Critical insights into elite sport staff understandings of athlete mental health and illness: from meaning to practice

There is a considerable risk that athletes will experience mental health issues and mental illness within their lifetimes due to a range of sport-specific risk-factors including injury, performance demands, and retirement. As such, sporting staff are being called upon to support the maintenance of athlete mental health, manage mental health concerns, and treat mental illness. There is an increasing number of recommendations for those working in sport regarding how to support athlete mental health. Despite the acknowledged importance of the staff role in this area, there is a lack of literature exploring how staff conceptualise mental health and illness, and their experiences of managing athlete mental health and illness within an elite sport setting. There is also a lack of focus on athletes’ experiences of severe mental illness, for example bipolar disorder. Thus, the voices of athletes living with mental illness continue to be marginalised. Therefore, the overarching aim of this thesis was to interpretively explore how an athlete with severe mental illness and those working in sport understand mental health and illness and investigate staff experiences of supporting athletes in this area.

This thesis is comprised of five empirical studies. Despite a wide range of documents adding to a growing understanding of applied mental health support, these documents were yet to be synthesised and critically evaluated. Therefore, in study one (chapter three), a systematic scoping review was employed to synthesise and appraise athlete mental health interventions, consensus and position statements, and grey literature. This review provides a comprehensive overview of athlete mental health literature and draws necessary connections across these different types of documents. Findings highlighted a lack of methodologically robust athlete mental health interventions, recommendations for staff that lack actionable detail, and a lack of national governing body polices regarding athlete mental health and illness.

Study two (chapter four) consisted of a reflexive thematic analysis to interpretively analyse performance directors’ understandings of athlete mental health and illness and their experiences of managing these within an elite sport setting. I constructed three themes: making sense of mental health: legitimacy vs. scepticism, mental health as athlete responsibility, and simplifying and sanitising mental health. This study provides critical insight into potential misperceptions some leaders in sport hold regarding mental illness causation, treatment, and the recovery process. Awareness of such misperceptions is fundamental to addressing how athlete mental health and illness are managed within elite sport organisations.

For study three (chapter five), I sought to gain insight into the experiences of another profession in supporting athlete mental health and managing athlete mental illness. There is a growing expectation within elite sport settings that sport psychologists will provide athlete mental health support as part of their role. However, research is yet to explore sport psychologists’ views on this development. Therefore, this study aimed to understand how sport psychologists perceive their role in relation to athlete mental health and illness and explore their experiences of supporting athlete mental health and managing mental health concerns. Through a thematic analysis I constructed three themes: a lack of consensus on remit and role, organisation-practitioner misaligned expectations, and the emotional toll of supporting athlete mental health. This study provides an insight into the tensions sport psychologists experience when managing athlete mental health as part of their role. Applied implications are also highlighted such as a lack of consistent service provision across the profession, the struggle for sport psychologists to practice in line with their values when working within a sporting organisation, and the uncertainty experienced by practitioners when receiving disclosures of mental health concerns.

In study 4 (chapter six), I aimed to address the lack of research investigating how multi-disciplinary staff teams support athlete mental health, manage mental health concerns, treat athlete mental illness. Taking a collaborative approach to supporting athletes is widely acknowledged as best practice. Therefore, I explore how sporting staff understand athlete mental health and illness, and their experiences of supporting athletes in this area when working as part of a multi-disciplinary team. I conducted focus groups with staff members from a range of sporting professions followed by a reflexive thematic analysis. I constructed three themes: an over-medicalised understanding of athlete mental health concerns, a multi-disciplinary team divided, and tensions when negotiating confidentiality. This study provided an insight into staff uncertainty regarding the identification and management of sub-clinical mental health issues. Findings also explored the potential for division between sport science and medicine staff and coaching staff regarding the mental health service provision within elite sport settings, and tensions regarding the handling of confidential mental health information within the multi-disciplinary team.

Addressing the lack of literature focused on athlete experiences of severe mental illness and complementing staff perspectives on athlete mental health and illness within the elite sport environment, the fifth and final study of this thesis (chapter seven) focuses on an athlete’s experience of living with mental illness while competing at an elite level. This study aimed to explore how Darrell, an Olympic athlete diagnosed with bipolar disorder, constructed his illness identity and how this construction shaped his experience of living with mental illness as an elite athlete. I conducted five semi-structured interviews across 10 months and analysed the data using dialogical narrative analysis to consider not only the content of Darrell’s story but also how he told his story of living with bipolar. Darrell constructed a de-stigmatised identity through a multitude of storytelling strategies. Emphasising athletic accomplishments, Darrell reinforced his athletic identity when sharing stories of his mental illness. To distance himself from his mental illness diagnosis, he told stigmatised stories of others with severe mental illness whilst highlighting his own high functioning. Stories of emotionally difficult moments were injected with humour, and manic episodes were portrayed in a glamourised way. This study illustrates how an athlete can construct an illness identity that can help them make sense of their experiences of severe mental illness and proposes that how athletes tell their mental illness stories can impact how staff relate to the athlete and offer support.

In conclusion, this thesis has produced insights into how those working in sport conceptualise and understand mental health and illness. It has examined the tensions and challenges experienced by individual professions and those operating within multi-disciplinary teams. And it has explored how athletes can construct their own illness identity to make sense of their mental illness experience, with the potential to impact how their mental illness is understood by sporting staff. Experiential insights from those in sport must continue to be sought to achieve an understanding of how the mental health service provision can be enhanced.