Treatment

Jayson is a 23-year-old professional baseball player, who after five seasons has worked his way to the major league team. Team staff think highly of Jayson's skills, and expect him to be a solid contributor to the team. However, they do have some concerns about his behavior toward teammates and the media. Always viewed as a bit aloof, Jayson has become even more so in recent months. He isolates himself from teammates in the clubhouse, actively avoids reporters after games, and is noticeably uncomfortable in even the most benign social situations. His teammates describe him as being awkward, and are unsure of how to approach him. After a conversation with management, Jayson agrees to meet with the team's psychologist. Based upon an intake session, the psychologist diagnoses Jayson with social anxiety disorder, and recommends several sessions of cognitive behavioral therapy, along with a referral to a psychiatrist for possible prescription of an anti-anxiety medication. After several weeks, although Jayson is still by no means a social butterfly, he appears much more relaxed around his team. He reports that both the medication and therapy have enabled him to better cope with uncomfortable social situations.

Although strong prevention efforts can reduce incidents of psychosocial health problems (Saxena, Jane-Llopis, & Hosman, 2006), and in some cases reduce costs (e.g., Wellander, Wells, & Feldman, 2016), complete prevention is unlikely. When psychosocial health concerns do manifest, treatment, also known as tertiary prevention, becomes the priority. In recent years, several high-level athletes have sought the use of mental health counseling for issues such as anxiety, depression, and substance abuse, and advocated for greater acceptance of these conditions in the sporting realm (Gleeson & Brady, 2017). Prominent athletes such as basketball player Kevin Love, American gymnast Simone Biles, and American football player Brandon Marshall have been at the forefront of criticizing traditional views of psychosocial health concerns as a sign of mental weakness, and de-stigmatizing common psychosocial disorders (Boren, 2018; Cogan, 2014). In this chapter I present an overview of psychosocial health treatment for high-level athletes. First, I discuss the various forms that treatment may take, and their efficacy. Second, I highlight the unique barriers to treatment for high-level athletes. Finally, I offer an overview of the state of psychosocial treatment services for high-level athletes in various sport organizations.

Forms of psychosocial treatment for athletes

The National Alliance on Mental Illness (NAMI) lists common types of psychosocial treatment, several of which have relevance for athletes (NAMI, 2018). In the following sections I focus on two forms of treatment and their application in high-level sport: (a) psychotherapy, and (b) psychoeducation. Although psychotropic medications are often part of the treatment plan for individuals with psychosocial health conditions, a focus on these drugs is beyond the scope of this text. I instead refer interested readers to Reardon and Factor (2010) for further information on the use of psychiatric medications for treating psychosocial health problems in athletes.

Psychotherapy

One of the most common forms of treatment for psychosocial concerns is psychotherapy. Psychotherapy occurs when individuals work with trained therapists/ mental health counselors to overcome or manage their psychosocial health problems (Herkov, 2016). Psychotherapists attempt to promote positive change in clients by establishing a therapeutic relationship (aka the therapeutic alliance) and using effective communication practices to help individuals gain self-awareness and learn strategies for handling challenging situations (Herkov, 2016). Although therapists may choose from a variety of therapeutic approaches in their work with athletes (e.g., psychoanalysis, behavior therapy), cognitive behavioral therapies (CBT) such as Albert Ellis’ (1957) rational emotive behavior therapy (REBT), and Beck’s (1970) cognitive therapy are among the most commonly used for both emotional health and sport performance enhancement. The popularity of CBT in sport stems from several factors, including their time-limited nature, an emphasis on empowering athletes to take control of their thoughts, and a substantial body of evidence supporting their effectiveness for ameliorating conditions such as depression, anxiety, and eating disorders in the general population (e.g., David, Cotet, Matu, Mogoase, & Stefan, 2018; Linardon, 2018).

Further, athletes are likely to find some comfort in CBT-based therapy, which in some ways mirrors the structure and prescribed repetition associated with sport training (Hays, 1999). Within sport, CBT-based interventions have been used to help athletes manage unhealthy perfectionism (Gustaffson & Lundqvist,

2016) , ease post-concussive symptoms (Splete, 2016), reduce performance anxiety (Gustaffson, Lundqvist, & Tod, 2017), optimize appraisals of organizational stressors (Didymus & Fletcher, 2017), and help athletes cope with injury (Mahoney & Hanrahan, 2011).

REBT-based techniques focused on reducing irrational beliefs (e.g., “I must always do well,” “Others must always treat me nicely.”) and promoting more functional patterns of thinking/self-talk are often employed by sport psychologists focused on performance enhancement (e.g., Vealey, 2005). Despite being the oldest form of CBT, it was not until recently that researchers took an interest in testing the effectiveness of REBT on indicators of psychosocial health in athletes. Turner et al. (e.g., Cunningham & Turner, 2016; Turner & Barker, 2013) have conducted and evaluated numerous REBT interventions with athletes. Interventions included face-to-face sessions in which athletes learned the fundamentals of REBT and had the opportunity to apply these principles to themselves. In one study, players at an elite youth soccer academy attended a single 60-minute workshop in which they were taught strategies for recognizing and disputing irrational beliefs. Although players’ endorsement of irrational beliefs decreased immediately following the workshop, they returned to preworkshop levels six weeks later.

