Removing the Stigma Around Mental Health in Sport

“We live in a society where there are challenges when we talk about mental health,” begins Dr Rod Jaques. “We still have a degree of stigma attached to the problem as a society and what we’re trying to do is dissolve those barriers as much as we can in a system which is always striving for excellence.”

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By John Portch

Dr Jaques, Director of Medical Services at the English Institute of Sport [EIS], is talking to the Leaders Performance Institute as UK Sport and EIS unveil increased measures to facilitate a positive mental health environment across Great Britain’s Olympic and Paralympic sport system. This Mental Health Strategy, developed by a Mental Health Steering Group that had representation from leading UK-based mental health charity MIND, will be implemented by the UK’s national governing bodies across the Tokyo cycle. Its four key pillars are education, provision, communication and assurance.

The launch was timed coincide with World Mental Health Day on 10th October and hopes to build on some solid foundations. “For over a decade we have had doctors who are consultants in sport and exercise medicine looking after our elite athletes,” says Dr Jaques. Support in place includes a network of external psychiatrists and psychologists, which can be referred to by EIS medical teams as well as in-house from national governing body and EIS doctors, psychologists and performance lifestyle advisors.

In the weeks ahead there will be a new Head of Mental Health appointed at EIS to head up the strategy, while there is the ongoing development of a new Mental Health Expert Panel that will include psychologists with an experience of elite sport, to provide guidance for the high performance system in dealing with mental health issues. We delve into some of those existing measures with Dr Jaques while he expresses his hopes for the Mental Health Strategy.

What are some of the measures UK Sport and EIS already had in place?

RJ: We have three groups of professionals working [on athletes’ mental health] in the English Institute of Sport; that is medical consultants in sport and exercise medicine; they’re all trained in some aspects of mental health. The second group of people are the sports psychologists and the third group of people are the performance lifestyle advisors. For over ten years we have picked up pieces of mental health problems in athletes, which we’ve dealt with accordingly. In the last four years, we’ve negotiated access to the Priory Hospital Group, which is a network of psychiatry and psychology in-patient centres so, if necessary, we can send athletes to those centres for either confidential out-patient treatment or, if necessary, in-patient treatment for a period of time.

How did this new Mental Health Strategy come to fruition?

RJ: We’ve realised that the public’s and sport’s awareness of mental health is increasing. There have been some well-publicised cases and we’ve felt the need to push very hard, not so much at treating the end consequence of mental health problems but getting it right in the early stages of an athlete’s career. We’re not pretending that we can switch off the problem but our belief is if we can get to these athletes earlier in their problems, we will get better performances, better continuity of training, and happier athletes as a result.

What are some of the ways you’re working to do this?

RJ: Every athlete, when they join the funding programme with a sport, will have what they call an induction. Historically, that induction has been a physical assessment process; to pick up early physical problems that may expose themselves during the course of the rigours of training to the Olympic or Paralympic standard. There’s also a general awareness of who you go to in the sport in terms of nutrition and performance lifestyle and biomechanics and ‘where’s your doctor?’ and ‘where’s your physiotherapist?’ It’s an orientation exercise for an athlete and we realised that this induction time is a rich opportunity for us to also ask the athlete some well validated questions, which are used in general practice in Europe, which pick up early mental health problems very sensitively and very efficiently. And once we’ve effectively identified those athletes we’ll put more resource around and more effort into their understanding of how best to work the system to their health and wellbeing benefit but also so that we can be more tuned into ensuring they have a higher level of care.

That touches upon assessment, which is one of your four key pillars. Can you elaborate upon the education component?

RJ: We have already started to push out what is called Mental Health First Aid Training so that physiotherapists and performance lifestyle advisors and nutritionists in particular can be more tuned into asking the right sort of questions when they sense on the couch, they’re treating them as a physiotherapist, or across the desk if they’re advising them as nutritionists, if the person is starting to develop a mental health concern. That training we’ve drawn down from a national course that is run for industry; we’ve moulded it into more sports-specific language and we are starting to train up staff who can then train further staff. We want to push that out to national governing bodies’ staff as well.

And the provision piece?

