M., & McAfee, A.D. (2019). Sports rehabilitation and interprofessional collaboration. International Archives of Medicine, 12(19). 10.3823/2613 Washington, K.T., Guo, Y., Albright, D.L., Lewis, A., Parker Oliver, D., & Demiris, G. (2017). Team functioning in hospice interprofessional meetings: An exploratory study of providers’ perspectives. Journal of Interprofessional Care, 31(4), 455–462. 10.1080/13561820.2017.1305950 Weinberg, R.S., & Williams, J.M. (2015). Integrating and implementing a psychological skills training program. In J.M. Williams & V. Krane (Eds.), Applied sport psychology: Personal growth to peak performance (pp. 329–359). McGraw Hill Education. White, M.J., Gutierrez, A., McLaughlin, C., Eziakonwa, C., Newman, L.S., White, M., Thayer, B., Davis, K., Williams, M., & Asselin, G. (2013). A pilot for understanding interdisciplinary teams in rehabilitation practice. Rehabilitation Nursing, 38(3), 142–152. 10.1002/rnj.75 Wiese-Bjornstal, D.M., Smith, A.M., Shaffer, S.M., & Morrey, M.A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10(1), 46–69. 10.1080/1 0413209808406377 Williams, J.M., & Andersen, M.B. (1998). Psychosocial antecedents of sport injury: Review and critique of the stress and injury model. Journal of Applied Sport Psychology, 10(1), 5–25. 10.1080/10413209808406375 World Health Organization. (2010). Framework for Action on Interprofessional Education & Collaborative Practice. https:// www.who.int/hrh/resources/framework_action/en/ Yalom, I.D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). Basic Books/Hachette Book Group. Youth Sports Safety Alliance. (2013). Youth Sports Safety Statistics. https://www.youthsportssafetyalliance.org/sites/ default/files/docs/Statistics-2013.pdf Zakrajsek, R.A., Fisher, L.A., & Martin, S.B. (2018). Certified athletic trainers’ experiences with and perceptions of sport psychology services for student-athletes. The Sport Psychologist, 32(4), 300–310. 10.1123/tsp.2017-0119

373

24 NATURE-BASED INTERVENTIONS IN ELITE SPORT Tadhg MacIntyre, Carina Nigg, Cassandra Murphy, and Violetta Oblinger-Peters

Introduction In recent years, there has been an increased emphasis on supporting athletes through sporting transitions (Stambulova & Wylleman, 2019), with the emergence of a range of support structures (e.g., Olympic debriefing, McArdle et al., 2014), increased access to service provision (Moesch et al., 2018), and educational interventions for mental health (Breslin et al., 2019). Position statements on mental health (Schinke et al., 2017; Schinke et al., 2019), mental health service provision (Moesch et al. 2018) by FEPSAC, ISSP, and other bodies and a series of review syntheses (e.g., Rice et al., 2016) are testament to this pivot. This shift in perspective was most notable during the response to the COVID-19 global pandemic when sporting events were cancelled, training disrupted, and access to treatment for injury limited (Lundqvist et al., 2021). An array of recommendations and resources were readily available to support adaptive responses from elite athletes, coaches, and other stakeholders. Guidelines from professional organisations, including AASP, from researchers (Schinke et al., 2020), and from practitioners (MacIntyre, Butler et al., 2020), including specific guidelines for athletes with COVID-19 (Han, Li & Wang, 2021), were rapidly developed and made available online. One recommendation, given the inconsistent access to training and competition venues, was to promote access to natural green and blue spaces for exercise, recovery, and mental health (MacIntyre, Butler et al., 2020). This chapter will focus on what are more appropriately termed nature-based interventions and how they can be used to promote mental health and well-being for athletes with potential co-benefits for nature too. The reader will be taken on a path to explore what these interventions are precisely, for whom they could be used, and how they can be optimised. The theoretical foundations, role of nature connectedness, and key concepts will be addressed and subsequently, guidelines on how they can be applied will be provided. Finally, a series of actions for both researchers and practitioners in the sporting context will be outlined. Firstly, the natural backdrop to this chapter is provided by the extant literature spanning almost four decades of research on the benefits of natural environments for health. To explain, early research on this topic, published in the journal Science suggested that postoperative stay was reduced for hospital patients assigned to rooms with windows showing a nature scene (Ulrich, 1984). Although this classic research was not without criticism, it was a first step in highlighting that even viewing nature could be beneficial for health outcomes. In recent decades this study has been augmented by a wealth of research at different levels from the individual case studies, to controlled studies and review syntheses. Most recently, substantive reviews provide consistent support for positive changes in health (Frumkin et al., 2017), mental 374

DOI: 10.4324/9781003099345-32

Nature-Based Interventions in Elite Sport

health, and reduced stress (Bratman et al., 2019) with inconsistent support for positive changes in psychophysiological parameters (Corazon et al., 2019; Gidlow et al., 2015). Researchers have sought to explore the benefits of human-nature interactions at different levels (see MacIntyre, Beckmann et al., 2020). A range of methodologies have been applied, from the analysis of nature exposure at district level using data from satellite imagery to estimate green space availability (Pereira Barboza et al., 2021), to quasi-experimental designs and case study narratives (MacIntyre, Walkin et al., 2019, MacIntyre, Oliver et al., 2019). Researchers have explored nature exposure (i.e., duration and frequency of visits), nature engagement and more recently, characteristics of the environment relating to, for example, biodiversity (Marselle et al., 2021), and the configuration of the natural features (e.g., tree canopy density; Jiang et al., 2014). Consequently, we can now draw tentative conclusions on key topics encompassed by the term nature-based interventions, nature-based therapy, and technological nature and green exercise. Firstly, we will explore the theoretical and conceptual underpinnings of the research on human-nature interactions including the predominant theoretical explanations, the role of nature connectedness, and potential links to pro-environmental behaviour and environmental concern.

Theoretical Explanations Two predominant theories have been employed historically to explain the positive impact of humannature interactions. Stress-reduction theory (Ulrich, 1984) and attention restoration theory (Kaplan, 1995) have led to decades of research with support for both outcomes in the literature. However, other potential outcomes and explanations may have been overlooked by the ‘chilling effect’ of these seemingly harmonious explanatory accounts. For example, restoration has primarily focused upon short-term cognitive performance enhancement, but in the sport setting the concept of recovery is multifactorial restorative process relative to time (Kellmann et al., 2018) where adequate balance between stress and recovery is a prerequisite for sustainable performance. Consequently, recovery processes can occur during various temporal and environmental settings ranging from for example, visits to nature (e.g., nature walk or green exercise) to micro-breaks, more informal breaks, so-called micro-breaks (Sonnentag et al., 2017). Organisational psychology additionally provides an extant literature which may merit further investigation. For example, Fritz and Sonnentag (2005) proposed four distinct recovery experiences: (1) psychological detachment from work (e.g., “switching off”), (2) relaxation (e.g., low sympathetic arousal), (3) mastery (e.g., challenging activities), and (4) control (self-determining a recovery strategy). Awareness of the different types of experience can provide useful knowledge for the autonomous regulation of wellbeing). Acquiring the ability to self-monitor and utilise recovery strategies can ameliorate stressors, reduce psychological distress, and enhance well-being and performance, both during and beyond ones’ sporting career, as will be discussed later.

Nature Connectedness A concept which is important to include in discussions on nature-based interventions in any context is nature connectedness or relatedness. A connectedness to nature creates a sense of belonging to the wider natural world as part of a larger community of nature. This concept emerged from the biophilia hypothesis (Wilson, 1984) which proposed that there is an innate human urge to form a connection with other living things, such as animals or plants, due to our evolution in natural environments. Nature connectedness, also frequently referred to as nature relatedness or connectedness to nature (Mayer & Frantz, 2004; Nisbet & Zelenski, 2013), stems from this biophilic need to connect with nature. This relationship with the natural environment goes much deeper than simply contact with nature. Nature connectedness puts the role nature plays in a person’s sense of self at the centre of the construct (Mayer & Frantz, 2009; Nisbet et al., 2009). Urbanisation is diminishing our nature contact (Schultz, 2002), with fewer people engaging with daily nature interactions, 375

Tadhg MacIntyre et al.

it is considered by some a health emergency (Soga & Gaston, 2016). People are becoming disconnected with nature, or for some, may have never experienced this relationship before. In elite sport, Eccles et al. (2022) have pointed out that rest and recovery are arguably the ‘forgotten session’ and how athletes recover is fundamental to the principle of a training cycle (Eccles et al., 2022). Their review concludes that recovering psychologically depends in part on engagement in sleep (i.e., high quality and recommended duration) wakeful resting. Wakeful resting involves obtaining specific resting experiences such as psychologically detaching from one’s sport. Nature can play a specific role in promoting psychological detachment from the demands of sport and by fostering nature connectedness, this may have both benefits, for the individual, and co-benefits, for the environment. Nature connectedness has been demonstrated to have several positive benefits for individuals including positive psychological and social well-being (Capaldi et al., 2014; Iqbal & Mansell, 2021; Pritchard et al., 2019). Having nature adjacent to your place of residence has shown to be beneficial in periods of low social interaction, similar to that which we saw during the COVID-19 pandemic (Cartwright et al., 2018). Outside of the social benefits, personal and psychological benefits have been discovered. In the world of sport, perception of body image can be a debatable topic (Sabiston et al., 2019). There have also been links found between nature connectedness and body appreciation and self-esteem among international samples (Swami et al., 2016). Recently, a large scale survey in Canada (N = 1251) reported that emotional connectedness to nature was the strongest predictor of proenvironmental behaviour in comparison to the other factors (Anderson & Krettenauer, 2021). We posit that it is more important than ever to support research that is eager to discover ways to help reconnect citizens with the natural world, both for the individual benefit to humans and for the co-benefits for the natural environment.

What Are Nature-Based Interventions? Nature-based interventions have been recently operationalised as “planned, intentional activities to promote individuals’ optimal functioning, health and well-being or to enable restoration and recovery through exposure to or interaction with either authentic or technological nature” (Gritzka et al., 2020, p. 2). Nature-based interventions, including green exercise, have the potential to be a non-invasive lowstigma preventative intervention for positive mental health and well-being” (MacIntyre, Calogiuri et al., 2019, p. 17). A sub-set of nature-based interventions is (see Figure 24.2), nature-based therapy is often referred to as forest therapy or ecotherapy (Oh et al., 2020). “Nature-based therapy differs substantially from the traditional therapy setting – defined as taking place inside a clinic – in that it encourages bodily involvement with the outdoor environment as an integrated part of the therapy, where therapeutic talk often takes place simultaneously” while walking (Corazon et al., 2011, p. 162). The most commonly known nature-based interventions are green and blue exercise which refer to physical activity in green space (e.g., park run) and blue space (e.g., in or adjacent to water) respectively (Donnelly & MacIntyre, 2019). Despite several reviews on green exercise (Lahart et al., 2019; Thompson-Coon et al., 2011), only tentative support exists for the additional positive impact above exercise in other settings (e.g., indoor). Arguably, this is largely due to the methodological inadequacies that have plagued the research literature and the complexity of the human-nature interactions highlighted in recent reviews and commentaries (Lahart et al., 2019; MacIntyre, Beckmann et al., 2020; Mnich et al., 2019). Recent research specifically on blue space from the Horizon 2020 research project BlueHealth (Grellier et al., 2017) has been promising. For example, a workplace-based walking study compared a seaside walk with an urban walk with positive changes in mood but inconsistent findings with respect to psychophysiological parameters including HRV and blood pressure (Vert et al., 2020). In the following sections, we will highlight the three key types of nature-based interventions and nature-based therapies, green and blue exercise, and technological or virtual nature (Figure 24.1). 376

Nature-Based Interventions in Elite Sport

Figure 24.1

Hypothesised Modes of Nature Contact with Recommendations for Athletes

Nature-Based Therapies In the case of nature-based therapy, arguably nature acts as a co-therapist. A recent review of nature-based therapies by Cooley et al. (2020) highlighted that time in nature can nurture our physical and spiritual existence. The therapeutic context in the studies reviewed varied from nature providing a passive backdrop to the therapy to actively incorporating nature through a therapeutic process or specific naturebased activities with nature in the foreground. The first author’s practitioner experience is illustrative with respect to the application of nature-based therapies. As an accredited sport psychologist providing psychological support in a professional sport context, the modes of delivery included client meetings in a formal office setting, discussions over coffee, group discussions on the pitch (e.g., ‘campfire’ chats), all of which are the norm within the field (Aoyagi et al., 2012), augmented by delivery in non-normative settings, for example, walk and talks in nature. This latter mode enabled access to natural environments for the application of evidence-based approaches including, for example, mindfulness-based stress reduction (Creswell, 2017). Moreover, the outdoor therapy opened a window for conversations on topics that would normally be limited due to mental health stigma. Additional benefits were that more creative solutions could be co-created with the client. 377

Tadhg MacIntyre et al.

Figure 24.2 Hypothesised Effects of Nature-Based Therapies for Athletes

Natural settings have previously been associated with increases in creativity. For example, in one study of divergent thinking, treadmill walking (indoors), being seated (indoors) with walking outside were compared with the latter condition associated with the highest levels of creative analogy generation (Oppezzo & Schwartz, 2014). Reflecting on my practice, the outdoor setting also had a perceived positive impact upon both client and practitioner well-being. For example, it reduced stress for both members of the therapeutic alliance and offered a window into a more interactive therapeutic context without the perception of hierarchy that one may find in an consulting room. One one level, it was difficult to evaluate which had the greater impact: The therapeutic alliance? The intervention or the natural setting? The undoubted complexity of therapy in nature has limited the genesis of the evidence base to date. Diverse approaches are employed by a range of practitioner approaches from accredited psychologists, to therapists and guides from a broad range of ecological perspectives. Broadly, qualitative evidence supports nature coaching or nature-therapy in limited ways. For example, Van den Berg and Beute (2021) reported that a walk and talk coaching programme was effective in reducing burnout and stress symptoms, albeit in non-sporting samples. Research on nature-based therapies to date does not provide conclusive evidence of the benefits (Coventry et al., 2021); nevertheless, the European 378

Nature-Based Interventions in Elite Sport

Commission is funding prospective research in this field (e.g., https://recetasproject.eu/). And in the professional practice field, organisations like the British Psychological Society developed specific guidelines for outdoor therapy as a response to the challenges of COVID-19 lockdown scenarios and mandated physical distancing (BPS, 2020).

Green and Blue Exercise Interventions Green and blue exercise, or using a more comprehensive term, nature-based exercise, refers to all exercise activities conducted in spaces that are dominated by natural features such as trees, lakes, trails, etc. (Araújo et al., 2019). From a theoretical perspective, ecological dynamic approaches argue that the variability of natural environments, such as various textures, gradients, and surfaces, requires continuous psychological engagement and adaptation of movement behaviors, hence promoting mental health and well-being (Araújo et al., 2019). To date, studies mostly investigated the psychological benefits of green and blue exercise in a public health context with non-elite athletes, with tentative support for enhanced affective benefits when exercising in natural environments (Donnelly & MacIntyre, 2019). However, findings to date should be viewed with caution as many studies took place in laboratory environments and it is doubtful in how much those results can be generalised to real-world environments when considering ecological dynamic approaches (Araújo et al., 2019). To date, studies including elite athlete samples are rare, but related research may show the potential of green and blue exercise also for this specific target group. One study discusses the potential of green and blue environments for athletes competing in the Olympics, arguing that green environments may benefit athletes’ health and performance not only via psychological pathways, but also via mitigating the risk of environmental pollutants, such as particulate matter (Donnelly et al., 2016). Hence, enriching elite athletes’ competition spaces with natural green and blue features has the potential to not only improve athlete’s mental health outside of the competition, but also to enhance their performance via biological pathways through improved environmental quality. Beyond that, green and blue exercise interventions may be valuable to improve athletes’ well-being and promote recovery outside of the high training and competition season. In a qualitative study with athletes that engaged in extreme sport, such as surfing, white-water kayaking, mountaineering, or skijumping, three themes arose that displayed the psychological benefits of nature for them: i) emotional response to nature, mainly referring to positive emotions that emerge via nature exposure; ii) nature for coping; and iii) restorative spaces, emphasising the unique contributions and pathways of green and blue spaces (MacIntyre, Calogiuri et al., 2019). Hence, especially for elite athletes for whom exercise is linked to pressure and competition in the professional context, green exercise may provide an alternative for elite athletes during less training-intensive times that also promote psychological well-being in recovery. In summary, drawing on theoretical considerations, research from public health, and case studies with elite athletes, green and blue exercise has a large potential to provide benefits both during and outside the high-training season for elite athletes. Future studies should further investigate green and blue exercise in elite athletes to allow for conclusions based on empirical findings.

Technological and Virtual Nature Researchers have been keen to couple technology with nature, to investigate if one can create the same positive effects with high fidelity simulations of natural spaces. Employing technologies that in various ways mediate, augment and simulate our experience of the natural world is referred to as ‘technological nature’ (Kahn, 2018). To test if simulated nature can lead to similar positive effects as actual nature, Caloguiri et al. (2018) used an immersive virtual environment for a nature walk, comprising either sitting on a chair or walking on a manually driven treadmill. They concluded that it may be a useful technique in 379

Tadhg MacIntyre et al.

the future to reproduce the beneficial effects of nature on well-being; however, limitations in terms of image quality and cyber sickness would have to be addressed. A more successful outcome was reported using micro-breaks as an intervention to promote restored attention (Lee et al., 2015). Participants’ perceptions of the restorativeness of two different city scenes (flowering meadow green roof scene vs a concrete roof scene) was as predicted. They reported that the nature scene was more restorative, as well as boosting their performance on a test of sustained attention compared to participants viewing the concrete scene, who showed worsening attention over the course of the task. Another technique that combines nature engagement and technological nature is nature savouring. A concept from positive psychology, savouring is defined as regulating the emotional impact of positive events by one’s cognitive or behavioural responses, and is linked to increased happiness based on self-report and neural measures. In a recent study applying technological nature, participants were assigned to either a control group, a nature scene group or a built environment scene group (Passmore & Holder, 2016). The participants were instructed not to change their daily routines on their campus commutes (i.e., walking across campus) but to take photographs of scenes along their route (i.e., natural environment or built environment). They were asked to ‘pay attention to how the objects around you make you feel’ and make a note of the emotions. The findings after two weeks were that mental well-being and pro-social behaviour were higher in the nature scene group. It was not time spent in nature per se that led to these differences (as routines did not change) but the actual nature engagement-noticing and attending to nature. This study provides support for the positive impact of nature on wellbeing and the possible reciprocal effects on mental well-being from engagement with nature. Advances in virtual reality technology and the increased availability of highfidelity equipment (e.g., Oculus Quest VR goggles) provides optimism for this future research stream.

