I. Foundations of psychosocial health

Before focusing on specific threats to athletes’ psychosocial health, or proposing ideas for the prevention and management of psychosocial health issues, it is first necessary to provide a conceptual foundation and establish a common language from which to discuss these issues. Although in practice it is nearly impossible to consider the different domains of health and well-being in isolation, for didactic purposes it is beneficial to consider them separately. In Chapter 1, I define key terms, offer an overview of research on well-being in sport, and highlight the importance of considering the psychosocial aspects of health for both athletic performance and global well-being.

In Chapter 2,1 introduce the cognitive and emotional domains of psychosocial health. Due to its implications for skill-learning and within-competition decision-making, the cognitive domain of psychosocial health is especially linked to sport performance. Beyond performance, sport can serve both as an enhancer and debilitator of important cognitive functions. Emotional health (often referred to as mental health) has received increased attention from elite sport organizations, due in part to several high-profile athletes speaking out about their conditions. Scholarly research on emotional health in athletes has also increased, and I share important findings relative to the prevalence of emotional health issues in sport, as well as the conditions under which sport may serve as a risk or protective factor for such issues.

Finally, Chapter 3 highlights the relevance of social and spiritual health for high-level athletes. Social health has most often been examined through the lens of Keyes’ (1998) theory of social well-being, which is one component of psychological well-being. In addition to reviewing two studies of social wellbeing in athletes, I synthesize the literature related to social support. I conclude the chapter with an introduction to spiritual health, which has most often been studied in athletes as spirituality or religiousness. Specifically, I discuss research suggesting competitive sport as an ideal site for the expression and realization of spiritual health, as well as the link between spiritual health and the emotional and social dimensions of psychosocial health.

The relevance of psychosocial health for high-level athletes

Garrett is a professional basketball player who has recently been traded to a new team. As part of the trade, his new team requires him to undergo a physical exam to ensure that he is healthy to train and compete. The exam is comprehensive, and includes questions on Garrett's medical history (e.g., past injuries), as well as biometric assessments such as heart rate, blood pressure, vision, and a general evaluation of posture, range of motion, and muscle strength. The physician gives Garrett a clean bill of health, and the trade is finalized. Things are going well until about mid-season, when Garrett begins arriving late to practice, missing team meetings, and performing below his usual standard. Upon being confronted by his coach and teammates, Garrett admits to having struggled on-and-off with his emotions for several years and agrees to get help from a mental health professional. After his in-take session with the therapist, Garrett is diagnosed with major depressive disorder, and begins a program of medication combined with regular psychotherapy. The front-office staff decides that future physical exams should go beyond the physical aspects of athletes' health.

High-performing athletes are revered for their remarkable feats of strength, speed, and endurance. Elite-level endurance athletes such as cross-country skiers can use almost twice the amount of oxygen as a typically trained adult (Hutchinson, 2014), and weightlifters who compete at the Olympics routinely lift two to three times their body weight from the floor to above their heads (Anon., 2012). Athletes in team sports possess an uncanny ability to quickly assess the situation and react to constantly changing circumstances, all while coordinating their actions with those of their teammates. Athletes who have achieved such impressive feats on the playing field are often called upon to be role models of healthy living (Lisanti, 2017). Paradoxically, these same high-performing athletes often struggle with a variety of health issues, including life-altering injuries, coach abuse, drug and alcohol dependence, and disordered eating behaviors (Safai, Fraser-Thomas, & Baker, 2015). Unfortunately, as seen in the hypothetical case of Garrett, such issues are often taken for granted by sport organizations.

The varied meanings of health

Before engaging in a critical discussion of athlete health, it is first necessary to discuss both how the term is commonly used in sport, as well as define how it will be used in this text. To illustrate the typical view of health in sport, imagine the head coach of a high-level team addressing the media prior to an important game or match. As reporters pepper her with questions, the subject of certain team members’ health naturally arises. Regardless of her response, the implied context is the physical status of the athlete in question. An expected answer might be “Player X has been cleared by the team doctor to play in today’s game,” or “Player Y has a stomach virus and will be out of action tonight.” Such answers reveal important assumptions about the nature of health. First, it seems clear that the coach has adopted a medical-model view, in which health is viewed as the mere absence of disease or injury (Laing, 1971). Second, it is exceedingly rare for a coach, athlete, or team official to address athlete health from a holistic perspective; instead, they tend to reduce the issue to one of physical illness or injury. That is, even if an athlete was struggling with a psychosocial health concern such as a bout of depression that put his ability to play in jeopardy, such issues are usually either not discussed, or not immediately considered as fitting under the purview of athlete health.

