Mental Health Awareness Week: Mental Health and Elite Football
Last Wednesday, with this article already taking shape, it was revealed that Everton winger Aaron Lennon had been detained by police under the Mental Health Act. The Merseyside club subsequently confirmed that the former Spurs player was “receiving care and treatment for a stress-related illness”. The news itself, as well as the way it was reported, discussed and (in some instances) appallingly misrepresented in the media, brought into sharp focus many of the questions I had been contemplating.
What, for instance, are the key psychological stressors experienced by professional footballers, both on a day-to-day basis and across the course of their whole careers? Is it fair to say that the supposedly beautiful game has an ugly secret: a significant and largely unacknowledged problem with mental health issues? How is mental illness perceived in dressing rooms and managers’ offices? Are clubs guilty of rank hypocrisy by preaching the value of speaking out and seeking help through their outreach work in local communities while simultaneously neglecting the mental well-being of their own employees? What provisions and sources of support are in place for players suffering mental ill health, and what more (if anything) can be done to improve the situation?
While what follows may not provide the answers, it will hopefully contribute to the discussion.
In recent years, national and local government and charitable organisations have often uncritically portrayed and embraced sport as a panacea for a variety of social ills – much to the consternation of a number of academics. Some of these academics argue that the fervent political and financial promotion of so-called sport development through community projects and grassroots participation in sport is either premature or disproportionate given the scant evidence upon which it is based. Others point to the numerous studies that reveal the world of elite-level sport as one in which violence, corruption, racism, sexism and homophobia are endemic. What’s more, at the highest level, sport has been shown to take a terrible toll on the health of participants, for whom the rigours and winning-at-all-costs mindset often mean sacrificing long-term physical and mental well-being for short-term success.
Nowhere, I would suggest, are the psychological pressures greater than in football. In a 2012 paper, Mark Nesti and colleagues argued that the Premier League is an environment characterised by chronic short-termism, incredible volatility and “intense organisational stress”. Such an environment is the inevitable consequence of frequent fixtures and commercial imperatives. It is into this world that players are thrust and expected to perform to the best of their abilities.
The specific stressors experienced by professional footballers are legion. First and foremost, there is the constant risk of sustaining a serious or even career-ending injury, whether accidentally or through the deliberate malicious actions of an opponent. Even a short spell on the treatment table could result in a player losing his place in the side in the long term, as could loss of form or the acquisition of a new player in the same position.
Beyond anxieties over deselection (or the threat of it), footballers are often at risk of culture shock, whether in the literal sense of having to acclimatise to a new and unfamiliar country or in the more metaphorical sense of having to adapt quickly to life at a new club or a new level: a Championship player moving to an established Premier League side, a youth-team star breaking into the first-team squad, a veteran making his way down the leagues.
Players have to endure abuse from the stands in person, but, in the modern world, they are also at the mercy of the media, frequently subjected to intense scrutiny and criticism in the mainstream press and to personal and obscene vilification on social media; sometimes, indeed, that vilification crosses over into the pages of the tabloids – just ask Ross Barkley.
The same papers are also regularly guilty of overhyping young footballers, many of whom subsequently buckle under the unbearable weight of expectation. The press are not solely to blame for this, however; Seamus Kelly, a former professional with Cardiff City and now an academic at University College Dublin, argues that pushy parents are also “a big problem, putting pressure on their ‘meal ticket’ to money/stardom”.
Becoming a professional footballer requires serious commitment and involves accepting restrictions on personal freedom, rigid codes of conduct and being under near-constant surveillance – all of which, you would imagine, might well have a damaging psychological impact in terms of players feeling that they are not in control of their own lives.
On this evidence, then, it is tempting to agree with the authors of the 2014 Mind report Performance Matters: Mental Health in Elite Sport that “[s]portspeople experience a unique set of pressures”. However, if you look a little closer, that view starts to unravel. Worrying about job security and prospects for the future, struggling to adjust to new surroundings, suffering anxiety as a result of what other people may say or think: all of these things are actually familiar to the vast majority of us. As Martin Roderick’s book The Work of Professional Football underlines, beneath the veneer of glamour and gloss lies a job that, in many ways, is actually not unlike most others.