Application by Sport Typology Within the realm of elite sport, one categorisation of sport typologies is whether the sporting federations are affiliated to the IOC for example or included in the Olympic and Paralympic movement for Winter and Summer Games. This system may overlook the opportunity to include unique samples from both ultra-endurance events and e-sport for example (Cotterill et al., 2019). A more inclusive approach may be required, to comprehensively address the potential for novel nature-based interventions across the sport spectrum. In Figure 24.3 is a classification based on the sport setting (indoor/outdoor) and structure (dynamic/static) used to convey the relevance of nature-based interventions across different sport. This should be illuminating in decisions about for whom nature-based interventions may be most relevant and furthermore, it may also help highlight challenges in implementation and potential adverse effects. In our classification illustrated in Figure 24.3, we suggest that indoor sport may benefit more from naturecontact than outdoors sport, for example. Sport activities that are cognitively demanding including chess and snooker may benefit more from nature due to the well-supported positive impact on attention restoration. Sport in wild nature and hybrid nature may already provide sufficient green and blue space for recovery, so a ceiling effect may be reached there. Furthermore, some indoor sport have complimentary outdoor modes (e.g., both cycling and swimming), which could ensure specificity of training is maintained by switching to more natural settings at least for recovery sessions. Additionally, some sport which have outdoor ‘urban’ setting like skate parks and indeed some hybrid venues (e.g., sport stadia) may lack natural stimuli, so in this scenario nature may play a key role in promoting recovery and it may also have ergogenic effects (Donnelly et al., 2016). One possibility is that the call room in a stadium or warm-up areas would be re-natured to reduce stress and further recommendations are highlighted in Table 24.1. While nature-based interventions require natural stimuli (e.g., greenspace) the specific typology may also be relevant, and the ‘nature of nature’ or the quality of the natural setting is an important consideration, which we will now address. One interesting issue is the role of biodiversity, a key factor for ecosystem health but until recently it was not evident that the levels of biodiversity were related to well-being. However, a recent review 380

Nature-Based Interventions in Elite Sport

Figure 24.3

Examples of Indoor and Outdoor Sport Across Different Settings

concluded through bird-species richness (including birdsong), followed by plant-species richness, habitat diversity and butterfly richness are all related to improved wellbeing (Aerts et al., 2018), increased positive affect (mood) and lower levels of anxiety (Wolf et al., 2017). This is why on the basis of the current evidence it is indeed valuable to distinguish sporting activities in ‘wilderness’ from those in outdoor settings (e.g., urban parks) without the same potential for biodiversity. Another factor to consider is that for competitors even in the most extreme wilderness settings their attention may be directed on cues other than the natural stimuli. This ironic effect is due to the attentional demands of their activity, notably at high levels of perceived exertion whereby attentional switching occurs (Brick et al., 2017). Thus green exercise is often prescribed at lower levels of exercise intensity to overcome any dampening of the effects from this attentional bias. One should also consider that athletes in extreme outdoor sport do report to be highly connected to nature with commensurate benefits according to case study reports (MacIntyre, Walkin et al. 2019).

Potential Adverse Effects Natural environments, in both their digital and non-digital form have potential risks and unintended consequences which require consideration as outlined in Table 24.1. For instance, the use of technological 381

Tadhg MacIntyre et al. Table 24.1 Recommendations for a Sample of Sporting Activities Sport Setting

Sporting Example

Recommendations

Potential Adverse Effects

Wild Nature

Sailing

Risk of fatigue for blue or green exercise interventions.

Artificial Outdoor

Archery

Pitch-Based

Soccer

Technological nature potentially useful for recovery from workload and stress. Blue or green exercise may be ideal for competition preparation, recovery and transitions. Nature-based therapies and technological nature may help with stress reduction and coping. Nature-based therapies may be ideal for consults, with benefits of technological nature for decompression post-game to aid sleep.

Indoor Dynamic

Swimming

Blue exercise may be ideal and perceived as complimentary by support staff and coaches, depending upon stage in macrocycle. Nature-based therapies and technological nature may help with stress reduction.

Indoor Static

E-sport

Green exercise may be useful for both competition preparation and recovery as workload considerations may not be as relevant. Naturebased therapies and outdoor consults may be useful for competitors as a contrast from their competition and training settings.

Technological nature maybe perceived as cognitively demanding in these activities.

Green exercise may simply lead to displacement of physical activity from existing training practice and lead to additional workload should be performed at low RPE. May be useful for those in transition or rehabilitation phases (depending on nature of injury). Similarly, blue exercise may simply lead to displacement of physical activity from existing training practice and lead to additional workload should be performed at low RPE. May be useful for those in rehabilitation or in transition phases due to change in buoyancy in water. Technological nature may be perceived as more screen time and additional cognitive workload and thus potentially contraindicated for stress reduction.

nature (e.g., virtual reality or digital nature) may itself be cognitively demanding and increase athlete workload further. VR itself has been associated with the risk of cyber-sickness for some individuals (Litleskare et al., 2020), and the risk of increasing sedentary behaviour may occur from extensive technological nature interventions. Time in nature can also expose individuals to risks from environmental hazards of noise and air pollution, for example, so it is important to ensure the nature of the nature is high quality. Even in areas of biodiversity, there are risks from pollen, insects, and challenges in terms of weather too. One interesting potential unintended consequence is ecoanxiety. Eco-anxiety refers to the distress caused by climate change and degraded natural environments where people are becoming anxious about their future (Coffey et al., 2021). A 2021 survey with approximately 10,000 young people (e.g., ages 16–25) reported a high prevalence of 382

Nature-Based Interventions in Elite Sport

eco-anxiety. Moreover, distress about climate change was associated with young people perceiving that they have no future and interestingly, this was exacerbated by their perception of government inaction. One consequence of individuals with eco-anxiety engaging in nature-based interventions is that their anxieties can be exacerbated if for example they perceive the greenspace areas for recovery to be a degraded environment. The choice of the natural environments used should consider this possibility.

Recommendations for Further Enquiry Our presented framework highlights the potential benefits of nature-based interventions in the context of sport. This can be used as a general advice using the basic parameters of a sport discipline. However, key questions with regards to the relation between nature-based approaches and elite sport remain to be answered through further exploration and well-conceived research questions. First and foremost among them is the effectiveness of the interventions and this and other issues including the acceptability of nature-based interventions and the sustainability of mega-events will be discussed in this section.

Efficacy of Nature-Based Interventions Athletes can provide unique insights into the effectiveness of nature-based interventions beyond the more generic recommendations of spending 120 minutes a week in nature (White et al., 2019). As a sample, they are often measured on a range of multidimensional health outcomes daily including HR, sleep, wellbeing, and additionally performance outcomes. Thus, sport can act as a natural laboratory for the exploration and subsequent evaluation of the array of approaches outlined in this Chapter (Donnelly et al., 2016). Subjective scales, objective markers (e.g., EEG), and biomarkers (e.g., cortisol) can provide converging evidence for the impact and will potentially expand the range of factors to be considered in the future (see MacIntyre, Calogiuri et al., 2019). Additionally, green exercise is integrally linked to more than seven sustainable development goals, which go beyond mere reductions in carbon footprint (Nigg & Nigg, 2021). Longitudinal research designs could offer a window into the potential benefits, risks, and mechanisms underlying nature-based interventions.

Acceptability of Approach One of the key challenges in helping athletes and other stakeholders cope in elite sport is mental health stigma. This factor potentially limits the application of what are termed direct approaches (e.g., mental health literacy) and may result in unintended consequences and increase stigma. Consequently, what have been termed low-stigma approaches including nature-based interventions may be useful as they have arguably less barriers to implementation than direct techniques. Early research from the field of exercise psychology may be instructive here. McKenna et al. (1998) reported that one of the key barriers to exercise prescription by physicians was the extent to which they were already physically active in sport. There was a threefold increase in exercise prescription from physicians who were in the action or maintenance stage of modifying their own exercise behaviours. One unknown is the readiness to participate in nature-based interventions among sporting stakeholders including coaches, sport scientists, sport-medicine staff, and psychologists. A shared mandate among an athletes’ support staff may help normalise this type of activity whereby they could model the behaviour for athletes and players to follow. For team-based interventions to be successful, it is likely that an integrated approach as outlined should be followed.

383

Tadhg MacIntyre et al.

Actions for Researchers and Practitioners Key Objectives 1

2

3 4 5

6

Conduct large-scale surveys of athletes’ eco-anxiety and nature connectedness. The former will assist with the genesis of interventions and the latter will provide foundation-level knowledge on the extent to which specific athlete groups (including age and gender and cultural characteristics) are amenable to nature-based interventions. Explore through focus groups, with athletes and their support staff (including rehabilitation specialists) their perceptions of workload, stressors, transitions, nature-contact, and engagement and attitudes towards the mental health and the environment. Identify trends in attitudes, behaviour, and usage of natural blue and green spaces in large-scale surveys or transdisciplinary activities (e.g., photo-voice methodology). Evaluate athletes’ perceptions of environmental quality of natural blue and green spaces, knowledge of biodiversity, and other factors. Co-create an evidence-based online education tool with multiple stakeholders pertaining to the application of nature-based interventions to support dual careers in sport, recovery from injury, and to cope with organisational stress by helping athletes self-monitor, increase their awareness about well-being, and self-determine their usage of different modes of nature contact to enhance well-being and promote a sustainable lifestyle. Develop policy recommendations to guide further education and training of stakeholders with advocates (e.g., athlete ambassadors) about the role of nature-based interventions in linking to a sustainability agenda encompassed by the UN SDGs, and accordingly inform existing and ongoing EUlevel policy initiatives.

Conclusions This chapter highlighted how a trend in sport, an increased awareness of the role of psychology in supporting athletes mental health, can be addressed by an awareness of specific strategies that brings nature into the lives of athletes. Nature-based interventions, and examples of different approaches, were outlined with the potential benefits and adverse effects. Elite sport have evolved to consider the primary goals of mental health and well-being and the seeds of research are emerging on the role of nature in supporting this.

Funding Acknowledgement The first three authors have been supported in developing this output by funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No.869764. Carina Nigg receives funding of the German Academic Scholarship Foundation (Studienstiftung des deutschen Volkes).

References Aerts, R., Honnay, O., & Van Nieuwenhuyse, A. (2018). Biodiversity and human health: Mechanisms and evidence of the positive health effects of diversity in nature and green spaces. British Medical Bulletin, 127(1), 5–22. 10.1093/ bmb/ ldy021 Anderson, D., & Krettenauer, T. (2021). Connectedness to nature and pro-environmental behaviour from early adolescence to adulthood: A comparison of urban and rural Canada. Sustainability, 13(7), 3655. 10.3390/su13 073655

384

Nature-Based Interventions in Elite Sport Aoyagi, M.W., Portenga, S.T., Poczwardowski, A., Cohen, A.B., & Statler, T. (2012). Reflections and directions: The profession of sport psychology past, present, and future. Professional Psychology: Research and Practice, 43(1), 32. Araújo, D., Brymer, E., Brito, H., Withagen, R., & Davids, K. (2019). The empowering variability of affordances of nature: Why do exercisers feel better after performing the same exercise in natural environments than in indoor environments? Psychology of Sport and Exercise, 42, 138–145. 10.1016/j.psychsport.2018.12.020 Bratman, G.N., Anderson, C.B., Berman, M.G., Cochran, B., de Vries, S., Flanders, J. et al. (2019). Nature and mental health: An ecosystem service perspective. Science Advances, 5(7), eaax0903. 10.1126/sciadv.aax0903 Breslin, G., Smith, A., Donohue, B., et al. (2019). International consensus statement on the psychosocial and policyrelated approaches to mental health awareness programmes in sport. BMJ Open Sport & Exercise Medicine, 5, e000585. 10.1136/bmjsem-2019-000585 Brick, C., Sherman, D., & Kim, H. (2017). “Green to be seen” and “brown to keep down”: Visibility moderates the effect of identity on pro-environmental behavior. Journal of Environmental Psychology, 51, 226–238. 10.1016/ j.jenvp.2017.04.004 British Psychological Society (2020). The use of Talking Therapy Outdoors. Available online at: https://www.bps.org. uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Use%20of%20talking%20therapy%20outdoors.pdf Calogiuri, G., Litleskare, S., Fagerheim, K. A., Rydgren, T. L., Brambilla, E., & Thurston, M. (2018). Experiencing nature through immersive virtual environments: Environmental perceptions, physical engagement, and affective responses during a simulated nature walk. Frontiers in Psychology, 8, 10.3389/fpsyg.2017.02321 Capaldi, C., Dopko, R., & Zelenski, J. (2014). The relationship between nature connectedness and happiness: A meta-analysis. Frontiers in Psychology, 5, 976. 10.3389/fpsyg.2014.00976 Cartwright, B., White, M., & Clitherow, T. (2018). Nearby nature ‘buffers’ the effect of low social connectedness on adult subjective wellbeing over the last 7 days. International Journal of Environmental Research and Public Health, 15(6), 1238. 10.3390/ijerph15061238 Cooley, S.J., Jones, C.R., Kurtz, A., & Robertson, N. (2020). ‘Into the wild’: A meta-synthesis of talking therapy in natural outdoor spaces. Clinical Psychology Review, 77, 101841. 10.1016/j.cpr.2020.101841 Corazon, S.S., Sidenius, U., Poulsen, D.V., Gramkow, M.C., & Stigsdotter, U.K. (2019). Psycho-physiological stress recovery in outdoor nature-based interventions: A systematic review of the past eight years of research. International Journal of Environmental Research and Public Health, 16(10), 1711. 10.3390/ijerph16101711 Corazon, S.S., Schilhab, T., & Stigsdottera, U.K. (2011). Developing the therapeutic potential of embodied cognition and metaphors in nature-based therapy: Lessons from theory to practice. Journal of Adventure Education and Outdoor Learning, 11(2), 161–171. 10.1080/14729679.2011.633389 Coffey, Y., Bhullar, N., Durkin, J., Islam, M., & Usher, K. (2021). Understanding eco-anxiety: A systematic scoping review of current literature and identified knowledge gaps. The Journal of Climate Change and Health, 3, 100047. 10.1016/j.joclim.2021.100047 Cotterill, C., McMillen, N., & Harris, B.S. (2019). Sport psychology in a virtual world: Considerations for practitioners working in eSports. Journal of Sport Psychology in Action, 10(2), 73–81, 10.1080/21520704.2018.1518280 Coventry, P.A., Brown, J.E., Pervin, J., Brabyn, S., Pateman, R., Breedvelt, J., Gilbody, S., Stancliffe, R., McEachan, R., & White, P.L. (2021). Nature-based outdoor activities for mental and physical health: Systematic review and meta-analysis. SSM - Population Health, 16, 100934. 10.1016/j.ssmph.2021.100934 Creswell, J.D. (2017). Mindfulness interventions. Annual Review of Psychology, 68, 491–516. Donnelly, A.A., & MacIntyre, T.E. (2019). Physical activity in natural settings: Green and blue exercise. Routledge. Donnelly, A.A., MacIntyre, T.E., O’Sullivan, N., Warrington, G., Harrison, A.J., Igou, E.R., Jones, M., Gidlow, C., Brick, N., Lahart, I., Cloak, R., & Lane, A.M. (2016). Environmental influences on elite sport athletes well being: From gold, silver, and bronze to blue green and gold. Frontiers in Psychology, 7, 1167. 10.3389/fpsyg.2016.01167 Eccles, D., Balk, Y., Gretton, T.W., & Harris, N. (2022). ‘The forgotten session”: Advancing research and practice concerning the psychology of rest in athletes. Journal of Applied Sport Psychology, 34(1), 3–24. 10.1080/10413200. 2020.1756526 Fritz, C., & Sonnentag, S. (2005). Recovery, health, and job performance: Effects of weekend experiences. Journal of Occupational Health Psychology, 10(3), 187–199. 10.1037/1076-8998.10.3.187 Frumkin H., Bratman, G.N., Breslow S.J., et al. (2017). Nature contact and human health: A research agenda. Environ Health Perspect, 1 (25), 075001. 10.1289/EHP1663 Gidlow, C.J., Jones, M.V., Hurst, G., Masterson, D., Clark-Carter, D., Tarvainen, M.P., Smith, G., & Nieuwenhuijsen, M. (2015) Where to put your best foot forward: Psycho-physiological responses to walking in natural and urban environments. Journal of Environmental Psychology, 45, 22–29. ISSN 1522-9610. Grellier, J., White, M.P., Albin, M., et al. (2017). BlueHealth: A study programme protocol for mapping and quantifying the potential benefits to public health and well-being from Europe’s blue spaces. BMJ Open, 7, e016188. 10.1136/bmjopen-2017-016188

