Well Being

Article

Mêdraœ and Bidziñska (2004) found that recreational males, former athletes and people who participate in aerobic exercise or sports (e.g. running, swimming, cycling) regularly engage in exercise addictive behaviours. But, the difference between commitment and addiction to exercise has been disputed. Commitment and addiction can be differentiated through the intellectual analyse of rewards and rationales […]

Mêdraœ and Bidziñska (2004) found that recreational males, former athletes and people who participate in aerobic exercise or sports (e.g. running, swimming, cycling) regularly engage in exercise addictive behaviours. But, the difference between commitment and addiction to exercise has been disputed.

Commitment and addiction can be differentiated through the intellectual analyse of rewards and rationales for exercise (Sachs, 1981). Sachs defined committed exercisers as driven by extrinsic rewards, have a important but not essential view and possess a low possibility of suffering withdrawal symptoms. In contrast, exercise addicts are defined as being driven by unrealistic intrinsic rewards, view exercise as central to their life and are highly likely to suffer from withdrawal symptoms.

In a study looking into the relationship between addiction and commitment to running, Szabo, Frenkl and Caputo (1997) found no such correlation and concluded that they are two independent concepts. However, there was a positive reciprocal relationship between addiction to exercise and the frequency, distance and the duration of training associated with negative addiction (Glasser, 1976). With this, Kjelsas, Augestad and Gotestam (2003) used Exercise Dependence Questionnaire (EDQ) to find a relationship between number of hours dedicated to sport and risk of addiction in females. For exercise addicts, the increased quantity of exercise heightens the perceived advantages of exercise thus causing the person to continually increase exercise tolerance (Hausenblas & Symons Downs, 2001).

The Obligatory Exercise Questionnaire (OEQ) is a well established standardised questionnaire which looks at secondary dependence (Veale, 1995) and the relationship between exercise behaviour, eating disturbance, and body image. Pasman and Thompson (1988) found that there is are significantly more eating disturbances in runners with females showing more eating psycho-pathology with a high need for perfection and control over their bodies.

Hausenblas and Symons Downs developed the Exercise Dependence Scale (EDS) which identifies individuals at risk, non dependent symptomatic, and non dependent asymptomatic through exercise withdrawal symptoms in athletes. This has been criticised for a limited concept of addiction and not differentiating primary and secondary exercise dependence.

The short form of the Exercise Addiction Inventory (EAI), similarly to the EDS, looks to distinguish between individuals at risk, moderate symptoms and no symptoms of exercise addiction based on Griffiths’ (1997) six components of addiction. The inventory addresses the athletes views on exercise behaviour such as the perceived importance, motivation and experience of benefits to exercise. Griffiths examined an amateur Jiu-Jitsu athlete with relatively stable background who suffered from exercise addiction using the six components. For the athlete, the sport slowly dominated her life and believed exercise helped her concentrate on other activities. She felt agitated when unable to exercise, her education and relationships began to deteriorate and was unable to reduce the amount of the exercise behaviour exhibited.

The first practical challenge exercise addiction presents is how to identify athletes that participate in addictive behaviours away from training and competition. To monitor athletes’ exercise habits, inventories such as the EDQ, OEQ, EDS, and EAI can be implemented regularly to track the frequency, duration, salience and feelings towards exercise.

Secondly, when an athlete is identified as having a possible exercise addiction, addressing the athlete can be a sensitive issue. For a psychologist, confidentiality and empathy is key to gaining trust from the athlete to confront their addiction. This can be difficult in younger athletes due as the parents have to be notified and educated on their excessive exercise behaviours.

Generally, regular exercisers do not voluntarily decrease or cease exercise and with injury common in sport, observing others experiencing withdrawals due to the removal of exercise can lead to the reinforcement to continue the exercise behaviour. Support staff can be also have a huge impact on the reinforcement of addictive behaviours, especially in sports like weightlifting, boxing and running. Addiction can be promoted by language that portrays the athlete as committed or a role model. To combat such reinforcement, support staff (i.e. coaches, physiotherapist) and athletes can be educated through psychotherapy on the cues to spotting exercise addiction and emphasis withdrawals are outweighed with the benefits and importance of rest and recovery.

