A Mental Health Guide for Athletes and Their Support Networks

Prepared for the RRCA by Rachel Tambling, PhD, LMFT.

It is clear that emotional and physical health impact athletic performance. Athletes are under a great deal of pressure to perform well in a variety of circumstances, to please sponsors and coaches, and to perform to their potential. Professional athletes, in particular, may be challenged to work through injury and training setbacks, which can be difficult and disappointing. Athletes experience many demands on not only their physical health, but the mental health and emotional resiliency. Factors like genetics, life transitions, and social support all impact mental health. 

Many professional athletes and organizations have recently begun to focus on athlete mental health both as a critical aspect of personal development, and as a contributing factor to optimal athletic performance. For example, Olympian Michael Phelps has been quite open (see https://www.usatoday.com/) in discussing his struggles with depression and the ways in which depression impacted his performance as a world-class athlete. In the NFL, several prominent athletes have spoken openly about mental health struggles, and work has begun to make team owners more aware of the emotional needs of players (https://www.usatoday.com/story/sports/nfl/). At the collegiate level, increased attention to student-athlete mental health has resulted in several new initiatives, including, notably, those at University of Michigan and Oregon State (http://www.oregonlive.com/beavers/).

Unfortunately, athletes are at especially high risk for experiencing psychological difficulties. As many as 15% of athletes (2-3% higher than the general population) will experience mental health concerns severe enough to seek professional help (Watson & Kissinger, 2007). Eating disorders are especially problematic among athletes (Gill, 2008), impacting many professional athletes. Rates are probably higher than those reported, as many athletes may be hesitant to seek help, even when they need it, or when their performance could benefit from emotional well-being.

While it is clear that athletes may have special challenges that impact emotional wellness, all athletes are human, and experience struggles and challenges that can become disruptive to peak performance and daily life. The following are resources designed to provide direction, support, and connection for athletes struggling with emotional well-being. We are the RRCA are hopeful that this will be a starting point, from which you can find a path to wellness, resiliency, and peak performance.

Common Problems, Knowing When to Seek Help

Body image and disordered eating

Athletes are especially at risk of developing problematic relationships with food and weight. For most athletes, weight, training, and fuel, are critical to peak performance. Messages from coaches and others about what to eat, the optimal training body shape, and the ways in which diet and training impact performance can be overwhelming or preoccupying. Approximately 8% of female athletes and 3% of male athletes experience disordered eating at some point during their competitive careers.

Signs and symptoms of disordered eating – endorsing more of these signs as true for you might indicate that it would be a good time to seek support from a mental health professional.

o   Weight fluctuations, loss of weight not in support of training goals

o   Periods of overeating or fasting not in support of training goals

o   Ritualistic eating (cutting food into small pieces, hiding food, eating alone)

o   Fixation with food

o   Hypervigilance about calories/nutritional content that is not in support of training goals

o   Avoidance of social functions, particularly those that involve food or drink

o   Anxiety, depression, or isolation

Stress and Anxiety

Some anxiety is a normal part of being an athlete, and a human being. The desire to perform well, and represent one’s team, coach, and sponsors will undoubtedly create some feelings of stress or anxiety. Anxiety becomes a problem when the symptoms linger, becoming problematic for functioning in everyday life. As many as one in ten adults struggle with anxiety at some point in their lives. This can be transient or persistent, and a combination of medication and behavioral skills can help.

Signs and symptoms of difficult anxiety – endorsing more of these signs as true for you might indicate that it would be a good time to seek support from a mental health professional.

o   Restlessness, feeling on edge or unable to relax

o   Difficulty concentrating

o   Irritability

o   Avoidance of situations that prompt anxiety

o   Difficulty controlling worries, racing thoughts, feeling out of control 

o   Difficulty falling asleep or staying asleep

o   Fatigue, muscle pain, and unexplained illnesses

Depression

Everyone experiences times when they feel sad, lonely, angry, or hopeless. These emotions can be linked to life events, or can occur without warning. When such feelings make it difficult to function in everyday life, depression may be the cause. Depression not only impacts mood, but thoughts, behaviors, and physical health, as well. For athletes, depression can be triggered by unavoidable aspects of the sport, including loneliness during training, travel or relocation away from social support networks, and training setbacks or poor performances. As many as one in five adults experience depression in their lifetime, and help is available. Medication can help, but research supports the use of counseling in emotional wellness.