385

Tadhg MacIntyre et al. Gritzka, S., MacIntyre, T.E., Dörfel, D., Baker-Blanc, J.L., & Calogiuri, G. (2020). The effects of workplace naturebased interventions on the mental health and well-being of employees: A systematic review. Frontiers in Psychiatry, 11, 323. 10.3389/fpsyt.2020.00323 Han Q., Li X., & Wang Z. (2021). How should athletes coping withCOVID-19: Focus on severity and psychological support. Frontiers in Psychology, 12, 559125. 10.3389/fpsyg.2021.559125 Iqbal, A., & Mansell, W. (2021). A thematic analysis of multiple pathways between nature engagement activities and well-being. Frontiers in Psychology, 12, 580992. 10.3389/fpsyg.2021.580992 Jiang, B., Li, D., Larsen, L., & Sullivan, W.C. (2014). A dose-response curve describing the relationship between urban tree cover density and self-reported stress recovery. Environment and Behavior, 48(4), 607–629. 10.1177/0013 916514552321 Kahn, P.H. (2018). Technological nature and human well-being. In van den Bosch, M., & Bird, T. (Eds.). Oxford textbook of nature and public health: The role of nature in improving the health of a population (pp. 160–164). OUP. 10. 1093/med/9780198725916.003.0003 Kaplan, S. (1995). The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15(3), 169–182. 10.1016/0272-4944(95)90001-2 Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A., & Duffield, R. et al. (2018). Recovery and performance in sport: Consensus statement. International Journal of Sports Physiology and Performance, 13(2), 240–245. 10.1123/ijspp.2017-0759 Lahart, I., Darcy, P., Gidlow, C., & Calogiuri, G. (2019). The effects of green exercise on physical and mental wellbeing: A systematic review. International Journal of Environmental Research and Public Health, 16(8), 1352. 10.3390/ijerph 16081352 Lee, J., Peng, Y., Lin, W.Y., Parrish, J.Z. (2015). Coordinate control of terminal dendrite patterning and dynamics by the membrane protein raw. Development, 142(1): 162–173. Litleskare, S., E. MacIntyre, T., & Calogiuri, G. (2020). Enable, reconnect and augment: A new ERA of virtual nature research and application. International Journal of Environmental Research and Public Health, 17(5), 1738. MDPI AG. Retrieved from 10.3390/ijerph17051738 Lundqvist, C., Macdougall, H., Noguchi, Y., Malherbe, A., & Abejean, F. (2021). When COVID-19 struck the world and elite sports: Psychological challenges and support provision in five countries during the first phase of the pandemic. Journal of Sport Psychology in Action, 13(2), 116–128. 10.1080/21520704.2021.1931594 MacIntyre, T.E., Butler, C., & Barr, J. (2020). How can elite athletes and players deal with coronavirus issues? Brainstorm (url: https://www.rte.ie/brainstorm/2020/0331/1127553-athletes-players-sport-olympics-tokoyo2021-coronavirus/) MacIntyre, T.E., Beckmann, J., Calogiuri, G., Donnell, A.A., Jones, M.V., Madan, C.R., Rogerson, M., Brick, N.E., Nieuwenhuijsen, M., & Gidlow, C.J. (2020). Editorial: Human-nature interactions: Perspectives on conceptual and methodological issues. Frontiers in Psychology, 11, 607888. 10.3389/fpsyg.2020.607888 MacIntyre, T.E., Walkin, M., Beckmann, J., Calogiuri, G., Gritzka, S., Oliver, G., Donnelly, A.A., & Warrington, G. (2019) An exploratory study of extreme sport athletes’ nature interactions: from well-being to pro-environmental behavior. Frontiers in Psychololgy, 10, 1233. 10.3389/fpsyg.2019.01233 MacIntyre, T.E., Oliver, G., Walkin, M., Calogiuri, G., Donnelly, A.A., Gritzka, S., & Ni Cheallaigh, M-T. (2019). From tracks to trails: Case studies in green exercise. In A.A. Donnelly & T.E. MacIntyre (Eds.), Physical activity in natural settings: Green and blue exercise (pp. 193–209). NY: Routledge. MacIntyre, T.E., Calogiuri, G., Donnelly, A.A., Warrington, Beckmann, J., Lahart, I., & Brick, N. (2019). Societal challenges, methodological issues and transdisciplinary approaches. In A.A. Donnelly & T.E. MacIntyre (Eds.), Physical activity in natural settings: Green and blue exercise (pp. 13–31). NY: Routledge. Marselle, M.R., Hartig, T., Cox, D.T.C., de Bell, S., Knapp, S., Lindley, S., Triguero-Mas, M., Böhning-Gaese, K., Braubach, M., Cook, P.A., de Vries, S., Heintz-Buschart, A., Hofmann, M., Irvine, K.N., Kabisch, N., Kolek, F., Kraemer, R., Markevych, I., Martens, D., & Bonn, A. (2021). Pathways linking biodiversity to human health: A conceptual framework. Environment International, 150, 106420. 10.1016/j.envint.2021.106420 Mayer, F.S., Frantz, C.M., Bruehlman-Senecal, E., & Dolliver, K. (2009). Why is nature beneficial?: The role of connectedness to nature. Environment and Behavior, 41(5), 607–643. 10.1177/0013916508319745 Mayer, F., & Frantz, C. (2004). The connectedness to nature scale: A measure of individuals’ feeling in community with nature. Journal of Environmental Psychology, 24(4), 503–515. 10.1016/j.jenvp.2004.10.001 McArdle S., Moore P., & Lyons D. (2014). Olympic Athletes’ experiences of a post games career transition program. The Sport Psychologist, 28, 269–278. 10.1123/tsp.2013-0046 McKenna, J., Naylor, P.-J., & McDowell, N. (1998). Barriers to physical activity promotion by general practitioners and practice nurses. British Journal of Sports Medicine, 32, 242– 247.

386

Nature-Based Interventions in Elite Sport Mnich, C., Weyland, S., Jekauc, D., & Schipperijn, J. (2019). Psychosocial and physiological health outcomes of green exercise in children and adolescents: A systematic review. International Journal of Environmental Research and Public Health, 16(21), 4266. MDPI AG. 10.3390/ijerph16214266 Moesch, K., Kenttä, G., Kleinert, J., Quignon-Fleuret, C., Cecil, S., & Bertollo, M. (2018). FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychology of Sport and Exercise, 38, 61–71. 10.1016/j.psychsport.2018.05.013 Nigg C., & Nigg, C.R. (2021). It’s more than climate change and active transport-physical activity’s role in sustainable behavior. Translations in Behavioural Medicine, 11(4), 945–953. 10.1093/tbm/ibaa129. PMID: 33410486. Nisbet, E.K., Zelenski, J.M., & Murphy, S.A. (2009). The nature relatedness scale: Linking individuals’ connection with nature to environmental concern and behavior. Environment and Behavior, 41(5), 715–740. 10.1177/001391 6508318748 Nisbet, E., & Zelenski, J. (2013). The NR-6: A new brief measure of nature relatedness. Frontiers In Psychology, 4. 10.3389/fpsyg.2013.00813 Oh, K.H., Shin, W.S., Khil, T.G., & Kim, D.J. (2020). Six-step model of nature-based therapy process. International Journal of Environmental Research and Public Health, 17(3), 685. 10.3390/ijerph17030685 Oppezzo, M., & Schwartz, D.L. (2014). Give your ideas some legs: The positive effect of walking on creative thinking. Journal of Experimental Psychology: Learning Memory and Cognition, 40(4), 1142–1152. 10.1037/a0036577 Passmore, H., & Holder, M. (2016). Noticing nature: Individual and social benefits of a two-week intervention. The Journal of Positive Psychology, 12(6), 537–546. 10.1080/17439760.2016.1221126 Pereira Barboza, E., Cirach, M., Khomenko, S., Iungman, T., Mueller, N., Barrera- Gomez, J., et al. (2021). Green space and mortality in European cities: A health impact assessment study. Lancet Plan Health, 5(10), e718–e730. Pritchard, A., Richardson, M., Sheffield, D., & McEwan, K. (2019). The relationship between nature connectedness and eudaimonic well-being: A meta-analysis. Journal of Happiness Studies, 21(3), 1145–1167. 10.1007/s10902-01900118-6 Rice, S.M., Purcell, R., De Silva, S. et al. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46, 1333–1353. 10.1007/s40279-016-0492-2 Sabiston, C., Pila, E., Vani, M., & Thogersen-Ntoumani, C. (2019). Body image, physical activity, and sport: A scoping review. Psychology of Sport and Exercise, 42, 48–57. 10.1016/j.psychsport.2018.12.010 Schinke, R., Stambulova, N., Si, G., & Moore, Z., 2017. International society of sport psychology position stand: Athletes’ mental health, performance, and development. International Journal of Sport and Exercise Psychology, 16(6), 622–639. Schinke, R.J., Si, G., Zhang, L., Elbe, A.-M., Watson, J., Harwood, C., & Terry, P.C. (2019). Joint position stand of the ISSP, FEPSAC, ASPASP, and AASP on professional accreditation. Psychology of Sport and Exercise, 38, 107–115. 10.1016/j.psychsport.2018.06.005 Schinke, R., Papaioannou, A., Maher, C., Parham, W.D., Larsen, C.H., Gordin, R., & Stewart Cotterill, S. (2020). Sport psychology services to professional athletes: Working through COVID-19. International Journal of Sport and Exercise Psychology, 18(4), 409–413. 10.1080/1612197X.2020.1766182 Schultz, P. (2002). Inclusion with nature: The psychology of human-nature relations. In: Schmuck, P. & Schultz, W.P. (eds) Psychology of Sustainable Development (pp. 61–78). Springer, Boston, MA. 10.1007/978-1-46150995-0_4 Soga, M., & Gaston, K. (2016). Extinction of experience: The loss of human-nature interactions. Frontiers in Ecology and The Environment, 14(2), 94–101. 10.1002/fee.1225 Sonnentag, S., Venz, L., & Casper, A., 2017. Advances in recovery research: What have welearned? What should be done next? Journal of Occupational Health Psychology, 22(3), 365–380. Stambulova, N., & Wylleman, P. (2019). Psychology of athletes’ dual careers: A state-of-the-art critical review of the European discourse. Psychology of Sport and Exercise, 42, 74–88, 10.1016/j.psychsport.2018.11.013 Swami, V., Barron, D., Weis, L., & Furnham, A. (2016). Bodies in nature: Associations between exposure to nature, connectedness to nature, and body image in U.S. adults. Body Image, 18, 153–161. 10.1016/j.bodyim.2016.07.002 Thompson Coon, J., Boddy, K., Stein, K., Whear, R., Barton, J., & Depledge, M.H. (2011). Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environmental Science & Technology, 45, 1761–1772. Ulrich, R.S. (1984). View through a window may influence recovery from surgery. Science, 224(4647), 420–421. 10.1126/science.6143402 Van Den Berg, A., & Beute, F., 2021. Walk it off! The effectiveness of walk and talk coaching in nature for individuals with burnout- and stress-related complaints. Journal of Environmental Psychology, 76, 101641.

387

Tadhg MacIntyre et al. Vert, C., Mireia Gascon, M., Otavio Ranzani, Sandra Márquez, Margarita Triguero-Mas, Glòria Carrasco-Turigas, Lourdes Arjona, Sarah Koch, Maria Llopis, David Donaire-Gonzalez, Lewis R. Elliott, Mark Nieuwenhuijsen. (2020). Physical and mental health effects of repeated short walks in a blue space environment: A randomised crossover study. Environmental Research, 188. 10.1016/j.envres.2020.109812 White, M.P., Alcock, I., Grellier, J., Wheeler, B.W., Hartig, T., Warber, S.L., Bone, A., Depledge, M.H., & Fleming, L.E. (2019). Spending at least 120 minutes a week in nature is associated with good health and wellbeing. Scientific Reports, 9(1), 1–11. 10.1038/s41598-019-44097-3 Wilson, E.O. (1984). Biophilia. Harvard University Press. Wolf, L.J., Zu Ermgassen, S., Balmford, A., White, M., & Weinstein, N. (2017). Is variety the spice of life? An experimental investigation into the effects of species richness on self-reported mental well-being. PLoS ONE, 12(1), e0170225. 10.1371/ journal.pone.0170225

388

25 YOUNG ATHLETES’ MENTAL HEALTH AND WELL-BEING Rosemary Purcell, Courtney Campbell Walton, Alan Currie, and Simon Rice

Introduction The transition from childhood and adolescence to emerging adulthood can be a challenging phase of life. Young people face a number of developmental ‘milestones’, including puberty, developing their sense of self and identity separate to that of their parents and family, establishing social networks and navigating more complex interpersonal relationships (including first romantic or sexual relationships), through to completing education and working towards career aspirations or goals (Purcell et al., 2011). This complex transitional process has altered both qualitatively (i.e., with young people largely being ‘digital natives’ compared to previous generations) as well as quantitatively in recent decades, with full, independent adulthood increasingly being successfully or securely attained into the mid- to late twenties (Arnett & Hughes, 2014). Given the confluence of experiences and transitions associated with this life stage, it is perhaps not surprising that mental ill-health is the number one health issue affecting young people in developed/high-income countries. At a phase of life when physical health is usually at its most robust, mental disorders are commonly experienced by young people (Insel & Fenton, 2005). Prevalence rates differ according to how ‘youth’ is defined, but among those aged 16–25 years, an estimated 26% will experience a diagnosable mental condition in any given year, with the incidence of mental ill-health in young people higher than any other age group (Australian Bureau of Statistics, 2008). The National Comorbidity Survey Replication in the United States indicated that half of all mental disorders emerge before the age of 14 years, with 75% emerging by the age of 25 years (Kessler et al., 2005). In addition to pubertal and transitional challenges, major risk factors for mental ill-health in young people include poverty and social disadvantage, as well as exposure to abuse, neglect, bullying, and other forms of trauma (Patel et al., 2007). Sport participation and physical exercise have conversely been shown to provide numerous benefits to the mental health and well-being of young people (Eime et al., 2013). There is considerable variability in the rates of participation in organised community sport globally (Aubert et al., 2018), however in many countries, the majority of young people are engaged in some form of sport. Biopsychosocial impacts of sport include the neurophysiological effects of physical activity, the psychological benefits of developing a sense of competence or mastery in an activity, along with improved confidence or self-esteem, and social benefits of increased social connection and shared goals (Walton et al., 2021; Vella, 2019). Research shows that the relationships between sport participation and mental health in adolescents are bidirectional, with

DOI: 10.4324/9781003099345-33

389

Rosemary Purcell et al.

time in organised community sport participation predicting future overall mental health, and vice versa (Vella et al., 2017; Graupensperger et al., 2021). Whilst there are many mental health benefits to sport participation, in elite sport the emphasis is on performance. This introduces additional risks to the well-being of those young athletes who are in an environment of professionalisation, specialisation, and competition. This chapter explores the literature regarding the prevalence and major risk factors for mental health symptoms and disorders in elite young athletes, with an emphasis on mental health promotion and early intervention for athletes at risk of developing mental health symptoms by virtue of their age and competitive endeavours.

Defining Elite Youth Athletes ‘Youth’ is conceptualised as the period between childhood and adulthood, which traditionally has been demarcated at the lower end by adolescence (i.e., 13 years) and at the upper end by ‘legal’ adulthood, which is recognised as the age of 18 years in many developed countries. More recent approaches, however, consider the concept of ‘youth’ as extending into early adulthood, particularly on the basis of the increasingly later acquisition of financial and/or familial independence which have traditionally been regarded as markers of adulthood (Arnett & Hughes, 2014). Consistent with the United Nations’ definition of youth, this chapter considers elite young athletes as including adolescents and early adults aged between 14–25 years, competitive in elite junior or ‘pathway’ systems in professional and elite (e.g., Olympic) sport, as well as college athletes (but does not consider the literature on general community samples of young athletes).

What Is the Prevalence of Mental Health Symptoms in Elite Young Athletes? A growing body of research indicates that a significant proportion of elite athletes experience mental health symptoms (Rice et al., 2016; Gouttebarge et al., 2019), including rates that exceed those in the general population (Purcell et al., 2020). Despite the proliferation of research into the mental health of elite athletes (Reardon et al., 2019), young athletes remain a critically under-researched population in this area of enquiry (Poucher et al., 2019; Walton et al., 2021). To date, only a handful of studies have examined the prevalence of mental health symptoms and/or disorder in young athletes, with significant variation in the reported results. Schaal et al. (2011) examined yearly psychological evaluations of French athletes from junior through to ‘high’ (elite) level. Psychological conditions were evaluated by psychologists or physicians working within the national sporting federations and included anxiety, mood, psychotic, substance and eating disorders, including lifetime, past 6 months, and current experiences. A total of 2067 evaluations were analysed, representing approximately 13% of the nationally categorised athletes. Athletes ranged in age from 12–35 years and the presence of psychological disorder (yes/no) was compared between those aged 12–17 years, 18–21 years, and 22 years and older. The results demonstrated that current psychopathology (at least one disorder) was more commonly evaluated in those aged 12–18 (15.1%) and 18–21 (13.1%), compared to those aged 22 years and over (10.4%). While the authors did not report the prevalence of psychological disorders according to age groups, younger athletes were more likely than older athletes to be evaluated as experiencing daytime sleep disturbance, but less likely to be assessed as experiencing depression (Schaal et al., 2011). Brand and colleagues (2013) examined the rates of mental health symptoms in a large cohort of elite German student athletes aged 12–15 years (n = 866) and compared these to two groups: (i) 80 studentathletes from the same schools who had recently been deselected from elite sport promotion due to failure to meet performance criteria, and (ii) age- and sex-matched non-sport athlete students from regular schools (n = 432). The elite athletes participated in a wide range of spor, including gymnastics, canoe/kayak, cycling, handball, judo, modern pentathlon, rowing, shooting, soccer, swimming, athletics, volleyball, and wrestling. The World Health Organisation’s (WHO) Composite International Diagnostic Interview 390

