The Evolution of Sport Psychiatry, Circa 2009

The Evolution of Sport Psychiatry,Circa 2009Ira D. Glick,1 Ronald Kamm2 and Eric Morse3

1 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine,

Stanford, California, USA

2 Sport Psychiatry Associates, Oakhurst, New Jersey, USA

3 Department of Sports Medicine, North Carolina State University, Raleigh, North Carolina, USA

Abstract Over the past three decades, the world of both amateur and professionalsports has expanded greatly and become more complex. In part related tothese changes – and relatively unknown to sports medicine practitioners – thefield of sport psychiatry has steadily evolved and grown. This paper focuseson what these changes have been.

A sport psychiatrist is a physician-psychiatrist who diagnoses and treatsproblems, symptoms and/or disorders associated with an athlete, with theirfamily/significant others, with their team, or with their sport, includingspectators/fans. The primary aims of the specialty are to (i) optimize health,(ii) improve athletic performance, and (iii) manage psychiatric symptoms ordisorders. The training includes medical training to provide knowledge andskills unique to physicians; psychiatric training to provide knowledge andskills inherent in that field, and training and/or experience in sport psychiatryto provide knowledge and skills about psychiatric aspects of sports.

The sport psychiatrist first makes an individual, family-systems and pheno-menological diagnosis of the clinical situation. Based on this evaluation,he sets goals for not only the athlete, but also for significant others involved.He delivers treatment based on the psychiatric disorder or problem using acombination of medication, psychotherapy or self-help group interventionsplus strategies targeted to specific sport performance issues. Evolution ofthe International Society of Sport Psychiatry as well as the field, includingincorporation into school and professional team sports, is described alongwith a ‘typical day’ for a sport psychiatrist. Case examples, a training curri-culum and core literature are included.

Over the past three decades, the world of bothamateur and professional sports has greatly ex-panded. In part related to this phenomenon – andstill relatively unknown to sports medicine prac-titioners – the field of sport psychiatry has stea-dily evolved and grown.

In 1990, Dan Begel[1] carved out a new sub-specialty in psychiatry. He envisaged sport psy-chiatry as ‘‘the application of the principles ofand practice of psychiatry to the world ofsports,’’ and identified some of its developmental,occupational, therapeutic and research aspects.

LEADING ARTICLESports Med 2009; 39 (8): 607-613

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ª 2009 Adis Data Information BV. All rights reserved.

Three observations, in particular, justified the eleva-tion of sport psychiatry to a specific subspecialty.‘‘First, an athlete’s state of mind has a significantimpact on performance; second, participation insports affects the mood, thinking, personalityand health of the participant in specific ways;and third, the psychiatric care of the athlete mustbe adapted to the athletic context in order to beeffective.’’ In the years since the publication ofthis article, sport psychiatry has continued toevolve.

In this current paper, we the authors – threesenior members of the International Society forSport Psychiatry (ISSP) – describe how the fieldhas grown, i.e. what a sport psychiatrist doesgiven the evolution of psychiatric issues associa-ted with amateur and professional sports overthe last two decades. We should say, at the onset,that the field suffers from a lack of controlledstudies (and data) on incidence, phenomenologyor treatment of psychiatric disorders in athletes.There are thus only very limited systematic stu-dies of athletes with psychiatric disorders and nocontrolled treatment studies that suggest thatathletes are to be treated differently to the generalclinical population. As such, controlled studieson psychiatry patients who are not primarilyathletes are often extrapolated to athletes.

1. What is a Sport Psychiatrist?

A sport psychiatrist is a physician-psychiatristwho diagnoses and treats problems, symptomsand/or disorders associated with an athlete, withtheir family/significant others, with their team, orwith their sport, including spectators. The pri-mary aims of the specialty are to (i) optimizephysical health, (ii) ethically improve athleticperformance including optimizing coping me-chanisms and positive psychological strengths,and (iii) manage psychiatric symptoms or dis-orders. It is different from both general internalmedicine and from psychology. The sport psy-chiatrist can recognize common medical condi-tions in the same way the internist can recognizecommon psychiatric conditions like severe maniaor depression, but the psychiatrist has the ex-

pertise necessary to manage these disabling con-ditions over the lifetime of the illness with the aimof maintaining athletic performance. Similarly,the sport psychiatrist has the competency to notonly prescribe medication, but also provideindividual, family or even group therapy (mod-alities that are at the heart of psychology prac-tice). Psychiatrists do not carry out psychologicaltesting.

