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Considerations for athletes in counseling

By Jessie Huebner April 11, 2022

“I have to do what’s right for me and focus on my mental health and not jeopardize my health and well-being.” 

Hearing those words from Simone Biles, the epitome of talent in the world of gymnastics, and witnessing her personal battle in deciding to remove herself from competition at the Summer Olympics in Tokyo was eye-opening, to say the least. 

As the world prepared to observe the talents of the athletes in the 2022 Winter Olympics this past February, it made me reflect on all of the groundbreaking disclosures by elite athletes concerning their personal challenges with mental health leading up to, during and after the conclusion of the prior year’s Summer Games. These challenges had never previously been disclosed and discussed to such magnitude.

For example, following the U.S. Olympic team trials, swimmer Simone Manuel disclosed that she was experiencing depression, anxiety and insomnia resulting from overtraining syndrome. Liz Cambage, a Women’s National Basketball Association player who was scheduled to compete for Australia in Tokyo, identified anxiety symptoms as the reason that she pulled out of the Olympics a week before the opening ceremony. She has since described how daily medication helps her manage her anxiety symptoms so that she can continue competing. 

Throughout the broadcast of the Summer Games and following the conclusion of competition in Tokyo, numerous brave, elite-level athletes shared their prior or current difficulties with mental health symptoms. U.S. shot-putter Raven Saunders shared her experience with depression and prior suicidal ideation and her need to continually monitor and focus on her mental health. Cross-country mountain biker Jenny Rissveds of Sweden disclosed that a year after winning gold in the 2016 Summer Olympics in Rio de Janeiro, two deaths in her family triggered depression symptoms that she has been addressing since that time. U.S. sprinter Sha’Carri Richardson qualified to run the 100 meters in the Summer Olympics in Tokyo, but a positive test for marijuana resulted in a temporary suspension, causing her to be ineligible to compete in the race. Richardson acknowledged using marijuana to cope with and avoid negative emotions following the death of her birth mother and the stress connected with elite performance expectations. American gymnast Sam Mikulak revealed that swimmer Michael Phelps’ openness about his mental health journey encouraged Mikulak to seek treatment and experience the benefits of therapy. Phelps’ disclosures about his own struggles with mental health continue to be highlighted through his endorsement of an online therapy service provider.

Not just Olympic athletes

Olympic athletes’ willingness to openly discuss their mental health seemed to spark discussions in the Olympic community about the need for increased support and mental health interventions for athletes. Because of concerns regarding the impact of stigma on discussions about mental health, the U.S. Olympic & Paralympic Committee in 2020 suggested administration of the Sport Mental Health Assessment Tool during routine physicals for athletes. The tool was first administered with a group of 165 USA Swimming and U.S. Soccer athletes; 58% of participants tested positive for a mental health issue, and four athletes were found to be potentially at risk for self-harming behaviors or having suicidal ideation.

Difficulties with mental health are not limited to athletes at the Olympic level. This suggests the need for counselors working with elite athletes at any level to be prepared to offer services that take into consideration this unique client population. 

A 2019 meta-analysis by Vincent Gouttebarge and colleagues identified that mental health symptoms and disorders for current elite athletes ranged from 19% for alcohol misuse to 34% for anxiety/depression. Symptoms for former elite athletes ranged from 16% for distress to 26% for anxiety/depression. Some studies noted that while athletes in general may be at comparable risk for these mental disorders in distinction against the general population, some subgroups of athletes (e.g., those in retirement, those experiencing performance failure) may be at elevated risk. 

Common sources of tension identified by elite athletes include stress, injury, errors on the sporting field, fatigue, and their club’s or organization’s climate. Athletes experience increased stress related to factors including restricted social and occupational opportunities, pressure to maintain superior fitness and performance, scheduling and time constraints, social isolation, demands of multiple relationships, lack of energy and motivation due to physical fatigue, limited funds due to restricted financial opportunities, public criticism, injuries, and fear of career-ending injuries. While some elite athletes endorsed employing active coping strategies in their everyday lives, athletes were more likely to use less adaptive (avoidance) strategies when faced with unexpected stressors. 

Seeking to learn more about the mental health of student-athletes, in 2015, Andrew T. Wolanin and colleagues implemented multiple measures with 465 college athletes during yearly physicals across three consecutive years of their athletic careers. Clinically relevant levels of depression symptoms were exhibited by 23.7% of the sample, with 6.3% exhibiting moderate to severe levels of depression symptoms. Significant gender differences were found, with females exhibiting 1,844 times higher risk of clinically relevant symptoms than males. Prior studies have also identified gender differences, with female student-athletes scoring significantly lower than males on sense of self-worth, stress management and leisure. 

