The stigma of mental illness in sport has recently come to prominence following the tragic suicides of several high-profile sportspeople.
German international football goalkeeper Robert Enke, Denver Bronco’s wide receiver Kenny McKinley, Austrian Olympic judo silver medalist Claudia Heill, Kenyan Olympic marathon champion Sammy Wanjiru andWales national football team manager Gary Speed.
This, tragically, is not a list of recent winners of a prestigious sports award, but a list of high profile people from the world of sport who have taken their own lives whilst at the height of their successful careers in the last three years.
Suicide remains one of the leading causes of death among young people worldwide, and for every high profile suicide that is reported in the media thousands of others leave ordinary families attempting to makes sense of, and come to terms with, the act. Around a million people commit suicide worldwide each year with rates for men being considerably higher than those for women in most countries. The number of suicides in England has been reducing in recent years but 4,400 people took their own life in 2009, a number that equates to one death by suicide every two hours.
As a way of better understanding suicide, The Confidential Inquiry into Homicides and Suicides by Mentally Ill People was established in 1992 with the aim of recording the details of, and researching, suicides amongst people with mental health problems, in order to help devise a strategy to respond to the situation. Perhaps the most striking fact that began to emerge at the time, and that has remained more or less consistent, was the fact that around a quarter of all suicides recorded (around 1000 per year) had some contact with the mental health services in the year before their death. This, of course, means that around three quarters did not.1
Reasons for suicide
For most people who complete a suicide a subsequent suicide note often reveals their belief that the act is the only viable solution to a seemingly unsolvable problem. This means that when considering suicide “solving the problem” rather than dying is often the driving force behind the act.
Periods of high unemployment or severe economic problems have been associated with higher rates of suicide. Other reported triggers have included feelings of hopelessness, depressive illness, major disappointment, rejection, failure, loss from relationship breakdown or bereavement, and witnessing family turmoil. However, suicide risk is complex and for many people it is a combination of factors that determines risk rather than any single factor.
Suicide in people involved with sport
The notion of sportsmen and women being better protected against mental health problems than others because a sound body somehow equals a sound mind has long been held in the public consciousness. Although often seen as heroes and larger-than-life characters, sportspeople remain human and as such prone to all of the stresses and problems that human condition brings. Across their life span, stressful life events that involve threat, loss, humiliation, or defeat influence the onset and course of depression and for some this is the start of their journey towards suicide.
A range of literature in recent years has however supported the idea that participation in recreational sport is a positive thing that can be conducive to mental health.2 It has cited the ideas that inclusion and a sense of belonging are created and that the activity helps combat social exclusion.3,4 Sports participation can contribute to increasing levels of self esteem and has been shown to promote positive feelings of inclusion and help create support networks.5 What this literature has not addressed in any detail however is the impact that intensely competitive sport can have on mental health
Baum6 suggests researchers have found, that contrary to popular belief, athletes may be more at-risk than their non-athlete peers for experiencing mental health difficulties, such as alcohol abuse, social anxiety and depressive symptoms. Reasons for this may stem from the culture of sports, which emphasizes being ‘mentally tough,’ ‘showing no sign of weakness’ and ‘fighting through the pain.’ In recent decades this has been compounded by the change in attitude and introduction of huge earning potential in sports.Tutko7 suggests that this is crystalised by an attitudinal move away from ‘it's not whether you win or lose but how you play the game,’ to ‘winning is the only thing.’Performing in front of thousands of fans, having your performance and mistakes scrutinised in public, and working in a field where success and failure are so clear-cut can also have a huge impact on the people involved.
One trait that is prominent amongst top sportspeople is the level of dedication they have to their sport. The perfectionist attitude this demands can totally dominate their time and their lives and in many sports finding a healthy work life balance can prove difficult.
The catch-22 with perfectionism is that the very traits that can lead to a person excelling can also generate incredible stress and anxiety. In a study on dancers and perfectionism Hamilton8 described a high incidence of depression among dancers and suggested that the same qualities of perfectionism that lead to significant achievement can also lead to self-destruction. Perfectionists are often very hard working, single minded, dedicated to the task of improving performance and completely focused on succeeding. This increases their level of expectations. The problem can be that the better they do, the more they expect of themselves. This can leads to a fear making mistakes and a high level of frustration with an imperfect performance even if it is only slightly flawed.