Young Athletes’ Mental Health and Well-Being

(CIDI) was used as a self-report measure to assess anxiety, mood and eating disorders, and substance abuse over the lifetime and past year. The lifetime prevalence of symptoms varied according to gender, with female elite athletes being more likely than males to report generalised anxiety (14.4% vs 9.0% respectively), posttraumatic stress (15.0% vs 7.1%), panic (19.7% vs 10.8%), and disordered eating (39.5% vs 14.0%). A similar pattern was observed for prevalence over the past year for depressive symptoms (36.5% for females vs 19.3% for males), although the rates of social phobia were similar (7.4% vs 6.7%) and alcohol abuse was higher for males (5.4%) compared to females (2.0%). The reported rates of somatisation, panic, and posttraumatic stress symptoms were significantly higher among the elite athletes compared to non-athlete students matched for gender. Comparisons between the deselected athlete cohort and the elite athletes indicated that deselected female athletes reported higher anxiety and depression symptoms than their elite female counterparts, whereas deselected males were only more likely to report higher substance use than elite male student athletes. This study indicated that gender differences are important to consider in young athlete mental health, as part of a broader need to respond to young athlete’s mental health needs, given the high rates of reported symptomatology. Nixdorf and colleagues (2016) examined depressive symptoms in a cohort of German elite young athletes (n = 199; mean age = 14.96; standard deviation = 1.56) and compared the rates according to whether athletes participated in individual or team sport. While overall scores on the Center for Epidemiologic Studies Depression Scale were not provided (which would have provided an indication of the proportion of moderate to severe symptomatology), athletes in individual sport were shown to report higher depression symptoms (mean score = 11.55) than those in team sport (mean score = 9.47). This study indicates that type of sport may need to be considered (in addition to gender) in relation to mental health in young athletes, with athletes in individual sport potentially more vulnerable to mental health difficulties given that internal attributions for success and failure are more common in individual sport than team sport. A recent scale developed to measure athlete guilt and shame, the Athletic Perceptions of Performance Scale, validated in a cohort of young professional athletes (Rice et al., 2021), may help to advance research in relation to the association between type of sport and emotional responses. Finally, Weber and colleagues (2018) examined self-reported symptoms of depression and anxiety (in the past 2 weeks) in a cohort of German athletes aged 12–18 years (n = 326; mean age = 14.3 years). The athletes were recruited from a range of Olympic sport, including boxing, gymnastics, ice speed skating, track and field, judo, rowing, soccer, volleyball, and weightlifting. Scores on the Hospital Anxiety and Depression Scale were compared between ‘late childhood’ athletes (12–14 years) and ‘late adolescent’ athletes (15–18 years). Overall, 6.7% of the sample reported subclinical anxiety scores (termed a ‘possible’ case) and 3.4% clinically relevant anxiety (termed a ‘probable’ case), with a corresponding 9.5% ‘possible’ and 3.7% ‘probable’ scores on the depression subscale. The mean anxiety and depression scores did not differ significantly according to age group or gender. The rates of possible and probable anxiety and depression in this sample were significantly lower than those observed in both normative adolescent samples and elite adult athletic cohorts. This might reflect under-reporting of symptoms by participants, or measurement of psychiatric symptoms in the past 2 weeks being overly sensitive in this age cohort, but the findings might also represent the the health benefits of sport in those athletes not yet exposed to the full force of adult elite sporting stressors. The importance of mental health and well-being amongst college student athletes in the National Collegiate Athletic Association (NCAA) has been increasingly recognised (Neal et al., 2013). While there have been no systematic or comprehensive studies to date of the prevalence of mental health symptoms or disorders across the NCAA, select studies have examined mental health symptoms in athlete cohorts. For example, Wolanin and colleagues (2016) assessed depressive symptoms in a sample of 465 Division I athletes across a range of sport from a single institution, finding that a quarter (23.7%) met the threshold for clinically relevant self-reported depressive symptoms, with 6.3% reporting moderate to severe symptomatology. Depressive symptoms differed according to gender, with female athletes 1.84 times 391

Rosemary Purcell et al.

more likely to report clinically relevant symptoms compared to males. In a study of pre-season anxiety and depressive symptoms and their relationship to injury amongst 958 Division I athletes from two institutions, 28.8% self-reported state/trait anxiety symptoms and 21.7% clinically relevant depressive symptoms (Li et al., 2017). Of the athletes who reported either symptoms, just under half (48.5%) indicated having experienced both anxiety and depressive symptoms. There were no gender differences for preseason anxiety symptoms (27.9% for males and 26.5% for females) or combined symptoms (17.7% vs 14.9%), although female athletes were significantly more likely to report depressive symptoms than their male counterparts (27.2% vs 19.3%). Cultural differences were also observed across all symptom groupings, with non-white athletes more likely to report symptomatology than white athletes. Finally, while there has been consideration of the clinical management of ADHD in college student athletes, to our knowledge, there are no studies that have systematically assessed the prevalence in this population. One study reported that 10.1% of 139 NCAA Division I athletes reported a diagnostic history of ADHD, but this was based on a single item from a concussion screening measure (Alosco et al., 2014), as opposed to a validated measure of ADHD or a clinical diagnosis. Overall, the rates of anxiety and depressive symptoms in elite college athletes are largely consistent with community rates in young people, although at least one study suggests that the incidence of suicide is lower in NCAA athletes compared to both the general U.S. population matched for age, as well as the general collegiate population (Rao et al., 2015). Nonetheless, given that suicide is largely preventable, understanding the risk factors for this outcome in sport is crucial, with Rao et al.’s (2015) study indicating a higher risk in male athletes compared to females, with male footballer players at elevated risk relative to males in non-football sport. The limited research to date on the prevalence of mental health symptoms and disorders in elite young athletes has focused on cross-sectional studies, in largely non-representative samples of young adolescent athletes, with significant variation in how mental health is measured (scales used and time period for reporting) and the corresponding reported rates of symptomatology. More empirical research is needed that examines a broader and ideally representative cohort of young athletes aged 14–25 years, using validated scales or diagnostic measures to assess clinically important mental health symptoms. Robust prevalence studies will be informative to determining whether young athletes are less susceptible to the rates of mental health symptoms observed in young people in general community studies, and/or whether young athletes are less likely to report symptoms given high rates of stigma in this cohort (Gulliver et al., 2012)

Mental Health Stigma in Young Elite Athletes Elite athletes are often adept at masking or downplaying the severity of their physical and emotional distress, since competitive and high-performance sport is an environment where mental toughness is prized. This mindset may be particularly pronounced in young athletes who are in the process of developing selfunderstanding, emotional maturity, and self-confidence, and especially amongst those young athletes already competing in adult sport settings. In their study exploring barriers to mental health help-seeking, Gulliver and colleagues (2012) found that athletes aged 16–23 described significant stigma around seeking help for a mental health problem, with athletes expressing that they shouldn’t show weaknesses, and reporting worry about what others would think of their ability to perform to their best, including teammates, coaches, opponents, and parents. Such findings highlight the sensitivity needed when working with young athletes in relation to their mental health, and some of the challenges in conducting research on this topic with this cohort.

Risk Factors for Mental Well-Being in Elite Young Athletes Research has considered a range of contextual factors and stressors related to high-performance sport that contribute to decreases in sport enjoyment, and increased rates of dropout, performance anxiety, and/or 392

Young Athletes’ Mental Health and Well-Being

burnout (Vella, 2019; Daniel, 2019) rather than specific mental health outcomes. These outcomes are considered here as sport dropout or decreased enjoyment, for example, may be precursor states or conditions for impaired mental well-being in elite young athletes.

Pressure to Perform and Perfectionism High school and college/university sport in some countries, such as the United States, can attract significant public and media attention, leading to increased sport specialisation and professionalisation from a young age (Craig, 2018). Many elite young athletes are increasingly exposed to consistent and elevated levels of performance pressure that can contribute to unhelpful or maladaptive perfectionism (Flett & Hewitt, 2014). Perfectionism is a multidimensional construct, and can be conceptualised via at least two key factors: (1) ‘perfectionistic concerns’ and (2) ‘perfectionistic strivings’ (Stoeber, 2011). Perfectionistic concerns relate to pursuing exacting standards imposed by significant others – such as parents, coaches, or teammates – along with perceived negative evaluation from others, and discrepancy between one’s expectations and performance, whereas perfectionistic strivings relate to pursuing self-imposed goals and standards. While not specific to young athletes, meta-analytic research indicates that perfectionistic concerns are associated with anxiety and poorer well-being, while concomitantly providing no benefit to sport performance (Hill et al., 2018). Alternatively, perfectionistic strivings tend to be associated with more adaptive variables (e.g., adaptive coping), however with consistently smaller effect sizes than those between perfectionistic concerns and maladaptive outcomes (Stoeber, 2020). In samples of young athletes, research demonstrates associations between perfectionistic concerns and burnout (Madigan et al., 2015; Jowett et al., 2016; Smith et al., 2018), while fear of failure (a construct highly related to perfectionistic concerns) has been associated with psychological stress (Gustafsson et al., 2017). At least one study has demonstrated that younger elite athletes report higher rates of perfectionistic concerns than their older counterparts (Jensen et al., 2018). This suggests an avenue for early intervention to target and ameliorate perfectionistic concerns in young elite athletes, in order to avert negative outcomes such as burnout or psychological distress and to ensure that maladaptive perfectionism doesn’t become entrenched.

Overtraining and Burnout Burnout refers to physical and emotional exhaustion, along with reduced sense of accomplishment and sport devaluation (Raedeke, 1997; see also Chapter 12). As earlier sport specialisation becomes increasingly common among athletes, parents, and coaches seeking future success, this practice can lead to young athletes overtraining, with a range of physical and psychological consequences (Mostafavifar, 2013; Myer et al., 2016). Brenner and colleague’s (2019) comprehensive review of the psychosocial consequences of early sport specialisation indicated that young athletes are at risk of various negative sequalae including social isolation; decreased family time; impaired academic performance; inadequate sleep; and increased anxiety, stress, and burnout. These consequences are especially concerning given that evidence suggests that early sport specialisation is generally not required for future elite success (DiSanti & Erickson, 2019), although there will be exceptions to this based on the peak ages of performance for specific sport. The stress-recovery balance is an important factor when considering the likelihood of overtraining and burnout in youth athletes (see also Chapter 22 for recovery and Chapter 13 for overtraining and burnout). For athletes to optimise performance and well-being, adequate recovery after training and competition is necessary to balance biopsychosocial stress (e.g., physical fatigue, social conflict, emotional stress). An imbalance between stress and recovery (high stress, low recovery) has been associated with mood disturbances (apathy, irritability), poor sleep, increased injury risk and endocrine changes in young athletes (Kellmann, 2010). In a study of 134 elite and professional youth athletes, Nixdorf and colleagues (2013) found a positive correlation between depression and sport-related and general stress, and a negative 393

Rosemary Purcell et al.

correlation between depression and sport-related and general recovery. Qualitative research has suggested that youth athletes may lack knowledge of both the significance of appropriate recovery, and how to adopt helpful recovery strategies into their own routines (Beckmann & Beckmann-Waldenmayer, 2019). Sporting organisations can play a role in encouraging and providing sufficient time for young athletes to implement optimal recovery strategies. Granz and colleagues (2019) identified a complex range of factors associated with an increased likelihood of burnout in elite young athletes, including type of sport (e.g., participating in a technical, endurance, aesthetic, or weight-dependent sport), coaching style (training under an autocratic or a laissezfaire coach), high subjective stress external to sport, poor sleep, and female gender. Conversely, a decreased likelihood of burnout was associated with fewer hours of training, low social pressure and high health satisfaction, along with low subjective stress external to sport and high willingness to make psychological sacrifices. Given the significant potential psychosocial impacts of overtraining and burnout on young elite athletes, more research is needed to determine specific sporting practices and interventions that can support young athletes (and their entourage) to safely pursue their sporting ambitions. This may include education materials for athletes, parents and coaches to assist them to better understand the riskbenefit ratios of early specialisation and overtraining, and enable all stakeholders to make safer and more prudent decisions, particularly in relation to the athlete’s mental and physical well-being.

Parental and Peer Conflict Parents of elite young athletes can be protective of and promote the mental well-being of their child by providing emotional, financial, and logistical support. However, they can also be a key source of stress and contribute to poor mental health in their offspring, particularly through negative or overly critical feedback, inappropriate behaviour or expressed emotion during training and competition, and unrealistic expectations in relation to their child’s abilities or prospects for success (Elliott & Drummond, 2017). How young athletes perceive parental involvement in their sport can vary according to gender, alignment of goals, the timing of involvement, motivational climate, and relationship quality (Knight et al., 2017; Knight, 2019). While the experiences of sport medicine practitioners working in talent development pathways have highlighted the detrimental role of ‘pushy parents’ to the mental health of elite young athletes (Hill et al., 2016) and first-hand athlete accounts attest to the (often long-term) emotional and physical damage that accompanies parental abuse in sport (Dokic & Halloran, 2017), there are no known studies to our knowledge that have examined the influence of parental style (i.e., authoritarian and controlling or autonomy-supportive; Holt et al. 2009) on mental health outcomes in elite young athletes. Nonetheless, burgeoning research is investigating how to better equip parents to understand and respond to their child’s unique needs. Beckmann-Waldenmayer (2019) notes that parents generally want to (and believe they do) act in the best interest of their child, although they may lack knowledge as to how to accomplish this in the sporting context. Designated ‘parental coaching’ may help parents to improve their communication skills, learn about their child’s development, and promote collaborative goal-setting with their child. Where appropriate, parents should be integrated into the sporting environment and collaborate with coaches and key staff in order to bolster the young athlete’s support system. Interpersonal conflict amongst peers is not uncommon and also occurs in sport (Wachsmuth et al., 2017). In the general population, a causal link has been demonstrated between bullying behaviour and a range of mental health symptoms and disorders, including depression, anxiety, substance use, self-harm, and suicidal ideation (Moore et al., 2017). While evidence suggests that bullying occurs more commonly in school settings than in sport (Evans & Hurrell, 2016), studies that have examined peer conflict in elite junior sport demonstrate negative outcomes for mental well-being. For example, amongst adolescent female team sport athletes, jealousy, personal characteristics, and coaching influences have been identified as key sources of interpersonal conflict, which are associated with performance anxiety and negative 394

Young Athletes’ Mental Health and Well-Being

emotional states such as sadness, embarrassment, anger, and low self-esteem (Partridge & Knapp, 2016). In a study of male adolescent football players, bullying behaviour was more likely to be perpetrated by those endorsing traditionally masculine traits, with this behaviour often encouraged or endorsed by influential male role models such as fathers, brothers, or coaches (Steinfeldt et al., 2012). Most sport require elite young athletes to engage with a range of other individuals (teammates/peers, coaches and support staff, parents, and other relatives), each with their power dynamic and hierarchy, personality characteristics, and motivations or ambitions for themselves and/or the young athlete. Future research should examine the ways in which these roles interact in relation to athlete mental well-being (Hayward et al., 2017).

Athlete Abuse and Maltreatment Elite young athletes are vulnerable to abuse and/or maltreatment perpetrated by a range of individuals operating within their sporting ecosystem, (Stirling, 2009). Central to the potential for abuse, maltreatment or exploitation is the inherent power imbalance that exists between young athletes and the adults who are responsible for decisions that critically impact upon their sporting aspirations and ambitions, including training priority, playing time, team selection, or medical treatment. Coaches, along with other high-performance staff such as medical, nutritional, and strength and conditioning specialists, hold positions of power in this context (Kerr et al., 2019) and parents can become socialised into accepting or tolerating an array of abusive practices in elite youth sport, leading to a lack of action in confronting abusive coaches (Kerr & Stirling, 2012). Two key forms of maltreatment can be considered: relational and non-relational (Crooks & Wolfe, 2007). ‘Relational maltreatment’ refers to the existence of a critical relationship role in which an other has significant influence over the young athlete’s safety, trust, and fulfillment of needs. Abuse and maltreatment in this context can involve neglect and/or physical, sexual, and emotional abuse. Non-relational maltreatment occurs outside the context of critical relationships, and can include harassment, bullying, exploitation (e.g., sexual, financial), institutional maltreatment, and abuse or assault. In a retrospective sample of over 4,000 adult athletes from Belgian and The Netherlands (Vertommen et al, 2018), the reporting of severe emotional, physical, and sexual abuse during childhood sport was predictive of mental health symptoms in adulthood. Overall, 9% of the athlete participants self-reported experiencing severe psychological abuse in childhood sport (similar across gender), while 8% experienced severe physical violence (12% of males and 5% of females) and 6% experienced severe sexual violence (7% for females and 4% for males). Examples of widespread, systematic sexual abuse and maltreatment of young elite athletes have also been documented (for example, the New York Times 2018 reporting of the Larry Nassar case, and the Netflix documentary Athlete A; New York Times, 2018). Athlete safety is of paramount importance, particularly for young athletes given their inherent vulnerability due to power imbalances. Safeguarding practices in sport are crucial (Mountjoy et al., 2015) and must be well-understood and adhered to by all those working with young athletes. A subsequent International Olympic Committee consensus statement (Mountjoy et al., 2016) provides recommendations for sporting organisations, sport medicine practitioners, and athletes to promote safe sport environments. The statement emphasises the need for a systematic and collaborative multi-agency approach to the prevention of abuse, recommending context-specific policy and procedure, law enforcement strategies, and universal education for those working in sporting environments. It is also important to recognise and respond to potential barriers to the implementation of safeguards to protect youth athletes. Of note, pessimism regarding the value of preventative approaches may need to be explicitly addressed, including perceptions that prevention strategies lack effectiveness, or will increase fear or hysteria and lead to unsubstantiated allegations of abuse (Parent and Demers, 2011). 395

Rosemary Purcell et al.

Injury and Concussion Young athletes may be at an increased risk of injury due to the ongoing physical and physiological changes that are associated with puberty and this life stage, along with underdeveloped coordination, skills, and perception (Caine et al., 2014). Injury is a robust predictor of impaired mental health in adult elite athletes (Reardon et al., 2019) and emerging research suggests it is a significant stressor for both acute and ongoing emotional responses in youth athletes (Forsdyke, 2016; Palisch & Merritt, 2018; Truong et al., 2020). Young athletes can experience anger, grief, and guilt when dealing with the physical pain of injury, frustration during the rehabilitation process, including isolation or exclusion from sport and teammates, and fear of re-injury or not being able to return to prior levels of ability (te Wierike, 2013; Aron et al., 2019). Of the limited research to date to have examined the mental health impacts of injury in elite junior athletes, symptoms of posttraumatic stress were endorsed by a majority of athletes (n = 27; mean age = 15 years) who had experienced an anterior cruciate ligament rupture (Padaki et al., 2018). Athletes who reported a stronger athletic identity had a greater tendency to report more severe symptomatology. Strong athletic identity may be a risk factor for poor mental health following injury, as removal from the daily training environment may challenge self-perceptions of vulnerability (Tracey, 2003). Concussion also frequently occurs in elite youth sport, though overall incidence varies significantly between sport. Research indicates that adolescent athletes significantly under-report post-concussive symptoms, often due to wanting to avoid having to leave the game/competition, not wanting to let their team down, or misunderstanding the severity of their injury (Ferdinand Pennock et al., 2020). While there is increasing understanding of the relationship between concussion and mental health in adult athletes (Rice et al., 2018), with symptoms of depression being the most commonly reported correlate of concussion, there is comparatively little research on the effects of concussion on mental health outcomes in youth athletes (Rivara et al., 2020), despite the vulnerability of the brain during this developmental period. The extant literature in competitive, but not necessarily elite athletic samples, indicates that young athletes (aged 8–18) who exhibit post-concussive symptoms for one month or longer are more likely to report anxiety, compared to their counterparts whose symptoms resolved within a week (Grubenhoff et al., 2016). Elevated symptoms of depression at 2, 7, and 14 days’ post-concussion were also reported in another sample of youth athletes (Kontos et al., 2012). In a study of 174 young people reporting a sportrelated concussion (or subsequent post-concussion syndrome), one in 10 (11.5%) reported experiencing a negative post-injury mental health outcome or worsening symptoms of a pre-injury mental health disorder (Ellis et al., 2015). Prevention strategies have been trialled to reduce the rates of concussion in youth and adult sport. Such strategies include policy introduction (e.g., banning header practice in training in football/soccer), sporting rule changes (e.g., that seek to reduce collision or body contact), equipment introduction (e.g., use of helmets), and modifying player technique (Waltzman and Sarmiento, 2019). The efficacy of such strategies is mixed, as rates of concussion often increase following policy and rule changes. This may be due to improved concussion awareness and subsequently increased reporting of concussion incidents (Krolikowski et al., 2017).