Dan Parnell is a Senior Lecturer at Manchester Metropolitan University, founder of The Football Collective and editor of a forthcoming book, Sport and Health, that examines the evidence base for using sport to deliver public health interventions and that contains a chapter on the damaging personal effects that elite sport can have on its participants. When I asked him to name the key stressors facing footballers, his answer was revealing: “They are normal fellas with the same stress as you or I. Work, family, money, kids, women, houses, diet, health, friendship, loneliness, boredom … and the rest.” In this view, then, professional players’ concerns are not specifically related to football and are essentially no different from those of anyone else.
If footballers are indeed “normal fellas”, then it stands to reason that some of them should suffer from mental health problems. Opening up about his own battles with mental ill health in the company of fellow former pro James Scowcroft for the Independent in 2012, ex-Norwich and Leicester player Darren Eadie observed that “depression is not an exclusive club. Wealth, race, age, gender – it can affect anybody at any time.” Those sentiments were echoed last week by Clarke Carlisle – Mind ambassador, former PFA chairman and founder of the Clarke Carlisle Foundation for Dual Diagnosis – who referred to the illness as “indiscriminate” in response to the reprehensible insinuation of The Daily Mail and others that the size of Aaron Lennon’s weekly pay packet should somehow guarantee him immunity: “He is no more immune to mental health issues than he is to flu or diarrhoea or anything of that order.”
On that logic, then, mental health issues are unlikely to be any less prevalent among professional footballers who live “privileged” lifestyles than among the wider population. But might they actually be more prevalent? After all, even though the stressors within elite-level football are not significantly different in nature from those felt by “ordinary” people, they are of a different magnitude and are experienced in an extraordinary context – one characterised by intense pressure and volatility, and thus one that hardly seems conducive to good mental health.
Research conducted in 2013 and led by Vincent Gouttebarge suggested that football might indeed have a problem with mental illness. Following a survey of 253 current and former players in Australia, Ireland, the Netherlands, New Zealand, Scotland and the USA, the researchers concluded that “[t]he prevalence of mental health problems and/or psychosocial difficulties … was found to be high”. Of the 104 respondents still playing the game, 26 per cent reported suffering from anxiety/depression.
Gouttebarge followed up that pilot study with a more extensive piece of research looking at common mental disorders, or CMDs (anxiety/depression, distress, sleep disturbance, adverse alcohol behaviour, adverse nutrition behaviour), among current professionals in Finland, France, Norway, Spain and Sweden. Once again, the symptoms of mental illness were reported by a greater proportion of the 540 respondents than would be expected of a similarly sized sample of the general population. Particularly alarming were the findings in Norway, where 43 per cent of players admitted to experiencing anxiety/depression and a staggering 74 per cent confessed to adverse nutrition behaviour.
Gouttebarge and his colleagues took pains to stress that the conclusions to be drawn from these results were necessarily tentative, freely acknowledging that there were many potential flaws and weaknesses with the studies. Nevertheless, they quite rightly insisted on the value of seeking to fill a conspicuous research vacuum. They also noted the considerable challenges that they faced in conducting what was (perhaps surprisingly) pioneering research: “The authors would like to emphasize how difficult it is to gather scientific information about mental health in professional football, since such a topic remains a kind of taboo.” This is, sadly, a sentiment echoed by countless other academics in more general terms. In a forthcoming paper, for instance, Conor Curran and Seamus Kelly refer to the professional game as a closed, often impenetrable world, one that is resistant or even openly hostile to research.
And what about elite-level English football in particular? Using a diplomatic turn of phrase, Gouttebarge and his colleagues noted that England was one of several countries “not ready to participate” in the second study. Responding to the historic sex abuse scandal that broke last year, FA chairman Greg Clarke commented: “I think institutionally, all organisations in the old days used to protect themselves by keeping quiet and closing ranks. That’s completely inappropriate and unacceptable today.” Fine words, but researchers suggest that there’s little evidence of any obvious move towards or appetite for openness and transparency within English football – in fact, quite the opposite.
We are continually told that when it comes to mental health, it’s good to talk. But when I approached Clarke’s FA for comment and information in advance of writing this article, no response of any kind was forthcoming. Repeated messages to the PFA, the LMA and the FAW, as well as to a quartet of Welsh clubs operating in the English league system (Cardiff, Swansea, Newport and Wrexham), were met with an equally deafening silence.
