**2. Psychotherapy**

In order to improve overall functioning, athletes dealing with mental health symptoms and disorders should seek psychotherapy. Psychotherapy, either as the sole treatment or combined with other nonpharmacological and pharmacological strategies, is a vital component in the management of clinical and subclinical mental health symptoms and disorders in elite athletes. For psychotherapy to be most effective with athletes, it must address athlete-specific issues while being validated as a "normal" or standard treatment for mental health difficulties by the athletes and their core stakeholders (partners, family, coaches, agents, etc.). As a means of decreasing the stigma often associated with mental health treatment, it may be helpful to reframe psychotherapy treatment as "performance help" as the goal is to improve functioning therefore improving athletic performance [7].

There are several different forms of psychotherapy that have been implemented and found to be successful in the treatment of athletes suffering from mental health symptoms and disorders. These are individual psychotherapy, marital/family psychotherapy, and group psychotherapy.

#### **2.1 Individual psychotherapy**

Individual psychotherapy involves a patient meeting with a trained mental health professional in a one-on-one setting. Oftentimes individual psychotherapy alone can be a sufficient treatment for less severe mental health issues such as mild depression, anxiety, and sports-related adjustment issues [8]. Individual psychotherapy provided by a sport psychiatrist or a psychologist or counsellor who specializes in the treatment of athletes can be useful in the treatment of psychiatric disorders as well as in improving adherence to medication.

The types of individual psychotherapies that are most commonly used in young adults, college students, and collegiate athletes are supportive therapy, cognitive behavioral therapy, motivational enhancement therapy, and psychodynamic therapy. These four therapies appear to have common healing factors including affective engagement, feeling understood by the therapist, offering a framework for understanding the problem/solution, therapist expertise, therapeutic structure/procedures, optimism regarding improvement, and experiences of success [9].

Of these therapies, cognitive behavioral therapy (CBT) has received the most empirical support [10]. CBT works to help patients understand how dysfunctional thoughts can lead to negative emotional activation and maladaptive actions or inactions [11]. This form of therapy is a very appropriate choice for athletes as it mirrors elements in physical training such as comfort with structure, direction, and practice [12]. As athletes are typically already comfortable with these elements, it can make this method of treatment one that makes practical sense to implement, especially athletes who participate in individual sports due to their familiarity with individual goal setting and self-reliance [8]. CBT appears to be most useful in

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

cases of depression, anxiety, substance use disorders, anger/aggression, insomnia, somatization, chronic pain, and general stress [13].

An athlete's feelings and opinions on substance use, legal or illegal, can be strongly influenced by peers, family, coaches, trainers, and other individuals that they are in close contact with. For example, a coach who notices that a new prescription has caused a slight drop in performance may attempt to convince their athlete to take less than the prescribed amount or stop taking the medication altogether. Teammates that often engage in illicit drug use may pressure other athletes to try it or believe that it is permissible. Motivational enhancement therapy (MET) uses principles of motivational interviewing to help patients understand their ambivalent feelings and opinions towards substance use [8]. Accordingly, MET appears to be most useful in cases of risky drinking and adverse alcohol behaviors, cannabis use, tobacco cessation, and medication adherence issues [14, 15].

Psychotherapy, compared to psychopharmacological treatments, is considered the best primary treatment of adjustment disorder, one of the more common mental health disorders experienced by athletes [8]. An adjustment disorder is an excessive emotional or behavioral reaction to a stressful event or change in a person's life. Athletes often face many situations requiring them to cope with stressful changes, including being traded to a new team, moving to new cities, and adjusting to injury. Due to the relatively short duration of adjustment disorders, psychotherapies that are short-term and problem-solving focused appear to be the most efficacious modality, given the shorter timeframe of the disorder [16].

#### **2.2 Couples/family psychotherapy**

Involvement of family in psychotherapy can help athletes understand how personal and family stress can impact overall athletic performance [14]. Spouses or partners and other family members can play a significant role in the mental health of an athlete. Part of that role can involve assisting the athlete in caring for their mental health. If an athlete is willing to involve family members, a healthcare provider may gain a better understanding and more well-rounded view of the patient as family members can provide important supplemental information [7]. Family members are often crucial in ensuring treatment adherence, and it is a common belief that in certain circumstances, psychoeducation should be required for patients as well as their partner/family member(s) before being able to start psychotropic medications [7]. If an athlete is amenable, coaches, trainers, agents, and other close individuals can provide additional supplementary information about the athlete as well as work to facilitate their adherence to treatment during daily activities. These individuals and family members are often the people who encourage athletes to seek out help in the first place.

In addition to helping, family can also be a source of stress for athletes, or elements of the athlete's life may be sources of stress for their family. Many times, familial issues may either be the source of the presenting problem or the problem itself when an athlete seeks treatment [8]. Recent studies have shown that family problems in a collegiate athlete's life may predispose them to mental health distress and could be used as a good screening method to assist referrals [17]. Some issues that are not exclusive to the family setting of athletes alone but may present themselves with greater frequency include substance use, domestic violence, time spent away from home, jealousy, and extramarital affairs [14]. These types of issues can also be the underlying causes of psychiatric symptoms that lead athletes to present for psychotherapy. Because of this, clinicians must be able to appropriately implement marriage/couple psychotherapy which can sometimes be difficult if both parties are not committed to participating in treatment [8].
