Consensus statement on improving the mental health of high performance athletes

Abstract

This consensus statement is the product of an international Think Tank on the initiative of the International Society of Sport Psychology. The purpose of the Think Tank was to unify major sport psychology organizations in a discussion of the current status and future challenges of applied and research aspects of athlete mental health. The contributors present six propositions and recommendations to inspire sport organizations and researchers. The propositions are: Mental health is a core component of a culture of excellence; Mental health in a sport context should be better defined; Research on mental health in sport should broaden the scope of assessment; Athlete mental health is a major resource for the whole athletic career and life post-athletic career; The environment can nourish or malnourish athlete mental health; and Mental health is everybody’s business but should be overseen by one or a few specified members. It is recommended that researchers unite to develop a more contextualized definition of athlete mental health and more comprehensive strategies of assessment, as well as join forces with sporting organizations to investigate sustainable elite sport environments and the role of the mental health officer. Sport organizations are advised to recognize athlete mental health as a core component of a healthy elite sport system and a key indicator of their effectiveness, support research initiatives, and to promote the mental health literacy of all their staff while engaging a mental health officer with the responsibility to oversee a support system.

Keywords:

• athlete mental health
• responsible elite sport
• athletic careers
• sport environments

This consensus statement is the product of an international Think Tank on Athlete Mental Health held at the University of Southern Denmark on the initiative of the International Society of Sport Psychology (ISSP), during September 2018. The Think Tank was a non-political and non-profit entity.¹ The purpose of the Think Tank was to unify major sport psychology organisations in a discussion of the current status and future challenges of applied and research aspects of athlete mental health, and to develop recommendations for sport organisations and researchers. The statement represents consensus views of an invited group of designated experts in the areas of sport psychology and athlete mental health.

Members

A consensus statement is a summary of the opinions of a panel of experts. Selection procedures for membership of the Think Tank were used to secure applied experience, research expertise, global representation, and collaboration between key organisations. The ISSP, the European Federation of Sport Psychology (FEPSAC), the Association of Applied Sport Psychology (AASP) and the Asian-South Pacific Association of Sport Psychology (ASPASP) were each asked to nominate an expert from their organisation. Selected professional sport organisations and national Olympic Committees were also offered a seat on the Think Tank. This process led to the selection of the following panel of seven experts, listed alphabetically:

• Kristoffer Henriksen (PhD) is an Associate Professor at the University of Southern Denmark. He is a Sport Psychologist in Team Denmark, a member of the ISSP Managing Council and the Think Tank co-organizer residing in Denmark.

• Carsten Hvid Larsen (PhD) is an Associate Professor at the University of Southern Denmark. He is also a Sport Psychologist in Team Denmark, representing the Local Organizing Committee as a co-organizer, and resides in Denmark.

• Sean McCann (PhD) is a Licensed Psychologist and Sport Psychologist with the United States Olympic Committee. He was nominated by AASP and resides in the United States.

• Karin Moesch (PhD) is a Senior Lecturer at Halmstad University. She is employed as a Sport Psychologist for the Swedish Sports Confederation, in the Managing Council of, and nominated by FEPSAC, and resides in Sweden.

• William D. Parham (PhD, ABPP) is a Professor at Loyola Marymount University and Director of Mental Health and Wellness Programme at the National Basketball Players Association (NBPA), who resides in the United States.

• Robert Schinke (PhD) is a Professor at Laurentian University, a Canada Research Chair, President of the ISSP and an experienced mental performance consultant who resides in Canada.

• Peter Terry (PhD) is a Registered Psychologist, a Professor at the University of Southern Queensland and Dean of Graduate Studies. He is an experienced sport psychology practitioner, nominated by ASPASP, who resides in Australia.

The contributors present six propositions and recommendations to inspire researchers in their efforts to understand and investigate athlete mental health, and to assist elite sport organisations to create an environment that optimally nourishes athlete mental health and provides thorough care for athletes experiencing mental health disorders.

Proposition 1:

Mental health is a core component of a culture of excellence.