Signs and symptoms of depression – endorsing more of these signs as true for you might indicate that it would be a good time to seek support from a mental health professional.

o   Feeling helpless or hopeless (nothing is good; there is nothing I can do to improve my situation)

o   Loss of interest in activities that used to be enjoyable

o   Feeling “flat”, or disoriented

o   Feeling less joy, happiness, and pleasure than usual

o   Appetite or weight changes

o   Changes in sleep patterns (more or less)

o   Anger or irritability

o   Lack of energy

o   Difficulty concentrating, making decisions, or remembering ordinary things

o   Fatigue, muscle pain, and unexplained illnesses

o   Self-loathing (feeling worthless, persistent negative self talk, or self punishment)

o   Self harming (cutting, reckless behavior, drinking or doing drugs)

o   Thoughts of suicide, or wanting to simply not be around anymore*

Skills and Strategies

There are many skills and strategies that can help you find balance emotionally. One of the easiest way to find good strategies is to search the internet for breathing or relaxation strategies and try anything that sounds appealing. Many apps are also available to guide users in breathing and relaxation techniques. There is some trial and error in finding skills and strategies that will help you find emotional balance and mental well-being. Try several strategies and have more than one that feels comfortable. Listed are some of the most common strategies for finding temporary emotional wellness.

Breathing strategies

One way to manage troubling emotions is to slow the automatic thinking that often accompanies unwanted feelings. Breathing strategies can help slow thinking, alleviate anxiety, and refresh the mind. For each strategy, be in a comfortable position, seated, standing, or lying down. Close the eyes and focus on the technique for 10-20 breaths.

  • 10 second breathing – Take a slow, deep breath in through the nose for a count of 4. Breathe out through the mouth for a count of 6.
  • Belly breathing – Place one hand on the center chest and one hand on the diaphragm/belly. Breathe in until both hands can feel a shift from the breath. Breathe out from the belly first, then the chest. Breathe slowly and deliberately.
  • Pause breathing – Take a slow, deep breath in for a count of 5. Breathe out for a count of 5. Pause for a count of 2 before the need to inhale comes again.

Scheduled worry

One of the ways worry and anxiety can feel overpowering is that they often come on without warning. Scheduling time to worry is one way to manage the worry time. Select a specific time each day for worry. Schedule this in the day and set a timer for 10-15 minutes. During that time, worry freely about anything and everything that comes to mind. Write notes, make lists, draw or doodle, and engage with the worry. Once time is up, set aside the worries by folding the list, or visualizing putting the worries in a box or room. Be intentional about setting the worry aside and focusing on the next task fully.

Relaxation techniques

Relaxation sounds easy, but can be difficult for many people, particularly when there is tension in life. Many relaxation techniques can be helpful. Great resources are available here: https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/relaxation-technique/art-20045368

Visualization for mental health

Athletes often use visualization to prepare for important tasks or competitions. Visualization can be used for emotional well-being, too. Typically, emotional visualization involves thinking about soothing or pleasing contexts and allowing oneself to exist in that soothing space metaphorically. Find a quiet time for the visualization, perhaps while siting or lying down. Set a timer for the desired time if needed. Take a few deep breaths and focus the mind on the visualization. Imagine yourself in the relaxing or soothing scene you have selected. Notice what you see, hear, smell, feel and possibly taste. Pay special attention to the textures, colors, and patterns that you can see. You may imagine different parts of the scene, such as the beach and the water on an island. You may imagine the scene over time, like watching a sunset. Use pictures, videos, artifacts (like a rock, a jar of sand, a soft pillow) or other visual/kinesthetic aids to help you focus on the scene. End the visualization by slowly walking away from the scene, or shifting the focus from the scene. End with a few deep breaths.

Making the Decision to Seek Professional Help

Making the decision to seek professional help is an important one – and one that may be worrisome. Many athletes feel an obligation to sponsors, teammates, friends, and family to perform well. Seeking help may feel like admitting weakness, or like you have failed. It is normal to feel this way. Just as one might seek support from a coach, mentor, or physical health practitioner, seeking help from a mental health professional represents a decision to focus on health and well-being, leading to peak performance.

Finding a Mental Health Professional

Finding a mental health professional is easy, confidential, and can be done online in most cases. The easiest way to find a counselor or therapist is to search one of the many online databases. Large, national databases enable searching for counselors via local area, insurances accepted, and specialty. Once a therapist has been identified, the next step is to contact the therapist via phone or email. Ask questions about the therapist’s experience, specialty, and payment options. It is expected that potential clients will ask questions, and that the first contact will feel a little like speed dating, or a comfortable interview. Look for an indication of connection, or personality compatibility. If you don’t feel connected to, or comfortable with a therapist, ask for a referral. Finding a good therapist is personal, a bit like finding a good coach. There are many good coaches, but not all coaches are good for you. The same is true for therapists.