In sports where weight is valued (i.e. boxing, weightlifting, gymnastics), athletes have a much higher possibility of having or developing secondary exercise dependence which is connected by an eating disorder. Eating disorders can be very secretive and therefore hard to identify. When recognised, it would therefore be advised to seek professional help from a clinical psychologist, but this could disturb the psychologist-athlete relationship.

 

Article

Throughout sport, exercise has been universally acknowledged as a healthy habit which can have many psychological and physical benefits for an individual (Szabo & Griffiths, 2007: Bouchard, Shephard & Stephens, 1994).  Paradoxically, exercise behaviour is now being looked at in a different light due to obsessive exercise being seen as a type of addiction (Garman, […]

Throughout sport, exercise has been universally acknowledged as a healthy habit which can have many psychological and physical benefits for an individual (Szabo & Griffiths, 2007: Bouchard, Shephard & Stephens, 1994).  Paradoxically, exercise behaviour is now being looked at in a different light due to obsessive exercise being seen as a type of addiction (Garman, Hayduk, Crider, & Hodel, 2004; Griffiths, 1997).  People who suffer with exercise addiction feel that exercise helps reduce anxiety about appearance concerns or becoming overweight (Cumella, 2005).  It has been found that exercise addiction raises endorphin levels, which in turn gives a person feelings of well being.  However, this person will also be unaware of the serious health problems that can arise from this condition as they will have a decreased awareness of physical and emotional pain (Cumella, 2005).

Baekland (1970) was one of the first people to study exercise addiction which has been replaced by different terms such as: excessive exercise, exercise dependence, compulsive exercise and obligatory exercise (McNamara & McCabe, 2012).  Glasser (1976) used the term positive addiction which looks at the positive impact exercise has on a person’s physical and psychological well being.  However this positive perception led individuals to believe that being strongly committed to their sport can be labeled as addiction.  Morgan (1979) acknowledged a problem with this definition and introduced the term negative addiction which allows people to realise that long term addiction can lead to negative consequences (Rozin & Stoess, 1993).  It has been argued that existing literature focusing around exercise addiction in fact measured commitment (Szabo, Frenkl & Caputo, 1997).  Sachs (1981) argued that committed exercisers who engage in exercise for extrinsic rewards do not view exercise as the main part of their life and do not suffer withdrawal symptoms.  On the other hand addicted exercisers who will be exercising for intrinsic rewards will see exercise as central to their life and will experience withdrawal symptoms when they stop exercising (Sachs, 1981).  It is therefore important to acknowledge the differences between committed exercisers and addicted exercisers (Terry, Szabo & Griffiths, 2004).

Along with other addictive behaviours there is no standard definition of exercise dependence (Johnson, 1995).  The definition which has gained the most interest was proposed by De Coverley Veale (1987) who recommended that there should be set standards for diagnosing dependence.  These set of standards are based on the DSM-IV diagnostic criteria for substance dependence (American Psychiatric Association, 1994). Exercise dependence must therefore be manifested by three or more of the following:

  1. Tolerance: increasing the amount of exercise so that an individual can feel a desired effect from it.
  2. Withdrawal: when the individual stops exercising they experience withdrawal symptoms such as anxiety and restlessness.
  3. Intention effects: unable to stay to one particular routine and constantly going over the time needed to spend on a routine.
  4. Loss of control: unsuccessful at reducing the time spent exercising.
  5. Time: too much time is spent preparing for and engaging in exercise.
  6. Conflict: social or recreational activities are given up because of exercise.
  7. Continuance: Continuing to exercise even though the individual knows that it is having an affect on them physically, socially and psychologically.

To understand the addiction in more depth it is important to look at exercise addiction in relation to other disorders that an athlete can experience.  Much research focused around exercise addiction has been associated with eating disorders (anorexia and bulimia) and there is a large amount of research which shows exercise addiction as a subset of an eating disorder (Adams and Kirby, 1998: Dara, 2003).  This has been called secondary exercise dependence (De Coverley Veale 1987).  Some people with these disorders will use exercise as their purging method as it is seen as more acceptable (Cumella, 2005). As well as looking at secondary exercise dependence it is also important to acknowledge primary exercise dependence which is used to describe someone who is addicted to exercise for reasons associated with doing an activity (De Coverley Veale 1987). Within this section we have seen how problematic exercise addiction can be and what characteristics are used to identify the addiction.

In sport. athletes are constantly training and exercising to reach the top level. However, to what extent does training become an addiction to exercise and how does this affect the athlete’s behaviour?

