GOLF AND MENTAL HEALTH
A FRAMEWORK FOR SUPPORTING GOLFERS
– Written by William Wynter Bee, Netherlands and UK, Danny Glover, UK, and Margo Mountjoy, Switzerland and Canada
WHAT IS MENTAL HEALTH?
Mental health is more than the absence of a mental health condition. It is important in everyday life to help a person realise their full potential, be resilient in adversity, and develop meaningful relationships and contributions to society. Psychological, physical, social, cultural, and spiritual factors all play a role in contributing to mental health1. It is important to recognise that mental health is a spectrum and at one end there are people at their peak performance or flow state (Figure 1). At the other end there are people suffering with mental health disorders and most people sit somewhere in between. It is a key skill for individuals to be able to identify what behaviours improve their personal mental health.
MENTAL HEALTH AND GOLF
In recent years, the importance of mental health (MH) and well-being in elite sport has been better recognised, as demonstrated by the International Olympic Committee’s (IOC) consensus statement on this topic3. The consensus reported that elite athletes suffer a range of MH symptoms and disorders, highlighted sport specific risk factors, reviewed diagnosis and management and identified the need for MH prevention and intervention strategies3.
Touring athletes, such as golfers, have specific MH challenges. High profile golfers, including Ryder Cup Captain Thomas Bjørn in his book Mind Games4, have talked openly about their MH struggles and how elite golf can cause mental stress. There is a difference between how the media presents elite sport and the reality for many golfers struggling to earn enough to keep playing and spending much of the year away from friends and family travelling from hotel to hotel5. Research entitled “Life in the Travelling Circus” reviewed elite golfers and highlighted several strong predictors of mental ill-health that are common in touring professionals, including loneliness, isolation, and low social support5.
Recent research on a cohort of 162 female golfers from 56 countries at the International Golf Federation (IGF) World Amateur Team Championships found that 32.5 % of them reported mental health symptoms in the prior 4 weeks with generalised anxiety, performance anxiety and low mood / depression being the most frequent MH problems6. Furthermore, research on the European Challenge Tour found a two-week prevalence of psychological distress (52%), obsessive thoughts and compulsive behaviour (28%), depression (10%) and anxiety (9%). The majority (2/3rds) of those who reported mental health symptoms did not seek psychological support7. This highlights the importance of developing MH support in golf and this article considers how athletes can be supported at home, and when travelling, through a robust mental health framework to prevent mental health problems from arising as well as recognising them early and managing them efficiently when they do occur. A framework should also support a larger number of golfers involved in national programs, which may include adolescent and adult athletes. Providing appropriate support can contribute to a safe, welcoming, and enjoyable environment, where golfers can flourish and set strong foundations for any transition towards a career in golf.
CONSIDERING A COMPREHENSIVE MENTAL HEALTH FRAMEWORK
In any sport it is key to understand the specific demands and stresses athletes face. There is a large number of different people and organisations that may be involved in supporting an athlete and all may therefore have an impact on the athlete’s mental health (Figure 2)
Golf worldwide has multiple organisations and stakeholders involved in assisting golfers. These include national federations/ governing bodies (i.e., Golf Australia, Norwegian Golf Federation), golf’s international governing bodies including the IGF (International Golf Federation), The R&A and the USGA (United States Golf Association) as well as college/ university and “Academy” programs. Individual “Tours” are essentially event organisers that organise golf tournaments for elite professional golfers. When thinking about supporting golfers at all levels it is key to consider how organisations can support individuals and work together to prioritise mental health. This recognises, that touring professionals typically are their own bosses (most are not employed by a federation or a tour), and that they can structure their own support, while sometimes benefitting from their National Federation’s support. The tours, similar to the ATP Tour tennis, or the UEFA, are responsible for providing health and safety, and appropriate medical support at events, but are not responsible for the day-to-day medical care of players.
There is a growing number of medical professionals and support staff involved in golf athlete care including Sport and Exercise Medicine (SEM) doctors, physiotherapists, strength and conditioning coaches, osteopaths, and sports psychologists as well as non-clinical support staff. It is important to consider how these staff interact to promote athlete MH both at home and when they are travelling.
Purcell et al. 2019 proposed a comprehensive framework (Figure 3) to support athletes and this article will consider how this framework can be implemented in golf. It considers prevention with early intervention to prevent and provide prompt treatment of MH problems6.