In this text I will adopt the World Health Organization’s more versatile definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946). Although some health concerns of athletes, such as injury, have clear physical implications, rarely are the antecedents and consequences ofsuch concerns purely physical. Depending on the severity of the injury, athletes can expect to experience a variety of cognitive, emotional, social, and even spiritual challenges in the process of recovery (Clement, Arvinen-Barrow, & Fetty, 2015). Substance dependence, although certainly a physical threat to athletes, is also often the result of social pressure to perform, and can in turn have profound psychological effects (Whitaker, Long, Petroczi, & Backhouse, 2013). Thus, a more complete approach to athlete health extends beyond the physical to include the cognitive (i.e., thinking), emotional (i.e., feeling), social (i.e., relating with others), and spiritual (i.e., connection with something greater than oneself) dimensions (Donatelle, 2015). For example, a collegiate volleyball player who recently transferred to a different university will ideally learn the strategy of her new team at an appropriate rate (i.e., cognitive health), effectively cope with the stress of transition (i.e., emotional health), form new productive relationships on and off the court (i.e., social health), and feel a sense of purpose and fulfillment as it relates to her academic and athletic career (i.e., spiritual health).

Taken together, these four dimensions of psychosocial health can be viewed as an indicator of athletes’ well-being, or “diverse and interconnected physical, mental, and social factors extending beyond traditional definitions of health” (Naci & loannidis, 2015, p. 121). As depicted in Figure 1.1, athletes’ psychosocial health and well-being are under constant bombardment from threats such as injury and transition (see Chapters 4-8). With careful planning, negative health concerns can be prevented (see Chapters 9-10). However, even the best prevention cannot eliminate all health concerns, and later-stage prevention and treatment are often warranted (see Chapter 11). Finally, for some athletes, the experience of health concerns and/or the process of treatment may be an opportunity for displays of resilience or the realization of personal growth (see Chapter 12).

PRE-HEALTH CONCERN

POST-HEALTH CONCERN

FIGURE 1.1 A conceptual model for understanding psychosocial health in high-level athletes

Well-being

Because the concept of well-being is, in and of itself, of interest to sport researchers, it warrants specific consideration. Numerous scholars have offered models of well-being in the general population, which usually involve some combination of social and emotional dimensions. For example, in his tripartite model of subjective well-being, Diener (1984) posited that degree of positive and negative affect (i.e., affective balance) and life satisfaction determine individuals’ wellbeing. Ryff’s (1989) six-factor model of psychological well-being emphasizes the factors of self-acceptance, personal growth, life purpose, environmental mastery, autonomy, and positive relations with others as forming the foundation of wellbeing. Central to current conceptions of well-being is the distinction between hedonic well-being (i.e., subjective well-being), or individuals’ subjective experiences of happiness, and eudaintonic well-being (i.e., psychological well-being), or the extent to which individuals pursue meaningful goals leading to personal fulfillment. A further component of psychological well-being (PWB) is social well-being, or individuals’ perception of the extent to which their social life is flourishing (Keyes, 1998). Social well-being is further divided into five components: (a) social acceptance, (b) social actualization, (c) social contribution, (d) social coherence, and (e) social integration. Each of these five components is discussed in Chapter 3.

It should be noted that Ryff and Diener’s conceptions of well-being represent a decidedly Westernized (i.e., individualistic) view of the construct, and some have questioned whether such a view accurately represents the experiences of individuals from more Eastern (i.e., collectivistic) cultures found in Asian and Middle Eastern countries (Lu & Gilmour, 2004; Suhail & Chaudhry, 2004). Eastern versus Western differences in the experience of subjective well-being (SWB) have been of interest to researchers who contend that happiness is culture-dependent. For example, Lu and Gilmour (2004) compared Chinese and American university students’ responses to the question “What is happiness?” They found that, as opposed to American students, who associated happiness with certain mental and emotional states, personal achievement, and autonomy, Chinese students tended to focus more on maintaining a sense of balance, or homeostasis, between themselves and their environment. Thus, although in this text I will primarily present views of health and well-being reflective of Western views (as nearly all of the research has been conducted with North American and European populations), readers should be aware that what counts as healthy and well is highly dependent on cultural norms and values.

When applying the Western view of well-being to athletes, from a hedonic perspective, an athlete may experience well-being in the form of happiness and pride in setting a new personal record time. This same athlete may also experience eudaimonic well-being due to training and competing in accordance with their personal values of being a strong role model, being coachable, and competing with integrity (see Table 1.1).

