When prominent athletes tell the world they’re struggling with their mental health, it serves as a reminder that athletic success can have little bearing on how one feels.
Earlier this year, Simone Biles, widely regarded as the world’s greatest gymnast, stepped back from the Olympic spotlight temporarily because she was uncomfortable with the pressures of her situation. The load of expectations had become heavy.
Tennis star Naomi Osaka, who has won four Grand Slam titles and has spent time as the No. 1-ranked women’s player in the world, acknowledged mental health issues when withdrawing from the French Open last May. She has since hinted she may not play again this year.
The essential point: Star athletes are not immune from mental health issues. The same is true of athletes at any level. Fortunately, Sanford Health has people who can help.
Coaching with a mental approach
Andy Gillham, Ph.D., is a senior sports performance specialist with Sanford POWER who advises athletes and coaches on developing and maintaining strong mental approaches to the sports they’re involved in.
Sometimes, Gillham said, the strongest mental approach begins with realizing you’re not where you need to be.
“What Naomi and Simone have done is to stand up and say ‘I’m just not square right now. I got a bunch going on. Upstairs, in my being, I’m just not OK right now. I need to take a step back and deal with me, the person — not ‘me’ the athlete, not ‘me’ the athlete that gets tweeted about,” Gillham said.
“From the outside, it’s like they’re different people. From the inside from their perspective, it’s all the same. They’re an athlete, but they’re also a sister, or a mother or a brother or a spouse or a sibling … they’re all of those things at the same time in addition to the most amazing athlete.”
Openness among famous athletes can be a great help in encouraging the not-so-famous to be sensitive to their own mental health issues. It is an encouraging trend.
“The media attention on mental health over the last decade has been a big help,” said Jacob Miller, M.D., a Sanford specialist in family and sports medicine who serves as Northern State University’s team doctor. “I feel like I’m having a lot more athletes reach out to me and tell me ‘I’m really not feeling OK with what is going on here.’”
‘It’s OK to talk about it’
There have likely been times in the past when someone in Biles’ situation would relay to the media that a bad wrist was going to get in the way of competing. They would do this because the real reason — a mental health issue — would create more trouble than it was worth.
Instead, with the eyes of the world upon her, Biles was straightforward in explaining why she wasn’t competing.
“We also have to focus on ourselves, because at the end of the day we’re human, too,” she said after declining to compete in the all-around competition in Tokyo. “So, we have to protect our mind and our body, rather than just go out there and do what the world wants us to do.”
Biles’ point was emphasized in an essay Osaka composed for Time magazine that explained her mental health challenges.
“There can be moments for any of us where we are dealing with issues behind the scenes,” Osaka wrote. “Each of us as humans is going through something on some level. I do hope that people can relate and understand it’s OK to not be OK, and it’s OK to talk about it. There are people who can help, and there is usually light at the end of any tunnel.”
Biles and Osaka are not the first to come forward to talk about the challenges that confront athletes who are dealing with depression, anxiety and high expectations. Swimmer Michael Phelps, winner of a record 23 gold medals over five Olympics, has been open about his ongoing challenges with anxiety and depression, as has Kevin Love, a five-time NBA All-Star.
Mental illness is common in athletes
Research suggests that anxiety or depression in current elite athletes is 34% according to a report from the British Journal of Sports Medicine. In contrast, the prevalence of any mental illness for adults in the U.S in a given year is 20%.
Typically, Dr. Miller will ask his patients if the way they feel is affecting sports performance. Is it affecting diet? Is it affecting sleep? In recent years, he’s found that athletes are more willing to come forward sooner.
“It has been good in terms of helping student athletes speak up for themselves and to try and intervene earlier when they feel like things are getting out of control,” Dr. Miller said. “I don’t feel like I’ve seen quite as many people who get to more of a dangerous situation.”
Disappointment is a part of sports. Many of the benefits of competition can be connected to the way the occasional failure can help in the development of coping skills. It can be a valuable piece of the sports and mental health narrative.
“What we’re talking about is the difference between a performance issue and a mental health issue,” Gillham said. “One can lead to the other and the other can be indicative of the other, right? It’s a chicken-and-egg sort of thing.”
One telling barometer is sleep, Gillham explained. Athletes need sleep to perform well. If they don’t get it, their performance may suffer. Alternatively, a poor performance can increase anxiety and lead to problems sleeping.
“Do we need to have weighted blankets and lavender and self-talk meditation before bed so we sleep better?” Gillham asked. “Or do we need to solve the performance issue?”
Separating clinical mental health from what Gillham refers to as “applied performance issues” gets at the chicken/egg nature of mental health for athletes. For parents and coaches of young athletes, it’s advisable to be sensitive to changes in behavior in either case.
“You have to decide how much of it is normal,” Gillham said. “It is 100% normal to care about your performance. It’s normal to not want to disappoint your parents and it’s normal to want to do well for your coach. Those are all normal things.”
Performance pressure vs anxiety
In explaining their reasons to take a break from competing, both Biles and Osaka referred to the pressure placed on them. In both cases, the fact that they’ve successfully handled these situations in the past did not guarantee this was always the way it was going to work. The challenges of dealing with pressure can accumulate, both for those who are the best in the world and younger athletes dreaming of getting there.
“I think it’s very important to know there is pressure inherent in just about everything we do in life,” Dr. Miller said. “It’s part of our jobs, our school and certainly on the athletic field. How we choose to handle that pressure — what we choose to shape that into to motivate us — can determine our performance and also how our personalities and how our responses to stress develop.”
As a doctor for college student athletes, Dr. Miller has many conversations with people living busy lives. They may not initially realize the extent to which they’re taking on what can be a long list of responsibilities. What they may discover is that they’re not giving themselves enough credit for all the things they have going on.
“Once you recognize that, then it can become easier to identify the things that are priorities for you,” Dr. Miller said. “Step two is listing those priorities. What is most important? What are the things that you have to get done every day? What things are really important for you to have so that you can function within a healthy paradigm?”
Sometimes the stress of competition is just that — stress fueled by anxiety that is created by uncertainty. It is a common part of athletics at every level.
“There is an almost exact inverse relationship between anxiety and self-confidence,” Gillham said. “One goes up and the other goes down. Essentially, the brain can’t handle being really confident and freaked out about the same thing at the same time. So you have to pick one or the other. You’re either really confident you can do something or you’re really anxious.”
Coping skills for athletes
The options for Gillham in helping athletes are to teach skills that lower anxiety or teach those that build confidence. In either case, anxiety levels vary from athlete to athlete. What may be a toxic level for one might not move the needle for another.
“One might have sweaty palms and butterflies in the stomach and think ‘Oh, I’m in trouble. This is going to be a rough day,’” Gillham said. “Another might have those exact same sweaty palms and butterflies in the belly and say, ‘This is game day, baby, I’m ready to go.’ And they’re dealing with the exact same data. They’re just interpreted very differently.”
Though the challenges are real for athletes and mental health, so are the benefits. Participation in sports, as researched by the Aspen Institute, leads to higher test scores early in life and lower health costs and reduced risk of heart disease, stroke, cancer and diabetes later in life. Most importantly in a mental health context, it leads to lower levels of depression and higher self-esteem as youth advance into adulthood.
“It’s not going to matter 50 years from now who wins this or that basketball game,” Dr. Miller said. “But knowing that you learned how to work within a team framework, knowing that you understood how to handle that pressure — that you were able to prioritize those things that were most important to you — those things are important. You can learn to put pressure into perspective so that you can use those same tools later in life.”
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