The training of a sport psychiatrist includesmedical training to provide knowledge and skillsunique to physicians; psychiatric training to pro-vide knowledge and skills inherent in psychiatry,and training and/or experience in sport psychiatryto provide knowledge and skills about psychiatricaspects of sports (see below).

2. What Does a Sport Psychiatrist Do?

2.1 Diagnosis

The sport psychiatrist initially always makes adetailed diagnosis of a clinical situation and thentries to determine the psychopathology underlyingthe presenting problem, symptom or disorder(such as anxiety, substance abuse or an eatingdisorder). The sport psychiatrist must possessspecial skills in interviewing not only the athletebut also the family or significant others, or thesystem (i.e. the coach, family, agent, team-mate,owners, league and all the individuals involved inthe recreational and business aspect of a parti-cular sport). There is an attempt at understandingthe impact of the athlete’s family on the devel-opment of the athlete’s mind, and the role thatsports play in the family system, as well as specificaspects of sports, such as aggression, anxiety, etc.Obviously, there is a special focus on mental ill-ness as well as on interpersonal problems anddisorders. A developing literature[2-5] has helpedpsychiatrists not familiar with the field see how toapproach an athlete who appears to be having a‘mental problem’, and sport psychiatrists havewritten articles in non-psychiatric journals thathave raised the awareness among sports medicinephysicians, and others, to sport psychiatry per-spectives on their patients and teams/systems.

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2.2 Goals

The goals of treatment should be clearly delin-eated. These include goals for the athlete and, insome cases, the team or the family. The family, infact, can be very important in helping to developgoals for the athlete, and to aid in treatment ad-herence. Derrick Adkins won the 400 metre hur-dles at the Summer Olympics in Atlanta in 1996,and was being treated with a selective serotoninreuptake inhibitor (SSRI). He had to taper theSSRI prior to the Olympic trials and the Olym-pics, in favour of serotonin (5-HT), because offatigue and slower running times. After the eu-phoria of winning the Olympics, the patient didnot feel it necessary to go back on the SSRI, buthis mother noticed him becoming more and moredepressed while watching him run on TV in theEuropean tour. The patient was restarted onSSRIs and made a recovery, although his com-petitive times suffered (table I).[6]

2.3 Treatment

There are a number of ways to categorize thetreatments a sport psychiatrist delivers. First, onecan describe the evidence-based treatment for aspecific psychiatric disorder associated with aparticular athlete (e.g. attention deficit hyper-activity disorder [ADHD], eating disorders, sub-stance abuse [including performance-enhancingdrugs], etc.). Second, one can subdivide treatmentaccording to the particular modality (or morecommonly combination ofmodalities) prescribed:here we include psychotherapy (individual, family,group, etc.), pharmacotherapy, self-help groupssuch as Alcoholics Anonymous, etc. Third, onecan provide interventions for a specific prob-lem, i.e. suicide, retirement issues, sex or racial

issues, etc. Finally, one can describe specificstrategies such as those found within the rubric ofmental skills training, targeted to specific sportperformance issues (lack of aggression, lack ofconfidence, too much arousal) or to unique stra-tegies for a specific sport (e.g. tennis, golf, boxing,football, gymnastics, etc.).

Needless to say, the sport psychiatrist hasspecific skills and techniques to use in his or herwork with teams, whether the problem is a highincidence of antisocial behaviour on the team oris related to performance issues or coach-player-team interpersonal dynamics.[7] There are nowprofessional and team assistance programmesmanaged by psychiatrists – although their effi-cacy and effectiveness are still unstudied.

The following three cases illustrate some ofthese issues.

2.3.1 Case Number 1

A boxer in his junior year of high school hadbeen evaluated extensively for ‘abdominal pain’.It soon became apparent that the boxer was suf-fering from DSM-IV Eating Disorder NOS (nototherwise specified).[8] Pre-occupation with weighthad begun when the coach had insisted that hedrop down a weight class in order to help his club.Extensive family therapy and psychotherapyhelped the patient to recover. Since the patientwanted to compete the following year, the sportpsychiatrist contacted the coach regarding thenecessity of not putting any pressure regardingattaining a specific weight on the athlete. Follow-up revealed that the coach disregarded the psy-chiatrist’s advice, precipitating another episodeof anorexia, which resulted in the athlete leavingthe sport.