Body Image Concerns Disordered eating behaviour includes restrictive diets, binge eating, purging, diet pills, dehydration, with or without excessive training (Wells et al., 2020). These behaviours are common in elite adult athletes, with upper estimates of 32.5% for males (Karrer et al., 2020) and 45% amongst females (Reardon et al., 2019). In a representative study of over 1,000 adolescent athletes (Giel et al., 2016), 32.5% fulfilled the criteria for eating disorder pathology, with 8% reporting constantly engaging in practices to lose weight, and 12% using compensatory methods (e.g., fasting, purging, and appetite suppressers). Little is known in 396

Young Athletes’ Mental Health and Well-Being

young athletes about comorbid mental health outcomes associated with disordered eating beyond anxiety being higher in those with eating pathology than those without (Vardar et al., 2007; Michou & Costarelli, 2011). A recent systematic review suggested that young athletes do not appear ‘prone’ to concerns around body image and eating, but that this becomes more prevalent in elite cohorts, particularly in sport that emphasise leanness (Stoyel et al., 2020).

Sleep Disturbance The bidirectional relationship between sleep and mental health is well established. Elite athletes frequently report inadequate sleep (Reardon et al., 2019); however, additional academic and social demands may accentuate this in young athletes. A recent systematic review indicated that young athletes report impaired sleep quality across a range of indices including sleep time, sleep efficiency, and waking after sleep onset, compared to young and middle age adults (Vlahoyiannis et al., 2020). This review estimated that athletes aged 6–18 years average six hours of total sleep time per night, which is considerably lower than the 8–11 hours recommended for this age group (Hirshkowitz et al., 2015). The use of electronic devices and screen-time at night may be an important factor, particularly for athletes traveling for training or competition. In non-sporting samples, there is moderately strong evidence for an association between screentime and depressive symptoms in young people (Stiglic & Viner, 2019).

Applying Research into Practice: Bolstering Mental Well-Being in Elite Young Athletes Many of the risk factors for impaired mental well-being in elite young athletes are dynamic and therefore amenable to intervention. Given that stigma may be a significant consideration in this population, therapeutic engagement should focus on normalising intervention or treatment and potentially framing this within a performance optimisation context, rather than managing symptoms or a disorder (Donohue et al., 2018; Poucher et al., 2019). This may apply beyond the young athlete to include parents for whom stigma may also be problematic. In working with elite young athletes in relation to their mental health, it’s also important to be cognisant that sport may not necessarily be a relevant contributing factor, especially given that this is a phase of life when other life challenges – such as interpersonal relationships and/or educational commitments – may be influential to mental ill-health. Practitioners working with young athletes are encouraged to adopt a person-centred approach where the ‘human’ experience is emphasised above the ‘athlete’, and to be mindful of the systemic (or ‘ecological’) factors that might also be impacting upon their mental well-being (Purcell et al., 2019).

Responding to Risk Factors In relation to the risks associated with early specialisation, overtraining, and/or burnout, understanding the athlete’s full workload – inclusive of academic, vocational/employment and social demands – along with sporting requirements is important to psychoeducation and working with the athlete to better monitor and balance their commitments (Pacewicz et al., 2019). Where early specialisation may be a risk factor, helping the elite athlete and their parents to reframe expectations of sport participation to emphasise intrinsic enjoyment (and even fun) is important. It can also be useful to explicitly address research findings that highly specialised or rigorous training regimes do not necessarily guarantee sporting success. Conversely, these may be risk factors for burnout, dropout, or impaired mental wellbeing (DiSanti & Erickson, 2019) and reduce the opportunities for a successful adult career. Working with athletes (and their parents where appropriate) to identify their values and non-sporting pursuits that are enjoyed and/or bring meaning to their life is also important in expanding the non-athletic identity and maintaining role balance. 397

Rosemary Purcell et al.

Practitioners should be mindful of differentiating overtraining, burnout, and a depressive illness (Frank et al., 2017). Features of overtraining include fatigue, low mood, insomnia, poor concentration, diminished appetite, weight loss, and reduced motivation (Meeusen et al., 2013) and have much in common with those found in a depressed athlete. Features of burnout include both physical and emotional exhaustion, and reduced sense of accomplishment or valuing of sport and therefore also significantly overlap with the symptoms of a depressive illness (Frank et al., 2017). An over-training syndrome (OTS) is more likely to emerge if the athlete is experiencing concurrent psychosocial stresses; the sorts of stresses that will also promote the development of a depressive illness. In addition, similar biological antecedents may be present in both OTS and depression where reduced immune function is found in some depressive disorders (Miller, 2020) and can also be induced by highintensity exercise (Gleeson, 2007). A symptomatic athlete presenting in a mainstream medical setting is more likely to receive a diagnosis of depression – and risk a diagnosis of OTS or burnout being missed – whilst the reverse is true for the athlete who presents symptoms to a sport medicine specialist (Schwenk, 2000). A possible distinguishing feature is that the burnt-out or over-trained athlete will respond to a period of rest, whilst the depressed athlete may experience increased symptoms if not exercising (Reardon & Factor, 2010). Young athletes dealing with serious or chronic injury, including post-concussive syndromes, should be recognised as a group at risk of impaired well-being and monitored accordingly. Where athletes are experiencing distress in relation to an injury, understanding whether physical pain, frustration with rehabilitation, fear of re-injury or of not returning to prior ability, and isolation from the daily training environment (or a combination of factors), will help to inform the intervention approach (Ross et al., 2019). Since serious or chronic injury is a relatively common occurrence in elite sport, compassion and acceptance-based psychological approaches may be particularly relevant (Huysmans & Clement, 2017; Baranoff & Appaneal, 2019; Walton et al., 2020). Indeed, compassion-focused therapies and enhanced self-compassion may be relevant to also responding to body image concerns (Eke et al., 2019) and performance difficulties (Barczak & Eklund, 2018; Ceccarelli et al., 2019). While poor sleep is a common problem in young athletes, it should not be minimised or trivialised. A thorough assessment of the athlete’s sleeping patterns and habits is necessary, including any disruptions that may be contributing factors (Gupta et al., 2017; Kroshus et al., 2019). Working with the athlete to implement sleep extension interventions are likely to be important, which including sleep psychoeducation (e.g., routines that facilitate sleep) and cognitive behavioural approaches, especially if insomnia is experienced. Finally, elite young athletes are particularly vulnerable to abuse and maltreatment. Athletes may not be able to readily disclose such violence or abuse and therefore responsible adults within sporting environments should be sensitive to signs of maltreatment or past abuse. However, as outlined in consensus statements and safeguarding frameworks (Sirling, 2009; Mountjoy et al., 2015, 2016), unless specially trained and qualified, such individuals should not attempt to evaluate or treat athletes experiencing harassment or abuse. Rather, they should refer these disclosures to relevant practitioners in social work, counselling, or medicine for further physical and/or psychological investigation and treatment. Some forms of abuse in youth sport may also require an individual to involve law enforcement agencies.

Pharmacological Considerations Medications may be necessary for the treatment of more severe mental health symptoms or disorders and would typically be combined with psychotherapy (individual or family) and multidisciplinary, systembased approaches, such as educational programmes in schools. The impact of medication on the athlete’s life functioning and the salience of sport in their life will influence the decision to prescribe. All else being equal, it is desirable to avoid performance-limiting side 398

Young Athletes’ Mental Health and Well-Being

effects, while not compromising care, as the primary prescribing concern is to ensure effective treatment. Additional considerations in athletes can be simplified as: 1) potential negative impacts on athletic performance; 2) potential performance enhancing effects; and 3) potential safety risks (Reardon, 2016). Common side effects such as sedation, weight gain, orthostatic hypotension, tachycardia, and tremor may negatively impact athletic performance (Johnston & McAllister-Williams, 2016). Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine that are prescribed to help treat depression and anxiety are generally better tolerated by athletes (and others) than older medications such as tricyclic antidepressants (Reardon, 2016). SSRIs have not been studied in youth athletes specifically, but several are approved for use in general. There are concerns about ergogenic (unfair) performance enhancement with stimulant medications which may be used to treat attention-deficit/hyperactivity disorder (ADHD) (Reardon & Factor, 2016). At higher levels of competition, stimulants are typically prohibited unless an application is made for a therapeutic use exemption (TUE: World Anti-Doping Agency, 2021). A successful TUE application needs to clearly demonstrate that the prescription is indicated for the athlete’s health for example to support their academic performance and daily functioning. Improvements in the athlete’s health might indirectly assist performance by reducing impairments but not by producing any additional enhancement. There are safety risks that may be especially relevant for youth athletes pushing themselves to physical extremes (Reardon, 2016). For example, stimulants used to treat ADHD may be a risk for heat illness. They may also decrease appetite, which can be a concern if athletes are expending large amounts of energy in sport and not able to maintain sufficient dietary intake.

Summary Elite young athletes are susceptible to impaired mental well-being by virtue of their age and lifestage, along with the high-performance stressors to which they may be exposed. Despite this, they represent a largely neglected population in mental health research. Unanswered questions abound in relation to the prevalence of mental health symptoms and disorders in this age group (including risk factors for, and rates of, self-harm and suicidal ideation), factors that are protective of mental health, the effectiveness of interventions to both prevent and respond to mental health symptoms and disorder, and how to support the athlete’s high-performance and sporting aspirations, while balancing other important life roles (social and academic) and non-athletic identity. Fundamental to working with elite young athletes is to understand their developmental context, and what is appropriate and normative behaviour for their lifestage (such as risk-taking behaviour) and what are appropriate expectations for treatment or interventions (for example, the capacity for self-reflection or ability to engage with cognitive techniques). Equally important is to understand the ‘ecology’ of their sporting environment and the role that parents, coaches and others (e.g., teammates/peers, the sporitng organisation) play in both supporting mental well-being and/or contributing to psychosocial difficulties (Purcell et al., 2019; Dorsch et al., 2022), both at an individual and collective/interactional level. Interventions for elite young athletes should extend – where appropriate – to include parents, coaches, and other key stakeholders who may influence the young athlete’s attitudes, behaviours, and experiences, with research needed to understand the role or timing of (multi) systematic approaches, including family therapies (Stillman et al., 2016).

References Alosco, M.L., Fedor, A.F., & Gunstad, J. (2014). Attention deficit hyperactivity disorder as a risk factor for concussions in NCAA division-I athletes. Brain Injury, 28(4), 472–474. 10.3109/02699052.2014.887145 Arnett, J.J., & Hughes, M. (2014). Adolescence and emerging adulthood. Pearson. 10.1093/acprof:oso/9780199929382. 001.0001

399

Rosemary Purcell et al. Aron, C.M., Harvey, S., Hainline, B., Hitchcock, M.E., & Reardon, C.L. (2019). Post-traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: A narrative review. British Journal of Sports Medicine, 53(12), 779–784. 10.1136/bjsports-2019-100695 Aubert, S., Barnes, J.D., Abdeta, C., Abi Nader, P., Adeniyi, A.F., Aguilar-Farias, N., … & Tremblay, M.S. (2018). Global matrix 3.0 physical activity report card grades for children and youth: Results and analysis from 49 countries. Journal of Physical Activity and Health, 15(s2), 251–273. Australian Bureau of Statistics. (2008). National survey of mental health and wellbeing: Summary of results. Australian Bureau of Statistics. Baranoff, J., & Appaneal, R.N. (2019). When disaster hits: Helping the injured athlete to accept and refocus. In K. Henriksen, J. Hansen, & C.H. Larsen (Eds.), Mindfulness and acceptance in sport: How to help athletes perform and thrive under Pressure. Routeledge. 10.4324/9780429435232-18 Barczak, N., & Eklund, R.C. (2018). The moderating effect of self-compassion on relationships between performance and subsequent coping and motivation. International Journal of Sport and Exercise Psychology, 18(2), 256–268. 10. 1080/1612197X.2018.1511620 Beckmann, J., & Beckmann-Waldenmayer, D. (2019). Talent development in youth football. In E. Fonter, J. Beckmann, & T. Loughead (Eds.), Football psychology: From theory to practice (pp. 283–296). Routledge. 10.4324/ 9781315268248-22 Beckmann-Waldenmayer, D. (2019). Parental coaching in football. In E. Fonter, J. Beckmann, & T. Loughead (Eds.), Football psychology: From theory to practice (pp. 269–282). Routledge. 10.4324/9781315268248-21 Brand, R., Wolff, W., & Hoyer J. (2013). Psychological symptoms and chronic mood in representative samples of elite student-athletes, deselected student-athletes and comparison students. School Mental Health, 5(3), 166–174. 10.1007/s12310-012-9095-8 Brenner, J.S., LaBotz, M., Sugimoto, D., & Stracciolini, A. (2019). The psychosocial implications of sport specialization in pediatric athletes. Journal of Athletic Training, 54(10), 1021–1029. 10.4085/1062-6050-394-18 Caine, D., Purcell, L., & Maffulli, N. (2014). The child and adolescent athlete: A review of three potentially serious injuries. BMC Sports Science, Medicine & Rehabilitation, 6(1), 1–10. 10.1186/2052-1847-6-22 Knight, C. (2019). Revealing findings in youth sport parenting research. Kinesiology Review, 8(3), 252–259. 10.1123/ kr.2019-0023 Ceccarelli, L.A., Giuliano, R.J., Glazebrook, C.M., & Strachan, S.M. (2019). Self-compassion and psychophysiological recovery from recalled sport failure. Frontiers in Psychology, 10, 1564. 10.3389/fpsyg.2019.01564 Craig, A.W. (2018). Elite youth sports—The year that was 2017. Pediatric Exercise Science, 30(1), 25–27. 10.1123/pes.2018-0001 Crooks, C.V., & Wolfe, D.A. (2007). Child abuse and neglect. In E.J. Mash & R.A. Barkley (Eds.), Assessment of childhood disorders (pp. 639–684). The Guilford Press. Daniel, G. (2019). The current youth sport landscape: Identifying critical research issues. Kinesiology Review, 8(3), 150–161. 10.1123/kr.2019-0034 DiSanti, J.S., & Erickson, K. (2019). Youth sport specialization: A multidisciplinary scoping systematic review. Journal of Sports Sciences, 37(18), 2094–2105. 10.1080/02640414.2019.1621476 Dokic, J., & Halloran, J. (2017). Unbreakable. Random House. Donohue, B., Gavrilova, Y., Galante, M., Gavrilova, E., Loughran, T., Scott, J., … & Allen, D.N. (2018). Controlled evaluation of an optimization approach to mental health and sport performance. Journal of Clinical Sport Psychology, 12(2), 234–267. 10.1123/jcsp.2017-0054 Dorsch, T.E., Smith, A.L., Blazo, J.A., Coakley, J., Côté, J., Wagstaff, C.R., … & King, M.Q.. (2022). Toward an integrated understanding of the youth sport system. Research Quarterly for Exercise and Sport, 1–15. 10.1080/02701367. 2020.1810847 Eime, R.M., Young, J.A., Harvey, J.T., Charity, M.J., & Payne, W.R. (2013). A systematic review of the psychological and social benefits of participation in sport for children and adolescents: Informing development of a conceptual model of health through sport. International Journal of Behavioral Nutrition and Physical Activity, 10(1), 1–21. 10.1186/1479-5868-10-98 Eke, A., Adam, M., Kowalski, K., & Ferguson, L. (2019). Narratives of adolescent women athletes’ body selfcompassion, performance and emotional well-being. Qualitative Research in Sport, Exercise and Health, 12(2), 175–191. 10.1080/2159676X.2019.1628805 Elliott, S.K., & Drummond, M.J.N. (2017). During play, the break, and the drive home: The meaning of parental verbal behaviour in youth sport. Leisure Studies, 36(5), 645–656. 10.1080/02614367.2016.1250804 Ellis, M. J., Ritchie, L. J., Koltek, M., Hosain, S., Cordingley, D., Chu, S., Selci, E., Leiter, J., & Russell, K. (2015). Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics, 16, 709–71810.3171/ 2015.5.peds15220.