As part of his 2013 BBC programme about mental health in football, Football’s Suicide Secret, Clarke Carlisle confronted the then FA chairman David Bernstein, demanding to know what he proposed to do about the situation. “He admitted the issue had been neglected and said he wants to tackle the stigma surrounding mental health issues because ‘the very nature of the problem is that it tends to be kept quiet’.” Bernstein’s implication, I think, was that it is footballers who keep mental illness quiet – but it does seem as though the national game’s various institutions might be working to do the same.
Why do so few footballers speak out, admit to concerns about their mental well-being and ask for help?
One explanation is that players suffering from mental health issues are not so much reluctant to talk as simply unable to recognise the symptoms. In this view, there are perhaps hundreds of professionals living with debilitating CMDs without actually realising it. Clarke Carlisle, for instance, has recalled that it was only when his wife was diagnosed with post-natal depression and he encountered Goldberg’s depression test that he became aware of his own mental illness. One wonders whether questionnaires like those used by Gouttebarge and his colleagues, which ask players to reflect on their own attitudes and behaviours and then to reply with the guarantee of anonymity, may also bring about self-awareness and enlightenment, whether inadvertently or by design.
The suspicion persists, however, that in many cases players are aware of having a problem but conceal it, knowingly or otherwise. Some might argue that players’ reticence to reveal mental health problems is only to be expected because they are victims of the societal pressures, norms and expectations surrounding their gender. In their paper, Conor Curran and Seamus Kelly note that emotional concealment and a reluctance to speak out are very common traits among young men – but, they pointedly add, these traits appear to be even more common among professional footballers.
To substantiate this theory – that the issue is more a matter of subconscious self-denial or active suppression than ignorance, and that it might affect footballers disproportionately – we need to look more closely at the culture and ethos of football’s closed world.
When, in November last year, Andy Woodward opened up to the Guardian’s Daniel Taylor about his horrific experiences at the hands of serial paedophile Barry Bennell, he described how he suffered in silence and referred to both “dressing-room bravado” and a within-these-walls “circle of trust” that could not be violated – the keeping quiet and closing ranks mentioned by Greg Clarke.
In the wake of Woodward’s revelations, the Independent reported that in the early noughties Clarke’s organisation had made efforts to improve child protection within English football via a specific research project, only to be thwarted by resistance. In one 2004 report, those working on the project described being “met by some traditionally robust masculine attitudes and failure to accept the relevance of CP [child protection] to that level of the game. Gaining credibility and establishing [trust from clubs] were considerable challenges, especially where researchers were unable to present credentials as current or former football players”.
Woodward’s enormous courage in coming forwards, which inspired David White, Paul Stewart and hundreds of other former players to follow suit and prompted numerous inquiries and investigations, was notoriously met with disdain by Eric Bristow, who derided the victims of abuse as “wimps” for not “sorting out” their abusers. Darts players, on the contrary, were “tough guys”, “proper men”. Bristow may have been unfavourably contrasting football with darts, but the fact is that he was giving voice to precisely the sort of attitudes that did and still do exist within football and that enabled the abuse to occur and to do so unreported in the first place.
In conversation with Roddy Forsyth in 2011 about his personal battles with depression, Neil Lennon observed: “It’s a very macho environment, obviously. You don’t want to give anything away and in that environment you have a group of highly charged men who might take the mickey out of you or who might look on it as a sign of weakness.” That last word, “weakness”, is one that crops up time and again in articles and academic literature. Admitting to suffering from a mental health condition is hard enough; to do so as a professional athlete, for whom well-being is prime and whose success and self-image is contingent upon physical and mental strength, is potentially career-threatening; and to do so within the hyper-intense “macho environment” of football is perceived as shameful and emasculating. Little wonder, then, that mental health is stigmatised and that players might prefer to keep quiet.