All of these factors can combine to make the pressures on successful sportspeople amplified and increase the potential for mental health problems such as anxiety and depression.
It is refreshing to see of the positive steps some sports organisations are beginning to take in acknowledging the problems. The Professional Footballers Association, for example, has recently stated that in their view, the overriding messages for players are the need to seek help, immediately and without fear, and to recognise that mental health is just as important as physical health.
This approach marks a turning of the tide in sports where for many years the emphasis was to use psychology as a tool primarily for enhancing performance rather than treating problems. Tom Ferraro9 describes how if you “pick up any basic text in sport psychology… you will find them filled with chapters entitled ‘Goal Setting’, ‘Imagery Training’, ‘Cognitive Strategies’, ‘Intensity Regulation’ and ‘Hypnosis.’” You will find little if anything on promoting mental health and dealing with failure. This turning of the tide is important because teaching budding sportspeople about the importance of maintaining mental wellbeing and developing techniques to build resilience against, and deal with, stress and depression could be some of the most important lessons they ever learn.
Stigma and mental health in sport
Admitting to a mental health problem is something that most people suffering mental ill health have difficulty with but in professional sports, where a top athlete often has to be seen as being almost unbeatable, it is probably even harder. Partially this may be because the experience of top sportspeople who have openly admitted mental health problems in the past has not been particularly encouraging for others in the field.
Former Northern Ireland international Neil Lennon openly admitted to receiving treatment for depression, but describes how difficult the admission was. “It’s a very macho environment, obviously,” said Lennon in an interview “You don’t want to give anything away and in that environment you have a group of highly charged men who might take the mickey out of you or who might look on it as a sign of weakness.” When ex-England international Stan Collymore openly admitted that he suffered from depression during his time playing for Aston Villa he was ridiculed by then-manager John Gregory.When Glasgow Rangers goalkeeper Andy Goram admitted he had schizophrenia, chants of “there’s only two Andy Gorams” came from both away fans and home fans.
Perhaps though the most notable negative response to a sportsman openly admitting to a mental health problem was the way the Sun newspaper responded to boxer Frank Bruno being admitted to a mental health unit. In the first edition of the paper the front page lead with a full page headline "Bonkers Bruno Locked Up" and the supporting text described Bruno as “a nut”. Although after a storm of protest the later editions headline were changed to read, "Sad Bruno in Mental Health Home", with the accompanying text describing him as a "hero", the damage had been done and high profile sportspeople were given an insight into what admitting to mental health problems might mean.
The last few years have seen a definite attempt by Government working in partnership with sports authorities to combat this culture of negativity in sport towards mental health and the first tangible results of this process are starting to filter through.
Joe Nickel, writing in a recently published Time To Change report,10 describes how The Football Association, along with the National Institute for Mental Health in England (NIMHE) and others, launched the Shift initiative to address the problem of stigma around the area of mental health. Part of this initiative was a project working in partnership with football agencies, to pilot and promote positive work to de-stigmatise mental health issues. Shift ran a successful conference and national football tournament to help promote this work in 2008. This anti-stigma work has been further developed by Time To Change, a programme launched in 2009 which has the remit to help end the discrimination faced by people with mental health problems. Led in partnership by Rethink and Mind, Time To Change (TTC) aims to create a 5% positive shift in public attitudes towards mental health problems and achieve a 5% reduction in discrimination by 2012.
One very positive component to the Time To Change process is the very public support it has received from some very high profile people from the world of sport who have talked openly and frankly about their mental health problems. These have included Arsenal and England footballer Tony Adams, England cricketer Marcus Trescothick and, perhaps significantly, Frank Bruno. This has lead to a steady rise in the number of high profile sportspeople who have begun to talk about how depression can feel, how treatment can be effective and more importantly how recovery from depression and a return to a normal life is possible.
One example is cricketer Marcus Trescothick. In a bravely open description of his depression Trescothick says: “There were times when I didn’t know how I was going to go on. I didn’t know how I was going to come through the pain. Getting through the night seemed so difficult; getting through the rest of my life, impossible.”11 He goes on to state that he got through by telling people about his problem and that admitting what he feared people would consider ‘a weakness’ helped him talk through his anguish and fears. His depression forced him to retire from international cricket, but his recovery has meant he has kept his family together and he still plays cricket for Somerset. “I’m one of the lucky ones,” he concedes. “I spoke out and got help before it got too late.”