There are several different kinds of helpers. Among the most common are:

  • Licensed professional counselors (LPCs, LMHCs) – the most common type of therapist, and one who generally works with a variety of proble
  • Marital and Family Therapists – counselors who specialize in helping individuals and supporting them in managing their lives and relationships better
  • Social Workers – found in many hospitals and institutional settings, focused on improving social functioning within the larger social sphere
  • Psychiatrists – medical doctors who can write prescriptions and provide medications

Online therapist search resources:

Finding the right fit with a therapist who understands you can be challenging, here are some questions to ask: https://www.nytimes.com/2017/07/17/smarter-living/how-to-find-the-right-therapist.html

Finding a Mental Health Professional on a Budget

For many athletes, the cost of seeking professional help can be a barrier. Most therapists accept insurance and many offer fees on a sliding scale based on income and ability to pay. Inquire with any potential therapist about payment options, and fee reductions.

College campuses often have mental health treatment centers that are accessible to non-students. Look for a center associated with an advanced degree training program, and inquire about accessibility for non-students. Many college counseling centers offer therapy services to the community at a drastically reduced cost – and college counseling centers frequently work with collegiate athletes and can understand the unique pressures of professional athletic competition.

Common Worries

Confidentiality – Counseling is confidential, meaning that anything you share with a licensed therapist cannot be shared with anyone else without your consent. There are some exceptions to this confidentiality, including if the therapist believes that you might kill yourself or someone else, or do serious bodily harm that might result in the death of you or someone else. The therapist will likely inform the appropriate authorities if you tell them about the abuse of minor children, incompetent adults, or others who are unable to care for themselves. Finally, counseling records may be considered health care records in some states, and may be open to subpoena. Discuss your concerns about confidentiality with the therapist early in the treatment, and make sure you understand your rights.

Training while seeking help – You probably won’t have to stop training while seeking help for mental health concerns. The therapist might encourage you to modify your training in some ways, or help you develop strategies to train at your best during difficult times. Your therapist might encourage you to speak with your coach, or trusted others, about your mental health. Speak with your therapist about your concerns related to training and work with them to find a way keep training on track as you work to find your peak performance.

Supporting a Friend or Teammate

Many athletes have an opportunity to support teammates, colleagues, and friends, who may be struggling with emotional health. Here are some easy ways to support a friend or teammate who might be struggling:

  • Assure your friend/teammate that you believe them, that their struggles are real. Make sure your friend/teammate knows that you value mental health and value their emotional wellness.
  • Support your friend/teammate in engaging in self-care strategies and developing new coping strategies. You might suggest some of the skills and strategies in this guide, or support your friend/teammate in doing the things that make them feel comfortable, safe, and soothed.
  • Encourage your friend/teammate to avoid drugs and alcohol. Drugs and alcohol do not have a positive impact on mental health, and avoiding them during times of struggle is best.
  • Encourage your friend/teammate to seek help from a professional, particularly if you notice any of the signs listed in the signs and symptoms section of this guide.
  • Be patient. It can take time to accept help, and to develop a positive sense of emotional well-being. Be patient with your friend/teammate through setbacks and successes. Reinforce your willingness to help and to stand with them during times of difficulty.

Resources

  1. ADAA Directory of Mental Health Apps: https://adaa.org/finding-help/mobile-apps# ~ A collection of apps focused on developing skills and strategies to promote mental health. Apps are reviewed and rated on a variety of factors, including ease of use and effectiveness.
  2. The University of Michigan Athletics Connected program: http://athletesconnected.umich.edu/ ~ Excellent resource for a variety of behavioral strategies to promote mental health, videos and scientific papers about mental health and athletic performance. Stories of athletes who were able to overcome difficult emotional states and find peak performance.
  3. NCAA Mental Health for Athletes: http://www.ncaa.org/sport-science-institute/mental-health ~ Research and facts about mental health and the student athlete.
  4. SAMHI Canada: http://www.samhi.ca/ ~ A forum for Canadian athletes to connect and share stories and resources.
  5. BU Mental Health Resources: http://www.bu.edu/shs/behavioral-medicine/behavioral-resources/ ~ A collection of resources organized by concern. Some are better than others, but there is a good selection of different topics.
  6. Eric Monday Foundation: http://www.ericmondayfoundation.org/resources.html ~ Resources and information focused on reducing stigma around mental health help seeking.

*If you or someone you know is experiencing thoughts of suicide, act immediately. If there is imminent risk, call 911. For transient thoughts, or for someone to talk to, call the national suicide hotline at 1-800-273-TALK or 1-800-SUICIDE. In many areas, dialing 211 will connect you to mental health resources and emergency psychiatric services.