400

Young Athletes’ Mental Health and Well-Being Evans, R., & Hurrell, C. (2016). The role of schools in children and young people’s self‐harm and suicide: systematic review and meta‐ethnography of qualitative research. BMC Public Health, 16(1), 1–16. Ferdinand Pennock, K., McKenzie, B., McClemont Steacy, L., & Mainwaring, L. (2020). Under-reporting of sportrelated concussions by adolescent athletes: A systematic review. International Review of Sport and Exercise Psychology, 1–27. 10.1080/1750984X.2020.1824243 Flett, G.L., & Hewitt, P.L. (2014). “The perils of perfectionism in sports” revisited: Toward a broader understanding of the pressure to be perfect and its impact on athletes and dancers. International Journal of Sport Psychology, 45(4), 395–407. Forsdyke, D., Smith, A., Jones, M., & Gledhill, A. (2016). Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: A mixed studies systematic review. British Journal of Sports Medicine, 50(9), 537–544. 10.1136/bjsports-2015-094850 Frank, R., Nixdorf, I., & Beckmann, J. (2017). Analyzing the relationship between burnout and depression in junior elite athletes. Journal of Clinical Sport Psychology, 11(4), 287–303. 10.1123/JCSP.2017-0008 Giel, K.E., Hermann‐Werner, A., Mayer, J., Diehl, K., Schneider, S., Thiel, A., … & GOAL Study Group. (2016). Eating disorder pathology in elite adolescent athletes. International Journal of Eating Disorders, 49(6), 553–562. 10. 1002/eat.22511 Gleeson, M. (2007). Immune function in sport and exercise. Journal of Applied Physiology, 103(2), 693–699. 10.1152/ japplphysiol.00008.2007 Gouttebarge, V., Castaldelli-Maia, J.M., Gorczynski, P., Hainline, B., Hitchcock, M.E., Kerkhoffs, G.M., … & Reardon, C.L. (2019). Occurrence of mental health symptoms and disorders in current and former elite athletes: A systematic review and meta-analysis. British Journal of Sports Medicine, 53(11), 700–706. 10.1136/bjsports-2019100671 Granz, H.L., Schnell, A., Mayer, J., & Thiel, A. (2019). Risk profiles for athlete burnout in adolescent elite athletes: A classification analysis. Psychology of Sport and Exercise, 41, 130–141. 10.1016/j.psychsport.2018.11.005 Graupensperger, S., Sutcliffe, J., & Vella, S.A. (2021). Prospective associations between sport participation and indices of mental health across adolescence. Journal of Youth and Adolescence, 50, 1450–1463. 10.1007/s10964-021-0141 6-0. Grubenhoff, J.A., Currie, D., Comstock, R.D., Juarez-Colunga, E., Bajaj, L., & Kirkwood, M.W. (2016). Psychological factors associated with delayed symptom resolution in children with concussion. The Journal of Pediatrics, 174, 27–32. 10.1016/j.jpeds.2016.03.027 Gulliver, A., Griffiths, K.M., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: A qualitative study. BMC Psychiatry, 12(1), 157. 10.1186/1471-244X-12-157 Gupta, L., Morgan, K., & Gilchrist, S. (2017). Does elite sport degrade sleep quality? A systematic review. Sports Medicine, 47(7), 1317–1333. 10.1007/s40279-016-0650-6 Gustafsson, H., Sagar, S.S., & Stenling, A. (2017). Fear of failure, psychological stress, and burnout among adolescent athletes competing in high level sport. Scandinavian Journal of Medicine & Science in Sports, 27(12), 2091–2102. 10.1111/sms.12797 Hayward, F.P.I., Knight, C.J., & Mellalieu, S.D. (2017). A longitudinal examination of stressors, appraisals, and coping in youth swimming. Psychology of Sport and Exercise, 29, 56–68. 10.1016/j.psychsport.2016.12.002 Hill, A., MacNamara, Á., Collins, D., & Rodgers, S. (2016). Examining the role of mental health and clinical issues within talent development. Frontiers in Psychology, 6, 2042. 10.3389/fpsyg.2015.02042 Hill, A.P., Mallinson-Howard, S.H., & Jowett, G.E. (2018). Multidimensional perfectionism in sport: A metaanalytical review. Sport, Exercise, and Performance Psychology, 7(3), 235–270. 10.1037/spy0000125 Hirshkowitz, M., Whiton, K., Albert, S.M., Alessi, C., Bruni, O., DonCarlos, L., … & Ware, J.C. (2015). National sleep foundation’s updated sleep duration recommendations. Sleep Health, 1(4), 233–243. 10.1016/j.sleh.2015. 10.004 Holt, N.L., Tamminen, K.A., Black, D.E., Mandigo, J.L., & Fox, K.R. (2009). Youth sport parenting styles and practices. Journal of Sport and Exercise Psychology, 31(1), 37–59. 10.1123/jsep.31.1.37 Huysmans, Z., & Clement, D. (2017). A preliminary exploration of the application of self-compassion within the context of sport injury. Journal of Sport and Exercise Psychology, 39(1), 56–66. 10.1123/jsep.2016-0144 Insel, T.R., & Fenton, W.S. (2005). Psychiatric epidemiology: It’s not just about counting anymore. Archives of General Psychiatry, 62(6), 590–592. 10.1001/archpsyc.62.6.590 Jensen, S.N., Ivarsson, A., Fallby, J., Dankers, S., & Elbe, A-M. (2018). Depression in Danish and Swedish elite football players and its relation to perfectionism and anxiety. Psychology of Sport and Exercise, 36, 147–155. 10.1016/ j.psychsport.2018.02.008 Johnston, A., & McAllister-Williams, R.H. (2016). Psychotropic drug prescribing. In A. Currie & B. Owen (Eds.), Sports psychiatry (1st ed., pp. 133–143). Oxford University Press. 10.1093/med/9780198734628.003.0010

401

Rosemary Purcell et al. Jowett, G.E., Hill, A.P., Hall, H.K., & Curran, T. (2016). Perfectionism, burnout and engagement in youth sport: The mediating role of basic psychological needs. Psychology of Sport and Exercise, 24, 18–26. 10.1016/j.psychsport. 2016.01.001 Karrer, Y., Halioua, R., Mötteli, S., Iff, S., Seifritz, E., Jäger, M., & Claussen, M.C. (2020). Disordered eating and eating disorders in male elite athletes: A scoping review. BMJ Open Sport & Exercise Medicine, 6(1), e000801. 10.1136/bmjsem-2020-000801 Kellmann, M. (2010). Preventing overtraining in athletes in high‐intensity sports and stress/recovery monitoring. Scandinavian Journal of Medicine & Science in Sports, 20, 95–102. 10.1111/j.1600-0838.2010.01192.x Kerr, G., Battaglia, A., & Stirling, A. (2019). Maltreatment in youth sport: A systemic issue. Kinesiology Review, 8(3), 237–243. 10.1123/kr.2019-0016 Kerr, G.A., & Stirling, A.E. (2012). Parents’ reflections on their child’s experiences of emotionally abusive coaching practices. Journal of Applied Sport Psychology, 24(2), 191–206. 10.1080/10413200.2011.608413 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. 10.1001/archpsyc.62.6.593 Knight, C.J., Berrow, S.R., & Harwood, C.G. (2017). Parenting in sport. Current Opinion in Psychology, 16, 93–97. 10.1016/j.copsyc.2017.03.011 Kontos, A.P., Covassin, T., Elbin, R.J., & Parker, T. (2012). Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Archives of Physical Medicine and Rehabilitation, 93(10), 1751–1756. 10.1016/j.apmr.2012.03.032 Krolikowski, M.P., Black, A.M., Palacios-Derflingher, L., Blake, T.A., Schneider, K.J., & Emery, C.A. (2017). The effect of the “Zero Tolerance for Head Contact” rule change on the risk of concussions in youth ice hockey players. The American Journal of Sports Medicine, 45(2), 468–473. 10.1177/0363546516669701 Kroshus, E., Wagner, J., Wyrick, D., Athey, A., Bell, L., Benjamin, H.J., … & Hainline, B. (2019). Wake up call for collegiate athlete sleep: Narrative review and consensus recommendations from the NCAA interassociation task force on sleep and wellness. British Journal of Sports Medicine, 53(12), 731–736. 10.1136/bjsports-2019-100590 Li, H., Moreland, J.J., Peek-Asa, C., & Yang, J. (2017). Preseason anxiety and depressive symptoms and prospective injury risk in collegiate athletes. American Journal of Sports Medicine, 45(9), 2148–2155. 10.1177/0363546517702847 Madigan, D.J., Stoeber, J., & Passfield, L. (2015). Perfectionism and burnout in junior athletes: A three-month longitudinal study. Journal of Sport and Exercise Psychology, 37(3), 305–315. 10.1123/jsep.2014-0266 Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., …Urhausen, A. (2013). Prevention, diagnosis, and treatment of the overtraining syndrome: Joint consensus statement of the european college of sport science and the American College of Sports Medicine. Medicine and Science in Sports and Exercise, 45(1), 186–205. 10.1249/MSS.0b013e318279a10a Michou, M., & Costarelli, V. (2011). Disordered eating attitudes in relation to anxiety levels, self-esteem and body image in female basketball players. Journal of Exercise Science & Fitness, 9(2), 109–115. 10.1016/S1728-869X(12) 60006-9 Miller, A.H. (2020). Beyond depression: The expanding role of inflammation in psychiatric disorders. World Psychiatry, 19(1), 108–109. 10.1002/wps.20723 Moore, S.E., Norman, R.E., Suetani, S., Thomas, H.J., Sly, P.D., & Scott, J.G. (2017). Consequences of bullying victimization in childhood and adolescence: A systematic review and meta-analysis. World Journal of Psychiatry, 7(1), 60–76. 10.5498/wjp.v7.i1.60 Mostafavifar, A.M., Best, T.M., & Myer, G.D. (2013). Early sport specialization, does it lead to long-term problems? British Journal of Sports Medicine, 47(17), 1060–1061. 10.1136/bjsports-2012-092005 Mountjoy, M., Rhind, D.J.A., Tiivas, A., & Leglise, M. (2015). Safeguarding the child athlete in sport: A review, a framework and recommendations for the IOC youth athlete development model. British Journal of Sports Medicine, 49(13), 883–886. 10.1136/bjsports-2015-094619 Mountjoy, M., Brackenridge, C., Arrington, M., Blauwet, C., Carska-Sheppard, A., Fasting, K., … & Budgett, R. (2016). International Olympic Committee consensus statement: Harassment and abuse (non-accidental violence) in sport. British Journal of Sports Medicine, 50(17), 1019–1029. 10.1136/bjsports-2016-096121 Myer, G.D., Jayanthi, N., DiFiori, J.P., Faigenbaum, A.D., Kiefer, A.W., Logerstedt, D., & Micheli, L.J. (2016). Sports specialization, part II: Alternative solutions to early sport specialization in youth athletes. Sports Health, 8(1), 65–73. 10.1177/1941738115614811 Neal, T.L., Diamond, A.B., Goldman, S., Klossner, D., Morse, E.D., Pajak, D.E., … & Welzant, V. (2013). Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological

402

Young Athletes’ Mental Health and Well-Being concerns at the collegiate level: An executive summary of a consensus statement. Journal of Athletic Training, 48(5), 716–720. 10.4085/1062-6050-48.4.13 New York Times (2018). The Larry Nassar Case: What Happened and How the Fallout is Spreading. https://www. nytimes.com/2018/01/25/sports/larry-nassar-gymnastics-abuse.html Nixdorf, I., Frank, R., Hautzinger, M., & Beckmann, J. (2013). Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology, 7(4), 313–326. 10.1123/jcsp.7.4.313 Nixdorf, I., Frank, R., & Beckmann, J. (2016). Comparison of athletes’ proneness to depressive symptoms in individual and team sports: Research on psychological mediators in junior elite athletes. Frontiers in Psychology, 7, 893. 10.3389/fpsyg.2016.00893 Nixdorf, R., Nixdorf, I., & Beckmann, J. (2017). Analyzing the relationship between burnout and depression in junior elite athletes. Journal of Clinical Sport Psychology, 11(4), 287–303. 10.1123/jcsp.2017-0008 Pacewicz, C.E., Mellano, K.T., & Smith, A.L. (2019). A meta-analytic review of the relationship between social constructs and athlete burnout. Psychology of Sport and Exercise, 43, 155–164. 10.1016/j.psychsport.2019.02.002 Padaki, A.S., Noticewala, M.S., Levine, W.N., Ahmad, C.S., Popkin, M.K., & Popkin, C.A. (2018). Prevalence of posttraumatic stress disorder symptoms among young athletes after anterior cruciate ligament rupture. Orthopaedic Journal of Sports Medicine, 6(7), 2325967118787159. 10.1177/2325967118787159 Palisch, A.R., & Merritt, L.S. (2018). Depressive symptoms in the young athlete after Injury: Recommendations for research. Journal of Pediatric Health Care, 32(3), 245–249. 10.1016/j.pedhc.2017.11.003 Parent, S., & Demers, G. (2011). Sexual abuse in sport: A model to prevent and protect athletes. Child Abuse Review, 20(2), 120–133. 10.1002/car.1135 Partridge, J.A., & Knapp, B.A. (2016). Mean girls: adolescent female athletes and peer conflict in sport. Journal of Applied Sport Psychology, 28(1), 113–127. 10.1080/10413200.2015.1076088 Patel, V., Flisher, A.J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. The Lancet, 369(9569), 1302–1313. 10.1016/S0140-6736(07)60368-7 Poucher, Z.A., Tamminen, K.A., Kerr, G., & Cairney. J. (2019). A commentary on mental health research in elite sport. Journal of Applied Sport Psychology, 33(1), 1–48. 10.1080/10413200.2019.1668496 Purcell, R., Goldstone, S., Moran, J., Albiston, D., Edwards, J., Pennell, K., & McGorry, P.D. (2011). Towards a 21st century approach to youth mental health care: The Australian initiatives. International Journal of Mental Health, 40, 72–87. 10.2753/IMH0020-7411400204 Purcell, R., Gwyther, K., & Rice, S.R. (2019). Mental health in elite athletes: Increased awareness requires an early intervention framework to respond to athlete needs. Sports Medicone Open, 5(1), 46–54. 10.1186/s40798-019-0220-1 Purcell, R., Rice, S., Butterworth, M., & Clements, M. (2020). Rates and correlates of mental health symptoms in currently competing elite athletes from the Australian national high-performance sports system. Sports Medicine, 50(9), 1683–1694. 10.1007/s40279-020-01266-z Raedeke, T.D. (1997). Is athlete burnout more than just stress? A sport commitment perspective. Journal of Sport and Exercise Psychology, 19(4), 396–417. 10.1123/jsep.19.4.396 Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Medicine, 40(11), 961–980. 10.2165/11536580-000000000-00000 Reardon, C.L. (2016). The sports psychiatrist and psychiatric medication. International Review of Psychiatry, 28(6), 606–613. 10.1080/09540261.2016.1190691 Reardon, C.L., & Factor, R.M. (2016). Considerations in the use of stimulants in sport. Sports Medicine, 46(5), 611–617. 10.1007/s40279-015-0456-y Reardon, C.L., Hainline, B., Aron, C.M., … & Engebretsen, L. (2019). Mental health in elite athletes: International Olympic Committee consensus statement. British Journal of Sports Medicine, 53(11), 667–699. 10.1136/bjsports-2019100715 Rice, S.M., Purcell, R., De Silva, S., Mawren, D., McGorry, P.D., & Parker, A.G. (2016). The mental health of elite athletes: A narrative systematic review. Sports Medicine, 46(9), 1333–1353. 10.1007/s40279-016-0492-2 Rice, S.M., Parker, A.G., Rosenbaum, S., Bailey, A., Mawren, D., & Purcell, R. (2018). Sport-related concussion and mental health outcomes in elite athletes: A systematic review. Sports Medicine, 48(2), 447–465. 10.1007/s40279-017-0810-3 Rice, S.M., Treeby, M.S., Olive, L.S., … & Purcell, R. (2021). Athlete experiences of shame and guilt: Initial psychometric properties of the athletic perceptions of performance scale within junior elite cricketers. Frontiers in Psychology, 12, 581914. 10.3389/fpsyg.2021.581914 Rao, A.L., Asif, I.M., Drezner, J.A., Toresdahl, B.G., & Harmon, K.G. (2015). Suicide in national collegiate athletic association (NCAA) athletes: A 9-year analysis of the NCAA resolutions database. Sports Health, 7(5), 452–457. 10.1177/1941738115587675