Before the death of Gary Speed, the world of football had already begun to address the problem of depression in footballers by producing a guidebook that focuses on mental health, how to try to build resilience against mental health problems and where to find appropriate help. Commissioned by the Professional Footballers Association, the guidebook includes case studies by Neil Lennon, Stan Collymore, Paul Gascoigne and PFA chairman Clarke Carlisle who has been treated for depression and alcoholism.
The death of sportspeople through suicide is always tragic, yet suicide is just one manifestation of depression.
Reliance on alcohol, drugs or gambling, as well other risk taking behavior, can be indications of problems with an individual’s mental health. Some of the greatest football players the world has ever seen from Jimmy Greaves and George Best to Paul Gascoigne and Tony Adams have battled addiction as have giants in other sports such as Jimmy “Whirlwind” White in snooker and tennis Grand Slam winner Jennifer Capriati.
The main driver towards recovery from problems and building resilience against future problems is first to acknowledge and admit the problem then to actively seek help. The current media climate of sensationalising the private lives of sports personalities along with the stigma experienced by those who do seek help means that in the highly scrutinised and competitive world of sport this process is incredibly difficult.
The findings of the National Confidential Inquiry into suicide and homicide that almost three quarters of people who took their own lives had no contact with mental health services in the year before their death contrasted sharply with the fact that a considerable proportion of individuals who complete suicide make contact with GPs and other healthcare clinicians before death. A review of 40 studies of contact with clinicians before suicide found that approximately 45% of individuals made contact with primary care clinicians in the month before death.13
This means that Primary care teams can play a key role in early identification and intervention in mental health issues for their patients.
The Royal College of General Practitioners suggest that this should involve teams developing closer links with Early Intervention teams and Assertive Outreach teams in the local mental health services, closer working with local drug and alcohol services, review systems for patients with long term mental health problems not under the care of specialist mental health services and education for primary care nurses on identifying common mental health problems such as depression, anxiety, dementia and psychosis.
The task for any nurse to engage with someone who is suffering from mental health problems and who has the type of focused, often driven, personality prominent in many successful sportspeople is a difficult one that can call for a high level of interpersonal skills and diplomacy. Helping someone overcome their frustration, anger and ultimately embarrassment at requiring help and supporting them in ways that help them maintain as much control as they can is a challenge for all nurses. It is one, however, that if done well can ultimately lead to a nursing intervention that can be as vital as any other more obvious life-saving nursing action.
1. Appleby L, Kapur N, Shaw J and Robinson J. Suicide and Self Harm. The British Journal of Psychiatry.2003;183:561-562.
2. Callaghan P. Exercise; a neglected intervention in mental health care? Journal of Psychiatric and Mental Health Nursing. 2004;11(4):476-483.
3. McIlroy P, Evans P and Pringle A. Sick as a parrot or over the moon; an evaluation of the impact of playing regular matches in a football league for mental health service users.Practice Development in Health Care. 2008;7(1):40-48.
4. Pringle A. The growing role of football as a vehicle for interventions in mental health care. Journal of Psychiatric and Mental Health Nursing. 2009;16(6):553-557.
5. Smith M and A Pringle A. The Latest Score; an evaluation of the “It’s a Goal!” programme. 2009; IAG: Macclesfield.
6. Baum AL. Suicide and Athletes, a review and commentary. Clinic Sports Medicine.2005;4:853-69.
7. Tutko TA. Personality change in the American sport scene, in Goldstein JH ed. Sports, games, and play. 1989; Wiley: New York: 111–127.
8. Hamilton L.Depression in dancers: Nobody's perfect--but try to tell that to an overachiever. Dance Magazine. 2003;77(10):50-53.
9. Ferraro T. Is Sports Psychology Failing The Athlete? The Online Journal of Sport Psychology. 2004;6(2).
10. Nickel J and Pringle A. Time To Change Sport and Mental Health Project Evaluation. 2011; Time To Change: London.
11. McRae D. Marcus Trescothick; Depression and me. The Guardian. Tuesday June 21st 2011. Available at: www.guardian.co.uk/sport/2011/jun/21/marcus-trescothick-interview
12. Denneson LA, Basham C, Dickenson KC, et al. Suicide Risk Assessment and Content of VA Ealth Care Contacts Before Suicide Completion by Veterans.Oregan Psychiatric Services. 2010;61(12):1192-1197.
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