Exploring the barriers and facilitators to mental health help-seeking behaviours in British elite track and field athletes

Abstract

Track and Field (T&F) is at the heart of the summer Olympic Games and research has highlighted mental health issues in this population, such as depression, anxiety, suicidal ideation, and eating disorders. Our qualitative study explored the barriers and facilitators to help-seeking behaviors among British athletes to help create, implement, and inform pathways for mental health support. Semi-structured interviews were conducted with nine elite T&F athletes (aged 21–27 years, M = 22.8), who had an average of five years’ international competitive experience, including participating at various Commonwealth, European and World Championships. Four key themes were constructed and categorized as a barrier or facilitator to mental health help-seeking behaviors. Barriers included a lack of access to and prioritization of mental health support in comparison to physical health support and the scrutiny of others regarding mental health issues within (e.g., sports commentators) and outside (e.g., the public) the sport. In contrast, facilitators included normalizing mental health experiences through tailored online platforms and storytelling by role models and the team around the athlete in promoting openness to, and engagement with help-seeking. Overall, there is a need to embed mental health support into elite athletes’ routines, to the equivalent level of physical health support. A novel outcome of our study identified the value of sports specific online platforms in increasing awareness and sharing experiences of mental health. Key stakeholders should consider supporting such online platforms and improve the dissemination of mental health information to strengthen communities that are supportive and nourishing to athletes.

Lay Summary: Nine elite track and field athletes discussed factors impacting help-seeking for mental health. Data indicated the need to increase the provision of psychological support, so it is on par with support provided for physical health and to consider harnessing the potential of sport specific online platforms to normalize mental health.

IMPLICATIONS FOR PRACTICE

• Our study reinforces the need for National Governing Bodies (NGBs) and sport practitioners to consider an increase in, and clarity over, the provision of sport psychology and mental health support in the track and field environment. It is essential to ensure that athletes know where and when to seek support and to normalize mental health issues within elite sport so they can be holistically supported.

• Sharing experiences of mental health via sport specific online platforms offer a novel but important context by which to empower athletes with their help-seeking intentions and challenges the stigma surrounding mental health in sport. NGB’s may wish to expand and utilize such platforms to promote mental health support services or educational programmes.

Mental health among elite athletes has received significant attention within academic literature (see Poucher et al., 2021). Anecdotally, the topic has recently been at the forefront of elite sport through the voices of well-known international athletes, such as Simone Biles, Naomi Osaka and Ben Stokes seeking to normalize conversations about mental health. Mental health has been conceptualized as a dynamic state of internal equilibrium that enables individuals to recognize their own and others’ emotions, cope with adverse life events, and make valuable contributions to society (Galderisi et al., 2015). Risk factors for an athlete’s susceptibility to poor mental health include ineffective coping skills, adverse life events, injuries, and poor sleep hygiene, which are largely consistent with the general population (Küttel & Larsen, 2020). The consequences of not seeking help for mental ill-health in athletes are wide-ranging, including a loss of athletic identity and early career termination (Poucher et al., 2021). Therefore, understanding help-seeking attitudes and behaviors for mental ill-health is crucial to understanding and supporting athletes through the demands of elite sport.

Track and Field (T&F) is at the heart of the summer Olympic Games and offers a unique population for investigation in Great Britain and Northern Ireland as one of the leading teams globally (Kelly et al., 2022). Recently, evidence has suggested that mental ill-health is a significant issue in T&F, as demonstrated by Timpka et al. (2021), where one in six athletes who have participated at the international level have reported experiencing suicidal ideations. Notably, T&F athletes experience several risk factors that increase their susceptibility to poor mental health, including; (1) the high occurrence of injury, (2) the risk of sexual and physical abuse (especially women), (3) the increased risk of experiencing anxiety and depression as an individual sport compared to team sports, and (4) the social and appearance-related pressures on high-performing female T&F athletes from coaches and training partners. These factors can potentially increase the likelihood of engaging in maladaptive coping strategies and disordered eating, such as self-induced vomiting and skipping meals (Jóhannesdóttir, 2018; Pluhar et al., 2019; Quinn & Robinson, 2020; Timpka et al., 2021). If left untreated, mental ill-health results in a longer period taken away from the sport for T&F athletes in comparison to physical ailments (Kelly et al., 2022). Hence, it is paramount to understand the help-seeking behaviors of T&F athletes’ when experiencing mental health concerns, as presently this is an under researched area (Poucher et al., 2021).

Researchers have identified factors that can prevent athletes from seeking help for mental health problems. For example, Gulliver et al. (2012) in their study of an adolescent elite athlete population, found that access to mental health services, poor mental health literacy, denial of the problem, pressure to meet personalized standards, and stigma around mental health were key barriers that influenced willingness and ability to seek support (Gulliver et al., 2012). Similarly, O’Keeffe et al. (2022) compared help-seeking behaviors of injured male and female young adult Gaelic footballers and found a lack of appreciation of the benefits and necessity of seeking help are key deterrents to help-seeking behaviors. Perceived stigma is the most common factor that deters athletes from seeking help for their mental health, with common perceptions amongst the public and peers that help-seeking is a sign of weakness (see Lebrun et al., 2018). An individual’s awareness of potential stigma could, in part, explain why the topic of mental health is discussed more openly upon retirement from sports participation. To reduce the barriers to seeking mental health support it is, therefore, crucial to listen to and seek to understand the experiences of currently competing elite athletes.