This paper suggests that “MH is everybody’s concern but should be overseen by a few people” and sporting organisations ( i.e., national federations, and event organisers) have a responsibility to ensure a mentally safe sport environment. Athletes and should be encouraged to discuss MH, and sport organisations should promote education, empower the athlete voice, ensure confidentiality, be prepared to early identify, and remove barriers to encourage help-seeking9,10. Furthermore, it is helpful to have a Mental Health Officer (MHO) responsible for education, building a referral network, developing a MH emergency action plan, being a contact for athletes, and overseeing athlete management and transition9,10.
A MH framework should also consider risk factors for mental ill health, including injury, performance failure, sport type (individual is higher risk than teams), transition out of sport, low social support, and poor sleep as well as the need to remove barriers to seeking MH support, including stigma, low MH literacy, negative past experiences, and busy schedules9,11. Coaches and peer-athletes are key to help facilitate MH supportive environments, and to decrease stigma to improve help-seeking11. Any intervention requires cultural competence, considering how health beliefs and behaviours impact MH service delivery11.
When applied to golf, this framework ideally brings in the four levels described in Figure 3. It is ideally overseen by a Mental Health Officer, who may be a suitably trained doctor to oversee the framework with support from a specialist MH team.
Timing is key. Staff education sessions and refreshers can be usefully undertaken before the start of the competition block, often at the same time as CPR/ first aid training. If mental health screening is undertaken, and an athlete is deemed at risk (e.g., transition, injury, performance concern) then MH support can be implemented early9. Key golf specific considerations are that the seasons are long, often running almost the entire year. It is also important to support players who do not perform and lose their status within a regional or national program, or within a competition structure, as this is a key time when mental health problems can present.
Level 1: Preventative components
EDUCATIONS IS KEY: At the first level education is important to develop an understanding of mental health issues (mental health literacy). This might consist of MH workshops for players and support staff as well as on-line delivery of educational information. The curriculum contents should be broad but should include a definition of mental health, risk factors for developing MH problems, what MH symptoms are and how to recognise someone who is struggling and where they can get help. A useful resource is the Sports Mental Health Recognition tool (SMHRT-1) created by the International Olympic Committee (IOC) which is a tool targeted for use by non-clinicians, such as support staff and the athletes themselves to recognise MH symptoms and to encourage early help-seeking12.
The aims of MH educational interventions are to reduce stigma, engage athletes, promote personal development, tease out athlete preferences and reduce MH literacy and barriers to help-seeking9. Clear and simple infographics can also be helpful to reinforce this and can be placed at opportune places at training venues or tournaments, for example (Figure 4).
A key area that educational institutions, national federations and tours can support is with event scheduling so that players have the ability to obtain adequate rest, to participate in other life priorities, and to not require constant travel , and an opportunity to engage with friends and family mental health.
SCREENING: Episodic MH screening is another area that can be supported by sport organisations (i.e., academic institutions, sport governing bodies/ federations) . Given that ill or injured athletes are at increased risk of MH issues, health facilities providing care for athletes during treatment and rehabilitation should consider MH screening, to identify at risk athletes. A useful tool that can be utilised is the Sport Mental Health Assessment Tool 1 (SMHAT-1) which offers clinicians a framework to assess an athlete12. Step 1 of the SMHAT-1 (the Athlete Psychological Strain Questionnaire (APSQ)) triages sport-related psychological distress. The APSQ is a brief 10-item self-report rating scale specific to sport exploring, self-regulation difficulties, performance concerns and externalised coping12. It’s accurate, easy to complete and is less intrusive than others12.
Step 2, for those athletes withan APSQ score of ≥ 17, contains six validated screening tools for common MH disorders in sport (i.e., depression, anxiety, eating disorders, sleep disturbance, alcohol and drug misuse). This screening helps to identify early athletes at risk and facilitates timely intervention including, early management, onward referral or monitoring as required.
Level 2: Early Detection
To prioritise early detection, it is important the athlete and those that support them can detect MH symptoms/signs and know what to do when they pick them up. These symptoms will be different for everyone but important symptoms/signs to identify are outlined in the Sports Mental Health Recognition Tool (SMHRT-1) and include12:
1. Thoughts: excessive self-criticism, low self-esteem, pessimism, problems with focus, concentration or memory.
2. Feelings: Irritability, anger, mood swings, sadness, extreme disappointment that you just can’t shake, depression, loneliness, emptiness, lack of passion and sense of purpose, lack of motivation.
3. Actions: Aggression, withdrawal from others / not going outside as much, being much more quiet than usual, unexpected drop in performance (e.g., in sport, school, work).