The opposite of mental “weakness” is mental toughness. Essentially viewed as the ability to not only cope with challenges and adversity but actually relish them, mental toughness is widely considered a key attribute for sporting success. In a 2014 study, researchers Clive Cook, Lee Crust, Martin Littlewood, Mark Nesti and Jacquelyn Allen-Collinson explored the phenomenon within the context of an unnamed Premier League academy and, through interviews with key members of the coaching staff, defined it with respect to four dimensions: “competitiveness with self and others” (which incorporated “commitment to excellence” and “motivation to achieve”), “mindset” (which incorporated “focus” and “confidence”), “resilience” (which incorporated “coping and rebounding after setbacks”, “perseverance” and “courage”) and “personal responsibility”. That fourth dimension, they wrote, “reflected coach perceptions that while the mentally toughest players did require some support from time to time, and generally, they were less needy than other players, usually taking responsibility for dealing with their problems”. In this light, it’s not hard to see why footballers might be reticent about seeking help for mental health issues: do so, and you run the risk of being branded “needy”, “high-maintenance”, incapable of looking after yourself.
The academics also observed: “Interestingly, most interviewees felt that a high proportion of players who ultimately gained professional contracts compensated for technical, tactical or physical limitations through being mentally tough, and thus mental toughness, rather than technical skill, was a better indicator of who would progress.” These coaches would no doubt point to the likes of Michael Johnson as a case in point. Johnson breezed into the Man City side at the tail-end of the 2006/7 season, and a series of assured performances soon earned the talented midfielder the tag “the new Colin Bell”. But that weight of expectation, combined with long-term injuries and addictions to drinking and gambling, resulted in mental health difficulties, trips to the Priory Clinic and ultimately the termination of his contract and tragically premature retirement at the age of just 24. A similarly precocious talent, German midfielder Sebastian Deisler seemingly had the world at his feet and the hopes of the nation in his hands, only for injuries and depression to cut short a once-promising career. In the coaches’ view, what players like Johnson and Deisler lack is not ability but mental toughness (and, we might add, the good fortune to avoid serious injury).
However, the most striking aspect of Cook et al.’s research was that, despite the coaches having “clear ideas about what constitutes mental toughness, they were less aware of how it might be systematically developed, highlighting the need for greater dissemination of sport psychology research”. Moreover, it was remarkable that within the academy in question, despite their avowed belief in the critical importance of mental toughness over and above skill levels or physical fitness, the coaches nevertheless paid far more attention to young players’ physiological development than to their psychological needs. This disjunction, the authors suggested, was not unique: “while EPL clubs have invested heavily in player development through provision of well-resourced centres that typically employ upwards of 15 full-time staff, there still appears to be little provision for psychological support.”
Like so much in the world of football, it simply makes no logical sense.
Let us suppose, hypothetically, that a player suffering from mental health issues is prepared to open up and seek help. To whom does he turn?
The most obvious person, as in most lines of work, would be his manager. The first recommendation of Mind’s 2014 Performance Matters report was as follows: “Coaches and managers need to understand the value of mental health and wellbeing, and be engaged in support of athletes, for change to happen at a club level. Educating coaches that dealing with problems early can be beneficial for both athletes’ personal wellbeing and for sporting performance is key.” To their credit, the LMA have put into place both training to enable managers to manage their own stress levels and mental health, and educational programmes designed to help them to understand and deal with players struggling with mental illness.
Sadly, the evidence suggests that such programmes are desperately needed. It is approaching 20 years since Villa manager John Gregory uncomprehendingly lashed out at Stan Collymore, only later admitting: “I failed miserably in showing any kind of compassion to his long drawn-out periods of depression.” Yet nothing much seems to have changed over the intervening period. In the wake of Aaron Lennon’s detention, the Secret Footballer recalled his own experience of confiding in his manager “Finally he leaned forward in his chair and said, ‘If at any time you’re not feeling quite right upstairs, then you must tell me.’ It was such a relief and I was grateful for his understanding. Then he said, ‘Because we have other players that can play.’” Having had the courage to open up about his problems, the Secret Footballer was rewarded by being told that his place in the team was now under threat.
That this was not an isolated incident is supported by research conducted by Seamus Kelly. For his recent book The Role of the Professional Football Manager, Kelly gained access into the usually closed world of football (aided, no doubt, by his status as a former player) and interviewed a host of managers in a bid to build up a picture of the various aspects of the position. While the discipline and control of players was regularly identified as a key dimension of the manager’s role, pastoral care and concern for players’ well-being was not. “Some managers care, but most don’t”, reveals Kelly. “Results and player availability is all they think about.”
