Psychotherapeutic Approaches to Addressing Mental Health Problems Among Elite Athletes

Athletes suffer from clinical and subclinical mental health symptoms and disorders that affect their lives and their performance. The objective of this chapter is to describe methods of psychotherapy used in treating elite athletes and the unique challenges that clinicians may face when working with this population. Psychotherapy, either as the sole treatment or combined with other nonpharmacological and pharmacological strategies, is a vital component in the management of clinical and subclinical mental health symptoms and disorders in elite athletes. Effective psychotherapy takes the form of individual, couples/family or group therapy and should address athlete-specific issues while validated as normative by athletes and their core stakeholders. This chapter summarizes research on psychotherapy for elite athletes with clinical and subclinical mental health symptoms and disorders. Though psychotherapeutic interventions are similar to those with non-athletes, working with elite athletes can present unique challenges. These can include diagnostic ambiguity, barriers to help-seeking behaviors, and altered expectations about services. Other personality factors occasionally associated with elite athletes could create difficulties when engaging in psychotherapy. These challenges may prevent athletes from seeking or continuing treatment.


Introduction
Just as with the general population, athletes can suffer from clinical and subclinical mental health symptoms and disorders that affect various areas of their functioning. A study conducted with elite athletes found that just under half of the respondents met criteria for at least one mental health "problem" including psychological distress, depression, general and social anxiety, panic disorder, and eating disorders [1]. Up to 60% of female athletes that participate in sports that require individuals to maintain a lean physique struggle with eating disorders [2]. College athletes display more binge drinking behavior than non-athlete college students [3], and 15% of student athletes have participated in pathological gambling behavior [4]. Athletes in the 30-50-year-old age have been shown to be at a 2-4 times higher risk of death by suicide than that of the general population in the same age range [5]. Within the athletic population, injured athletes experience more depression, anxiety, and lower self-esteem immediately after injury and during recovery than uninjured athletes [6]. In the case of elite athletes, these symptoms and disorders may have negative effects on performance, therefore potentially further impacting their well-being. The objective of this chapter is to discuss various forms of psychotherapy that are appropriate for the elite athlete population and to highlight several unique challenges that mental health professionals may face when working with this population.

Psychotherapy
In order to improve overall functioning, athletes dealing with mental health symptoms and disorders should seek psychotherapy. Psychotherapy, either as the sole treatment or combined with other nonpharmacological and pharmacological strategies, is a vital component in the management of clinical and subclinical mental health symptoms and disorders in elite athletes. For psychotherapy to be most effective with athletes, it must address athlete-specific issues while being validated as a "normal" or standard treatment for mental health difficulties by the athletes and their core stakeholders (partners, family, coaches, agents, etc.). As a means of decreasing the stigma often associated with mental health treatment, it may be helpful to reframe psychotherapy treatment as "performance help" as the goal is to improve functioning therefore improving athletic performance [7].
There are several different forms of psychotherapy that have been implemented and found to be successful in the treatment of athletes suffering from mental health symptoms and disorders. These are individual psychotherapy, marital/family psychotherapy, and group psychotherapy.

