The New Mental Health Treatments That Might Save Our Athletes

“What combination of of blankness and concentration is required to sink a putt or a free-throw for thousands of dollars in front of millions of unblinking eyes? What goes through their minds? Are these athletes real people? Are they even remotely like us?” – David Foster Wallace, How Tracy Austin Broke My Heart

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The answers aren’t obvious. On one hand, athletes are real people, exactly like the rest of us, subject to taxes and gravity and growing old; on the other, they work and play in what can seem and feel like a parallel universe. Consider football and boxing and MMA brains reduced to quivering jellyfish due to relentless poundings and stress that most of us cannot comprehend, much less face down for a living. Consider bodies pushed into perfection, then sliding down the gore-slicked back side of the bell curve into inevitable decay. Consider it all and then imagine how in the world one could possibly go about addressing the issues in play.

Read More: Brandon Marshall, Mental Illness, and Making It All OK

Indeed, it’s something of a given that athletes require specialized approaches to mental health and substance abuse treatment. The rash of suicides, homicides, and domestic abuse cases plaguing the NFL demands larger questions about the sport’s consequences, and about its morality. Once upon a time, so did the alarming (and possibly erroneous) discovery of downright unbelievable suicide rates for retired cricketeers.

Athletes, from Brandon Marshall to Ben Scrivens, have become some of our most outspoken mental health advocates, but they remain among our most under-served and vulnerable citizens.

What is wrong with our athletes, and how can we help them?

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University of Nevada, Las Vegas psychology professor Dr. Brad Donohue is seeking the answer.

A champion amateur boxer in his undergrad days at Kansas—he won the 1986 PAL national championship at 178 lbs and was one of the top five amateur boxers in the country —Donohue is uniquely qualified to approach psychological issues from a sporting perspective, something he sees as key to the future mental health of athletes. While sport psychology is focused primarily on performance, the preventative and therapeutic benefits it could provide have gone largely unexplored, as scientists, athletes, coaches, and leagues chase victory, but ignore mental health.

“I think that there have been a lot of professional efforts, usually through sports psychologists, that have worked on sport performance, and often times that’s what coaches and athletic administrators consider the most important thing, the athletes consider that the most important thing,” Donohue said via phone from Las Vegas. “They focus on those areas, and unfortunately, they have life events around them; sport performance is just a small percentage of their life, and so they have all these life goals that they need to accomplish or life stresses that are out there that act to kind of contaminate their sport performance.”

While there is nothing wrong with sport psychology focusing on performance per se, the obsession with performance has lead to something of a blind spot in the field.

“I think it’s because we have people who specialize in sport performance that really don’t have the skill sets to work with the mental health aspects, and then we have a lot of people with mental health professionalism that really don’t have the sport background,” Donohue said.

The conflation of these closely related—yet parallel, rather than overlapping—fields may be the key to treating mental health and substance abuse disorders in the athletic community. To that end, Donohue, the director of UNLV Family Research Services, is now also principle investigator for The Optimum Performance Program in Sports (TOPPS), which does just that.

TOPPS utilizes evidence-based treatment methods—that is, methods clinically proven to be effective with large samplings of the population—and modifies them to better fit athletes specifically.

Donohue offers up Family Behavior Therapy (FBT) as an example; FBT revolves around incorporating the family and friends of the individual afflicted in their treatment. For athletes, TOPPS augmented the classic FBT model to include coaches and teammates, co-mingling the athlete’s nuclear, extended, social, and sporting families into one support system.

“We look at it like the people that are around them aren’t necessarily the causes of the problems they may be experiencing, but they certainly are part of the solutions,” Donohue said. “If we can get everybody working on things, communicating with one another so that they are all on the same path, then it becomes a lot easier to accomplish the goals that the athlete might have.”

In a sense, the TOPPS FBT program is the august ideal of sport made manifest: a team working in conjunction towards one common—and noble—goal. In essence, UNLV is attempting to fulfill the great promise of intercollegiate athletics: the betterment of those who play them.

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Treatment methods for mental health and substance abuse disorders (such as depression, of which the World Health Organization says there are “effective treatments”) can be just as clinically sound as treatments for other more common pathologies. For example, according to Illinois Institute of Technology psychology professor Patrick Corrigan, depression care is comparable to that afforded people with hypertension in its success rate. If such programs exist—and custom-made, no less—and work, why are athletes, and vast swaths of the population in general, still suffering?