The reason for this attitude should by now sound familiar. “From a manager’s perspective”, Kelly says, “if they think a player will ‘bottle it’ or ‘crap themselves’ during a game, then they’re out of the team and are rarely picked ever again. Managers need to trust they will ‘do their jobs’. Publicly, managers will support mental health awareness, but deep down some will view ‘mentally weak’ players as having no place in the game.” The sad truth, notes Dan Parnell, is that it is entirely understandable why many managers in the modern game might be indifferent to the long-term mental health of those in their charge, and why they prize mental toughness so highly: “In real terms, we could argue that if you are a club manager, you need to focus on performance and incentives, or you get sacked.”
So much for troubled players receiving a sensitive and compassionate response from managers. What about from teammates? You would assume that those who share a dressing room and an intimate understanding of the specific stresses and strains of life as a footballer would be inclined to show a greater degree of sympathy. Certainly, the recent outpouring of support for Aaron Lennon on social media from both current and former professionals suggested as much.
However, we should recall Neil Lennon’s comment about the potential perils of disclosing your mental health issues to “a group of highly charged men who might take the mickey out of you or who might look on it as a sign of weakness”. These fears might prove to be unfounded – but their mere existence will no doubt convince many players against candour.
Indeed, Vincent Gouttebarge’s pilot study found that a lack of support from teammates (and trainers) can actually be a contributory factor with regard to mental health problems. In opening up to peers, then, a player might risk worsening his condition rather than begin to alleviate it. After all, dressing rooms are not always harmonious places; a group of researchers led by Mark Nesti flagged up “antagonism from other teammates, especially those who are not currently in the starting team” as one of several “critical moments” during which professional footballers might experience stress levels sufficiently high as to cause mental health issues.
What, then, of the PFA? Surely the body whose sole reason for existence is to support the needs and interests of professional footballers would give members suffering from CMDs the sympathy and support they need? The Performance Matters report lists an impressive number of recent initiatives undertaken by the organisation with regard to mental health: “The PFA set up a National Counsellors Support Network, launched a 24-hour helpline for players, trained its coaches in mental health first aid and teamed up with the anti-stigma campaign Time to Change to publish The Footballers’ Guidebook, including advice on how to deal with depression, anxiety, panic and anger.” The fact that increasing numbers of players are contacting the PFA to express concerns about their own mental well-being does not necessarily indicate that football has a worsening problem; on the contrary, it may actually indicate that footballers are now more aware of and able to identify the symptoms, feel more comfortable admitting to them and have the PFA-backed provisions and services to be able to do so.
Nevertheless, it is alarming to read of players whom the PFA have let down. Take Leon McKenzie, for example, the former Peterborough and Norwich striker, who attempted to take his own life after experiencing a serious injury that coincided with the breakdown of his marriage. Clarke Carlisle admitted: “As chairman of the Professional Footballers’ Association, I was shocked to hear that Leon had phoned my organisation to talk about his depression yet had not been given an understanding response.” Darren Eadie, meanwhile, has spoken warmly of the support given to him personally by Carlisle, but described the level of assistance offered by the PFA in general (and others from within the world of football) as “disappointing” – not least because his copy of The Footballers’ Guidebook never arrived.
If managers, teammates and the players’ own union cannot be guaranteed to offer sympathetic support, then what about psychologists? Elite-level footballers may have a greater susceptibility to CMDs due to the world in which they live, but they also have easier and more frequent access to psychologists than members of the general public. The glittering professional career of Gianluigi Buffon – a player who has proven himself to be one of the world’s most outstanding talents at the very highest level for two whole decades but who for a spell was crippled with depression – is testimony to the value of counselling sessions with mental health professionals: “I did see a psychologist and that helped me enormously. … [Psychologists] are people who are there to help you and if you find a good psychologist, they will allow you to talk about everything and open up, without the slightest of fears, and that is no easy thing.”
