**3. Unique challenges**

Due to differences in lifestyle and other factors, mental health clinicians must keep in mind several considerations when working with elite athletes compared to the general population. Although psychotherapeutic interventions are similar to those with non-athletes, elite athletes can present unique challenges including diagnostic ambiguity, barriers to help-seeking behaviors, and altered expectations about services.

#### **3.1 Diagnostic ambiguity**

When attempting to diagnose athletes, there are many considerations that a clinician must keep in mind. One is that many of the symptoms and behaviors that athletes may present with are shared between mental health disorders and typical/expected athlete behavior. Take over-training syndrome and clinical depression: shared symptoms are fatigue, appetite loss, weight change, cognitive deficits, and a general lack of energy and motivation [20]. These symptoms have two different causes and therefore require different treatments to resolve symptoms. Athletes may also perform ritualistic behavior in order to relieve anxiety during athletic performance [21]. This could include behaviors such as unique free-throw warm-ups in basketball, avoiding stepping on the foul line while taking the field in baseball, or eating Skittles™ before every football game. While this may lead a clinician to suspect a diagnosis of obsessive–compulsive disorder, these behaviors are limited only to competitive settings and result in no overall life impairment [22].

In addition to the presenting symptoms and behaviors themselves, the underlying cause of them may be different for athletes than for individuals in the general population. Due to their experiences and lifestyles, athletes have unique triggers that may cause their psychiatric symptoms. Depression can be brought on by

*Psychotherapeutic Approaches to Addressing Mental Health Problems Among Elite Athletes DOI: http://dx.doi.org/10.5772/intechopen.96978*

overtraining, poor performance, or retirement from a sport [2, 22]. Athletes in contact and even non-contact sports are constantly exposed to the potential for severe injury which can bring about mood disturbance, tension, and anger [23]. There are also greater prevalence rates of performance anxiety and jetlag induced insomnia among elite athletes in comparison to the general population [24].

Even within the elite athlete population, athletes who perform in different sports may have varying risks for different mental health symptoms and disorders. Research shows that athletes who participate in individual sports, compared to those in team sports, may be at a greater risk for depressive symptoms [25, 26]. Because of these ambiguities and potential differences in symptoms and behaviors, mental health practitioners must carefully consider each case in order to choose correct diagnoses and methods of treatment.

#### **3.2 Barriers to help-seeking behaviors**

The most common barrier to athletes seeking treatment is stigma associated with mental health [27]. Some athletes may hold the belief that receiving mental healthcare is a sign of "weakness" and evidence of being "crazy" or untrustworthy [2]. In one study, student athletes in Australia reported poor understanding of mental health and past negative experiences in help seeking as other barriers to seeking out treatment [28]. Because of these misperceptions and misunderstandings of mental health, many athletes may refuse to seek help due to their own beliefs or the beliefs held by their peers, family, and coaches. Research has shown that perceived stigma, confidence in consolation, cultural preferences, and openness can be used to predict a coach's likelihood of referring their players to mental health services [8]. This means that coaches who view mental health as less stigmatizing, have greater confidence in positive outcomes from consolation, have receiving therapy as a cultural preference over other forms of treatment or no treatment, and have higher levels of openness are more likely to refer their athletes to therapy for issues regarding mental health.

Another barrier to seeking or continuing treatment is when a problematic behavior is viewed as positive or helpful to an athlete's sport performance. A wrestler or fighter may justify an eating disorder such as anorexia nervosa or bulimia nervosa because it helps them to maintain or cut weight before contests [20]. A football or baseball player may choose to struggle through mood disturbances and inter-personal difficulties while using anabolic steroids if they believe that the steroids are helping them to build muscle and perform at higher levels [4]. If an athlete is currently in treatment, beliefs such as these may cause strains in the patient-therapist relationship when the clinician points out the negative effects of these behaviors that are viewed as beneficial by the athlete [8].