With athletes being channeled into specific sports at younger ages and with the associated changes in sport and life demands, mental health symptoms for athletes may begin even earlier. This is especially concerning because young athletes possess even fewer psychological coping skills. Among the identified stressors connected with mental health symptoms for youth athletes are pressure to perform and perfectionism, maintenance of academic and social balance, interpersonal conflict or abuse, injury and concussion, body image and weight pressures, and disrupted sleep. These stressors have been correlated with burnout and overscheduling, bullying and hazing, and risk-taking behaviors (e.g., early use of tobacco, misuse of prescription drugs, the restriction of calories, weight-dropping behaviors, use of performance-enhancing drugs). 

Student-athletes, in particular, have to endure the constant demands of intense practices, competition schedules, and the need to maintain or improve upon their strength and physical skills, all while maintaining passing grades to remain eligible for athletic competition. Additionally, student-athletes often have difficulty making time for leisure activities and may be less satisfied with such activities. 

Areas of focus for athlete clients

Counselors who work with athletes can assist these clients by focusing on personal and social issues that athletes commonly experience. Counselors can also help these clients in their development as individuals separate from their identity as athletes. Specific approaches might include relaxation training, solution-focused techniques, time management, cognitive behavior techniques, decision-making techniques, life management and career planning, coping skills strategies, and crisis intervention. 

Perfectionism

Athletes experience both personal and external expectations of perfection. Professional skateboarder Nyjah Huston has shared about the pressure of being an elite athlete and how he is often “really hard” on himself when he does not win. Counselors can support these clients by communicating understanding and empathy regarding the exceptional standards for athletes. 

Counselors can use psychoeducation to explain that extreme self-criticism can affect clients’ well-being and athletic performance and to encourage clients to identify the positive and negative aspects of perfectionism. Additionally, counselors can assist clients in setting their own realistic expectations of performance. 

Incorporating the topic of perfectionism is especially important because of the potential for athletes to turn to risk-taking behaviors to achieve perceived perfection in their sport. 

Burnout

Athletics is an environment in which psychological symptoms are often downplayed by the individual, likely exacerbating risk for continued symptoms, overtraining and burnout. In addition to mental health symptoms, overtraining is often connected to poor eating and sleeping patterns and increased risk of injury. Counselors should ask athlete clients about their current sleep habits or sleep disruptions. Counselors might consider offering sleep hygiene, psychoeducation and cognitive behavior approaches to promote healthy sleep behaviors. 

Student-athletes may experience burnout due to the constant need to balance sport, academic and emotional demands. Counselors should communicate understanding of the totality of clients’ commitments and assess for symptoms of burnout, including physical and emotional exhaustion, sport devaluation and reduced sense of accomplishment. 

Counselors can assist athletes experiencing burnout by opening discussion of what the client enjoys or previously enjoyed about involvement in their sport and what may have changed. Counselors can also encourage the reframing of clients’ (and, possibly, caregivers’) expectations of sport participation, foster fun and enjoyment both inside and outside of athletics, and explore clients’ overall values and nonathletic interests to expand their identity and promote balance between athletic and nonathletic identity. 

Interpersonal needs

Athletes may be perceived to have frequent peer interactions due to constant interactions with other athletes in sport, but many athletes have been found to lack interpersonal skills in everyday social interactions. Often, athletes are isolated from peer interactions and social opportunities outside of their athletic community. 

Counselors can guide these clients in assessing their schedules and time management techniques to identify nonathletic social opportunities and offer psychoeducation on the importance of interactions and connections that are not connected to their athletic world. Additionally, counselors should assess for signs of bullying or harassment (e.g., hazing; body shaming; encouragement to dope, cheat or play when injured) occurring for clients, especially for those identifying as being in a minority group at higher risk for negative interpersonal experiences in sport.

Injury

Athletes’ mental health can be affected by the fear of, and actual experience of, injuries that could affect their future athletic careers and, potentially, their overall life plans. Injured athletes have been found to exhibit greater depression and anxiety symptoms and lower self-esteem than controls, both immediately and in the months following their injury. 