Increasingly competitive international sport has led to increased pressure on elite, Olympic and professional athletes. Increasing training loads and performance demands present potential threats to athlete mental health. Several studies have demonstrated significant levels of mental ill health among athlete populations and therefore present cause for concern (e.g. Foskett & Longstaff, 2018; Schaal et al., 2011). Just as physical training must be balanced with adequate recovery to see progress, so too, psychological demands must be balanced with strategies to support mental health. Winning “at any cost” is incompatible with a modern responsible sport system that values the human behind the performer. We regard supporting mental health as a core component of any culture of excellence. Notably, many elite sport organisations are presently focusing on athlete mental health and solutions through their sport resources and organisational environments.

Recommendation. Sporting organisations, practitioners and researchers should pay due attention to athlete mental health in their efforts to promote athletic performance, and this should be stated explicitly in procedure and protocol manuals.

Proposition 2:

Mental health in a sport context should be better defined.

The World Health Organisation (WHO) has defined mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014). Moving beyond the conceptualisation of mental health as an absence of mental illness, the WHO definition represents significant progress towards a more holistic view of mental health. The contributors to this consensus statement identify three key notions that should inform a definition of mental health in sport.

First, mental health is more than the absence of mental ill health. Within the sport science literature, mental health researchers often survey the prevalence of specific mental disorders, such as depression, anxiety, and eating disorders (Schinke, Stambulova, Si, & Moore, 2017). Mental health is indirectly conceptualised as the absence of such conditions. Assuming that all athletes who do not present with clinical disorders are healthy is overly simple. Mental health is a human lived experience and a highly dynamic feature of life. All athletes experience challenging life situations, ups and downs, and a full range of emotions. This is part of the human condition. We must, therefore, be careful not to pathologize normal human experiences. We need to distinguish between clinical mental health disorders (diagnosed according to recognised criteria), subclinical mental ill health (not severe enough to meet diagnostic criteria), the human condition (periodic experiences of adversity and unpleasant thoughts and emotions as a consequence of living a full life), and the athlete condition (periodic experiences of unpleasant thoughts and emotions, such as performance anxiety, as a consequence of engaging in athletic pursuits).

There can be many reasons why sport practitioners, including athletes, coaches, and managers, want mental health conditions to be diagnosed (insurance, financial support); why mental health professionals prefer diagnoses (clear treatment plans); and why researchers focus on diagnoses (clear inclusion and exclusion criteria). We issue a word of caution; language creates reality, and diagnostic language can potentially pathologize normal aspects of the human condition as well as cause practitioners to overlook athletes with mental health problems that do not meet diagnostic criteria. Athletes do not need to have a clinical mental disorder to need help to manage their mental health.

Second, mental health is contextualised. Mental health is about alignment between the individual and the context. An athlete may thrive in one sport environment or area of life and struggle in another, pointing to the importance of the person-environment fit. Behaviours considered dysfunctional in one context may be considered functional in another. For example, perfectionism may be considered functional in some elite sport settings but less so in life. What may look like mentally unsound behaviours may reflect a normal reaction to abnormal circumstances. At the same time, mental health and how it is fostered will vary depending on contexts. Contexts include the individual context (e.g. race, gender, religion, ethnicity), environmental context (e.g. national, organisational, political, sport specific), and developmental context (e.g. age, career phases and transitions). These contexts shape motives, self-reflections, and the intrapersonal lived experience of mental health. Understanding the complexity of identity in situ (i.e. in relation to training environments and sport sub-culture) is key to understanding mental health, as the positive recognition of identity is a precondition for flourishing (Schinke et al., 2017).

The third notion that should inform a definition of mental health in sport is that it is related to, but separate from, performance (Moesch et al., 2018). Athletes with good mental health stand a better chance of performing well, particularly over the long term, and have reduced risk of experiencing career-ending issues. At the same time, sound mental health is not a prerequisite for performance. Some athletes achieve world-class performances despite mental health issues and clinically diagnosable disorders. Although some contemporary psychological scientists propose a mental health continuum from active mental illness to peak performance (Lardon & Fitzgerald, 2013), with degrees of psychological wellness/distress and effective/reduced functioning between the two, we recognise that mental health and performance, while related, should be understood as separate.