Individual psychotherapy
Individual psychotherapy involves a patient meeting with a trained mental health professional in a one-on-one setting. Oftentimes individual psychotherapy alone can be a sufficient treatment for less severe mental health issues such as mild depression, anxiety, and sports-related adjustment issues [8]. Individual psychotherapy provided by a sport psychiatrist or a psychologist or counsellor who specializes in the treatment of athletes can be useful in the treatment of psychiatric disorders as well as in improving adherence to medication.
The types of individual psychotherapies that are most commonly used in young adults, college students, and collegiate athletes are supportive therapy, cognitive behavioral therapy, motivational enhancement therapy, and psychodynamic therapy. These four therapies appear to have common healing factors including affective engagement, feeling understood by the therapist, offering a framework for understanding the problem/solution, therapist expertise, therapeutic structure/procedures, optimism regarding improvement, and experiences of success [9].
Of these therapies, cognitive behavioral therapy (CBT) has received the most empirical support [10]. CBT works to help patients understand how dysfunctional thoughts can lead to negative emotional activation and maladaptive actions or inactions [11]. This form of therapy is a very appropriate choice for athletes as it mirrors elements in physical training such as comfort with structure, direction, and practice [12]. As athletes are typically already comfortable with these elements, it can make this method of treatment one that makes practical sense to implement, especially athletes who participate in individual sports due to their familiarity with individual goal setting and self-reliance [8]. CBT appears to be most useful in cases of depression, anxiety, substance use disorders, anger/aggression, insomnia, somatization, chronic pain, and general stress [13].
An athlete's feelings and opinions on substance use, legal or illegal, can be strongly influenced by peers, family, coaches, trainers, and other individuals that they are in close contact with. For example, a coach who notices that a new prescription has caused a slight drop in performance may attempt to convince their athlete to take less than the prescribed amount or stop taking the medication altogether. Teammates that often engage in illicit drug use may pressure other athletes to try it or believe that it is permissible. Motivational enhancement therapy (MET) uses principles of motivational interviewing to help patients understand their ambivalent feelings and opinions towards substance use [8]. Accordingly, MET appears to be most useful in cases of risky drinking and adverse alcohol behaviors, cannabis use, tobacco cessation, and medication adherence issues [14,15].
Psychotherapy, compared to psychopharmacological treatments, is considered the best primary treatment of adjustment disorder, one of the more common mental health disorders experienced by athletes [8]. An adjustment disorder is an excessive emotional or behavioral reaction to a stressful event or change in a person's life. Athletes often face many situations requiring them to cope with stressful changes, including being traded to a new team, moving to new cities, and adjusting to injury. Due to the relatively short duration of adjustment disorders, psychotherapies that are short-term and problem-solving focused appear to be the most efficacious modality, given the shorter timeframe of the disorder [16].

Couples/family psychotherapy
Involvement of family in psychotherapy can help athletes understand how personal and family stress can impact overall athletic performance [14]. Spouses or partners and other family members can play a significant role in the mental health of an athlete. Part of that role can involve assisting the athlete in caring for their mental health. If an athlete is willing to involve family members, a healthcare provider may gain a better understanding and more well-rounded view of the patient as family members can provide important supplemental information [7]. Family members are often crucial in ensuring treatment adherence, and it is a common belief that in certain circumstances, psychoeducation should be required for patients as well as their partner/family member(s) before being able to start psychotropic medications [7]. If an athlete is amenable, coaches, trainers, agents, and other close individuals can provide additional supplementary information about the athlete as well as work to facilitate their adherence to treatment during daily activities. These individuals and family members are often the people who encourage athletes to seek out help in the first place.
In addition to helping, family can also be a source of stress for athletes, or elements of the athlete's life may be sources of stress for their family. Many times, familial issues may either be the source of the presenting problem or the problem itself when an athlete seeks treatment [8]. Recent studies have shown that family problems in a collegiate athlete's life may predispose them to mental health distress and could be used as a good screening method to assist referrals [17]. Some issues that are not exclusive to the family setting of athletes alone but may present themselves with greater frequency include substance use, domestic violence, time spent away from home, jealousy, and extramarital affairs [14]. These types of issues can also be the underlying causes of psychiatric symptoms that lead athletes to present for psychotherapy. Because of this, clinicians must be able to appropriately implement marriage/couple psychotherapy which can sometimes be difficult if both parties are not committed to participating in treatment [8].
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Group therapy
A third form of psychotherapy that may benefit athletes is group therapy. This form of therapy involves individuals coming together in a group setting with a mental health professional to receive psychoeducation and psychotherapy. In addition, the individuals are able hear and learn from the experiences of the other individuals in the group. Finding these shared experiences may lead to greater change than what can be provided by therapy and medication [18].
This form of psychotherapy is often used for athletes with substance abuse issues and can include groups such as Alcoholics Anonymous and Narcotics Anonymous. Group therapy is often used in combination with medication, particularly for substance use disorders, and can be led by qualified mental health clinicians [8]. Group psychotherapy may be particularly effective for team sport athletes as they are accustomed to performing as a member of a team (the group) and following the leadership of a coach (the mental health professional), and this format may provide an added level of comfort [7,8].
A common issue with high profile athletes that may work as a deterrent to this form of psychotherapy is the issue of confidentiality and anonymity [8]. Athletes are more likely to agree to using this approach to therapy if they have had positive experiences with it in the past, confidentiality can be guaranteed, and it can be well integrated into their life [19].