RJ: I touched on provision earlier, but an additional piece is to have a Mental Health Expert Panel, which we’ve not had historically. So we’re recruiting a small panel of sports psychiatrists and sports psychologists who, between them, will have had 10-20 years’ experience of looking after elite athletes at this level and who will work together to advise the system in a number of different ways. The assessment process will be partially the responsibility of that panel and to make certain that we are making a difference to the system; a difference might be measured in the number of referrals that we’re making through to the Priory Hospital Group on an annual basis; it might be the difference between those people at the point of induction in their screening, when we repeated that screening one, two or three years later, so the same group of athletes that had been inducted, their scores are improving; that’s how we’d measure improvement.

How will the Mental Health Expert Panel offer assistance in delivering the assessment piece?

RJ: The first job is really to have the panel accessible to not just the doctors and the sports psychologists that we employ but also our performance directors and to chief medical officers in the sports, to be able to pick up the phone and say, listen, we think that such and such in our sport is starting to develop problems, they don’t want to talk about it yet but everyone else knows it’s happening to them. How do we go about starting to assist this person to make the best decisions about their mental healthcare? So what we’re trying to do is provide a resource not only for the English Institute but also the Scottish Institute, Welsh Institute and Northern Irish Institute and the national governing bodies to be able to phone up and have an expert on the end of the telephone who can talk them through the cases that have, for the moment, not come forward. The second area, which is quite a challenging one, is for those athletes who have gone off-site, as it were, to the Priory Hospital and either had a series of out-patient appointments there or may have been an in-patient; often those athletes come back and they want to remain below the parapet as far as the sport is concerned about the psychiatric issues they may have had; but the sport knows they’re coming back and the athlete may say to the attending doctors and psychologists that I don’t want you to share any of my information with anyone within sport, but the sport will know they’re coming back perhaps with the label of depression and the sport will be able to speak to the panel. Again, we know that such and such is coming back, how we can make certain that they land back on deck with us in a smooth and efficient way; and that we’re sensitive and compassionate with the problems that they have so that they don’t relapse.

How vital are the coaches vital to the success of your strategy?

RJ: They’re central. If you ask an athlete who is the most important person in my sport then it’s their coach; so at the centre of this relationship is the athlete-coach relationship and all of these support personnel effectively surround that pairing. So very often we have to take into close consideration what the coaches are saying about the athlete but remembering that the athlete in this instance is a patient and if they choose to remain confidential about this then we have to respect that confidentiality. Trust is key to a successful team. We know that teams who are trusting of each other both between the athletes and between the athletes and the coaching staff and the performance director are the teams that are the most successful.

What is the impact when someone such as Helen Richardson-Walsh speak up about their mental problems?

RJ: I think it’s very helpful when you have senior athletes speaking up around this subject. It makes it easier for a more junior athlete to come forward. Sport is, to some extent, led by role models and when you have a highly successful medal-winning athlete like Helen Richardson-Walsh deciding to go public about her mental health issues in the past then one hopes and expects that junior athletes would feel more comfortable at coming forwards.

Mental conditioning – before something goes ‘wrong’ – must be a large component of your work.

RJ: Very much so and that’s the domain of our sports psychologists and our performance lifestyle advisors; our sports psychologists are particularly trained in looking at managing anxiety around competition, allowing that anxiety to express itself in a positive way rather than a negative way; and our performance lifestyle advisors in particular will look at how the athlete manages the rest of their life outside sport and also plan for the future. One hopes that’s a holistic approach for the athletes, their wellbeing is maintained through psychology and performance lifestyle.

The health monitoring and support programmes for athletes within the national governing bodies – what will they look like in practice from induction to after their exit from World Class Programmes?

RJ: As they come into a sport as part of this induction, they would have a screening for their mental health; if they figure on that mental health screening then they would be picked up by the mental health team, the sport, the doctor, the sports psychologist and performance lifestyle advisor and they would bring in other experts as they need to. For instance, if it was around an eating disorder, you could also bring in the nutritionist early on; then they’d review that on a regular basis. They would clearly always consent the athlete for any discussions outside of that group; on an annual basis, I would hope the sport would keep an eye on the mental health and wellbeing of their team. A year out from retirement, if you can predict retirement, at that point the performance lifestyle advisor would really start to have conversations around exit from sport, about how to put together a CV, about practicing interview techniques, about contacts in sport in the outside world and start to introduce them to organisations like the British Athletes’ Commission, who have a huge role to play in that phase of time after an athlete’s immediate retirement.

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Dr Craig Ranson, Director of Athlete Health at EIS, is one of the proponents of the Mental Health Strategy and will be talking athlete wellbeing and support at the 2018 Leaders Sport Performance Summit in London on 12-13 November.