TABLE 1.1 Characteristics of hedonic and eudaimonic aspects of well-being for athletes

In her comprehensive treatment of well-being research conducted in sport through 2010, Lundqvist (2011) noted an inconsistency in how researchers chose to operationalize well-being. From a hedonic perspective, the construct has been operationalized as the self-reported presence or absence of positive and negative emotions as measured by inventories such as the Positive and Negative Affect Scale (PANAS; Watson, Clark, & Tellegen, 1988), and/or as measured by psychological traits and states such as body satisfaction and self-esteem (e.g., Martin DiBartolo & Shaffer, 2002; Reinboth & Duda, 2004). Even among researchers who did clearly state their orientation toward well-being (i.e., subjective vs. psychological), Lundqvist (2011) noted a failure to use assessments which align with the stated orientation. Inspection of the literature on well-being in sport published since Lundqvist’s review shows a general improvement in both the specification of researchers’ orientation to well-being and the alignment of this orientation to assessment (e.g., Ferguson, Kowalski, Mack, & Sabiston, 2014; Jeon, Lee, & Kwon, 2016; Lundqvist & Raglin, 2015). For example, in their study of well-being in injured athletes, Lu and Hsu (2013) clearly articulated their interest in subjective well-being, and chose measurements that fit with this approach—the Trait Hope Scale and the Chinese version of the PAN AS.

In response to the lack of conceptual clarity within research on well-being in sport, Lundqvist (2011) proposed an athlete-specific model of well-being. The model is informed both by conceptualizations of well-being in general, and extant research on well-being in sport. As seen in Figure 1.2, the model accounts for global and sport-specific well-being, as well as hedonic and eudaimonic dimensions of well-being. The resulting model allows for a multi-dimensional view of well-being in sport, in which athlete well-being can be understood across six domains: (a) global subjective well-being (i.e., life satisfaction), (b) sport subjective well-being (i.e., sport satisfaction), (c) global psychological well-being (i.e., life purpose), (d) sport psychological well-being (i.e., purpose in sport), (e) global social well-being (i.e., general social acceptance), and (f) sport social well-being (i.e., social acceptance in sport).

Using the model as a guide, Lundqvist and Sandin (2014) interviewed ten elite orienteers to explore factors characterizing the different forms of well-being. Hedonic indicators of well-being such as life satisfaction and sport enjoyment

Global well-being

Hedonic

Eudaimonic

level

Global

Subjective well-being (SWB)

• -Life satisfaction
• -Long-term affect

Psychological well-being (PWB)

• -Self-acceptance
• -Positive relation to others
• -Autonomy
• -Environmental mastery
• -Purpose in life
• -Personal growth

Social well-being

• (Social WB)
• -Social acceptance
• -Social actualization
• -Social contribution
• -Social coherence
• -Social integration

Sport-related well-being

Hedonic

Eudaimonic

Subjective well-being in sport (SWB-S)

Psychological well-being in sport (PWB-S)

Social well-being in sport (Social WB-S)

level

Contextual

• -Sport satisfaction
• -Sport-related affect
• -Self-acceptanceas an athlete -Positive relation to coach and teammates
• -Autonomy in sport practice -Sport environmental mastery -Purposein sport

^-Personal growth as an athlete

• -Social acceptance in sport
• -Social actualization

through sport

• -Social contribution to sport
• -Social coherence in sport
• -Social integration in sport

FIGURE 1.2 An integr ated model of global well-being and context-specific well-being related to sport. Reprinted with permission from Lundqvist, C. (2011). Well-being in competitive sports—The feel-good factor? A review of conceptual considerations of well-being. International Review of Sport and Exercise Psychology, 4,109-127. doi:10.1080/1750984X.2011.584067

interacted with eudaimonic indicators such as autonomy and personal growth to produce orienteers’ well-being experience. Further, orienteers’ global, nonsport specific well-being at a given point in time served as the foundation for their sport well-being. This finding highlights the importance of adopting a holistic approach to athletes’ health and well-being emphasizing both sport and non-sport aspects.

Sport as an enhancer or debilitator of optimal psychosocial health and well-being

Although much has been written about the role of sport in shaping desirable (or undesirable) psychosocial qualities in youth (e.g., Ferris, Ettekal, Agans, & Burkhard, 2015), the psychosocial health and well-being of adult athletes competing at a high-level have been mostly ignored. Importantly, this includes a focus on the potential for competitive sport to undermine psychosocial health. As Safai, Fraser-Thomas, and Baker (2015) articulated about the documentary Road to the Olympics in their text Health and Elite Sport:

As social scientists who study health and sport, we were struck by the paradox of experiences that made up these Olympians’ journeys. We recognized their incredible physical capabilities of fitness, strength, and skill, their psychological motivation, determination and focus, coupled with their widespread appeal as models of health, work ethic, sportspersonship and character. But we were also struck by the notable and consistent attention paid to pain and injury as part of each athlete’s personal story.