Recommendation. Researchers should develop a clear definition of mental health in sport (1) as more than the absence of mental ill health, (2) as contextualised, (3) as decoupled from performance, and (4) in ways that acknowledge the full range of human emotions.

Proposition 3:

Research on mental health in sport should broaden the scope of assessment.

Much of the current research and applied initiatives, such as screening, employ standardised tests based on recognised diagnostic criteria (e.g. DSM V, ICD11; Moesch et al., 2018). Although standardised tests certainly make important contributions, we issue words of caution. First, current scales tend to measure mental illness (e.g. Gorczynski, Coyle, & Gibson, 2017; (Rice, Purcell, De Silva, Mawren, McGorry & Parker, 2016) rather than mental health. Second, standardised tests inevitably delimit what we find. When we use scales to assess eating disorders, depression and anxiety, those are the only constructs we identify. Related, scales to assess mental ill health fail to consider contextual variables (e.g. gender, race, culture, social class) that influence the manner in which the mental ill health condition is expressed. There is a multitude of mental health issues that practitioners see in their applied work that may never be expressed, such as loss of identity, relationship issues, lack of sense of purpose, isolation, or domestic violence issues. Third, scales are often decontextualised rather than adapted to specific sport and/or socio-cultural contexts. Fourth and finally, standardised tests typically measure symptoms, not the underlying issues (e.g. Nixdorf, Frank, Hautzinger, & Beckmann, 2013). Employing multiple methods (e.g. surveys, clinical intake interviews and broader qualitative inquiries, including observations) would allow a broader appreciation of the complexity of athlete mental health.

Recommendations. Sport organisations should call for and financially support research aimed at developing sport relevant mental health research and screening programmes. Researchers should: (1) develop sport-specific measures of mental health; (2) develop tools to screen both athletes and organisations for risk and protective factors; (3) employ multiple methods; (4) provide room for individual narratives that may expand our conceptualisation of mental health; and (5) recognise the contextual nature of mental health.

Proposition 4:

Athlete mental health is a major resource for the whole athletic career and life post-athletic career.

Athletic careers are uneven and involve progressions, stagnations, and decays. Mental health is an important resource for athletes when they make career decisions and need to cope with various athletic and non-athletic transitions, whereas a lack of mental health is a barrier to effective decision-making and transition coping (Schinke et al., 2017). Sport-specific phases and transitions such as injuries, periods of high training load and extensive travel, or relocation to new cultural settings call for extra attention to the mental health of the athletes. Career termination is a particularly difficult transition that can trigger pre-existing and previously unrecognised or unacknowledged life challenges and issues that exacerbate the transition process. Although many elite athletes enjoy a healthy transition into retirement from high-performance competition, a proportion of elites experience a more difficult switch to a non-athlete status. Factors including premature retirement due to a range of unforeseen factors such as injury and de-selection, or having failed to plan ahead and make post-career financial and other lifestyle provisions can cause athletes to suffer transition distress (Erpič, Wylleman, & Zupančič, 2004; Kuettel, Boyle, Christensen, & Schmid, 2018).

Recommendations. Sport organisations should view their athletes as whole persons from a life-span perspective, and be especially vigilant in reducing threats to mental health during difficult career transitions. Researchers are recommended to pay more direct attention to how mental health may affect athletic careers and how career transitions may affect mental health.

Proposition 5:

The environment can nourish or malnourish athlete mental health.