403

Rosemary Purcell et al. Rivara, F.P., Tennyson, R., Mills, B., … & Four Corners Youth Consortium. (2020). Consensus statement on sportsrelated concussions in youth sports using a modified Delphi approach. JAMA Pediatrics, 174(1), 79–85. 10.1001/ jamapediatrics.2019.4006 Ross, W., Kylie, R-D., Lynne, E., Karen, H., Jade, S., & Ceri D. (2019). Sport psychology consultants’ perspectives on facilitating sport-injury-related growth. The Sport Psychologist, 33(3), 244–255. 10.1123/tsp.2018-0110 Schaal, K., Tafflet, M., Nassif, H., … & Toussaint, J.F. (2011). Psychological balance in high level athletes: Genderbased differences and sport-specific patterns. PLoS ONE, 6(5), e19007. 10.1371/journal.pone.0019007 Schwenk, T.L. (2000). The stigmatisation and denial of mental illness in athletes. British Journal of Sports Medicine, 34(1), 4–5. 10.1136/bjsm.34.1.4 Smith, E.P., Andrew, P.H., & Howard, K.H. (2018). Perfectionism, burnout, and depression in youth soccer players: A longitudinal study. Journal of Clinical Sport Psychology, 12(2), 179–200. 10.1123/jcsp.2017-0015 Steinfeldt, J.A., Vaughan, E.L., LaFollette, J.R., & Steinfeldt, M.C. (2012). Bullying among adolescent football players: Role of masculinity and moral atmosphere. Psychology of Men & Masculinity, 13(4), 340–353. 10.1037/a002 6645 Stiglic, N., & Viner, R.M. (2019). Effects of screentime on the health and well-being of children and adolescents: A systematic review of reviews. BMJ Open, 9(1), e023191. 10.1136/bmjopen-2018-023191 Stillman, M.A., Brown, T., Ritvo, E.C., & Glick, I.D. (2016). Sport psychiatry and psychotherapeutic intervention, circa 2016. International Review of Psychiatry, 28(6), 614–622. 10.1080/09540261.2016.1202812 Stirling, A.E. (2009). Definition and constituents of maltreatment in sport: Establishing a conceptual framework for research practitioners. British Journal of Sports Medicine, 43(14), 1091–1099. 10.1136/bjsm.2008.051433 Stoeber, J. (2011). The dual nature of perfectionism in sports: Relationships with emotion, motivation, and performance. International Review of Sport and Exercise Psychology, 4(2), 128–145. 10.1080/1750984X.2011.604789 Stoeber, J., Madigan, D.J., & Gonidis, L. (2020). Perfectionism is adaptive and maladaptive, but what’s the combined effect? Personality and Individual Differences, 161, 109846. 10.1016/j.paid.2020.109846 Stoyel, H., Slee, A., Meyer, C., & Serpell L. (2020). Systematic review of risk factors for eating psychopathology in athletes: A critique of an etiological model. European Eating Disorders Review, 28(1), 3–25. 10.1002/erv.2711 te Wierike, S.C., van der Sluis, A., van den Akker-Scheek, I., Elferink-Gemser, M.T., & Visscher, C. (2013). Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: A systematic review. Scandinavian Journal of Medicine and Science in Sports, 23(5), 527–540. 10.1111/sms.12010 Tracey, J. (2003). The emotional response to the injury and rehabilitation process. Journal of Applied Sport Psychology, 15(4), 279–293. 10.1080/714044197 Truong, L.K., Mosewich, A.D., Holt, C.J., Le, C.Y., Miciak, M., & Whittaker, J.L. (2020). Psychological, social and contextual factors across recovery stages following a sport-related knee injury: A scoping review. British Journal of Sports Medicine, 54(19), 1149. 10.1136/bjsports-2019-101206 Vardar, E., Vardar, S.A., & Kurt, C. (2007). Anxiety of young female athletes with disordered eating behaviors. Eating Behaviors, 8(2), 143–147. 10.1016/j.eatbeh.2006.03.002 Vella, S.A., Swann, C., Allen, M.S., Schweickle, M.J., & Magee, C.A. (2017). Bidirectional associations between sport involvement and mental health in adolescence. Medicine and Science in Sports and Exercise, 49(4), 687–694. 10.1249/MSS.0000000000001142 Vella, S.A. (2019). Mental health and organized youth sport. Kinesiology Review, 8(3), 229. 10.1123/kr.2019-0025 Vertommen, T., Kampen, J., Schipper-van Veldhoven, N., Uzieblo, K., & Van Den Eede, F. (2018). Severe interpersonal violence against children in sport: Associated mental health problems and quality of life in adulthood. Child Abuse & Neglect, 76, 459–468. 10.1016/j.chiabu.2017.12.013 Vlahoyiannis, A., Aphamis, G., Bogdanis, G.C., Sakkas, G.K., Andreou, E., & Giannaki, C.D. (2020). Deconstructing athletes’ sleep: A systematic review of the influence of age, sex, athletic expertise, sport type, and season on sleep characteristics. Journal of Sport and Health Science, 10(4), 387–402. 10.1016/j.jshs.2020.03.006 Wachsmuth, S., Jowett, S., & Harwood, C.G. (2017). Conflict among athletes and their coaches: What is the theory and research so far? International Review of Sport and Exercise Psychology, 10(1), 84–107. 10.1080/1750984X.2016.1184698 Walton, C.C., Baranoff, J., Gilbert, P., & Kirby J. (2020). Self-compassion, social rank, and psychological distress in athletes of varying competitive levels. Psychology of Sport and Exercise, 50, 101733. 10.1016/j.psychsport.2020.101733 Walton, C.C., Rice, S., Hutter, V., Currie, A., Reardon, C., & Purcell R. (2021). Mental health in youth athletes: A clinical review. Advances in Psychiatry, 1(1), 119–133. 10.1016/j.ypsc.2021.05.011 Waltzman, D., & Sarmiento, K. (2019). What the research says about concussion risk factors and prevention strategies for youth sports: A scoping review of six commonly played sports. Journal of Safety Research, 68, 157–172. 10.1016/ j.jsr.2018.11.005 Weber, S., Puta, C., Lesinski, M., … & Gabriell, H.H.W. (2018). Symptoms of anxiety and depression in young athletes using the hospital anxiety and depression scale. Frontiers in Physiology, 9, 182. 10.3389/fphys.2018.00182

404

Young Athletes’ Mental Health and Well-Being Wells, K.R., Jeacocke, N.A., Appaneal, R., … & Hughes, D. (2020). The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport. British Journal of Sports Medicine, 54(21), 1247–1258. 10.1136/bjsports-2019-101813 Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50(3), 167–171. 10.1136/bjsports-2015-095756 World Anti-Doping Agency (2021). TUE Physician Guidelines – ADHD. https://www.wada-ama.org/en/resources/ therapeutic-use-exemption-tue/medical-information-to-support-the-decisions-of-tuecs-adhd

405

INDEX

Note: Bold page numbers refer to tables and italic page numbers refer to figures. Abdulshakur, A. 273 abnormality, categorization of 3–4 Acceptance and Commitment Therapy (ACT) 167 Acute Recovery and Stress Scale (ARSS) 343 addiction disorders in athletes 121; addictive behaviours 121–122; alcohol 122–123; cannabinoids 123; general prevalence 122; management 125–126; nicotine 123; practical implications 126–127; prescription drugs 124; prevention 125; problem gambling 124–125; sport-related gambling 124; stimulants 123–124 adolescence 107 aetiology 87 Aftab, A. 34 Åkesdotter, C. 153, 162, 349 alcohol 122–123 Alcoholics Anonymous (AA) 332 Allen-Collinson, J. 37 American Counseling Association (ACA) 316 American Psychological Association (APA) 314 amphetamine 303 Andersen, M.B. 317, 323, 350 Anderson, A.G. 316 androgens 302–303 anorexia nervosa (AN) 102–105 anticipation 131 antisocial personality disorder (ASPD) 151 Antonovsky, A. 33, 34 anxiety 64, 210, 226, 228; assessment of 231–232; competitive 226–228; determinants and risk factors 232–234; emergence of 227; future directions 236–237; intervention strategies 235–236; mental health and well-being, relation with 230–231; performance, relation with 229–230; person factors 232–233; practical implications 234–236; prevention

strategies 235; situation factors 233–234; social physique 229; sport injury 228–229 anxiety disorders 159–161, 160; assessment 166; contributing factors 164–166; future directions 169; generalised anxiety disorder (GAD) 162–163; manifestations of 165; non-pharmacological treatment 167–168; panic disorder 163–164; pharmacological treatment 168; prevalence rates 161–164; related disorders 164; social anxiety disorder 163; spectrum of anxiety in elite sport 159; treatment 166–168 Appaneal, R.N. 91 approach goals, defined 246 Armstrong, L.E. 190 Armstrong, S. 85 Arnold, R. 23, 24, 153 Aron, C.M. 164 Assessment Inventory of Disordered Eating Determinants (AIDED) 103–104 assessment of mental health 8 Association for Applied Sport Psychology (AASP) 314–315 athlete abuse and maltreatment 395 athlete burnout 52, 86 Athlete Burnout Questionnaire (ABQ) 86, 178 athletes, mental health in 63; anxiety 64; assessment of mental health 8; burnout 64–65; coach’s impact on 70; depression 64; Keyes’ (2002) continuum of mental health and illness 62–63; mental health vs. mental illness 3–6; neurobiopsychosocial model 63; practical implications 8–9; quality of life 7–8; research perspectives 9; teammates’ impact on 70–71; total network impact on 71; well-being 6–7 Attentional Control Theory of Anxiety 138 attention-deficit/hyperactivity disorder (ADHD) 399

406

Index Australian Institute of Sport (AIS) 281 authenticity 18 autonomy 36 avoidance goals, defined 246 Avoidant/Restrictive Food Intake Disorder (ARFID) 102, 105 Awad, E.A.A. 150

183; meta-analyses 180–183; organisational interventions 183–184; Raedeke’s (1997) commitment model 178–179; reducing 180; Smith’s (1986) cognitive-affective model 178 Busireddy, K.R. 181

Baddeley, A.D. 131, 132 Baddeley and Hitch’s (1974) model 131–132 Baker, J. 234 Balyan, K.Y. 233 Bandura, A. 252 Basile, B. 111 Bastian, B. 35 Baumeister, R.F. 35 Beck, A.T. 90 Beckmann, J. 36, 89 Beckmann-Waldenmayer, D. 394 Beck`s cognitive model 90 Beck’s Depression Inventory (BDI II) 86 Bennie, A. 50, 51 Berlin Concussion in Sport Group Consensus Statement 215 Besharat, M.A. 48, 49, 51 beta agonists 303 beta blockers 304 binge-eating disorder (BED) 102–105 Biopsychosocial Intervention and Observation Disordered Eating (BIODE) model 100, 101 Biopsychosocial Intervention and Observation Team Approach (BIOTA) 350, 351, 352 biopsychosocial model (BPS/BPSM) 150, 246 Bird, M. 70 Boan-Lenzo, C. 85 Bodies in Motion program 114 body dysmorphic disorder (BDD) 105 body image 107–110, 396–397 body mass index (BMI) 333 borderline personality disorder (BPD) 151, 152 Brand, R. 390 Breuer, C. 87 Breivik, G. 40 Brenner, J.S. 393 Brewer, B.W. 323 British Association of Sport and Exercise Sciences (BASES) 314 British Psychological Society 379 Brown, D. 14 Brown, D.J. 13, 14, 16, 23, 24, 25 Brown, G.P. 90 Bulimia Nervosa (BN) 102–105 burnout 64–65, 177–178, 189, 251; critical considerations and recommendations 184–185; current review 180; Deci and Ryan’s (2002) selfdetermination theory (SDT) 179; development 178–179; importance of 179; individual interventions

caffeine 303 Campbell, J.L. 233 cannabidiol (CBD) 123 cannabinoids 123 Caplan, G. 92 cardiovascular reactivity (CVR) 248, 255 career transitions in sport; crisis-prevention approach (case study) 292–293; helping athletes find alternative scope 294; preventative approach (case study) 293–294; relation to mental health 289; responsive approach (case study) 291–292; social identity approach to 289–291; social support 294; support for transition 294–295; types of 287–289; using all of athletes’ available resources 294 Castaldelli-Maia, J.M. 271 Cattell, R.B. 232 Center for Epidemiological Studies-Depression (CES-D) 84, 85, 86 Cerin, E. 92 Certified Mental Performance Consultant (CMPC) credential 324 challenge state, defined 246 Checa, I. 273 Cheval, B. 20, 21 Chow, G.M. 34, 38, 39 chronic traumatic encephalopathy (CTE) 211–212 Clement, S. 271 Clinical Feeding and Eating Disorders (CFEDs) 102, 105 coach–athlete relationship 65, 69–70 coach-created facilitative environment 56–57 coaches’ mental health 69 coach’s impact on athlete’s mental health outcomes 70 Coakley, J. 66 cocaine 303 cognitive behavioural therapy (CBT) techniques 56, 111–112, 167, 183, 215, 330 college athletes, depression in 84–85 collegiate sport, concussions in 204 Collins, N.L. 14 competition-day urine drug testing 125 competitive anxiety 227–228 competitive sport, anxiety in 226; defining of terms 226–227; emergence of anxiety 227 concussion-related mental health consequences 214; primary prevention strategies 214–215; secondary prevention strategies 215; tertiary prevention strategies 215 concussion-related mental health symptoms 208; depression, depressive symptoms, and anxiety 210; health-related problems following a concussion 211–212; major risk factors of 212–214; mental health

407

Index disorders and concussions, symptom overlap between 213–214; mental health issues 211; model of anxiety and mood clinical profile 208–209; post-concussion syndrome (PCS) 209; pre-existing mental health symptoms 213; repeated concussions 213; sex, race, and sport 212–213 concussions 201; applied sport psychologists 217; causes of 202–203; clinical history 206; in collegiate sport 204; definition of 201–202; diagnosis of 206; implications for practice 216–218; implications for research 215–216; management of 207–208; medical staff 217; physical examination 206; prevalence of 203–204; in professional sport 203–204; symptoms and symptom profiles 204–206; team 218 confidentiality and informed consent 317–318 Connor, K.M. 47 Connor-Davidson Resilience Scale (CD-RISC) 51, 52 Cooley, S.J. 377 coping self-efficacy (CSE) 252; defined 246 coping strategies 90 coping theory 67 Cosh, S.M. 287 Costa, V. 12 couples/family psychotherapy 331–332 Covassin, T. 210 COVID-19 pandemic 57, 339–341, 376 Cox, H. 56 creatine 304 Cropley, B. 316 Csikszentmihalyi, M. 40 Cumming, S. 279 Cunningham, J. 137 Czekierda, K. 34 Daily Analysis of Life Demands for Athletes (DALDA) 343–344 Daumiller, M. 256 David, J. 23 Davidson, J.R. 47 Deci, E.L. 13, 15, 16, 18, 19, 22, 26, 38, 40, 179 decision making 131 Deen, S. 56 dehydroepiandrosterone (DHEA) 302 Deisler, Sebastian 32, 34–35, 38 demand appraisals, defined 246 Den Hartigh, R.J.R. 54 dependent personality disorder (DPD) 152 depressed mood 194 depression 64, 83, 91, 189, 210; aetiology 87; college athletes 84–85; coping strategies 90; definition of 83–84; dysfunctional attitudes and perfectionism 90–91; indirect measurements 86–87; individual and team sport, differences between 91–92; international elite athletes 85; practical implications and guidelines 92–93; prevalence of 84–86; psychological vulnerabilities 90–91; recovery, lack of 89; research perspectives 93–94; self-rating questionnaires 86;

sport-specific differences 85–86; sport-specific mechanisms 91–92; stress and stressors 88–89 depression, burnout, and overtraining; aetiological similarities and differences 194–196; definitional similarities and differences 192–194; future research 196; integrative model of 194–196; practical recommendations 196–197; similarities and differences between 192 depression, depressive symptoms, and anxiety 210 depressive episodes, symptoms of 84 depressive symptoms 210 Desimone, L. 26 De Simone, S. 181 diagnostic ambiguity 333 Diagnostic and Statistical Manual (DSM) 145 Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) 121 Diamond, A. 132 diathesis 87 Diener E. 7 dimensional approach to mental health 4, 4, 5 dimethylamylamine 303 disordered eating (DE) 99; anorexia nervosa 102–105; binge eating disorder 102–105; biopsychosocial influences 101–102; body dysmorphic disorder (BDD) 105; body image 107–110; bulimia nervosa 102–105; case vignette 106–107; Cognitive Behavioural Therapy (CBT) 111–112; health risks, well-being, and quality of life 110; historical perspective of 100; individual and team-based assessment, prevention, and treatment 110–113; mindfulness 112–113; orthorexia nervosa (ON) 105–106; support groups for eating disorders 113–114; weight control behaviour 107–108 disordered eating behaviours (DEBs) 99, 107, 108 diuretics 304 D-methamphetamine 303 Docherty, C.L. 7 Dodson, J.D. 229 Donohue, B. 169 doping and drug misuse in elite sport 300; androgens 302–303; beta agonists 303; beta blockers 304; growth hormone and growth factors 303; non-drug performance-enhancing measures 306; nutritional supplements 304; other prescription drugs 304–305; oxygen transport, methods to increase 304; performance-enhancing substances 301–306; practical implications 307–308; recreational drugs 305–306; sport organisation policies 300–301; stimulants 303 doping and mental health 306; management 307; prevention 306–307 Dou, K. 42 Dreison, K.C. 181 Drew, B. 48, 52, 73 drugs: management 125–126; prevention 125 Ducrocq, E. 138 Dweck, C.S. 37, 39

408

Index Eating Disorder Examination (EDE) 110 eating disorders (EDs) see disordered eating (DE) Eccles, D. 376 Edwards, B. 349 effective professional, becoming 316 Elbe, A.M. 235 elements of mental health 6; quality of life 7–8; well-being 6–7 elite golfers 15 elite youth athletes, defined 390 emotion control 254 emotion control/regulation, defined 246 Engel, G.L. 100, 350 enthusiastic commitment 38 ephedrine 303 European Federation of Sport Psychology (FEPSAC) 4, 5 executive functions 130; definition 131–133; elite athletes 134–136; impact on mental health 136–137; implications for practitioners 137–138; measurement 133–134 existential frustration 37 Feeney, B.C. 14 fenfluramine 303 Ferraro, T. 144 Filbay, S. 7 Fischer, E.H. 269 Five Factor Model (FFM) 146 Fletcher, D. 153, 315 Flett, G.L. 34 Fogaca, J.L. 323 Folkman, S. 246, 254 Foskett, R.L. 234 Frank, R. 36, 91 Frankl, V.E. 31, 32, 33, 34, 34–35, 37, 38, 39 Frankl, Viktor 31 Freeman, P. 15, 25 Fritz, C. 375 future directions 236–237 Galli, N. 47, 48, 51 gambling; management 126; prevention 125 gambling disorder 121 Garet, M. 26 gene doping 306 general health questionnaire (GHQ) 85 General Health Questionnaire 30 (GHQ-30) 52 generalised anxiety disorder (GAD) 159, 162–163 Gervais, M. 19 Giles, S. 6 Glasgow Coma Score 201 glucocorticoids 305 Goldstein, K. 16 golf-based life skills program 56

Gouttebarge, V. 35, 85 Granz, H.L. 394 green and blue exercise interventions 379 Grolnick, W.S. 38 Gross, J.J. 234, 235, 254 group psychotherapy 332 growth hormone and growth factors 303 Gucciardi, D.F. 48, 52 Gulliver, A. 85, 162, 163, 392 Haase, A.M. 233 Habeeb, C.M. 66, 68, 71 Hage, S.M. 92 Hall, H.K. 233 Halldorsson, V. 40 Hallmann, K. 87 Hammond, T. 86, 88, 91 Hanrahan, S.J. 92 Harmon, K.G. 205 Harttgen, U. 37, 38 Harwood, C. 272 Haslam, C. 290 Haugen, E. 349 health-related quality of life (HRQOL) 7, 8 Healthy Eating and Actions for Lifetime Happiness (HEALTH) Guidelines 113, 114 Heil, J. 230 Heintzelman, S.J. 35 Heisel, M.J. 34 help-seeking behaviours 68, 333; altered expectations about services 334–335; personality factors 335–336 Hendawy, H.M. 151 Hendawy, H.M.F.M. 150 Henriksen, K. 319 hidden addiction 125 Hill, D.M. 231 Hill, Y. 54 histrionic personality disorder (HPD) 152 Hitch, G. 131, 132 Hosseini, S.A. 48, 51 Hoyer, J. 36 Huijgen, B.C.H. 134 hypothalamic–pituitary–adrenal (HPA) axis 248 Iancu, A.E. 181 individual psychotherapy 330–331 informed consent 317–318 Ingram, R.E. 87 injury and concussion 396 injury prevention and rehabilitation 349; biopsychosocial and interprofessional team considerations for 362–367; biopsychosocial approach to 350–352; iTeam Checklist 354, 355–361, 361; iTeam for injury prevention and rehabilitation 352–354 international elite athletes, depression in 85