(P- 1)

Indeed, such pain often extends to include the cognitive and emotional domains of athlete health, such as when gymnasts develop distorted views about the size and shape of their bodies (Neves, Meireles, de Carvalho, Schubring, Barker-Ruchti, Caputo Ferreira, 2017), American football players choose to withhold symptoms of head trauma (Kuhn, Zuckerman, Yengo-Kahn, Kerr, Totten, Rubel, Sills, & Solomon, 2017), and elite athletes struggle with the transition from competition to a “normal” life (Cosh, Crabb, & Tully, 2015). As discussed further in Chapter 5, when the sport culture is designed with performance and winning as the primary value, athletes are more likely to push themselves in unhealthy ways, and are often celebrated for their efforts in doing so (Hughes & Coakley, 1991). The pressure on coaches to deliver championships can exacerbate the situation, as they may at best be complicit in athletes’ unhealthy pursuit of glory, and at worst resort to physical and emotional abuse in the name of performance (Stirling & Kerr, 2015). As prominent governing bodies of sport such as the National Collegiate Athletics Association (NCAA) and the English Institute of Sport (EIS) begin to prioritize athlete well-being independent of performance, sport researchers and professionals need a comprehensive resource in this area.

In this book I synthesize current research related to psychosocial health in high-level athletes, and offer suggestions for future research and practice related to the psychosocial health and well-being of high-level athletes. For the purpose of this text, I define high-level sport participants as those who devote significant time and resources to training and competition, and who compete regularly at the regional, national, international, or professional level. Figure 1.1 is a schematic representation of this text. The concentric circles depict each of the four dimensions of psychosocial health, from those elements most central to the athlete to those elements most external (Chapters 2-3). The boxed arrow pointing downward from above the circles represents common threats to athletes’ psychosocial health, including organizational stress, psychological pressure to perform, abuse, injury, and transition. At the core of threats to the psychosocial health of athletes is the aforementioned “win-at-all-costs” culture of high-level collegiate, international, and professional sport. The boxed arrow pointing upward from below the circles represents primary, secondary, and tertiary approaches used to prevent adverse psychosocial outcomes in high-level athletes (Chapters 9-11). Finally, the bent upward pointing arrow to the right of the circles illustrates the potential for resilience and psychosocial growth in athletes due to the experience of threats to psychosocial health (Chapter 12).

References

Anon. (2012, July 29). North Korean Olympian lifts 3 times his weight. CBS News. Retrieved from https://www.cbsnews.com/news/north-korean-olympian-lifts-3-times-his-weight/

Clement, D., Arvinen-Barrow, M., & Fetty, T. (2015). Psychosocial responses during different phases of sport-injury rehabilitation: A qualitative study. Journal of Athletic Training, 50(1), 95-104. doi:10.4085/1062-6050-49.3.52

Cosh, S., Crabb, S., & Tully, P. J. (2015). A champion out of the pool? A discursive exploration of two Australian Olympic swimmers’ transition from elite sport to retirement. Psychology of Sport and Exercise, 19, 33e41. Retrieved from http://www. pasap.eu/wp-content/uploads/2015/04/Australians-Swimmers-2015.pdf

DiBartolo, D. M., & Shaffer, C. (2002). A comparison of female college athletes and nonathletes: Eating disorder symptomatology and psychological well-being. Journal of Sport & Exercise Psychology, 24. doi:10.1123/jsep.24.1.33

Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95(3), 542-575.

Donatelle, R. J. (2015). Health: The basics (11th ed.). Pearson eText. Retrieved from https://www.pearson.com/us/higher-education/product/Donatelle-Health-The-Basics-1 lth-Edition/9780321910424. html?tab=resources

Ferguson, L. Kowalski, K. C., Mack, D. E., & Sabiston, C. M. (2014). Exploring selfcompassion and eudaimonic well-being in young women athletes. Journal of Sport & Exercise Psychology, 36, 203-216. doi:10.1123/jsep.2013-0096

Ferris, K. A., Ettekal, A. V., Agans, J. P., & Burkhard, В. M. (2015). Character development through youth sport: High school coaches’ perspectives about a character-based education program. Journal of Youth Development, 10(3), 127-140. doi:10.5195/jyd.2015.13

Hughes, R., & Coakley, J. (1991). Positive deviance among athletes: The implications of overconformity to the sport ethic. Sociology of Sport Journal, 8, 307-325.