Recognizing the limitations of the one-time group session approach, Deen, Turner, and Wong (2017) conducted a series of five, 60-minute, one-on-one REBT sessions with five elite squash players. In addition, players completed homework to reinforce the in-session content. A key aim of the intervention was to promote rational beliefs through the development of personal credos prompting athletes to think rationally about various circumstances they would encounter. Not only did all athletes report a decrease in irrational beliefs, but three of the five also reported an increase in self-reported resilient qualities (Deen et al., 2017). In another study, mixed martial arts fighters exposed to REBT reported reduced irrationality and self-depreciation and increased unconditional self-acceptance. Most importantly, these changes remained in two of the three athletes 6 months post-intervention. Thus, REBT shows some promise for enhancing psychosocial health in non-clinical high-level athletes. A logical next step is to test REBT as a psychotherapeutic treatment for athletes with diagnosed psychosocial health problems such as anxiety, depression, and eating disorders.

As principles of mindfulness, such as present moment contact and non-judg-mental awareness, have been embraced by sport psychology practitioners for performance enhancement (e.g., Buhlmayer, Birrer, Rbthlin, Faude, & Donath,

2017) , there is similar interest in applying mindfulness-focused CBT approaches (e.g., acceptance and commitment therapy) for enhancing athletes’ psychosocial health and well-being. Mahoney and Hanrahan (2011) implemented a four-session, one-on-one acceptance and commitment therapy (ACT) intervention with four injured athletes. Athletes were educated on several key elements of ACT, including cognitive defusion, mindfulness, acceptance, and values, and the researchers guided athletes through experiential exercises to reinforce each element. Although little quantitative change in athletes’ self-reported mindfulness, injury anxiety, and acceptance was noted from pre- to post-intervention, in post-intervention interviews the athletes reported that they found several of the techniques useful, and would use them again in the future.

Influenced by the shift from thought-control-focused CBT approaches to mindfulness-based approaches in clinical and counseling psychology, Gardner and Moore (2004) introduced a sport-specific model of performance and wellbeing enhancement for athletes—the mindfulness-acceptance-commitment program (MAC). MAC is a seven-module program aimed at promoting mindful awareness and non-judgmental acceptance in athletes (Gardner & Moore, 2004). Although primarily used as an approach for performance enhancement, Gross, Moore, Gardner, Wolanin, Pess, and Marks (2018) recently examined the psychosocial health benefits of MAC. Using a sample of female collegiate athletes, the researchers compared pre-post changes in self-reported psychological distress, psychological flexibility, emotion regulation, and mindful awareness between randomly assigned groups of 11 student-athletes receiving the seven-week MAC program and 11 student-athletes receiving a seven-week psychological skills training program. As hypothesized, the athletes receiving the MAC intervention reported positive changes in psychological distress, substance abuse, and hostility. Further, athletes who received the MAC intervention reported significant decreases in general anxiety, disordered eating, and distress between the end of the intervention and the one-month follow-up. The athletes receiving psychological skills training did not report any significant changes in the psychosocial health variables. Because of its sport-specific approach, the MAC protocol holds promise as a psychosocial health treatment approach in high-level athletes. The authors also suggested that MAC may be used as a tool for primary prevention in athletes, and this represents a fruitful line of investigation for the future.

Psychoeducation and support groups

The first module of the MAC protocol, psychoeducation, is also another common form of psychosocial treatment. Psychoeducation involves educating individuals about a health condition that they or their loved ones are experiencing (Virtual Medical Centre, 2014). The health condition addressed in psychoeducation may or may not be of a psychosocial nature, but the goal is always to use education of the physical, psychological, and social factors associated with the health condition as a way of alleviating distress and enhancing self-efficacy (Virtual Medical Centre, 2014). Because groups offer potential for individuals to positively influence each other through factors such as the instillation of hope, imparting of information, and conveying the feeling that they are not alone in their experiences (Yalom, 1995), psychoeducation, often, but not always, occurs in a group setting (Gerrity & De-Lucia-Waack, 2006).

Within sport, the health condition targeted may be any of the threats discussed in this text, including transition, injury, or organizational stress. Alternatively, psychoeducation may be employed to address maladaptive patterns of thinking, such as was done by Mosewich, Crocker, Kowalski, and DeLongis (2013) in evaluating a psychoeducational self-compassion intervention with female collegiate athletes. Danish, Petitpas, and Hale (1993) made a case for the power of psychoeducation to enhance athletes’ life skills and promote healthy behaviors. The authors discussed a psychoeducational program known as Going for the Goal (Goal), in which student-athletes learned to set goals and develop action plans for attaining them, including strategies for handling barriers and proper use of social support. Although the authors reported positive feedback from participants, no formal evaluation data was presented.

Psychoeducation with athletes has most often been used to support the process of transition. For example, freshman collegiate student-athletes who participated in an eight-session program of psychoeducation regarding the transition into college sport reported the experience as helpful for managing transition stress, and strongly recommended the program to future students (Harris, Alterkuse, & Engels, 2003). In another study, female collegiate athletes reported being satisfied with a retirement transition program that included psychoeducation (Constantine, 1995). Unfortunately, researchers have not included control groups when examining the effectiveness of psychoeducation on adjustment to transition. Nor have they assessed the influence of psychoeducational programs on psychological and subjective well-being (e.g., life purpose, life satisfaction, affect).

 
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