As noted earlier, confidentiality can be difficult to ensure or maintain at times. Some athletes – especially those who are particularly well known in their area, state, or country – may fear being recognized while attending or traveling to and from treatment sessions. These athletes may prefer that mental health professionals come to them to provide services at team facilities or their home or hotel in order to avoid public exposure [27]. While this may be permissible, mental health professionals must consider to pros and cons of providing treatment outside of the clinical setting [8]. Some athletes may prefer not only confidentiality from the public but also confidentiality from individuals involved in their personal lives. Even though coaches, trainers, agents, and family may prefer to be involved and included in psychoeducation and psychotherapy as they are accustomed to being involved in the athlete's life, this can create complexities regarding confidentiality [2].

#### **3.3 Altered expectations about services**

Elite athletes are often accustomed to special treatment and accommodations that are not given to the general population. Many athletes have assistants or people within their organizations who create and organize schedules, arrange travel accommodations, and complete day to day tasks for them [27]. This can become a challenge for the mental health professional when it is preferable to speak with the athlete than with their assistant [14].

While some athletes prefer that mental health clinicians meet them where they are for confidentiality purposes, some athletes make this request because it is what is normal for them. Oftentimes athletes will have healthcare professionals and others meet them at team facilities or their home, so this is what is typical and expected. As stated earlier, mental health professionals must consider the advantages and disadvantages of providing psychotherapy outside of the clinical setting [8]. With their busy schedules and frequent traveling combined with repeated accommodations by others, athletes may expect that clinicians can provide services at any time if it is convenient for the athlete. This can make establishing and maintaining boundaries difficult for the clinician if they attempt to schedule and travel to meet the athlete's preferences [27].

Although many elite athletes may be well-off financially, they may not be accustomed to paying for certain services [2]. For example, agents may try to provide tickets, passes, or merchandise that are equal in value to the charge for treatment [2]. Accepting these in lieu of monetary payment is unethical and could lead to future boundary issues as the professional patient-therapist relationship could be viewed as a more personal one by both parties [2].

In all situations, the clinician's goal should be to balance "flexibility with appropriate boundaries" [2]. This is done by balancing the unique needs of the athlete with providing appropriate treatment based on the athlete's diagnosis, their specific circumstances, and the context in their sport [29].

#### **3.4 Personality factors**

Narcissism and aggression are personality traits that can be common among elite athletes [7]. These are traits that the clinician may encounter during mental health services with athletes, or they could be the presenting issue for a patient coming in for treatment.

Elite athletes may often achieve great fame and wealth. They are often held in high esteem by fans, family, teammates, coaches, and others. People admire them for what they are able to accomplish and follow not only their athletic performances but also their personal lives through the media. Because of social media, athletes' lives are more accessible to the public than they used to be, and they may receive praise and attention via this platform in addition to what they receive in person. All of this can lead to feelings of superiority or narcissism as they are often the center of attention and may be accustomed to being in the spotlight [8]. Because of this, an athlete may feel as though they are not in need of help since they receive so much adoration on a constant basis, or they may have unrealistic expectations about therapy [2]. For example, if they do not see immediate results from therapy or it does not come as naturally to them as their sport does, then they may decide that it is not beneficial to them and not worth their time or effort. In extreme cases, these athletes may develop grandiose beliefs, lose their ability to empathize, and respond with fury to real and imagined slights [8].

Recent research has found a positive relationship between anger, aggressiveness, general aggressive behavior, antisocial behavior toward opponents and teammates,

*Psychotherapeutic Approaches to Addressing Mental Health Problems Among Elite Athletes DOI: http://dx.doi.org/10.5772/intechopen.96978*

and the experience of and expression of anger [30]. This supports previous findings that antisocial traits may often lead to outbursts of anger, especially within training, practices, and games [8]. Due to their pride being built upon the praise of others, many successful athletes are insecure or have fragile egos and may exhibit rage and aggression when confronted with real or imagined threats to their sense of selfworth [7, 31]. The loss of praise and increase of criticism due to a poor performance or decision by an athlete can "injure" the ego, which can lead to a response of "impulsive and explosive rage" as they deal with a cycle of praise and criticism that is uncommon in other populations [31].
