As Players Open Up, the NBA Tackles Mental Health

John Watson

Disclosures

January 06, 2020

In recent years, several NBA All-Stars have spoken about their mental health struggles. Even the league's own commissioner remarked on how surprised he was by the level of anxiety and unhappiness he has observed in the players.

This past summer, unease around the league may have come to a head: The NBA announced a series of mandatory mental health guidelines to address these burgeoning issues. These guidelines will require that teams have at least one licensed mental health professional on their full-time staff, retain a licensed psychiatrist to be available when necessary, and have specific action plans codified in writing for mental health emergencies.

To understand what a change of direction this is for the NBA, one only needs to look back to 2012, when a young player named Royce White was drafted in the first round of the lottery. White was very transparent about having generalized anxiety disorder and how it might affect his ability to travel and participate in other aspects of playing in the league. Despite showing considerable promise, he was soon out of the NBA, the victim of what he considers a league-wide blackballing for having a mental health condition.

Medscape spoke with Jennifer Carter, PhD, director of sports psychology at The Ohio State University Wexner Medical Center, about the NBA's evolving stance on mental health initiatives and how they may benefit nonprofessional athletes as well.

It's been less than a decade since Royce White was drafted, yet in the intervening years the NBA seems to be applying a much more responsible approach to addressing mental health in its players. What's changed?

Awareness of mental health (in general and in sports) has increased, while stigma has decreased. One reason for these changes is the bravery of athletes like Royce White to blaze a path of honesty and helping others.

Risk factors include...stunted identity development in which there is a lack of balance in their lives due to the consuming nature of their sport.

Athletes have always had mental health disorders, but the athletic culture of invulnerability has discouraged them from talking about them in public. Hopefully, we will keep improving our understanding of mental health disorders as increasingly common human issues instead of as secret or shameful signs of weakness.

Prominent NBA players such as Kevin Love and DeMar DeRozan have spoken out about their struggles. We've heard such things from retired players, but it seems somewhat new for those who are still actively playing to do so. Do you think this reflects something unique about the NBA, its players, and what they face? Or is this probably similar to what high-profile athletes in other sports are also experiencing?

Mental health resources have grown across professional sports and college sports, particularly in the past 5 years. NBA players probably experience mental health disorders at similar rates to other professional athletes, but it does seem like a good number of NBA players have come forward with their struggles recently. To speak about mental health issues while actively playing is especially courageous.

In 2018, the National Basketball Players Association named psychologist Dr Bill Parham as the director of mental health and wellness—the first position of its kind in professional sports.

What other factors may be contributing to mental health issues in athletes, not just those in the NBA?

Athletes face mental health issues like anyone else, experiencing protective and risk factors. Factors that protect athletes from experiencing mental health disorders include the benefits of exercise for lowering anxiety and depression, as well as the social support provided by the team.

Risk factors that increase mental health disorders in athletes include athletic injury, extreme pressure in multiple facets of life, a "no-excuse" culture in which athletes minimize or deny feelings, and stunted identity development in which there is a lack of balance in their lives due to the consuming nature of their sport.

Athletes may experience symptoms of mental health disorders differently from non-athletes. For example, athletes may drink alcohol less frequently but binge drink more often than non-athletes.

How much of this is a generational shift, whereby high-profile athletes simply now feel more open to discussing this, whereas in the past they probably might not have been?

There is a higher prevalence of anxiety and depression in young people compared with past generations, combined with increased awareness of mental health disorders in the public.

I applaud these athletes for sharing their stories. Once one high-profile athlete speaks out about his or her struggles, it becomes easier for other athletes to follow their example and take that risk. After sharing their stories, high-profile athletes often hear that their message was very meaningful to individuals who have felt alone in their struggle—sometimes even saving lives by preventing suicide. This positive reinforcement spurs further disclosure.

In a conference this past March, NBA Commissioner Adam Silver directly remarked on how prominent the isolation, anxiety, and unhappiness he's observed in players is. He considered it "a direct result of social media." How do you think social media plays into this?

There is a connection between increasing use of social media and rising feelings of depression, anxiety, and isolation, but it may be premature to claim that one causes the other before solid longitudinal research establishes causation.

...the trappings of fame often cause additional problems unanticipated by athletes who simply want to make a living from their talent and skills.

Some studies have found that Generation Z (born between 1996 and 2010) is the most connected on social media but the loneliest generation we have seen. Like anything else, social media has its pros and cons, and moderation is useful. I have heard that some high-profile athletes choose not to read comments on social media, which is probably a wise choice, given the anonymous vitriol aimed their way.

Of course, there will be people who say, "What reason do rich and successful celebrity athletes have to be unhappy?" This was basically the reaction of Charles Barkley to Silver's comments, who in his very Barkley way said, "That's the stupidest thing I ever heard any commissioner say." Is there a risk that a public stance may lead to a backlash, and players will think twice about discussing this?

Pain is pain, and it's unwise to judge the experiences of others without walking in their shoes. Those who haven't encountered mental health disorders may not understand the experience, but denying that these problems exist doesn't make them go away. Clinical depression is no different from a broken leg—both need treatment and rehabilitation.

Instead of causing a backlash, public support for mental health resources is a great way to decrease stigma and improve treatment outcomes. Fame may seem like the key to happiness, but the trappings of fame often cause additional problems unanticipated by athletes who simply want to make a living from their talent and skills.

High-profile athletes often feel used by those who want their money and status. And who would want their job performance and personal life to be scrutinized by the public? Quality relationships, a sense of meaning, contributing to society—these are contributors to happiness, not fame or money.

We're focusing on the NBA here because it's obviously a high-profile and popular league, whose players are household names. But are the stressors reported by professional athletes also shared by younger, amateur athletes?

Younger athletes may not struggle with celebrity to the same extent, but they experience stressors like balancing sport with school or work and financial difficulties, in addition to stressors already mentioned, like injury and a culture of toughness.

Do you think there's currently a good understanding of these stressors at the college and high school level? And even if so, are these programs generally equipped with any kind of sports psychology component to deal with this?

Dr Brian Hainline, chief medical officer of the National Collegiate Athletic Association, has done wonders for college athlete mental health. Many Division I universities, including Ohio State, now offer mental health services tailored to the unique needs of their student athletes.

It's rare for high school athletic departments to offer mental health resources, but this is one area that will probably grow. In addition to mental health, sport psychologists can offer mental training to athletes, addressing the mental aspects of performance.

Do you have recommendations for practitioners treating younger athletes of what to look for when it comes to signs of mental health struggles? Is there a particular point when they should be considering a referral to a mental health professional?

We all experience depressed mood or worry from time to time. Changes in mood or behavior rise to the level of a mental health disorder when they, one, cause significant distress and, two, interfere with functioning in school, work, sport, and/or relationships.

If there is significant distress or impairment in functioning (for example, the individual is having ongoing sleep problems that affect performance), it's a good idea to refer to a mental health professional. The referral becomes more urgent with the presence of suicidal thoughts or urges. It is okay to ask, "Are you thinking about suicide?" or "Are you thinking about killing yourself?" Then follow up with a mental health professional or emergency department.

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