2.3.2 Case Number 2

This case illustrates a sport psychiatrist beingcontacted via the internet. All of the authors havea website, in addition to the website of the ISSP(www.TheISSP.com). This website has been inexistence for almost 10 years and we have han-dled questions from coaches, parents and ath-letes, often about youth sport issues. The websiteshave served as a source of information for the

Table I. Treatments in sports psychiatry

Medication management, i.e. pharmacotherapy

Psychotherapy: individual, family, group, cognitive behavioural

therapy, etc.

Performance-enhancing techniques and strategies

Substance abuse/dependence management and treatment

Mental skills training

Self-help groups

The Evolution of Sport Psychiatry, Circa 2009 609


general public and medical/sport medicine pro-fessionals as well.

A father contacted a sport psychiatrist becausehis son, a junior playing lacrosse for a local highschool, was suddenly denied significant playingtime. Two freshmen had come onto the team andthere was the appearance of favouritism, in thatone of the freshman’s parents worked at theschool, and rumour had it that the coach hadpromised the parent that the freshman would getsignificant playing time. The second freshman’sfather was the coach of a travelling team on whichthe patient’s coach’s son was a player. The pa-tient had been a stellar player, and, according tothe father, spectators and other coaches wereperplexed as to why he would be benched. Thebenching and the attention surrounding it re-sulted in a performance decline, and the patientleft the team midway through the season.

The father contacted us via the website to seewhether the boy should switch schools for hissenior year, whether he should quit the sport, orwhether there was a way to salvage his senior yearat the same high school.

2.3.3 Case Number 3

A college football player complained of beingpicked on by his coach and singled out. He wasdiagnosed with major depressive disorder andhad to leave the team while he was treated withpsychotherapy and medication. The depressionimproved but the decision was made that theplayer should transfer to another college. A peti-tion was made to the National Collegiate AthleticAssociation (NCAA) that the patient not lose theyear because he had a serious medical disorder.The request was granted and the patient went onto have a successful college career at anotheruniversity.

There have been articles by sport psychiatriststhat have helped bring about changes in a sport.Tofler et al.[9] wrote their ‘achievement by proxy’article in the mid-1990s. It was a significant factorin influencing US gymnastics to raise the age ofeligibility for the Olympics to 16 years, as therehad been concern in the Sport Medicine andSport Psychiatry communities that the intensepressure to make the Olympics on 12-, 13- and

14-year-old female gymnasts was leading to anincreased rate of physical and psychological dis-orders in this population.

2.4 Evolution of the Field

Over the last two decades, sport psychiatrists(and other mental health professionals) havemoved from a peripheral position to becomingincorporated into college and professional teamsports.[10] The reasons underlying this are multi-ple, including not only competitive pressures towin, but also the need to help handle the asso-ciated fallout that may follow bizarre behaviouron and off the field, an overemphasis on or in-appropriate aggressive tactics or cheating, familyproblems, the anabolic steroid scandals (baseball,track and cycling most prominently), and finallythe abuse of substances used by athletes (in partas a way to manage stress) seen in virtually everysport.

Physicians are now heavily involved in thesubstance-abuse problem, as we have describedabove, and every professional league has an‘expert’ – often a psychiatrist – as part of theleague structure. They treat Axis I Disorders,[8]

e.g. anxiety disorders or Tourette’s disorder.Sport psychiatrists are now being integrated

into the treatment team for problems such asgambling, as well as being central to under-standing the effects of injuries in certain sports(e.g. brain damage in soccer, football, boxing, etc.)and of career termination issues. In that regard,one of the authors (RK) serves on the board ofa boxing organization, Fighters Initiative forSupport and Training (FIST). This organizationhas helped to develop a programme dedicatedtoward helping fighters transition to anothercareer before brain damage occurs.

By way of example, here is a description of atypical day of practice for a pioneering full-timesport psychiatrist (EM):

I work with athletes two afternoons a week atmy local university’s training room as part ofthe sports medicine team. Besides providingpsychiatric services, I do team substance useprevention work, team building exercises toimprove group dynamics, and consultations with

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coaches. I also see athletes a few hours a weekin my private practice.

ADHD is probably the most common mentalillness I treat. Stimulants are still first-linetreatment. Since they can be performance-enhancing, we do extensive testing and clinicalinterviews by more than one clinician to make acertain diagnosis, rule out other issues, andprovide documentation for applying for specialaccommodations. The proper documentation inthe Sports Medicine chart prevents difficultieswith positive urine drug tests for stimulants. Anyathlete with Olympic aspirations needs to applyfor a therapeutic use exemption from USADA(United States Anti-doping Agency).