To best guide treatment interventions, counselors should assist clients in identifying specific sources of distress related to the injury (e.g., physical pain, trauma of injury incident, isolation, irritation with rehabilitation, fear of reinjury, fear of not returning to sport). Counselors can support their injured clients by being mindful of the significant distress that often accompanies injury for elite athletes, offering compassion-based and acceptance-based approaches, and reframing the injury as an opportunity for growth and development. 

If the client’s injury involves a concussion, counselors should be knowledgeable about the psychological symptoms (e.g., irritability, anger, depression, anxiety, impulsivity) commonly associated with concussion injuries and the risk that clients may minimize symptoms or not present with awareness of the connected symptoms. 

Vulnerabilities

Athletes have been identified as vulnerable to disordered eating and risk-taking behaviors such as hazardous drinking, unprotected sex, driving while intoxicated and doping. 

Counselors can potentially assist in early detection of eating disorders in this at-risk population. Techniques identified to address disordered eating among youth athletes include interventions targeting motivation to change, dialectical behavior therapy skills training to develop ability to tolerate subjective distress and improve emotion regulation, and interpersonal skills development. Preventive measures to target disordered eating may include cognitive distortion psychoeducation, groups targeting improved self-esteem, and techniques to target negative coping strategies and encourage positive coping mechanisms. 

A 2020 study by Stephen P. Bird and Benjamin D. Rushton found that elite youth athletes generally lack fundamental nutritional knowledge, specifically information related to dietary reference intakes and supplementation. Therefore, nutrition education with this population is crucial; however, counselors should be aware of any specific requirements of the sport to support trust building and credibility with the athlete and to align treatment goals accordingly. 

Doping is also a prevalent problem among elite athletes (across all ages). Counselors should educate themselves on signs of doping and ask clients if they are currently using performance-enhancing drugs or have been pressured to use such drugs by coaches, parents or peers. Counselors are encouraged to address doping by implementing interventions that match the specific needs and readiness of the client. Counselors may begin by helping the client identify and discuss their desire to change their behavior and offer support and alternative views or behavior options for the client. If the client presents with resistance to changing their behaviors, counselors should avoid arguing and instead work with the client on improving their self-efficacy. 

Fostering the whole self

Elite athletes tend to identify themselves as athletes early in life. Individuals who exhibit this strong athletic identity can be at greater risk of emotional and social challenges, physical injury caused by overcommitment, and difficulties with transitions and future career identity development. 

In 2007, Clint Galloway separated athletic identity into three separate factors: social identity, exclusivity and negative affectivity. An athlete’s social identity involves the degree to which the individual identifies as an athlete from a social perspective. In some instances, an athlete’s success in sport and their connection to this identity, status and preferential treatment may result in a sense of entitlement, permissiveness and dependence. When this is shattered by the athlete’s injury or retirement, deficits in tasks such as independent decision-making, planning, organization and time management are evident and potentially detrimental.  

According to Galloway, exclusivity involves the degree to which an individual’s self-worth is determined based solely on their success in the athletic role. Elevated exclusivity can be especially detrimental when an athlete is injured or ages out of their athletic career because they may not have explored other career, educational and lifestyle options outside of their sport. 

Galloway’s final identified factor, negative affectivity, relates to how the individual experiences negative emotional reactions to poor outcomes in sport. Dutch professional cyclist Tom Dumoulin highlighted the impact of an athlete’s identity conflicts when he commented about needing to leave a training camp to clear his head, noting that he was finding it “very difficult … to know how to find my way as Tom Dumoulin the cyclist.” 

Counselors can support their athlete clients in developing and fostering their whole selves, expanding perspectives about their entire identity, and visualizing aspects of the self beyond their role as an athlete. Available measures to assess a client’s athletic identity include Britton W. Brewer and colleagues’ Athletic Identity Measurement Scale and Suzanne A. Nasco and William M. Webb’s Public-Private Athletic Identity Scale. Separately or in conjunction with formal measures, counselors can encourage clients to process past important experiences in their life and identify values, skills and roles that they used in these moments. Clients can then be asked to envision important experiences for their future, using their past experiences and skills as the foundation and starting point for their future life plan that may or may not be related to sports. 

Counselors can play an important part in highlighting and supporting other roles in the client’s life. Counselors can assist the client in seeking balance by incorporating friend and family life, education, and activities outside of their sport. In 2011, Natalia Stambulova suggested that counselors encourage clients to sort information and life experiences into separate categories (e.g., client as person, client as athlete, client’s social roles and environment, client’s near past, client’s present situation, client’s perceived future) to visualize the role or impact of their athletic identity. Additional interventions include assisting clients with time management, fostering motivation to establish other aspects of their self and life, and reviewing their schedule to offer opportunities for experiences and social interactions unrelated
to sport. 