Several factors have been identified that can facilitate help-seeking behaviors for mental health concerns among athletes; notably social support, positive attitudes from peers, improving mental health literacy, and positive relationships with staff (Gulliver et al., 2012; O’Keeffe et al., 2022). To illustrate, Wahto et al. (2016) found collegiate athletes were more likely to seek out and receive support for their mental health when referred by a family member or friend. Similarly, as shown by Plateau et al. (2015), T&F coaches can have an important role in facilitating the help-seeking and treatment process for athletes (especially among those with eating disorders), given the closeness, high frequency of interactions, and the collaborative and trusting nature of the relationship that athletes will often have with their coach. Overall, the literature has thus far primarily explored mental health help-seeking behaviors of athletes in team sports (O’Keeffe et al., 2022; Ogden et al., 2022; Perry et al., 2022) or within student athletes (Wahto et al., 2016), but to the authors’ knowledge, only one study has explored help-seeking behaviors through the lens of an individual sport (see King et al., 2022). Although the team and individual sports share similarities where athletes train as part of a group, athletes in individual sports cannot share the responsibility of a loss. Consequently, evidence suggests that athletes in individual sports may be more likely to negatively attribute failure or guilt internally and experience loneliness, which over time can increase the risk of depression and anxiety (see Pluhar et al., 2019). A comprehensive understanding within individual sports of how researchers and practitioners can promote help-seeking behaviors is therefore warranted.

Our study extends the existing literature surrounding help-seeking behaviors for mental health issues in elite athletes (Gulliver et al., 2012; King et al., 2022; O’Keeffe et al., 2022; Perry et al., 2022). Although research has developed an understanding of mental health in T&F (Timpka et al., 2021), no research has explored the factors to mitigate mental health issues in this population or why these athletes may or may not choose to seek help. Furthermore, research is important as mental ill-health poses a substantial threat to T&F athletes’ careers. Hence, it is imperative to understand how to best support them as currently there is little insight into support mechanisms available for these athletes. The purpose of our study is to (1) contribute to the extant mental health literature by understanding the experiences of athletes in an underrepresented individual sport and (2) provide sport practitioners, key stakeholders, and organizations with knowledge and understanding surrounding the barriers and facilitators to seeking mental health support, as such knowledge is a critical driver to create, implement, and inform pathways and interventions for support. Thus, the research question guiding our study is: what factors act as barriers and facilitators to mental health help-seeking in elite T&F athletes?

Methods

Study design

Our qualitative study adopted a relativist, social-constructionist onto-epistemological stance, to allow for participants to voice their personal experiences of mental health help-seeking behaviors within T&F. A relativist ontology was assumed to support the belief that reality is built upon multiple truths, while a social constructionist epistemological perspective appreciates that knowledge is a personal truth socially constructed through the point of view of the individual and their interactions within their social worlds (Braun & Clarke, 2019). The researcher plays an important role in the co-construction of knowledge and in doing so a reflexive thematic analysis was undertaken. In using this approach, it is important to acknowledge researcher positionality (Braun & Clarke, 2019). The lead author, who carried out the interviews and led the analysis has personal experience of being a track athlete with mental health issues. This personal experience allowed for an appreciation of the value of seeking professional services to support mental health and ensured awareness about the challenges faced by individuals experiencing mental health issues in this sport. Such an understanding of mental health experiences on a personal level highlighted the need for reflexivity by the lead author due to the closeness to the data to minimize bias. For example, during interviews the lead author was empathetic and understanding of participant experiences of personal instances of mental ill-health. The coauthors acted as critical friends (Smith & McGannon, 2018), supporting the design of the study, prompting reflexivity in the research process, and engaging in critical discussion during the analysis stages of the research. For example, the coauthors challenged the lead author on the interpretation of the sub-themes, allowing the lead author to reflect and reframe arguments with other plausible explanations in mind.

Participants

Participants were eligible to take part in the study if they were classified as “elite athletes” (Swann et al., 2015) or were granted access to train under the Elite Athlete exemption during the United Kingdom Covid-19 2020–21 restrictions. Nine elite athletes who competed in T&F (3 males, 6 females) were recruited, with an age range of 21–27 (M = 22.8, SD = 1.86), a range of 7–17 years of competing in T&F (M = 10.6, SD = 3.28), and with 2–8 years international experience (M = 4.7, SD = 2). Athletes represented a variety of events including 110 m or 100 m Hurdles (n = 4), 100/200 m (n = 1), Shot Put (n = 1), Javelin (n = 2) and Heptathlon (n = 1). Participants had competed at a range of elite competitions including Commonwealth, European and World athletics championships. At the time of data collection, two participants reported they were in consideration for the Tokyo 2021 Olympic Games. Through this observation, participants in our study could be classified as “competitive-elite,” where athletes have consistently competed to the highest level in sport (see Swann et al., 2015). Participants were not screened for underlying mental health issues prior to the interviews. The intent was to acquire a range of perspectives and experiences around mental health (including participants without direct personal experience of seeking support for mental health concerns) to ensure the rigor of our study and provide a holistic overview of the support systems in T&F. Three participants self-reported experiences of mental health issues such as depression, anxiety, and eating, while one participant experienced seeking help for their mental health issue (see Table 1 for the participants characteristics).

Table 1. Participant characteristics.

Participant (pseudonym)	Gender	Age	Highest standard of competition	Years in the sport
Tom	Male	22	European	9
Pedro	Male	24	World	12
Matt	Male	22	European	12
Tracy	Female	27	World	17
Milly	Female	21	World	13
Helena	Female	23	Commonwealth	7
Lucy	Female	21	European	8
Lizzie	Female	22	European	7
Maddy	Female	23	World	10

Procedure

Following ethical approval (ethics reference number: 2021-4985-4203), a purposeful sampling strategy was adopted to enable the researcher to identify and select individuals likely to provide detailed accounts relevant to the phenomenon studied (Smith & Sparkes, 2016). The study was advertised at one of the UK’s national centers for athletics. Additionally, a recruitment advertisement was put out via numerous social media platforms, such as Instagram, Twitter, and Facebook. Semi-structured interviews were used to allow for a deeper insight into individual perspectives, alongside providing greater flexibility so participants could direct discussion based on their personal experiences (Smith & Sparkes, 2016). An interview guide was designed to prompt participants to reflect on their personal experiences and a copy of this is available on request from the lead author. The interviews began with questions relating to the participant’s background and journey toward elite sport to establish rapport. This was followed by questions surrounding the participant’s knowledge and awareness of mental health and help-seeking behaviors for mental health. During the interview, key terms were defined, for example, “barriers” were defined as factors that make it difficult for an athlete to seek help, whereas “facilitator” was defined as factors that make it possible for athletes to seek help. Example questions included: “From your experience, what is needed to improve the mental health of athletes in your sport?” and “Within athletics, can you describe ways in which you would go about seeking help for mental health problems?” Questions were broad and open-ended, allowing participants to provide an in-depth account of their personal experiences. All interviews were carried out online via Microsoft Teams and were audio recorded. Interviews lasted between 41 and 61 min, with a total of 465.1 min of data (M = 51.7 min).