Treating depression or anxiety is probably thenext most frequent referral. Athletes’ exerciseand nutrition regimen tend to be healthier thannon-athletes’. So when they meet DSM-IVcriteria for a mood or anxiety disorder, medica-tion management is often required. I usuallyrecommend psychotherapy (sometimes in split-treatment) combined with medication.

As a board-certified addiction psychiatrist,evaluating and treating substance use disordersin athletes is my specialized niche. I do theaddiction counseling myself. I use motivationalinterviewing techniques more in athletes than12-step facilitation or CBT [cognitive behav-iour therapy], in comparison with my non-athletes. I find it challenging to convince mostathletes to go to a 12-step meeting (AA or NA[narcotics anonymous]).

I also work with athletes who suffer with eatingdisorders. Most fall into the category of‘Anorexia Athletica’ or in DSM-IV terms,Eating Disorder NOS. We use treatment con-tracts that will involve input from coaches,parents, athletic trainers, sports medicine phy-sicians, dieticians and other providers. Weprovide support in some cases to the team oraffected teammates. On some teams, we need todo some educational programs and address theteam culture. Athletes may have ‘The Over-Doers Triad,’ meaning an eating disorder,obsessive-compulsive disorder and exercise de-pendence. SSRIs can be extremely helpful in

reducing obsessional thinking and help theathlete do better in therapy.

2.5 Child and Adolescent Sport Psychiatry

Over the past two decades there has been agradual increase in athletes aged from (mostly)8–18 years consulting with sports psychiatrists.The reasons for consulting tend to fall in twoareas: (i) DSM-IV disorders like anxiety disorder,phobic disorder and even obsessive-compulsivedisorder, and (ii) performance-enhancing inter-ventions. For example, an 11-year-old tennisplayer’s family called for help in ‘focusing’ duringa match, while a 15-year-old swimmer asked forhelp for ‘negative thoughts before races’. Strate-gies and techniques are designed to (i) learn toconcentrate, (ii) set goals, (iii) ‘relax’ and (iv) stayfocused. Anecdotally, all have been found to im-prove performance to varying degrees. In addi-tion, treatment has been found to uncover familyconflicts about a child’s (or even spouse’s) ath-letic choices for performance or more commonlylong-standing family conflicts.

2.6 Curriculum

There are now at least two curricula to supportsport psychiatry training programmes.[11] Theyare targeted to psychiatry residents or fellows andare consistent with the requirements set forth bythe Residency Review Committee for generalpsychiatric residency training programmes. Thecurriculum is used as an elective for psychiatrists,but it can be used as a foundation for developinga fellowship in sport psychiatry as well. The edu-cational objectives include (i) knowledge of sportpsychiatry, (ii) specific skills, and (iii) attitudesto be developed during the elective, plus learn-ing experiences actually working with athletes.Learning experiences include both clinical anddidactic experiences.

2.7 Organization and Turf Issues

In addition to the psychiatrist, there are manyother disciplines involved in the field includingtrainers, psychologists, counsellors (broadlydefined) and self-styled so-called gurus working



with a particular person or field. Unfortunately,in some cases, some of these people are the sup-pliers of performance-enhancing substances likeanabolic steroids, amphetamines or other com-pounds. On the other hand, useful collaborativerelationships are being forged with other profes-sionals – sport psychologists being one example.There is now at least one practice that combinessport psychiatry and sport psychology, as men-tioned above. It has an Association for AppliedSport Psychology (AASP)-certified sport psychol-ogist, a masters-level sport psychology consultant,three ISSP sport psychiatrists, another licensedpsychologist, and two licensed professional coun-sellors, all working together (E. Morse, personalcommunication, January 2008).

Since the Begel article was written,[1] the ISSPhas grown and now serves, in part, as a resourcefor the field. The core purpose of the ISSP is ‘‘tofacilitate scientific communication about, andunderstanding of, disorders of the brain and be-havior associated with sport, and to advance theirprevention and treatment’’. The ISSP has an an-nual meeting in which the latest techniques anddata are presented, has organized and sponsoreda well attended symposium at the annual meetingof the American Psychiatric Association (APA)for the last 10 years, and has provided a curricu-lum for the field. The website is evolving into aforum for the exchange of ideas in the field, thedissemination of a quarterly newsletter, and amembership list to assist in referral to sport psy-chiatrists in different geographic locations.

As mentioned, ISSP members have consultedwith all the professional leagues around issues ofpsychiatric disorders, inappropriate behaviour(including aggression and substance abuse),medical-psychiatric issues like concussions, andother psychiatric issues.