Within addictions it is important to take into account the personality of an individual. Gossop and Eyensck (1980) examined whether there is an addictive personality type and many studies have been conducted looking at the relationship between personality and exercise dependence.  Results have shown that there is a positive relationship between exercise dependence and perfectionism (Cook, 1996), trait anxiety (Coen & Ogles, 1993) and obsessive compulsivness (Hausenblas & Symons Downs, 2002).  It is also important to understand the athlete’s behaviour of exercise addiction in relation to mood changes that will occur.  When a person is addicted to exercise their mood can be associated to the withdrawal symptoms that they would experience (Guszkowska & Rudnicki, 2012).  Studies have shown that when individuals are withdrawn from exercise they experience high levels of depression, anxiety and tension (Morgan, 1979).  Therefore an athlete might be training longer and harder to feed his perfectionist tendencies and to reduce feelings of withdrawal symptoms.

One problematic issue within exercise addiction concerns the distinguishing of healthy exercise from exercise addiction (Freimuth, Moniz, Kim, 2011).  To understand the differences Friemuth’s (2008) developed a model for distinguishing phases of addiction.  There are four stages which are broken down into three components: motivation, consequences and frequency.

Phase one: recreational exercise

A person will be taking part in recreational exercise because they find it rewarding and enjoyable.  Research has shown that in this stage individuals may be motivated to exercise to increase their levels of fitness (Thornton & Scott, 1995).

Phase two: at risk exercise

Within this stage an individual’s motivation to exercise will change from enjoyment to relief from stress.  Thornton and Scott (1995) found that exercise addiction is more likely to occur for those who exercise to escape feelings of unpleasantness compared to those who exercise to improve their health.

Phase three: problematic exercise

Problematic exercisers will start to revolve their day around their exercise programme.  During this phase the exerciser will be constantly pushing themselves to reach new limits and if they do not have control over their behaviour they will start to experience withdrawal symptoms.

Phase four: Exercise addiction

In this phase exercise becomes a persons life. The main motivation within this phase is to avoid withdrawal symptoms.  Exercise will start to have an affect on the individuals daily functioning and could start to cause problems within their social and work life.

By acknowledging the differences among each stage we are able to understand the athletes motivations, behaviours and relationship with exercise within their sport.

Within sport, not only is there coach, family and peer pressure but there is also societal pressure for an athlete to be at the peak of their physical condition.  As mentioned one of the most problematic causes related to exercise addiction is being able to distinguish healthy exercise from addicted exercise.  From a coaches perspective exercise addiction could be simply seen as over training.  Therefore coaches need to be educated on the key differences and attributes between healthy exercise and exercise addiction.  Specialists must be aware of the signs and symptoms of exercise addiction in relation with substance use disorders and behavioral addictions (MacLaren & Best, 2010)

When treating an athlete with exercise addiction it is important to take many factors into account.  Cumella (2005) identified eight treatment factors which can help a patient with exercise addiction.

  1. Nutritional status: nutritionists should assess an athletes diet as they may be participating in disordered eating and lack nutritional knowledge.
  2. Medical status: athletes should be assessed on current medical status.
  3. Eating disorder behaviours: Individuals with eating disorders are at a high risk of exercise addiction.
  4. Body image and self-esteem: individual and group interventions should be used to help an individual develop self esteem which is not focused around appearance and body image.
  5. Motivation: people should understand the athlete’s motivations for recovery.
  6. Cognitions and skills: to change an athlete’s attitude towards exercise, different cognitive behaviour approaches can be used.
  7. Athlete specific issues: people must be aware that athletes may not want to return to their sport because of the recovery risks. In sports where there are weight categories, athletes have greater risk of relapse.
  8. Healthy exercise: Once the athlete is in a healthy stable condition, education and practice in healthy exercise is key.

All of these factors show us that there are many processes which can underlie the disorder of exercise addiction.  By sport psychologists educating dieticians, coaches, sport scientists and doctors on the pressures that athletes experience they can help create a supportive environment which will allow an individual to enjoy exercising at a high level.