Data analysis

The analysis process was guided by procedures set out by Braun and Clarke (2019) using reflexive thematic analysis. Reflexive thematic analysis was used as it is a robust process to identify patterns in qualitative data (Smith & Sparkes, 2016). This method of analysis is compatible with the social constructionist standpoint of our study, allowing participants to articulate different perspectives of the phenomenon studied (athlete help-seeking behaviors), aligning to answer our research question. Moreover, Braun and Clarke (2019) advise that reflexive thematic analysis involves several stages of data analysis, including familiarization, coding, development of themes, revision and defining of themes and producing the report, although acknowledging that this process is flexible. In our study, all interviews were transcribed verbatim and were carefully checked by reading and re-reading for accuracy. This was repeated to enable familiarization with the data. In line with our philosophical position, an inductive approach to coding was adopted, where a variety of latent and semantic codes were generated, for example, semantic codes such as “Lack of Accessibility” or “No Information” reflected surface level codes within the sub-theme “A Lack of Signage” (Braun & Clarke, 2019). The construction of themes was achieved by grouping together similar codes across the data set. For example, from our data set, codes such as “role model,” “normalisation,” and “relatedness,” contributed to the construction of a theme regarding athletes’ likeness to other significant figures within the sport and their mental health experiences (Role Models). Themes were reevaluated and checked in line with the original data to ensure that they accurately represented the phenomenon described.

Methodological rigour

We used Tracy’s (2010) criteria for establishing rigor to ensure the integrity and trustworthiness of the research. Our study is both timely and a worthy topic due to the recent status afforded to raising awareness of mental health in elite sport (Poucher et al., 2021). The richness of data was supported using direct quotations to give voice to participants’ experiences and to resonate with other members of the elite sport community. A reflexive journal was kept by the lead author to ensure an in-depth engagement with the self and the recognition of any biases or key events which may have influenced the data analysis and collection processes. For example, during one interview an athlete became distressed when discussing de-selection and how this negatively impacted their mental health. In this instance, the lead author reflected and made note of the welfare of the participant, how the interviewer reacted in this event (e.g., gave the athlete time to compose themselves) and how their experience resonated with the interviewer. The lead author communicated with the coauthor about what further steps should be taken to support the athlete and agreed to direct the participant back to the participant information resources where contact for support was detailed. Lastly, all participants were contacted to engage in member reflections to ensure the accuracy of the transcripts and clarify any missing information from the data (Smith & McGannon, 2018). Two participants engaged in this stage of the analytical process and reviewed the coded data to share any discrepancies in the interpretation, thus ensuring the credibility of the study (Tracy, 2010). For example, one participant offered further elaboration about the usefulness of sport specific online platforms, which was then included in the data analysis.

Results and discussion

Our study endeavored to provide an understanding of the barriers and facilitators to mental health help-seeking among elite T&F athletes. The participants recognized the issue of mental health problems across elite T&F, where participants were able to relate to and comment upon the process of seeking mental health support and provide detail on the current support mechanisms within the sport. In line with the confidentiality of our study and to maintain participant anonymity, they are referred to only via pseudonyms. From the reflexive thematic analysis, four main themes were constructed: (1) Physical Health versus Mental Health Support, (2) Athlete First, Person Second, (3) Normalizing Conversations about Mental Health, and (4) Supportive Team around the Athlete. Each of these main themes, and any associated sub-themes, are categorized as either a Barrier (themes 1 and 2) or Facilitator (themes 3 and 4) to seeking mental health support (see Table 2 for a breakdown of the themes and sub-themes with example quotes).

Table 2. Themes and subthemes.

Primary themes	Sub themes	Example quotes
Physical versus Mental health Support	The Dichotomy of Availability of Support Services A Lack of Signage	“If someone got a physical injury, it wouldn’t mean they were a weak person, it just means that they’ve been physically injured” (Milly) “I don’t think there’s sort of like, access to help. It’s not necessarily neglected, but I think there’s just not enough support” (Tom)
Athlete First, Person Second	Public Scrutiny Sign of Weakness	“I think the public’s perception needs to change for sport psychology, because I think that discourages athletes from doing it in the first place” (Lucy) “Some people are sort of embarrassed to admit the fact they have gotten help” (Tom)
Normalizing Conversations about Mental Health	Sport Specific Online Platforms Role Models	“Within track and field, we’ve got the start of The Athlete Place, people are discussing it a lot more and it is more open” (Lucy) “Really high-profile athlete such as Adam Gemili coming out and saying he’s really struggling” (Maddy)
Supportive Team around the Athlete	The Role of the Coach Encouragement from Peers	“I can turn up to training, get whatever I need to off my chest, and then I have a much better chance of focusing on the session. And it also means if I have a bad day, my coach can be much more understanding” (Maddy) “I think the biggest thing is talking about it. I bottled it up for ages. And like I said, I was quite lucky that the people around me sort of noticed it.” (Helena)

Barriers to mental health support

Two main “Barrier” themes have been identified. First, was the lack of accessibility to mental health services (in comparison to support for physical issues) where participants highlighted their experiences of a lack of knowledge and understanding of the availability of support. Furthermore, the negative attitudes of others were perceived by all participants as a barrier to help-seeking behaviors among T&F athletes.