An elite sport organisation or environment (e.g. structure, personnel, and culture) does not cause mental health problems per se. Individuals respond differently to different environments. The environment can, however, nourish or malnourish athlete mental health. We have seen examples where sport organisations have publicly acknowledged that they have allowed cultures to arise that compromised athlete mental health and have since taken measures to remedy these situations (e.g. Australian swimming, British cycling, USA Gymnastics). From such examples, it becomes clearer how the elite sport system and the “medals at all costs” mantra is a potential threat to athlete mental health. Environments undoubtedly jeopardise athlete mental health when they allow bullying, condone excessive weight control, or fail to prevent sexual abuse. We also need to consider the potential impact of more accepted practices and characteristics such as pressure to specialise and invest at an early age, pressure to train and compete while injured, pressure to forego academic pursuits and non-sport friendships, and periods of intense training without sufficient recovery. Daily hazards have cumulative deleterious effects on mental health.

At the same time, environments can actively nourish athlete mental health, and young athletes who regard their talent development environments as high quality report higher well-being (Ivarsson et al., 2015). Research findings in athletic talent development, athlete safeguarding, organisational psychology in sport, and cultural psychology, allow us to hypothesise that environments supportive of athlete mental health are integrated, values based, send clear messages and engage in practices that are coherent with these values, allow multiple identities, and empower the athletes (Henriksen & Stambulova, 2017; Mountjoy, Rhind, Tilbas, & Leglise, 2015).

Pressure to win and the potential financial rewards of successful performance may press athletes, coaches, and managers to compromise, to not pay due attention to mental health and the potential human cost of medals, and even to collude in unhealthy practices. Everyone in the sport environment is morally, ethically, and sometimes legally bound to speak up when sport cultures normalise toxic practices. Overlooking athlete mental health is a primer for a dysfunctional environment.

Recommendations. Sport organisations should consider mental health as a key indicator of their effectiveness and develop guidelines to openly and critically review the degree to which their environment is a resource for their athletes’ mental health. Researchers should investigate the features of sporting environments that nourish and malnourish athletes’ mental health with the aim to inform sport environments, such as federations, clubs, and talent academies.

Proposition 6:

Mental health is everybody’s business but should be overseen by one or a few specified members.

Everyone in a sport organisation who intersects with athletes, including coaches, sport psychologists, medical staff, managers, dual career support providers, and other integrated support team members, has a responsibility to be aware of the person behind the performer, including their mental health status. Organisations have a responsibility to create an elite sport environment that support athlete mental health, which includes building and promoting cultures that encourage inclusivity, identity centralisation, and positive pathways.

Sport organisations should: (1) be open to discussing mental health; (2) provide the structures and resources to promote early identification and effective treatment of athletes at risk or mentally unwell and ensure that all involved persons have knowledge about these structures and resources; (3) encourage testimonials from athletes who have suffered from mental health problems to normalise and promote openness; (4) take steps to cultivate help-seeking behaviours, which includes identifying and removing barriers and reducing stigma; (5) set up educational initiatives for athletes, coaches and other stakeholders to increase mental health literacy; and (6) provide athletes with the opportunity to give back to the sport and thus experience meaning and purpose beyond their own results. We recognise that the systems set in place to support athlete mental health worldwide must vary to account for cultural and organisational differences, yet we encourage sport systems to seek inspiration from good examples (Moesch et al., 2018).

Mental health should be one or a few people’s assigned responsibility to manage. Many roles are involved in helping athletes cope with mental health challenges, including sport psychology consultants, licensed clinical psychologists, psychiatrists, sports medicine specialists, and the athlete’s general practitioner. Athletes may also be involved in more than one intervention of a psychological nature at a time, for example, a performance enhancement initiative and a mental ill-being treatment. These interventions are often carried out by different service providers and are not coordinated. Moreover, athletes might experience interventions in several contexts simultaneously, such as in the case of an athlete who is involved in a club team and a national team at the same time. Within these circumstances, athletes run a further risk of having uncoordinated assistance, which in turn could compromise the quality of interventions whilst causing the athlete confusion.