Hutchinson, A. (2014). Who has the greatest VO2max of them all? Runner’s World. Retrieved from https://www.runnersworld.com/training/a20832549/ who-has-the-greatest-vo2max-of-them-all/

Jeon, H., Lee, K., & Kwon, S. (2016). Investigation of the structural relationships between social support, self-compassion, and subjective well-being in Korean elite student athletes. Psychological Reports, 119(1), 39-54. doi: 10.1177/0033294116658226

Kerr, G. A., & Stirling, A. E. (2015). Professionalization of coaches to reduce emotionally harmful coaching practices: Lessons learned from the education sector. International Journal of Coaching Science, 9(1), 21-36.

Keyes, C. L. M. (1998). Social well-being. Social Psychology Quarterly, 61(2), 121. doi:10.2307/2787065

Kuhn, A. W., Zuckerman, S. L., Yengo-Kahn, A. M.. Kerr, Z. Y., Totten, D. J., Rubel, К. E., ... Solomon, G. S. (2017). Factors associated with playing through a sport-related concussion. Netirosuigery, 64(Suppl. 1), 211-216. doi:10.1093/neuros/nyx294

Laing, R. D. (1971). The politics of the family and other essays. New York, NY: Pantheon Books. Lisanti, J. (2017). Body count. Sports Illustrated, 127(9), 40-45.

Lu, L., & Gilmour, R. (2004). Culture and conceptions of happiness: Individual oriented and social oriented SWB. Journal of Happiness Studies, 5(3), 269-291. doi:10.1007/ S10902-004-8789-5

Lu, F. J.-H., & Hsu, Y. (2013). Injured athletes’ rehabilitation beliefs and subjective wellbeing: The contribution of hope and social support. Journal of Athletic Training, 48(1), 92-98. doi:10.4085/1062-6050-48.1.03

Lundqvist, C. (2011). Well-being in competitive sports—The feel-good factor? A review of conceptual considerations of well-being. International Review of Sport and Exercise Psychology, 4(2), 109-127. doi:10.1080/1750984X.20H.584067

Lundqvist, C., & Raglin, J. S. (2015). The relationship of basic need satisfaction, motivational climate and personality to well-being and stress patterns among elite athletes: An explorative study. Motivation and Emotion, 39(2), 237-246. doi:10.1007/ S11031-014-9444-Z

Lundqvist, C., & Sandin, F. (2014). Well-being in elite sport: Dimensions of hedonic and eudaimonic well-being among elite orienteers. Sport Psychologist, 28(3), 245-254. doi:10.1123/tsp.2013-0024

Naci, H., & loannidis, J. P. A. (2015). Evaluation of wellness determinants and interventions by citizen scientists. JAMA, 314(2), 121-122. doi:10.1001/ jama.2015.6160

Neves, С. M., Meireles.J. F. F., de Carvalho, P. H. B., Schubring, A., Barker-Ruchti, N., & Caputo Ferreira, M. E. (2017). Body dissatisfaction in women’s artistic gymnastics: A longitudinal study ofpsychosocial indicators. JournaZo/'SportsSriewies, 55(17), 1745-1751. doi:10.1080/02640414.2016.1235794

Reinboth, M., & Duda, J. L. (2004). The motivational climate, perceived ability, and athletes’ psychological and physical well-being. The Sport Psychologist, 18(3), 237-251. doi:10.1123/tsp,18.3.237

Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069-1081. doi:10.1037/0022-3514.57.6.1069

Suhail, K., & Chaudhry, H. R. (2004). Predictors of subjective well-being in an eastern Muslim culture. Journal of Social and Clinical Psychology, 23(3), 359-376. doi:10.1521/ jscp. 23.3.359.35451

Safai.P., Fraser-Thomas, J., & Baker, J. (2015). Sport and health of the high performance athlete: An introduction to the text. In ). Baker, P. Safai, & J. Fraser-Thomas

(Eds.), Health and elite sport: Is high performance sport a healthy pursuit? New York, NY: Routledge, Taylor & Francis Group.

Stirling, A., & Kerr, G. (2015). Safeguarding athletes from emotional abuse. In M. Lang, & M. Harthill (Eds.), Safeguarding, Child Protection and Abuse in Sport: International Perspectives in Research, Policy and Practice (pp.143-152), London: Routledge Press.

Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS Scales. Journal of Personality and Social Psychology, 54(b), 1063-1070. Retrieved from http://www.cnbc.pt/jpmatos/28. Watson.pdf

Whitaker, L., Long, J., Petroczi, A., & Backhouse, S. (2013). Using the prototype willingness model to predict doping in sport. Scandinavian Journal of Medicine and Science in Sports, 24. doi:10.1111/sms.l2148