Physical health versus mental health support

This theme encapsulates two sub-themes: the availability and visibility of support for mental health in contrast to physical health support, and issues regarding information and education around mental health services.

The dichotomy of availability of support services

Participants expressed the dominance of physical health in T&F and how support for physical injury is readily available and visible within the sport, yet there is little to no guidance on where to seek support for their mental health or the criteria for receiving such support:

It needs to be more accessible (mental health). For example, whenever I go to [training centre], I always see like four or five physios just in the indoor athletic centre, going around the whole time, and just athletes can go and see them kind of whenever… and it’s so easily accessible… if I was having a really rough time, I wouldn’t even know where to start. I wouldn’t know who to talk to… they’re (sport psychologists) not as broadcasted as like physical therapy. (Milly)

Knowing where to seek support is the first crucial step toward addressing mental health problems (Sandgren et al., 2023). Furthermore, when discussing what organizations could do and how to create a climate supportive of an athlete’s mental health, Milly expressed a need for greater openness surrounding the topic and sport practitioners should be more readily available to aid athlete mental health:

Accessibility to mental health practitioners. It almost needs to be as accessible as physical therapists which I don’t think it is at the moment… But definitely be actively seeking people to be put into positions at tracks or within organisations or within training centres where there are people there that you can look into. (Milly)

The lack of availability of psychological support may suggest that this support is undervalued by the governing body in the elite athlete environment, with the predominant support provision focused on physical rather than mental health: “I think it all comes down to kind of resources and finance, I think some organisations aren’t exactly athletes centred” (Milly). These findings represent novel insights into the structure of T&F athletes’ training environment, with no known previous research having highlighted the differences between physical and mental health support availability. Preventing and treating physical injuries was considered the norm, but treating mental ill-health was not held to the same standard. Lizzie concurred that mental health should be treated similarly to physical health: “If it’s like coming back to physio I think, do I need help? I’d probably reach out. So, I guess the same with mental health as well.” Previous researchers demonstrate that within T&F there is a strong correlation between experiencing a physical injury and poor mental health (Jóhannesdóttir, 2018), suggesting a need for combined provision of physical and mental health support at such times. Our results extend previous research by Ogden et al. (2022) who highlighted the difference in professional cricket player experiences between taking time away from the sport to manage physical injuries versus mental health issues, where the latter was scrutinized and not held to the same importance as a physical injury. Increasing the presence and availability of mental health support and practitioners may be beneficial in T&F, as it has been previously documented that endorsing support services that value athletes’ privacy can facilitate early disclosure of mental health issues, especially for athletes who do not want those in the sporting context to be aware (i.e., coaches, training partners, and parents), and to mitigate against the reciprocal stance of silence between athletes and psychologists (Sandgren et al., 2023). Furthermore, NGB led promotion of available confidential support can allow athletes to create positive relationships with sport practitioners and normalize the current issue of mental health in T&F. This could support opportunities to develop combined mental and physical health treatment plans for athletes who sustain sport related problems, like injuries, to expedite the recovery process (see Moesch et al., 2018).

Furthermore, the participants in our study reported beliefs that mental health support in T&F was targeted toward those who currently have a mental health concern as opposed to those who may wish to support their mental well-being in a preventative manner or when athletes are performing well:

I think people think we have to have psychology and is something that you should do if you’re broken. And I just don’t think it’s the case. Like, even if you’re doing well, then sport psychology can be beneficial and then helpful. (Lucy)

Lucy explained how sport psychology, tailored to athletes’ well-being, can be beneficial beyond just managing an existing mental health issue. She pointed toward the need for improved access to, and provision of, mental health support should be holistically considered by coaches and practitioners. Although participants were aware that support services for mental health existed, they had limited knowledge of how to identify and access the support they needed in a manner that they would do for physical injury or preventative treatment:

You’d advertise like, hey, this is the physio clinic, you’d be like, hey, this is the mental health service you can access… hey, this is where you can go. I actually don’t know how you go about it other than kind of searching it up. I can’t really name a local mental health service, I can name a local physio, I can’t name any mental health services or experts at the top of my head. (Lizzie)

Existing research suggests a lack of communication between athletes and sport professionals with regard to mental health concerns, and a lack of knowledge among both athletes and sport professionals about where to seek support (Sandgren et al., 2023). These findings are reinforced within our study but extend to include suggestions about how to successfully incorporate mental health support, that values confidentiality and privacy, within the training environment. Participants described how receiving treatment and support for their physical health is embedded in their training regime, for example, weekly physiotherapy; Maddy suggested that accessing mental health support should be held to the same standard: “I just see it as another part of almost being an elite athlete (mental health support), like you train, you get your physio, you get your nutrition, and you get your psychological help.” Our findings demonstrate that T&F athletes appreciate the importance of mental health support provision, with a desire for increased presence and availability. This contrasts with athletes in other contexts, for example, a study with injured Gaelic footballers indicated that seeking mental health support was of less importance due to cultural issues, denial, and gender stereotypes (O’Keeffe et al., 2022).