Unique challenges
Due to differences in lifestyle and other factors, mental health clinicians must keep in mind several considerations when working with elite athletes compared to the general population. Although psychotherapeutic interventions are similar to those with non-athletes, elite athletes can present unique challenges including diagnostic ambiguity, barriers to help-seeking behaviors, and altered expectations about services.

Diagnostic ambiguity
When attempting to diagnose athletes, there are many considerations that a clinician must keep in mind. One is that many of the symptoms and behaviors that athletes may present with are shared between mental health disorders and typical/expected athlete behavior. Take over-training syndrome and clinical depression: shared symptoms are fatigue, appetite loss, weight change, cognitive deficits, and a general lack of energy and motivation [20]. These symptoms have two different causes and therefore require different treatments to resolve symptoms. Athletes may also perform ritualistic behavior in order to relieve anxiety during athletic performance [21]. This could include behaviors such as unique free-throw warm-ups in basketball, avoiding stepping on the foul line while taking the field in baseball, or eating Skittles™ before every football game. While this may lead a clinician to suspect a diagnosis of obsessive-compulsive disorder, these behaviors are limited only to competitive settings and result in no overall life impairment [22].
In addition to the presenting symptoms and behaviors themselves, the underlying cause of them may be different for athletes than for individuals in the general population. Due to their experiences and lifestyles, athletes have unique triggers that may cause their psychiatric symptoms. Depression can be brought on by overtraining, poor performance, or retirement from a sport [2,22]. Athletes in contact and even non-contact sports are constantly exposed to the potential for severe injury which can bring about mood disturbance, tension, and anger [23]. There are also greater prevalence rates of performance anxiety and jetlag induced insomnia among elite athletes in comparison to the general population [24].
Even within the elite athlete population, athletes who perform in different sports may have varying risks for different mental health symptoms and disorders. Research shows that athletes who participate in individual sports, compared to those in team sports, may be at a greater risk for depressive symptoms [25,26]. Because of these ambiguities and potential differences in symptoms and behaviors, mental health practitioners must carefully consider each case in order to choose correct diagnoses and methods of treatment.

Barriers to help-seeking behaviors
The most common barrier to athletes seeking treatment is stigma associated with mental health [27]. Some athletes may hold the belief that receiving mental healthcare is a sign of "weakness" and evidence of being "crazy" or untrustworthy [2]. In one study, student athletes in Australia reported poor understanding of mental health and past negative experiences in help seeking as other barriers to seeking out treatment [28]. Because of these misperceptions and misunderstandings of mental health, many athletes may refuse to seek help due to their own beliefs or the beliefs held by their peers, family, and coaches. Research has shown that perceived stigma, confidence in consolation, cultural preferences, and openness can be used to predict a coach's likelihood of referring their players to mental health services [8]. This means that coaches who view mental health as less stigmatizing, have greater confidence in positive outcomes from consolation, have receiving therapy as a cultural preference over other forms of treatment or no treatment, and have higher levels of openness are more likely to refer their athletes to therapy for issues regarding mental health.
Another barrier to seeking or continuing treatment is when a problematic behavior is viewed as positive or helpful to an athlete's sport performance. A wrestler or fighter may justify an eating disorder such as anorexia nervosa or bulimia nervosa because it helps them to maintain or cut weight before contests [20]. A football or baseball player may choose to struggle through mood disturbances and inter-personal difficulties while using anabolic steroids if they believe that the steroids are helping them to build muscle and perform at higher levels [4]. If an athlete is currently in treatment, beliefs such as these may cause strains in the patient-therapist relationship when the clinician points out the negative effects of these behaviors that are viewed as beneficial by the athlete [8].
As noted earlier, confidentiality can be difficult to ensure or maintain at times. Some athletes -especially those who are particularly well known in their area, state, or country -may fear being recognized while attending or traveling to and from treatment sessions. These athletes may prefer that mental health professionals come to them to provide services at team facilities or their home or hotel in order to avoid public exposure [27]. While this may be permissible, mental health professionals must consider to pros and cons of providing treatment outside of the clinical setting [8]. Some athletes may prefer not only confidentiality from the public but also confidentiality from individuals involved in their personal lives. Even though coaches, trainers, agents, and family may prefer to be involved and included in psychoeducation and psychotherapy as they are accustomed to being involved in the athlete's life, this can create complexities regarding confidentiality [2].