One benefit of the symposia has been the de-stigmatization of emotional problems in sports.At the APA, high-level athletes like Julie Krone(jockey), Derrick Adkins (track), Gerry Cooney(boxing), Pete Harnish (baseball), WendyWilliams (diving), Terry Bradshaw (football) andothers have openly discussed their struggle withAxis I Disorders, and Krone and Bradshawbecame the first high-profile athletes to acknowl-

edge taking SSRIs while competing. The mediahas helped raise the public’s awareness of the factthat athletes (long thought to be the epitome ofwellness) sometimes receive psychiatric medica-tion too. Ms Krone’s revelation and other ath-lete’s disclosures have also made it far easier forgeneral psychiatrists to convince their patientsof the tolerability of psychiatric medications –after all, if a high-level athlete can take a medi-cation and compete as well or better than before,what does the patient have to lose by tryingto add such a medication to their treatmentregimen?

Members of the ISSP have also hosted mediasessions at the annual convention of the APAdiscussing movies (When They Were Kings,[12]

Remember the Titans[13]) with important sportpsychiatry themes. Child psychiatrist members ofthe ISSP have also hosted media sessions atAmerican Association of Child Adolescent Psy-chiatry annual meetings. Lastly, sport psychia-trists have consulted with media to help the publicunderstand puzzling events in the athletic worldas they unfold – a boxer biting another boxer’sear, a football player making a ‘suicide attempt’,a wrestler killing his family and then himselfwhile using anabolic steroids, and stimulant andanabolic steroid use by baseball players.[14]

We envisage that this field will evolve over thenext 20 years like other subspecialty areas of psy-chiatry such as legal psychiatry, child psychiatry,etc., which means implementation of ethicalstandards, specialized training programmes, cer-tification examinations and boards, etc. Sportspsychiatrists will become more involved in ama-teur as well as professional sports as the stigma ofmental illness diminishes.

2.8 Summary and Conclusion

In this paper we have described the develop-ment and growth of sport psychiatry. We havedescribed the evolution of what has happened tothe field in the last two decades. Although wehave described a variety of new roles for the sportpsychiatrist, the rapid change in the field and theinternational growth of sports has led to newchallenges and new treatments to improve the

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health of the athletes (and significant others) withwhom we work, as well as their teams.

Acknowledgements

We are indebted to Dan Begel, MD for helpful commentson an earlier draft. No funding was received for this article,and the authors have no conflicts of interest that are directlyrelated to the content of this article.

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5. Stryer HK, Tofler JR, Lapchick R. A developmental over-view of child and youth sports in society. Tofler JR, editor.Child Adolesc Psychiatr Clin N Am 1998; 7: 6997-724, vii

6. Adkins D. Exercise, athletic participation, and mentalhealth: when it works and when it doesn’t. Paper presentedas part of symposium 26. American Psychiatric Associa-tion Annual Convention; 2001 May 7; New Orleans (LA)

7. Kamm RL. Group dynamics and athletic success. Presentedat the American Group Psychotherapy Association’sAnnual Meeting; 2000 Feb 18; Los Angeles (CA)

8. Diagnostic and statistical manual of mental disorders. 4thed., text revision. Washington, DC: American PsychiatricAssociation, 2000

9. Tofler IR, Stryer BK, Micheli LJ, et al. Physical and emo-tional problems of elite female gymnasts. New Engl J Med1996; 335: 281-3

10. Nicholi A. Psychiatric correlation in professional football.New Engl J Med 1996; 31: 1095-100

11. Bogacki DF, Newmark TS. A psychiatric curriculumdirected toward sport psychiatry. Camden (NJ): CooperUniversity Hospital, 2007

12. KammRL, Calhoun J, Tofler I. When we were kings.Mediasession at the American Psychiatric Association AnnualConvention; 1998 Jun 2; Toronto (ON)

13. KammRL, Tofler I. Remember the Titans. Media session atthe American Psychiatric Association Annual Convention;2002 May 22; Philadelphia (PA)

14. Mitchell GJ. Report to the Commissioner of baseball of anindependent investigation into the illegal use of steroidsand other performance enhancing substances by players inmajor league baseball. New York: Office of the Commis-sioner of Baseball; 2007 Dec 13

Correspondence: Prof. Ira D. Glick, 401 Quarry Road, Suite2122, Stanford, CA 94305, USA.E-mail: [email protected]



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The Evolution of Sport Psychiatry, Circa 2009