A lack of signage to services

Whilst the previous sub-theme outlined the contrast between physical and mental health support in the elite athlete environment, this sub-theme emphasizes the lack of awareness and knowledge of pathways to mental health support in general. Participants expressed limited knowledge about mental health services, so in times when they were suffering, they would have no knowledge of where to seek support for this: “I feel like people don’t know where to access a sport psychologist or how to go about it.” (Maddy). The lack of an overt presence of a sports psychologist or mental health specialist in the elite athlete environment mirrors that of previous mental health research in an individual sport, for example, Irish jockeys (King et al., 2022). Echoing Maddy’s sentiments, Tom thought there was a paucity of signage that could help guide athletes toward available and athlete-specific services and described ways to improve pathways to support, such as education and resources around mental health services:

How to find people that are, experienced with dealing with track and field athletes, or, even just sports people generally? Kind of being given, names and numbers and emails will be very beneficial, because it kind of just makes the whole process a lot easier. (Tom)

Despite the advancement in knowledge and attention surrounding elite athletes’ mental health (Poucher et al., 2021), the present findings are in line with previous research on help-seeking in athletes, describing a lack of clear routes to finding mental health support (Gulliver et al., 2012; O’Keeffe et al., 2022). Although Ogden et al. (2022) suggested enhancing the stability in contracts for cricketers as one way to mitigate mental health issues, our study suggests that providing athletes with contact information for mental health support services and guidance on when to seek support may be simple but crucial efforts to promote help-seeking behaviors. Our research, therefore, expands current thinking by advocating for greater signage and awareness around support tools and pathways in T&F to facilitate change (Moesch et al., 2018; Sandgren et al., 2023).

It should be noted that T&F athletes in the UK on the World Class Performance Pathway (WCP) have 24/7 access to mental health support (Kelly et al., 2022). However, none of the participants in this sample was on the WCP at the time of the study and the consensus was that support for their mental health was scarce. At the time of our study, just 69 able-bodied and 48 para-athletes were on the British Athletics WCP. Furthermore research with athletes on the WCP is needed to ascertain the frequency of seeking support, the availability and usefulness of this funded support for mental health and to explore whether the barriers to help-seeking are different in this selected elite group. Overall, our results suggest the visibility and inclusion of mental health support in T&F athletes’ support structure is not yet sufficiently well established to facilitate help-seeking behaviors, despite the support that may be provided to the WCP athletes.

Athlete first, person second

This theme explores athlete beliefs on the public perception of T&F athletes concerning mental health issues and seeking support and that their own emotions are often disregarded, misunderstood, and dehumanized. Furthermore, this theme identifies how seeking help for mental health may be perceived as a sign of weakness, both internally and externally to the sport.

Public scrutiny

Participants believed that external judgment by others was a barrier when considering mental health help-seeking behaviors. Lizzie commented on how the public does not appreciate or understand the complexities of being an elite athlete:

They (the public) just don’t understand the whole thing, they are either a) “trolls” or b) they just don’t get it. They feel as though you’re a sports person, just kind of get on with it. They don’t appreciate that there are other elements to it other than just train, turn up, compete. (Lizzie)

Specifically, Milly stated beliefs that within athletics, mental health was not perceived to be important by the wider public: “elite athletes in track and field to the general public, their mental health isn’t really considered.” It was agreed by participants that their elite athletic status was what defined them; rather than as human beings with emotions:

Everyone thinks elite athletes are super humans and they’re really not… The top elite athletes, you sometimes think, “oh they’re superhuman,” they don’t get affected by mental health problems. But in reality, there’s so many demands that does put pressure on them. (Helena)

Participants expressed a lack of knowledge or understanding from the public surrounding the demands required for competing at an elite level, with an immunity to the consequences for an athlete’s mental health. Participants reported numerous demands of being an elite T&F athlete, such as time constraints, technical aspects of their events, adaptation to training and competition schedules, and balancing of other life commitments. A feeling of a lack of understanding or empathy for athletes places them under additional stress and from a competitive perspective can be seen as a sign of weakness by peers (Lebrun et al., 2018). One participant expressed how the public does not understand the reality of what it takes to be an elite athlete and the potential challenges for mental health:

They (the public) don’t see athletes as people, they see athletes as mediums for national success. And I think that’s a serious issue, is that people don’t care. They don’t care. They seem to think that, oh, you’re gifted, so you shouldn’t be doing this, you must be mentally well and whatnot. They don’t seem to care. What they say or what they do, I don’t think that they see it as an issue at all (mental health). (Pedro)

Our findings add to the concept that athletes are dehumanized, specifically highlighting mechanistic dehumanization—where athletes are not allowed to portray and act with human emotions (Larkin et al., 2020). Our findings indicate how athletes are defined by their athletic prowess and success when representing the nation, where they are merely tools and are disregarded as individuals, and their mental health is devalued.

The perception of the media and public was deemed important as they shift attention onto the most successful athletes, which can exacerbate stigma surrounding mental health support: “I think the public’s perception needs to change for sport psychology because that I think discourages athletes from doing it (seeking help) in the first place” (Lucy). Furthermore, Maddy described how athletes may be discouraged to open up regarding mental health issues as judgment is unavoidable due to the public scrutiny surrounding athletes:

I think especially because it’s an individual sport… I think, maybe seem a little bit more daunting. But I think at an elite level, just the fact that you can log on to Twitter and see other people making comments about you. And it’s, you know, it’s the scrutiny of the public. (Maddy)

Lizzie specifically expressed how commentators at elite-level competitions often discuss and describe athlete performances in a manner that can add to the negative perception from the public:

Sometimes you go back to watch a race and you’ll hear commentators say something that doesn’t quite align to what what’s happening. You’re not even yourself. You watch another athlete and you’ll know their circumstances, how they’ve just come back from injury, or they’ve just had something really tragic happening and them being here is fantastic. And then you hear the commentators say, they really are not performing at their best, they’ll be disappointed. Also, there’s always a journey that the athletes have been through, to get to that point and maybe there’s nothing bad that you can point out, but sometimes it’s more than that. It’s actually a massive achievement them being there on the start line, or on the runway, or in the circle. So, mental health from the point of commentators and kind of how athletics is perceived as sometimes doesn’t quite align, I think, to how the sport wants to treat mental health. (Lizzie)