Altered expectations about services
Elite athletes are often accustomed to special treatment and accommodations that are not given to the general population. Many athletes have assistants or people within their organizations who create and organize schedules, arrange travel accommodations, and complete day to day tasks for them [27]. This can become a challenge for the mental health professional when it is preferable to speak with the athlete than with their assistant [14].
While some athletes prefer that mental health clinicians meet them where they are for confidentiality purposes, some athletes make this request because it is what is normal for them. Oftentimes athletes will have healthcare professionals and others meet them at team facilities or their home, so this is what is typical and expected. As stated earlier, mental health professionals must consider the advantages and disadvantages of providing psychotherapy outside of the clinical setting [8]. With their busy schedules and frequent traveling combined with repeated accommodations by others, athletes may expect that clinicians can provide services at any time if it is convenient for the athlete. This can make establishing and maintaining boundaries difficult for the clinician if they attempt to schedule and travel to meet the athlete's preferences [27].
Although many elite athletes may be well-off financially, they may not be accustomed to paying for certain services [2]. For example, agents may try to provide tickets, passes, or merchandise that are equal in value to the charge for treatment [2]. Accepting these in lieu of monetary payment is unethical and could lead to future boundary issues as the professional patient-therapist relationship could be viewed as a more personal one by both parties [2].
In all situations, the clinician's goal should be to balance "flexibility with appropriate boundaries" [2]. This is done 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 [29].

Personality factors
Narcissism and aggression are personality traits that can be common among elite athletes [7]. These are traits that the clinician may encounter during mental health services with athletes, or they could be the presenting issue for a patient coming in for treatment.
Elite athletes may often achieve great fame and wealth. They are often held in high esteem by fans, family, teammates, coaches, and others. People admire them for what they are able to accomplish and follow not only their athletic performances but also their personal lives through the media. Because of social media, athletes' lives are more accessible to the public than they used to be, and they may receive praise and attention via this platform in addition to what they receive in person. All of this can lead to feelings of superiority or narcissism as they are often the center of attention and may be accustomed to being in the spotlight [8]. Because of this, an athlete may feel as though they are not in need of help since they receive so much adoration on a constant basis, or they may have unrealistic expectations about therapy [2]. For example, if they do not see immediate results from therapy or it does not come as naturally to them as their sport does, then they may decide that it is not beneficial to them and not worth their time or effort. In extreme cases, these athletes may develop grandiose beliefs, lose their ability to empathize, and respond with fury to real and imagined slights [8].
Recent research has found a positive relationship between anger, aggressiveness, general aggressive behavior, antisocial behavior toward opponents and teammates, and the experience of and expression of anger [30]. This supports previous findings that antisocial traits may often lead to outbursts of anger, especially within training, practices, and games [8]. Due to their pride being built upon the praise of others, many successful athletes are insecure or have fragile egos and may exhibit rage and aggression when confronted with real or imagined threats to their sense of selfworth [7,31]. The loss of praise and increase of criticism due to a poor performance or decision by an athlete can "injure" the ego, which can lead to a response of "impulsive and explosive rage" as they deal with a cycle of praise and criticism that is uncommon in other populations [31].

Conclusion
Elite athletes are a unique population that can provide uncommon challenges, but they also have strengths and circumstances that make them good candidates for psychiatric treatment. The goal of treatment is to improve mental health in order to maintain peak athletic functioning. Psychotherapy is a common form of treatment for mental health issues and may be particularly effective for elite athletes in the form of individual psychotherapy, marital/family psychotherapy, or group psychotherapy. Due to the nature of the elite athlete population, mental health clinicians may face several unique challenges in providing services to these individuals. These include diagnostic ambiguity, barriers to help-seeking behaviors, altered expectations about services, and personality factors. Elite athletes face many pressures and stressors that are not common to the general population. Mental health professionals should keep these considerations in mind during treatment and work to normalize and reduce stigma towards receiving mental health services within the elite athlete population.