409

Index International Olympic Committee 4 International Society of Sport Psychology 4, 5 intrapersonal strategy: direction of relational movement 24–25; self-awareness of the opposites of UPR 24 Inverted-U-Hypothesis 229 Isoard-Gautheur, S. 256 iTeam Checklist 354–362 iTeam for injury prevention and rehabilitation 352–354 Ivanova, M.Y. 146 Jacobson, J. 135 Javed, A. 267 job control, defined 246 job task analysis (JTA) 314 Kallus, K.W. 343 Kamal, A.F. 233 Kang, S. 48, 53 Kant, Immanuel 35 Kaye, M.P. 234 Kegelaers, J. 69 Kellmann, M. 37, 341, 343 Kenny, D.A. 75 Kenow, L.J. Kenttä, G. 194 Kerr, G. 16, 22 Keyes, C.L. 5 Keyes, C.L.M. 46, 62, 249 Keyes, L.M. 4; continuum of mental health and illness 62–63; two-dimensional model 4–6 Kilic, Ö. 57 Kim, I. 48, 53 Kim, S.S.Y. 69 King, L.A. 35 Kleinert, J. 36, 228 Klinger, E. 33 Knowles, C. 57 Kondos-Field, V. 13 Kreisman, J.J. 151 Krok, D. 34, 39 Kroshus, E. 72 Kuhl, J. 35, 36 Kuhl’s Personal Systems Interactions theory 39 LaGuardia, J.G. 38 Landau, I. 32 Larson, G.A. 63 Lax, I.D. 137 Lazarus, R.S. 246, 254 Lee, H.F. 181 Lee, K. 48, 53 Levit, M. 165 Li, C. 179 Li, J.B. 42 Liang, Y. 42 Liddle, S.K. 278, 279

Longstaff, F. 234 Lu, F.J.H. 48 Lukas, E.S. 37 Lundqvist, C. 6 Lusher, D. 75 Lux, M. 20 Luzzeri, M. 34, 38, 39 M2SP2-Revised (M2SP2-R) 271–273, 271 Machnik, M. 86 Madigan, D.J. 180 Madsen, E.E. 57 Mageau, G. 22 Maher, J. 315 Mahmoud, M.A. 273 Major League Baseball (MLB) players 204 Male Adaptation of the Body Project 114 Maniar, S.D. 70 Manley, G. 137 Maricutoiu, L.P. 181 Markser, V.Z. 153 Martela, F. 35, 36 Martens, M.P. 315 Martin, S.B. 272 Maslow, A.H. 15 Masten, A.S. 46 Masten, R. 233 mastery goals, defined 246 Matthaeus, L. 135 Matthews, J. 48, 52, 73 McCrory, P. 202 McEwan, H.E. 317 McHenry, L.K. 18, 20, 21, 24, 25 McKenna, J. 383 McLoughlin, E. 162, 234 meaning in life 32–33; finding 34–39; and health 33–34; literature on 31 meaninglessness in elite sport 32, 34 Meeusen, R. 190 Meijen, C. 247 Ménard, Jean François 22 mental disorders 3 mental health, defined 3 mental health intervention impacting knowledge and behaviours 72–73 Mental Health Inventory (MHI) 51 mental illness vs. mental health 3; abnormality, categorization of 3–4; dimensional approach to mental health 4, 4, 5; Keyes’ two-dimensional model 4–6 mental performance consultants (MPCs) 22, 23 mental toughness 63, 66 methylphenidate 303 micro-flow 40 Milles, D. 37, 38 mindfulness 112–113; -based interventions 56 Mindfulness-Based Stress Reduction (MBSR) 183 Mitchell, R.L.

410

Index Miyake, A. 132, 134 Mobley, M. 315 modafinil 303 Moen, F. 48, 53 monothematic orientation 37 Moore, Z. 318 Morris, R. 288 motivational enhancement therapy (MET) 331 multicultural competencies in sport psychology 315–316 multiple role relationship (MRR) 322; ethical considerations associated with 322–323; teacherclinician MRR 322 Murphy, S.C. 35 Myall, K. 57 narcissism 146 narcissistic personality disorder (NPD) 152 Narcotics Anonymous (NA) 332 Nässi, A. 344 National Collegiate Athletic Association (NCAA) 126, 204, 280, 391 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 151, 152 National Hockey League (NHL) 203 nature-based interventions in elite sport 374; acceptability of approach 383; application by sport typology 380–381; efficacy of 383; nature connectedness 375–376; potential adverse effects 381–383; researchers and practitioners, actions for 384; technological and virtual nature 379–380; theoretical explanations 375 nature-based therapies 377, 378; green and blue exercise interventions 379 negative social interactions 62, 67 neurobiopsychosocial model 63 Nezhad, M.A.S. 49, 51 nicotine 123 Nixdorf, I. 6, 85, 88, 89, 91, 92, 195, 234, 340, 391, 393 Nixdorf, R. 6, 87, 88, 195 non-functional overreaching 191 Norman, D.A. 133 nutritional supplements 304 objective control, defined 246 obsessive-compulsive disorder (OCD) 164, 333 obsessive-compulsive personality disorder (OCPD) 152 Ochentel, O. 181 O’Connor, P.J. 89 O’Halloran, L. 290 Olympic dream achievement during pandemic (case vignette) 362–363 one-dimensionality 37 Ong, N.C.H. 272 Oomen-Early, J. 85 organizational stressors 88 orthorexia nervosa (ON) 102, 105–106

other health-related problems following a concussion 211–212 other mental health issues 211 Other Specified Feeding or Eating Disorder (OSFED) 102, 105, 106 overtraining and burnout 393–394 overtraining syndrome (OTS) 189, 190–192, 398; definition and models 190–192 oxygen transport, methods to increase 304 Panagioti, M. 181 panic disorder 163–164 Papaioannou, A. 319 paranoid personality disorder (PPD) 151 parental and peer conflict 394–395 Patient Health Questionnaire (PHQ) 86 Patient Health Questionnaire 9 (PHQ-9) 342 Paulhus, D.L. 148 pemoline 303 perceived (subjective) control, defined 246 perceived control 253–254 perfectionistic thinking 90 performance: -enhancing substances 301–302; relation of anxiety with 229–230 performance goals, defined 246 PERMA approach 39 persistent post-concussive symptoms and postconcussion syndrome 209 Perski, O. 182 personality: defined 145–146; history of 145 Personality Assessment Instrument (PAI) 85 personality disorders (PD) 144, 146–147; Biopsychosocial Model (BPS) 150; case presentation 155–156; characterisation of 148–150; diagnosing 150–152; factors involved in the development of 147–148; impact on elite athletes 153–154; names and characteristics of 149–150; practical applications and guidelines 154–155; social-emotional functioning, impact on 152–153; treatment of 154 personal qualities, developing 55–56 person-cantered theory (PCT) 13, 15, 18, 22 Peterson, J.G. 204 Phelps, Michael 57, 112 Phillips, L.H. 137 Pica 102, 105 pituitary-adrenocortical (PAC) systems 248 Pluhar, E. 234 positive psychology 6 post-concussion syndrome (PCS) 209 post-traumatic stress disorder 164 Poucher, Z.A. 162 practical implications 234; intervention strategies 235–236; prevention strategies 235 practitioners: as advocates for a culture of thriving 22–24; as enablers of thriving through interpersonal relationships 24–25; as exemplars of thriving 22

411

Index prescription drugs 124 presence of meaning in life 32, 34; defined 31 problem gambling 124–125 Proctor, S.L. 85 professional considerations for clinician 313; competence and appropriate use of referrals 314–317; confidentiality and informed consent 317–318; effective professional, becoming 316; multicultural competencies in sport psychology 315–316; multiple role relationship (MRR) 322–323; referrals 316–317; supervision, ethical issues regarding 323–324; telepsychology 318–321 professional cyclist’s recovery and return to racing (case vignette) 364–365 professional sport, concussion in 203–204 Profile of Mood States (POMS) 343 progressive overload 191 pseudoephedrine 303 psychological syndromes, athletes with 4 psychological vulnerabilities: coping strategies 90; dysfunctional attitudes and perfectionism 90–91 psychology 6 Psychology Interjurisdictional Compact (PSYPACT) 320 psychotherapy 329; altered expectations about services 334–335; couples/family psychotherapy 331–332; diagnostic ambiguity 333; group psychotherapy 332; help-seeking behaviours, barriers and resistances to 333–336; individual psychotherapy 330–331; personality factors 335–336; unique challenges 332–333 purpose in life 34 quality of life 7–8 Quartiroli, A. 315 Raanes, E.F.W. 49, 53 Raedeke, T.D. 86, 178, 189 Raedeke’s (1997) commitment model 178–179 randomised controlled trials (RCTs) 180 Ranson, C. 279 Rao, A.L. 392 Rational Emotive Behaviour Therapy 183 Reardon, C.L. 166, 340 recombinant human growth hormone 303 recovery 339; future directions 345; impact of COVID19 on athletes 339–340; lack of 89; mental health in athletes 340–341; practical implications 344–345; stress and well-being 341; and stress monitoring 342–344 Recovery-Stress Questionnaire for Athletes (RESTQSport) 342–343 recreational drugs 305–306 Reed, M.-G. J. 46 Rees, T. 15, 25 Reeve, A. 182

referrals 316–317 Rein, I. 23 relevant social network research, review of 69; coach–athlete relationship 69–70; coach’s impact on athlete’s mental health outcomes 70; teammates’ impact on athlete’s mental health outcomes 70–71; total network impact on athlete’s mental health outcomes 71 resilience and mental health 45, 47–51; clinical indices 52; coach-created facilitative environment 56–57; conceptualising 45–47; COVID-19 impact on sport, resilience, and mental health 57; critique of literature and future research 54–55; defined 46; personal qualities, developing 55–56; social support, strengthening 56; studies of 48–50; subclinical indices 52–54 resilience scale for adults (RSA) 53 resource appraisals, defined 246 Rice, S.M. 72, 164, 234, 339, 340 Roberts, G.C. 232 Roderick, M. 32 Rogers, C.R. 18, 19, 20, 22, 24, 25, 26 Romano, J.L. 92 Ronkainen, N. 37, 40 Ronkainen, N.J. 290 Roth, G. 18 rumination disorder (RD) 102, 105 Ryan, R.M. 13, 15, 16, 18, 19, 22, 26, 38, 40, 179 Ryba, T. 37 Ryba, T.V. 315 Sagar, S.S. 150 salami slicing 55 Sandel, N. 208 Santos, F. 12 Schaal, K. 85, 160, 161, 162, 163, 340, 390 Scheier, I.H. 232 Sebbens, J. 72 Smith, A.L. 86, 189 Smith, E.P. 90 Schinke, R. 319 Schinke, R.J. 4, 56 Schnell, T. 35 Schumacher, J. 7 Schönfeld, P. 253 search for meaning, defined 32 selective androgen receptor modulators (SARMs) 302 selective serotonin reuptake inhibitor (SSRI) 301 selegiline 303 self-actualization 15–16 self-determination 36 self-determination theory (SDT) 13, 14, 18, 22, 33, 179, 184 self-efficacy 252–253; defined 246 Seligman, M. 7, 39 Selye, H. 246

412

Index sense of coherence (SOC), defined 33 Shallice, T. 133 Short Form 36 Health Survey 8 Short Recovery and Stress Scale (SRSS) 343 sibutramine 303 Sideridis, G.D. 256 Sigfusdottir, I.D. 40 Silani, G. 20 Simon, J.E. 7 situation selection 235 Skinner, E.A. 253 Skodol, A.E. 152 sleep disturbance 397 Smith, R.E. 178, 252 Smith’s (1986) cognitive-affective model 178 Smittick, A. 15, 25 social-actor-focused mental health interventions 71–72 social anxiety disorder 163 social identity, defined 246 social identity approach to career transitions and mental health 289–291 Social Identity Model of Identity Change (SIMIC) 290–291 social network and coach 62; anxiety 64; burnout 64–65; coach–athlete relationship 65, 69–70; coaches’ mental health 69; coach’s impact on athlete’s mental health outcomes 70; depression 64; future research directions 73–75; help-seeking behaviours 68; identification 67–68; integration of social actors within holistic athlete support network 73; Keyes’ (2002) continuum of mental health and illness 62–63; longitudinal tracking 74; mental health intervention impacting knowledge and behaviours 72–73; mental health interventions, assessment of 74; neurobiopsychosocial model 63; referral to mental health services/sources 68; relevant athlete mental health frameworks 62–63; relevant athlete mental health outcomes 63–65; relevant social network research 69–71; social-actorfocused mental health interventions 71–72; social network analysis 75; social support and negative social interactions 66–67; social support interventions, assessment of 74–75; sport-based social actors 65–66; sport culture and stigma 66; teammates’ impact on athlete’s mental health outcomes 70–71; total network impact on athlete’s mental health outcomes 71 social network of athlete, relevance of 65; coaches’ mental health 69; help-seeking behaviours 68; identification 67–68; referral to mental health services/sources 68; social support and negative social interactions 66–67; sport-based social actors 65–66; sport culture and stigma 66 social network awareness trainings 72 social physique anxiety 229 Social Physique Anxiety Scale 232 social support: defined 246; strengthening 56 Sonnentag, S. 375

Sorkkila, M. 49, 53 Spielberger, C.D. 227 Sport and Exercise Psychology Accreditation Route (SEPAR) 314 sport and performance psychology (SPP) 313 Sport Anxiety Scale (SAS) 232 sport-based social network of athletes 65–66 The Sport Concussion Assessment Tool, fifth edition (SCAT5) 207 sport culture and stigma 66 sport injury anxiety 228–229 sport Injury Trait Anxiety Scale (SITAS) 232 Sport Mental Health Assessment Tool 1 (SMHAT-1) 166 sport organisation policies 300–301 Sport Psychology Attitudes – Revised form (SPA-R) 273–274 sport psychology services 274–276 sport-related gambling 124 sport-specific mechanisms 91; individual and team sport 91–92 sport wagering 124 Spreitzer, G. 16 Stambulova, N. 293 Standal, S.W. 20 State-Trait Anxiety Inventory 232 Steger, M.F. 31, 32, 33, 35, 40 Stephen, S.A. 69 steroids 109 stigma 66, 392 stigmatisation of mental health 267; future directions 281; intra and interpersonal strategies 276–279; sport psychology services 270–274, 274–276; structural efforts to reduce stigma 279–281 Stillman, M.A. 167 stimulants 123–124, 303 Storch, E.A. 85 Straus, H. 151 stress 67, 88–89, 244–246; practical implications 257–258; research perspectives 258; TCTSA-R and mental health 249–257; TCTSA-R framework 246–249 stress monitoring, recovery and 342–344 stressors 88–89 Strong, S. 269 Structured Clinical Interview for DSM-5 (SCID-5) 166, 169 Structured Clinical Interview for DSM Disorders (SCID) 342 strychnine 303 Sue, D.W. 315 Suleiman-Martos, N. 182 supervision, ethical issues regarding 323–324 supervisory attentional system (SAS) 133 support groups for eating disorders 113–114 Suzuki, T. 49, 53

413

Index sympatho-adrenomedullary (SAM) activity 248 symptoms, mental health 390–392 system of elite sport 31 Tapper, A. 137 TCTSA-R and mental health 249; achievement goals 255–256; demands versus resources 251–252; emotion control 254; perceived control 253–254; physiological indicators of challenge and threat 256–257; predispositions 250–251; self-efficacy 252–253; social support 254–255 TCTSA-R framework 244, 246–249 teacher-clinician multiple role relationships 322 teammates’ impact on athlete’s mental health outcomes 70–71 telepsychology 318, 321; ethical issues associated with 320–321; legal issues associated with 320 tetraydrocannabinol (THC) 123 therapeutic use exemptions (TUEs) 301, 399 Thorlindsson, T. 40 threat state, defined 246 thriving 12; business models to support thriving 23; defined 16; future directions 25–26; humanistic model for 18–21; intrapersonal strategy 24–25; practitioners as advocates for a culture of 22–24; practitioners as enablers of 24–25; practitioners as exemplars of 22; processes of thriving sport organizations 23–24; theoretical foundations of 13–17; unconditional positive regard (UPR) 25 Tod, D. 316, 317 Tomlinson, J.M. 14 transition, defined 287 Transtheoretical Model 307 Transtheoretical Model of Behaviuor Change 271 traumatic brain injury (TBI) 201 Trigueros, R. 49, 52 Turner, J.L. 269 Turner, M.J. 56 two-continua model 4–5 Ueno, Y. 49, 53 unconditional positive regard (UPR) 16, 19–21, 25 unconditional positive self-regard (UPSR) 18, 20, 22, 25 Unspecified Feeding or Eating Disorder (UFED) 102, 105 U.S. Olympic & Paralympic Committee (USOPC) 280 Vallerand, R. 22

Van Raalte, J.L. 317, 323 Vaughan, R.S. 136 Vealey, R.S. 47, 48, 51, 233, 234 Vella, S.A. 49, 56 verbal abuse 147 Vestberg, T. 134, 135, 137 Vitali, F. 49, 52, 53 vulnerability of elite athletes to mental health problems 36–38 vulnerability-stress model 87 Wagstaff, C. 49, 53 Weber, S. 391 weight control behaviour 107–108 well-being 6–7; relation of anxiety with 230–231 well-being, mental, of young athletes 389; athlete abuse and maltreatment 395; body image concerns 396–397; bolstering mental well-being in elite young athletes 397–399; injury and concussion 396; mental health stigma in young elite athletes 392; mental health symptoms 390–392; overtraining and burnout 393–394; parental and peer conflict 394–395; pressure to perform and perfectionism 393; risk factors for 392–397; sleep disturbance 397 Werner, K.B. 151 West, C.P. 182 White, R.L. 50, 51 Widiger, T.A. 148 Willer, B.S. 137 Williams, J.M. 234, 350 Williams, K.M. 148 Wilson, K.A. 274 Wisconsin Card Sorting Task 134 Wolanin, A. 85, 91, 391 working memory 131 World Anti-Doping Agency (WADA) 168, 300–301 World Health Organisation 5, 8, 370 Wu, D. 50, 53 Yamada, K. 50, 52 Yang, J. 84 Yerkes, R.M. 229 Youth Self-Report (YSR) 146 Youth Sports Safety Alliance 349 Zizzi, S.J. 323 Zizzi. S.J. 315 Zurita-Ortega, F. 50, 52

414