Lizzie highlighted how commentators’ judgements were typically performance centered and may not accurately reflect the athlete’s journey or the obstacles they have had to negotiate to compete. She emphasized how this lack of understanding of an athlete’s personal experience can be detrimental to their mental health, further highlighting the “athlete-first, person-second” narrative and stigma. This novel finding highlights the potential role of commentators in limiting awareness of mental health issues and in exacerbating mental health stigma within the sporting environment. For example, previous researchers have reviewed the impact of commentators’ statements in women’s sports and how they have the potential to impact viewers, exacerbating any negative attitudes they may hold (Fink, 2015); however, no research to date has highlighted the potential impact on an athlete’s mental health. Lizzie noted that commentators will often reference the athlete’s injuries or missed performance expectations without appreciation for their journey back to an elite competitive environment. Milly further elaborated: “like if someone had a hamstring injury, it’s very common the commentators will comment on that and talk about that” (Milly). Members of the media and journalists have been previously documented as key figures in the sport who contribute toward negative pressure onto athletes, for example by requiring athletes to do press conferences immediately after losses and by shining a spotlight on them without consideration for their mental health (Faustin et al., 2022). Our study provides initial insights into how commentators could contribute toward the negative pressures and stigma around mental ill-health; however, more in-depth research is needed to support this. It is recommended that further research should be conducted in sports broadcasting to ascertain attitudes toward and potential impact on competing athletes’ mental health, and how the public perceives athletes based upon commentators’ views.

Sign of weakness

The stigma surrounding seeking mental health support was a pertinent topic among participants and had a strong influence on their help-seeking behaviors. Whilst participants in T&F perceived a recent reduction in terms of stigma surrounding mental health concerns, they agreed that it is still considered to be a sign of weakness:

I think people are starting to talk about it. Now that stigma is sort of leaving, but definitely, you know, in years gone by there is a stigma because a lot of athletics is obviously individual performances and you’re very much head-to-head against someone else. So, revealing anything that could put you at a disadvantage or make you seem weak may sort of defer people from actually speaking out about their mental health. (Helena)

Helena believed that disclosing information regarding one’s personal mental health grants others a performance advantage, as having poor mental health was deemed as a ‘weakness.’ The fear of being seen as weak was a strong deterrent to seeking support. Tom reinforced this by stating: “Some people are sort of embarrassed to admit the fact they have gotten help,” inferring that seeking mental health support is a taboo topic in T&F. Our findings are in line with previous work across sports that suggests that experiencing mental health difficulties is perceived as a weakness (Gulliver et al., 2012; King et al., 2022; O’Keeffe et al., 2022).

Despite identifying that mental health issues were seen as a sign of weakness in the media and wider public, when participants were asked what their opinion was concerning other athletes seeking support for mental health, they had a positive consensus:

I’d just encourage it completely. I think it was a no judgement thing. From my perspective, I think that’s great. You know, if you don’t necessarily need it, if you’re struggling, if you’re doing it to help you thrive in a competition then fantastic, fair dues. I think everyone should be doing it, because if you’re on trying to reap 1% of advantages then why wouldn’t you? (Lucy)

Lucy indicated there may be performance benefits to seeking mental health support, but also recognizes the stigma that can be associated with receiving help and how this may create a dilemma and tension that many struggle with. Creating a nonjudgmental environment where athletes can seek support for their mental health, in both a preventative manner and when they are struggling is needed. Tom elaborates on the idea that seeking mental health support could be seen positively and how it can impact athletes’ wider well-being as well as their athletic performance:

I think it’s not something to be ashamed of, it’s something to celebrate is the fact that like, you’re actually getting help, you’re making sure that you personally are getting better, you’re putting yourself first. I think it is very important. So, I think, more athletes should most definitely do it because it will improve their quality of life just generally and their performances again. (Tom)

The results point toward the importance of peer support as a vehicle for reducing perceptions of stigma for athletes seeking mental health support. Despite positive attitudes toward help-seeking among the sample, the stigma around mental health remains a barrier to help-seeking behaviors.

Facilitators to seeking mental health support

Factors highlighted as supportive of mental health help-seeking behaviors among T&F athletes were (1) normalizing the topic of mental health and (2) the team around the athlete. Novel insights emerged as participants described the value of engaging with sport specific online platforms and communities as a source of support and as a tool to normalize conversations surrounding mental health.

Normalizing conversations about mental health

Participants discussed how the rise in sport specific online platforms and the influential actions of others play an active role in promoting the importance of seeking support for mental health.

Sport specific online platforms

A novel finding emerged in our study, whereby participants described how sport specific online platforms have been pertinent in reducing stigma around athletes’ mental health, as participants noted the emergence of online social communities: “Like within track and field, we’ve got the start of “The Athlete Place,” people are discussing it a lot more (mental health) and it is more open… I do think it’s helping” (Lucy). Across the interviews, five participants praised the usefulness and practicality of The Athlete Place as a means of de-stigmatizing the topic of mental health. The Athlete Place is an online platform that emerged in the UK in 2021, was developed by athletes, and was specifically designed to empower T&F athletes to discuss their mental health and personal sporting struggles (The Athlete Place, 2021). The platform allows athletes to write and share blogs or stories on the forum and social media, such as Instagram and Twitter, creating communities for athletes to comment upon and relate to, as Lizzie explained: “Initiatives to get people talking. I think that’s brilliant. Just starting to kind of connect people, different ways. Creating those communities that didn’t necessarily exist before” (Lizzie). The content of the platform is moderated internally, with more sensitive topics researched before publishing to ensure legitimacy and to ensure suitability to the audience for the T&F community. Additionally, the platform has extended its content from simply disseminating information and sources for supporting athletes’ mental health, but also indirectly supports athletes and parents financially by providing access to discounts with various brands. Our study demonstrates how online social communities can hold value to athletes as a tool for widespread communication and assists in de-stigmatizing previously taboo topics. It could be recommended for governing bodies, sport practitioners, and key stakeholders to invest knowledge, finance, and resources to help such athlete-led platforms develop to better support the T&F community.