4. Physical Changes: Low energy, poor sleep, changes in appetite, changes in weight and appearance, physical signs of harm by self or others including cuts and bruises, evidence of alcohol or other substance misuse.
The SMHRT-1 also highlight important red flag symptoms not to miss that require urgent attention which include comments related to harming self or others, talking about feeling hopeless or so overwhelmed that you cannot function, dramatic weight changes, highly uncharacteristic behaviors, or emotions12.
The SMHRT-1 also offers advice about what to do if you are concerned about someone, including allowing the athlete to tell their story, use of non-judgmental listening, considering how the athlete’s training load might be reduced, ensuring the person helping looks after their own mental health and having knowledge of some useful resources that might help and understanding local systems / medical teams that could offer support12.
Athletes will often not turn first to the medical team if they are experiencing mental health problems so maximizing the number of people in the athlete’s entourage who have a basic level of education with tools like the SMHRT-1 can have a significant impact on supporting athlete mental health and early detection when problems arise.
Level 3 – Early Intervention
The upskilling of MH interested persons/navigators and clinical staff such as sports doctors and physios to deliver early interventions and assessment skills is key. Research from the World Amateur Team Championship and on tours highlights that a sizeable minority of athletes have/had mental ill-health symptoms prior to competition, and also identified that many do not seek help, nor have resources available to them within their program6.
Knowing that simple measures can help, allowing the athlete to tell their story can often help to reduce MH symptoms and use of simple techniques such as deep breathing techniques may be helpful in reducing intrusive symptoms. Having clear processes can help staff and athletes to know what to do within an organisation, what interventions are available and what to do in an emergency. For example, the National Collegiate Athletics Association (NCAA) provides a comprehensive MH emergency action plan (Figure 5).
Good mental health and well-being is important for health and performance. Life in golf can come with significant pressure and helping an individual to look after themselves and build up personal resilience can support their well-being and ability to perform. This could include looking after their physical health such as ensuring good quality sleep, healthy nutrition, and finding time to relax as well as spending time speaking with friends and family. The Athlete 365 resource from the IOC (Athlete365 | Latest Athlete News, Official Statements, Learning, Apps (olympics.com) can assist golfers and athletes, while an example of a toolkit to support golfers is shown in Figure 6.
Level 4 – Specialist Mental health Care
A specialist MH team, with a Sports Psychiatrist and Clinical Psychologists / Therapists can help provide support to sporting organisations / federations, ideally with support from a 24/7 confidential helpline and access to support, as is available on the DP World Tour. This specialist team could support delivery of workshops, provide expert MH treatments, advise on development of a Mental Health emergency action plan (MHEAP) and develop the formation of robust processes and a comprehensive MH referral network14. Many clinical facilities that look after golfers regularly have psychology/ psychiatric practitioners on staff, and available if issues are volunteered, or detected at screening, while national federations often think through what sports psychological, clinical psychology, and medical support is available, and what would help golfers most. An awareness of free resources available through a national health service, or through other means can also be beneficial, particularly in systems where funding can be a limiting factor.
CONCLUSIONS AND FUTURE DIRECTIONS
To improve mental health support in golf we need to support further research to better understand the spectrum of conditions and risk factors seen in different sports and populations. With this information, it is also important to subsequently improve educational resources to reduce stigma and increase mental health literacy. It is important for psychologists, psychiatrists, physiotherapists, doctors, strength and conditioning coaches working at clinics, and hospitals, with national federations and on tours, to develop competencies in this area. Enhancing sport environments, and event timetables to better support mental health and well-being, and intervening early to support golfers is another important strategy. Event organisers have also been making progress in considering how they can best support their athletes and work with national and international governing bodies and all organisations involved in golf to support golfers through mental health education, consideration of screening and easy access to trained professionals when required. As golf is a global sport, it is important to build a network of reliable and informed mental health support across the globe.
William Wynter Bee M.D. 1,2
Danny Glover M.D. 3
Margo Mountjoy M.D., Ph.D. 4,5
1. Medical and Scientific Department, EDGA (formerly European Disabled Golf Association), Wassenaar, Netherlands
2. Medical and Scientific Department, The R&A, St Andrews, Scotland, United Kingdom
3. Ladies European Tour Health and Performance, Ladies European Tour, Denham, United Kingdom
4. Medical and Scientific Department, International Golf Federation, Lausanne, Switzerland
5. School of Medicine, McMaster University, Hamilton, Canada.
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Header image by David Wilson (Cropped)