While science has made strides—it is one of our great myths that we cannot effectively help the depressed and anxious and schizophrenic—society has not; social and structural stigmas keep many from admitting they need help, much less seeking it

This is exacerbated by the culture of sport, which, in some darker reaches, can preach that strength is equivalent to not showing, or ignoring, weakness. “Play through the pain” may be solid advice for abrasions and wounded egos, but can be lethal for the depressed or narcotic-addicted.

“What that does is it in a sense may punish the person for feeling like they need to go out and talk to their friends, or pursue a professional intervention,” Donohue said. “That causes stigma, and stigma leads to people just not getting the services that would have prevented some of the problems that kind of build up.”

TOPPS is keenly focused on de-stigmatization; the UNLV athletic department has been supportive of the program, an important step in legitimizing it, and everything—right down to the very language—is meant to assuage the feelings keeping individuals away.

“We don’t use psychological terms,” said Donohue. “For instance, instead of ‘psychologist’ or ‘therapist’, which have a lot of psychological stigmas, we use words like ‘performance coach’ and ‘performance interventions’ and ‘optimization of performance’ as compared to talking about disorders or things that aren’t going right with the athletes.”

A focus on positivity, on not totally solving an issue so much as achieving a goal, fits handily into the predominant sporting rhetoric; there’s certainly nothing wrong with optimizing one’s performance.

Results have been promising so far; TOPPS published the program’s first three research papers in late-summer, and the National Institute on Drug Abuse has awarded the program a $2 million grant. In one case study, an athlete who went through the TOPPS program reported reduced binge drinking, unprotected sex and better relationships with teammates, as well as substantial decreases on standardized psychological tests measuring stress and troublesome thoughts.

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In addition to the sports-specific stressors that come from being expected to achieve under immense scrutiny—and the anxiety and depression they can produce—athletes face a litany of other, familiar problems in unique and unfamiliar ways.

Body image issues and eating disorders can affect any athlete, as their body is the locus of their identity, and are particularly acute in the combat sports. Athletes are also prone to tie their self-worth and identity into their ability to perform; in such cases, a career-ending injury is less a setback than a kind of death, an entire life seemingly shattered.

Collegiate athletes, already facing the same financial, academic, social and environmental problems as their peers, have additional time management issues due to their sport commitments. Some, having survived their college years through a highly regimented lifestyle—as good athletes should—graduate rudderless, finding an open world frighteningly impossible to navigate sans coaching and structure.

The training required for elite level competition is both physically and mentally strenuous, as well as time-consuming. “Throw in distracting criticism from others,” Donohue wrote, “and lack of opportunities for life skills development, and non-optimal mental health and sport performance can easily occur in athletes.”

Lack of life skill opportunities may sound innocuous, but the rise of specialization, coupled with athletes beginning to train much longer and much younger, can hamper social development. A sport-centered childhood at the expense of other interests leaves precious little room for activities which may help to buffer against future mental health issues, including the various social and intimate mores and skills picked up through close friendships, or business practices first learned in part-time jobs. Sport may be breeding a generation of athletes unable to avail themselves of these basic social tools, thanks to a system which actively discourages them from learning them later.

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TOPPS has been seeing good results so far, according to Donohue, and the mental health landscape may finally be shifting away from stigma, with sports helping to lead the way. With effective, and sport-centric, methods in place, it is now upon the athletes and society to see that programs like TOPPS help as many as possible.

Athletes have nearly unmatched potential as role models and heroes; few people are as dogmatically beloved as the All-American All-Star, the national champ; their greatness is, as David Foster Wallace, himself a former athlete who struggled with mental health, once wrote, “a matter of public statistical record.” Can professional athletes use their stature to radically alter how mental health and substance abuse disorders are understood and treated in athletes and, ergo, us all?

“In my opinion, the speed at which performance programs will be widely adopted will depend on the courage of elite athletes, like Brandon Marshall, Michael Phelps, and others, to indicate how these programs are helpful,” Donohue wrote, “and the compassion of their fans to appreciate their sometimes unique circumstances.” A compassion which can hopefully extend to everyone.