A proliferation in the use of online platforms can offer a tool by which to share stories but also in raising awareness, educating athletes, and portraying that they are not alone in having mental health issues, as Lucy described:

I think it’s good that we’ve got a starting place where people aren’t afraid to have those discussions and start those blogs. And I think it’s more of an awareness thing that the way that you might feel as an athlete, you’ve been there or just fall out of love with your sport, that it’s nice to see that other people might feel the same. So as an athlete, it’s nice to have that relatable content rather than just in the successes, particularly someone struggling, that can be really hard, you don’t ever see the bad parts of people’s careers. (Lucy)

Pedro further emphasized: “so many people struggle with this and they had the strength to come forward, I can do the same.” The introduction of sport specific online communities and platforms builds on existing findings by King et al. (2022) of the benefits of targeted media campaigns for jockeys on Twitter as a useful method in facilitating mental health help-seeking in athletes. The participants acknowledged that reading about somebody else’s experience can create a desire for athletes to also seek support for their mental health. Thus, the results reflect a potential opportunity around the use of online social platforms as a tool by which to educate athletes on mental health and promote help-seeking behaviors in elite sport. Furthermore, our findings provide practical implications for other sports to develop online communities that target the mental health of their athletes and help combat stigma through minimizing loneliness, creating shared spaces, and normalizing conversations surrounding mental health. Our findings extend previous knowledge from the general population where online mental health support groups have been demonstrated to be a powerful mechanism to challenge help-seeking stigma and create a safe space in which to share experiences of mental ill-health with like-minded others (Naslund et al., 2016).

Role models

Role models were an important source for normalizing mental health in sports. Participants reported that the profiling of athletes discussing mental health was topical within elite sport and valuable in normalizing and validating their mental health struggles and experiences:

Looking at other athletes who are like elite, or even just older, seeing that they’ve faced the same adversities, but are still performing to the best of their abilities and best in the country, some are competing against the best in the world. It’s good to see that struggling with your mental health doesn’t necessarily mean that you’re not going to perform well. (Tom)

The importance of storytelling by key role models within the sport was emphasized here and was beneficial in encouraging others to seek help. Research has shown how storytelling is beneficial to promoting help-seeking for mental health. For example, a reduction in stigmatizing attitudes toward mental health among men was observed after viewing videos of first-person accounts of depression and help-seeking experiences (Keum & Ogrodniczuk, 2022). Storytelling can invoke feelings of relatedness among athletes, which can have a positive influence on motivation to seek help for their mental health when it is congruent to their openness for support (Lockwood et al., 2002). Milly acknowledged that having positive role models can help to address the barriers, normalize the help-seeking process and encourage athletes at all levels to seek support:

I definitely feel like it requires role models such as like Simone Biles to kind of create that pathway with other people, because it’s kind of seen as quite a taboo subject still because people still view mental health as you’re a weak person. And I'm not sure why because if someone got a physical injury, it wouldn’t mean they were a weak person, it just means that they’ve been physically injured. And I feel like we should view mental health in the same way. (Milly)

The participants expressed how it is essential for athletes to believe they are not isolated in their feelings and Milly’s example highlighted how high-profile athletes, regardless of their sport, can be key influencers for other elite athletes to open up about their own experiences. Indeed, evidence from the general population has highlighted how famous role models discussing their experiences of mental health struggles and challenging misconceptions around mental health, can be an important mechanism by which to promote mental health help-seeking behavior among typically hard-to-reach groups (e.g., men; Sagar-Ouriaghli et al., 2019). This study suggests this technique may be useful for encouraging help-seeking behaviors among athletes. Providing real-life examples of people experiencing the same or similar difficulties can elicit a sense of social comparison. Affiliation is an important part of role modeling; having people who you consider to be similar to yourself to look up to and emulate is key. However, women may be less likely to have positive role models in sports due to fewer women competing at an elite level (Midgley et al., 2021). Promoting strong female role models in elite sport specifically around mental health and help-seeking is therefore of significant importance. Our study sample is mainly comprised of women, providing key examples of women in elite sport speaking out about mental health and extending previous recommendations (Küttel & Larsen, 2020; Perry et al., 2022). Ensuring athletes take an interest, engage in conversations, and learn about the topic of mental health through high-profiled athletes is an important priority for NGBs. Promoting an environment where athletes can flourish and encourage openness surrounding mental health has the potential to impact athletes’ competing at a lower level and promote positive mental health help-seeking intentions more broadly across the sport.

Supportive team around the athlete

Participants recognized support from training partners, family members, friends, and coaches as crucial to enabling behaviors that are conducive to positive mental health.

Encouragement from peers

Opening a line of communication between the athlete and friends could be beneficial for creating a more positive training atmosphere as exemplified by Lucy:

I think it would (sharing my own experience), (a) it would have helped me and (b) it would have helped others. I think it would have been like releasing as well. Like, okay [athlete name] is feeling this way. This explains why her throwing wasn’t great or we can adapt training to help support her. (Lucy)

Lucy described how sharing her emotions with others generated a shared experience, allowing them to understand how she was feeling, thus being able to support her accordingly with her psychological well-being and training. These findings contrast previous help-seeking research where the athletes indicated they did not want their coach and teammates to find out about their mental health struggles and help-seeking (Gulliver et al., 2012). Instead, our study highlights that teammates and coaches would be the first point of contact if they required support. Existing evidence recognizes the importance of high-quality teammate friendships in protecting against the development of mental health issues (e.g., Scott et al., 2020). This study extends this work to suggest that training partners and peers may also play an important role in prompting access to support. Participants discussed how being sufficiently comfortable to disclose their mental health issues to their social support network is key as it promotes acknowledgement and acceptance of their experiences. Helena noted how her friends knowing the signs of her mental health deteriorating was beneficial for early intervention:

I really, really struggled with anxiety, more than anything. I developed an eating disorder through that as well… I think the biggest thing is talking about it. I bottled it up for ages. And like I said, I was quite lucky that the people around me sort of noticed it. And I spoke to people about it. That’s why I'm quite thankful that I've sort of got that support system around me. (Helena)

Helena described the importance of open lines of communication with her support network. Through embracing vulnerability, and through voicing out loud her struggles to her peers, Helena reported feeling more supported emotionally, and that this contributed toward creating a kinder environment within which she trained and competed in (Brown, 2010). Furthermore, participants applauded others who have sought help, highlighting the acceptance of mental health in the sport. It is possible that the participants in our study felt more able to ask for help due to being in healthier and more sustainable environments (Moesch et al., 2018) and feeling empowered as a result of recent public disclosures from high-profile athletes (for example, Naomi Osaka and Simone Biles).