Sometimes “everybody’s business” means “nobody’s responsibility” and there is a risk that no systematic attention is paid to mental health. Mental health officer(s) (MHO, or similar title) is a relatively new addition to the athlete support staff. We advocate that, having primary responsibility to address mental health issues, the Mental Health Officer is a core component of a healthy elite sport system. The main functions of MHOs are to manage, monitor, and evaluate a structure to support athlete mental health, which includes designing, implementing and evaluating a system for assessing its effectiveness, ongoing relevance and strict adherence to professional, ethical, and moral standards. The cornerstones of such a system are confidentiality and an athlete-centered approach.

The functions of MHOs typically include: (1) education of key stakeholders (coaches, athletes, experts, medical staff) to increase mental health literacy; (2) building and maintaining a network of service providers and setting up a system of referral; (3) being the main point of contact for athletes; (4) setting up a system of screening for athlete vulnerability and organisational risk factors; (5) overseeing that case management and communication between different people involved in an athlete’s mental health work within the boundaries of confidentiality; (6) informing and educating coaches and athletes about the possibilities of getting help, possibly in the general national health care system; and (7) following athletes through their transition to career end. Everybody in the sport system should know the role and functions of the MHO.

To fulfil these functions, MHOs must have a range of competencies and resources. First, they should have training and experience in treating mental health issues and possess clinical skills as evidenced by traditional markers such as a national license or accreditation. Although these people will not necessarily engage in treatment as part the job, knowledge of how to refer athletes, of what mental health issues are best treated how and by whom, and of ethical issues is important. Second, MHOs should have the organisational skills to support communication and collaboration with a range of providers (including medical doctors, physiotherapists, and sport psychology consultants) as well as several layers of management, in an environment characterised by high goals and expectations. Third, MHOs should have a solid familiarity with the sports world as a basis to build a system that is sensitised to the specific culture. Fourth, MHOs should have a strong network that includes specialists in several mental health areas and good relationship skills to maintain it.

Recommendations. Sport organisations should: (1) employ one or a few well-trained, licensed or certified and experienced professionals who have the mental health of the athletes as a primary focus, (2) collaborate with universities to develop specific courses to ensure properly educated people are available to fulfil the role, and (3) educate all people in the sport system to increase their mental health literacy. Researchers should investigate the functions, competencies and challenges involved in the successful fulfilment of the role as a MHO to support organisations’ recruitment and education initiatives.

Conclusions

The topic area of athlete mental health has become increasingly prominent due to the range of healthy and unhealthy manifestations that occur during athletic careers. This consensus statement is intended to inform and inspire future initiatives focused on athlete mental health, whilst also sparking discourse among high-performance sport communities regarding the salience of mental health as a core principle in elite athlete training programmes. With the increasing recognition of what elite sport can but sometimes does not, afford the athlete, there is a powerful need to improve understanding of what mental health is in a sport context, how researchers may investigate it, and how sport organisations can provide environments that support it.

Together, we recommend that researchers unite to develop a more contextualised definition of athlete mental health and more comprehensive strategies of assessment, as well as join forces with sporting organisations to investigate sustainable elite sport environments and the role of the mental health officer. We recommend that sport organisations recognise athlete mental health as a core component of a healthy elite sport system and a key indicator of their effectiveness, support research initiatives, and promote the mental health literacy of all their staff while engaging a mental health officer with the responsibility to oversee a system to support athlete mental health.

Acknowledgements

The Think Tank that led to this Consensus Statement was supported by grants from Team Denmark and the University of Southern Denmark.

Additional information

Funding

The Think Tank that led to this Consensus Statement was supported by grants from Team Denmark and the University of Southern Denmark.

Notes

1 We recognize that mental health is too complex a topic for any group of experts to grasp in its nuanced entirety during a two-day think tank. We also recognize that, as a result of procedures for selection and invitation, the inaugural Think Tank was gender biased and the participants mostly represented organized systems in modernized societies (of note, one female participant was a last minute cancellation). Future think tanks on the topic will recruit a broader diversity of global representation, culture and ethnicity, gender, and sexual orientation. Finally, we acknowledge that this consensus statement represents a snapshot in time and should be updated regularly to account for scientific and applied progress in relation to athlete mental health.