Conor Curran and Seamus Kelly endorse a holistic approach to sports psychology, and Steve Mellalieu, Professor in Sport Psychology and the Associate Dean for Research for the Cardiff School of Sport, is in agreement, though confesses to disliking the term. Mark Nesti, a practising psychologist with experience of working at several top clubs, regards psychology as having a closer relation to philosophy than to science, and prefers to talk about an “existential” or “phenomenological” approach that focuses on such issues as meaning, identity, anxiety and authenticity (being true to yourself), as perceived by the individual rather than from an external perspective.
However, as laudable and beneficial as such an approach would be for players’ long-term mental health, few practitioners are able or willing to adopt it within the world of football, where the fixation with results has led to a narrow focus on performance psychology – on merely equipping players with the mental skills to successfully negotiate pressurised game scenarios. As Nesti himself has noted in a paper co-authored with Michael McDougall and David Richardson, psychologists working within elite sport are – like professional footballers – continually expected to prove their worth in “volatile, unpredictable and incredibly demanding” circumstances. Just like managers, their job security hinges on being able to demonstrate clear impacts and improvements brought about by their work – hence the obsession with data, metrics, numerical analysis, predictions and quantitative measures in general. Even then, for psychologists to (in Dan Parnell’s words) “legitimise their existence”, those impacts and improvements ultimately have to be manifested in terms of positive team performances and results rather than individual well-being.
Nesti has rejected as a “false dichotomy” the idea that his qualitative approach is incompatible with the quantitative nature of “a performance-focused sports psychology service”, because “[t]he work with a sports performer is always oriented towards helping them to maximise their sport performances in some way”. As a practising psychologist with experience of working at a number of top clubs, his opinion on this carries significant weight. However, in another article co-written with Noora J. Ronkainen, Nesti has claimed that his role in working with an individual is “to help the player to seek and pursue the best options even and especially where these may cause difficulties for them with the coaching team, their peers or others in their lives beyond soccer”. If a psychologist is meeting players in one-on-one sessions and actively encouraging them to pursue selfish goals at the expense of the team and in contravention of a manager’s authority, then it is hardly surprising that the manager – already prone to viewing mental health issues as symptomatic of “weakness” – might be deeply suspicious of him or her.
This is presumably another reason why, according to Kelly, players are “often afraid” to be seen meeting with sports psychologists. Even the word “psychology” itself, he says, is taboo.
When German goalkeeper Robert Enke took his own life in 2009, the country’s football authorities responded by introducing a host of measures to help combat mental illness within the elite game. As part of the research for his documentary, Clarke Carlisle witnessed these developments first-hand: “Every professional club has access to psychiatric treatment, there is a 24-hour hotline for players who think they might be suffering from depression and the Robert Enke Foundation tries to raise awareness of mental illness.” The latter was no doubt subsequently the inspiration and model for Carlisle’s own charity. Similarly, here in the UK, the death in 2011 of Wales manager Gary Speed – who had kept his depression a secret even from his closest family members – gave rise to the raft of initiatives put into place by the PFA mentioned above.
It is to be hoped that Aaron Lennon’s experience will ultimately prove to be an equally effective catalyst for positive change. Aside from former Crystal Palace striker Andy Johnson making use of social media to raise a significant sum of money for Mind (including a sizeable donation of his own), Lennon’s case – as a high-profile player, albeit not one who has willingly divulged his issues – has at the very least brought the subject of mental health in elite football and all of the issues surrounding it to the fore. It really is good to talk.
But it is also good to act – and to act without having to be prompted to do so by tragic circumstances. As appears abundantly clear, there is much, much more that could – and indeed should – be done. Asked whether he thinks the situation within the professional game is improving, Dan Parnell is blunt: “No, it’s not. The football machine is at its height. Players’ welfare is nowhere near the top priority. Player performance is. This doesn’t make sense, but deeper player troubles take longer to help players with and football demands performance, now.”
By way of a conclusion that draws together some of the threads discussed above, what follows are five recommendations for how mental health issues could be more effectively tackled within elite-level football.