The role of the coach

All participants expressed how supportive coach behaviors were important in promoting help-seeking for a mental health issue, reflecting previous research by O’Keeffe et al. (2022). One participant exemplified the trust that athletes have in their coach and the importance of this for keeping the athlete grounded:

My coach was incredible at keeping me from going off the edge, essentially, going into the deep end, he gave me pep talks constantly and checks up on me. He was just there for me to kind of speak to talk things through. (Tom)

Here, it is evident the coach was beneficial in acting as an important source of reassurance and guidance, ensuring that the coach’s support is known. Our results are supportive of the work by Plateau et al. (2015) who examined coaches’ supportive behaviors toward T&F athletes with disordered eating. Participants in the present study explained how their coaches’ behaviors, such as regular checkups and support through treatment seeking, were beneficial in creating training environments conducive to openness in discussing mental health. Communication is one of the central tenets of a high-quality coach-athlete relationship; indeed, a lack of communication can be damaging to athletes’ help-seeking and disclosure of mental health issues (Sandgren et al., 2023).

For most, the coach is the primary contact when they are struggling mentally and a gatekeeper for future support working as part of a team to help the athlete: “they’re almost like in charge of your career almost sort of thing. You know, if they don’t know exactly what’s going on, then they can’t help you” (Maddy). The findings highlight how coaches are seen as an asset for direct support, thus coaches should have the knowledge to be aware of and recognize symptoms of mental health disorders (Plateau et al., 2015). The coach can make an important contribution toward creating a positive environment, which is beneficial not only to enhance athletic performance but to facilitate openness and communication channels with an athlete regarding mental health difficulties: “If there’s ever kind of any business within the group that’s creating a nasty atmosphere, she will make sure she removes that” (Milly). Previous research has evidenced that when athletes are placed in situations of conflict, they are more susceptible to anxiety, sleep issues, and low mood (Wachsmuth et al., 2018). Recognizing and responding to the signs and symptoms of mental health issues at an early stage can help to remove and prevent tensions and conflict, so athletes can train in healthy and sustainable environments (Sandgren et al., 2023).

Summary

Our study is the first to directly explore the unique barriers and facilitators to mental health help-seeking behaviors among elite T&F athletes and contributes to an emerging body of knowledge that can aid in holistically understanding mental health in elite sport. Given the voluntary nature of the research, the sample may reflect the experiences of those more willing to speak openly about mental health issues. Further exploration with male athletes may be needed to ensure these findings accurately reflect their experiences. Therefore, future researchers should extend more broadly to reflect in-depth experiences of different genders, cultures, and sports.

Key implications emerged from our study that can help to inform guidelines for NGBs, and those working with T&F athletes in the future, regarding the awareness, provision, and clarity of mental health treatment and support. It is worth stating that our study did not address the issue of funding mental health support within T&F, thus it is for NGBs to determine whether further funding is required to deliver on some of the recommendations below and consider what changes to the organizational structure and delivery of mental health support may be required. Our data point toward a need for greater education and awareness programmes, to address the stigma around seeking support for mental health issues, to clarify and educate athletes on what support is available, and how to access it in a comparable manner to that of physical health support. Indeed, this education could be achieved proactively at a national level through implementing workshops across T&F clubs, with the aim of clarifying and communicating the pathways available for confidential mental health support.

NGBs may wish to further harness and expand the potential of online athlete-specific support networks. Our evidence has suggested that the content on these platforms may be effective at reducing stigma and improving the mental health literacy of athletes. These platforms can offer a mechanism by which to promote mental health and sport psychology services so that athletes can gain familiarity and form relationships with practitioners, improve their knowledge of the help available, and confidentially seek support through contacting appropriate individuals, removing potential tensions surrounding help-seeking outlined in previous research (Sandgren et al., 2023). Based on our data we recommend that the platforms themselves could advertise or direct athletes and stakeholders toward relevant mental health literacy workshops, that aim to educate coaches, athletes, and parents on the specific challenges of T&F, enhancing the role of the support team around the athlete. In combination, the proposed initiatives could help to create a more positive culture and environment, characterized by a nonjudgmental, athlete-centered focus, which incorporates interdisciplinary and holistic athlete support.

In conclusion, our findings demonstrate the differences in emphasis and priority placed on the provision and availability of support for athletes’ physical health versus their mental health. Mental health support availability, visibility and prioritization appear insufficient within the T&F environment. There is an opportunity to explore how the availability and reach of sport specific digital platforms and communities could be used to empower athletes to share and relate to mental health experiences, mitigating the perceived stigma surrounding mental health in sport. Sports beyond T&F may wish to develop and launch similar strategies to help raise awareness and support for mental health, including the potential benefits from the utilization of digital platforms. Furthermore, our study raised important research questions regarding mental health in relation to the content and scrutiny of sports broadcasters in their commentary and feedback. The implications from our study could assist NGB, coaches, and support staff in developing tangible and tailored mental health support for T&F athletes, considering their specific challenges in recognizing and seeking help for mental health concerns.