Incorporating athletic skills

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Elite athletes are unique. For athletes to reach their level of performance and skill, they depend on mental qualities (e.g., responsibility for self, adaptability, self-aware learning, determination, confidence, optimal performance state, game sense, attentional focus, mental toughness) and strategies/skills (e.g., physical preparation, process orientation, routines, self-talk, visualization, commitment, flexibility, creativity, problem-solving, decision-making) that can be applied in other areas of life to foster success.

Counselors might consider using solution-focused techniques to assist athletes in identifying what resources they have developed in the past that can be used in their future life. In general, counselors should assist in preparing the athlete for success for their whole self. This includes incorporating discussions of how the interventions or techniques offered to address current athlete-specific needs can also be used for other stressors that may present for the client outside of their athletic world. This mindset will support the client in recognizing aspects of their life outside of their athletic identity and prepare the client for when they are no longer an athlete due to injury or retirement (whether planned or forced). 

Planning for the future

When faced with the end of their athletic careers, athletes are at increased risk of experiencing mental health symptoms. This risk is exceedingly higher when the transition was not expected (e.g., as the result of injury). These symptoms are often connected to the athlete’s losses of their athletic identity, their sources of satisfaction, their identification as a sport hero, and their daily routines and connections associated with sport. 

Counselors can assist clients through this transition from life as an athlete to their new path, whether academic or professional. Clients with a strong athletic identity may have experienced disempowerment and the loss of personal autonomy, which may have resulted in limited opportunities to reflect on their personality or sense of self outside of their athletic identity. Counselors who are working with athletes can play a role in reducing the risk for problems during transition times by engaging in academic advising, life management techniques and career planning with clients while they are still active in their sport. 

Most athletes will not make it to the professional or Olympic level in their sport, so they would benefit from interventions that focus on skill development and life planning across the life span. Career development for athletes can incorporate discussions about the client’s knowledge, abilities and opportunities that can be transferred to areas outside of athletics. In helping clients develop coping strategies to use when dealing with unexpected and unforeseen life events in general, counselors might also be preparing these clients for future events that may occur in their athletic careers.

Be prepared for resistance

Athletes have been raised within a community and a culture that emphasizes the importance of being not only physically tough but also mentally tough. At elite performance levels, this may result in athletes being resistant to seeking or engaging in mental health services. Additional barriers to athletes seeking counseling include time limitations, a lack of problem awareness, a difficulty or unwillingness to express emotion, fear of the potential impact of help seeking, and concerns that their high degree of visibility may be a threat to their confidentiality and privacy. 

Counselors should be familiar with the culture of sport and the specialized needs of athletes and how these factors may affect athletes’ service engagement. Identified preferences when athletes seek counseling have included the counselor’s familiarity with sport; the counselor’s race, ethnicity or gender; and counselors who offer expanded operating hours to accommodate athletes’ schedules. 

Final thoughts

Athletes are a special client population. When counselors are working with a client involved in, or previously involved in, elite sport, consideration should be given to the client’s unique experiences, presentations and needs. As is the case with all clients, the diversity of client athletes (e.g., race, ethnicity, socioeconomic status, age, ableness, sexual orientation) must also be considered. Also be aware that there are many differences in athletes’ motivations for being involved in sport, their preparation or development for sport, their academic needs, and the perceived importance of their athletic role in life planning. When working with current or former athletes, counselors should consider their client’s athletic identity, pressures for perfectionism, time and physical commitments, and elevated vulnerabilities to problematic behaviors. 

The openness of Olympic athletes has sparked new awareness of the potential mental health needs of all athletes. It is now our turn as counselors to promote the need for mental health services for athletes at all levels of sport and to adjust our assessments, techniques and treatment planning for this unique client population.

 

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Jessie Huebner is a licensed clinical social worker and a doctoral candidate at Northern Illinois University in counselor education and supervision. Jessie’s current professional role is as a clinical screener for children and adults involved in child welfare. Prior professional experience includes counseling, supervision and administration for children and adolescents receiving residential treatment and juveniles with sexually problematic behaviors. Contact Jessie at jhuebnerlcsw@gmail.com.

 

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