1. Mental health needs to be taken more seriously.
Steve Mellalieu is right to point out that there is always a disconnect between grassroots and elite levels in any sport – but football clubs and authorities are currently guilty of not always or even often practising what they preach through community projects. For instance, the FA and the LMA are among the signatories to the Mental Health Charter for Sport and Recreation, which involves making a commitment to (among other things) “[p]ublicly promote and adopt good mental health policies and best practice within our sports and recreational activities”, “[a]ctively tackle discrimination on the grounds of mental health to ensure that everyone is treated with dignity and respect”; and “[r]egularly monitor our performance, assess progress and take positive action on mental health issues”. Both need to do more to ensure that they are not merely paying lip service to these pledges.
Clarke Carlisle has gone further, identifying the self-regulatory aspect as a problem: “The biggest flaw in football is that there is no legislation for football clubs to follow. The Football Association has not put in place measures for the psychological and emotional well-being of their employees. It’s in the contract that they should take care of any injury – physical or mental – and pay for the rehabilitation but there is no stipulation about the base level of care that is needed. This is inadequate because it’s then down to a club’s interpretation, so whatever they think is appropriate, they will put in place but another club might do nothing.” Both clubs’ duty of care to their players and the extent and nature of that care need to be enshrined in contract law.
2. Key positions for individuals with responsibility for mental health should be created.
Such appointments would be one obvious way of signalling an acceptance of the importance of mental health issues. Dan Parnell argues that “there appears to be a need for someone funded independently [by the Premier League] to work within football clubs and [the league] to provide confidential, non-performance-related psychological and health and well-being support”. He also talks of the “inconsistent cultures in football clubs, set by their owners” – something that the appointment of professional sporting directors (a role for which he is a keen advocate), in tandem with the legislation proposed by Carlisle, might help to rectify.
3. Elite-level football must accept the need for openness and grant greater access to both psychologists and researchers.
To be able to combat incidences of mental illness among professionals, psychologists must be given the freedom, time, resources and indeed encouragement to employ qualitative rather than merely quantitative approaches, to treat players holistically as human beings rather than merely as elite athletes, and to address their individual concerns about issues such as identity and meaning rather than merely any performance anxieties.
The only way to ascertain the prevalence of depression and other CMDs within the professional game is through studies like those conducted by Gouttebarge and his colleagues – and so, if football is indeed serious about tackling mental health, it needs to be far more receptive to researchers. It is simple common sense: only with a better understanding of the nature, scale and causes of a problem can effective, precisely targeted solutions be found and evidence-based best practices be recommended.
4. Clubs should devote more attention and resources to developing mental toughness.
If mental toughness is indeed the critical component in a successful footballer’s psychological make-up, and indeed more important than physical attributes, then this needs to be reflected in training and coaching methods, especially at academy level. As Slaven Bilic has suggested, young players need support and to be adequately prepared for the rigours of life at the top, not only physically and tactically but also psychologically, and not only on the pitch but also off it. Again, increased research is vital to discovering how best to achieve this, and how to coach and develop mental toughness most effectively. After all, prevention is far better than cure.
5. There needs to be an emphasis on facilitating self-diagnosis and self-management.
Despite public conversations and campaigns, mental illness is unlikely to lose its stigma overnight, whether in the wider world or within the world of football in particular. Consequently, many players suffering from CMDs are likely to continue to keep quiet. However, as Gouttebarge et al. conclude, if exposed to the right awareness-raising messages and equipped with the appropriate tools to diagnose and manage their own conditions, those players need not suffer in silence.
Sadly, though, as the careful (not to mention patient) reader may have suspected, this piece cannot end on a positive note.
As long as professional football is fuelled by commercialism, results will be the be-all and end-all, short-termism will be endemic and internal pressures will be intense. Furthermore, the hyper-competitive edge, stresses and macho culture of elite football demand mental toughness, and its team ethos inevitably means that individual well-being is less important than collective performance.
Beyond football, we live in a country where governments can still actively discriminate against those suffering from mental illness and prominent figures in the media can publicly tell those who pluck up the courage to speak out about mental health problems to “man up”.
All of the recommendations made above could and should be implemented. But it is very hard to imagine a fundamental shift, of sufficient magnitude to allow stigma and suffering to be eradicated, occurring in either the culture of professional football or the wider context in which it is played – if such a shift would even be possible at all.
Thanks to Seamus Kelly, Steve Mellalieu, Dan Parnell, Mark Nesti and Simon Whitmore for their help with and contributions towards this article.