 

Article

With Injury comes a loss of confidence (Doran, 1984). Whilst low confidence can be a result of injury, it can also cause injury e.g. not fully committing when going in for a rugby tackle. Magyor & Chase (1996) conducted a study looking at the consequences of having low self-confidence pre- and post-injury in gymnasts and […]

With Injury comes a loss of confidence (Doran, 1984). Whilst low confidence can be a result of injury, it can also cause injury e.g. not fully committing when going in for a rugby tackle. Magyor & Chase (1996) conducted a study looking at the consequences of having low self-confidence pre- and post-injury in gymnasts and found negative relationships between

  • Fear of injury and confidence in avoiding injury
  • Fear of injury and confidence in own ability to perform successfully
  • Probability of injury and confidence in avoiding injury

When working with an injured athlete I suggest that Sport Psychologists adopt the following rehabilitation guideline (Heil, 1993). I have successfully used this framework with a Premier League Academy footballer.

  1. Pre-injury
  2. Immediate Post-injury Period
  3. Treatment Decision & Implementation
  4. Early Rehabilitation Period
  5. Late Rehabilitation Period
  6. Specificity Period
  7. Return To Play

Firstly, (pre-injury) when dealing with an injured athlete you should identify the factors that created the environment in which the injury occurred. These can be addressed later on in the rehabilitation process.

Having done this, you then have to understand how the athlete is feeling (immediate post-injury period). Bearing in mind that so much of his/her life revolved around playing sport. All of a sudden it has been taken away from them. Consequently the athlete is likely to be experiencing emotions such as, depression, anger and guilt. It is vital you gain the athlete’s trust, otherwise the rehabilitation process will fail. Trust can be achieved by simply giving an accurate diagnosis, and proposing a course of treatment, with a realistic estimation of the duration of treatment.

Having gained their trust, attention turns to treatment (treatment and implementation). It is important to prevent the athlete from making any rash decisions regarding treatment, as they may not have thought about the long term consequences. At this point you must listen to the opinions from the athlete, coach and medical staff, and stress that they all must be in agreement before any treatment begins. The athlete needs reassuring that the final decision was made in his/her best interests and not the managements’.

Having set out the rehabilitation process the athlete then begins the long or short journey back to full fitness (early rehabilitation stage). Before any treatment begins the athlete and yourself should agree on early rehabilitation goals. Goals give the athlete something substantial to aim for and get actively involved in. These early goals should be short-term, relatively easy to achieve and not too strenuous (Brewer et al., 1994). Pain levels will be high so an emphasis should be placed on goals being more psychologically based rather than physical. At this stage of the process, levels of physical practice are limited therefore an emphasis is placed on mental practice. Fortunately the brain does not differentiate between real and imagined events, making it a formidable tool if used regularly. The following can all lead to an increase in confidence; Mental Imagery, Relaxation Training, Positive Self-talk and Biofeedback (Rose & Jevne, 1993; Cupal & Brewer, 2001).

As physical practice steadily increases the athlete then sets late rehabilitation goals (late rehabilitation stage). These should be long and short-term, challenging but realistic and involve both physical and mental practices. Having a sustained input from the athlete is vital, so they constantly feel in control maintaining self-confidence. At this point you should slowly introduce the athlete back into the team set-up, e.g. team meetings and practices so they realise they have not been forgotten about or replaced. Eventually, the athlete will partake in regular physical training.

The end is in sight (specificity period). Although he/she will require less mental training they still need constant reassurance that they will return to pre-injury form and achieve success again. The athlete may still want to discuss parts of their rehabilitation process.

Finally, once the athlete, coach, medical staff and yourself are all in agreement, the athlete will return to competitive action (return to play). If rushed back too early the athlete could experience low levels of self-confidence which not only increases the risk of re-injury, but could also lead to receiving a negative public perception. This could potentially destroy all the psychological healing achieved during the rehabilitation process.

An emphasis should be placed on carrying out follow up tests once he/she returns to action to hopefully identify signs of high self-confidence e.g. willing take risks, but also for any signs of low-confidence e.g. playing overly cautious. Some athletes successfully go through the injury rehabilitation process e.g. Petr Cech. In 2006, he suffered a depressed skull fracture from a tackle by Stephen Hunt. He returned wearing a scrum hat. The coaches did not mind the hat as it seemed to boost Cech’s confidence. In his first game back, Chelsea lost 0-2 to Liverpool. However, Cech then went 810 minutes in the English Premiership without conceding and was the first goalkeeper since Tim Flowers in 2000 to receive player of the month.

Some athletes however, begin the injury rehabilitation process and never return to their pre-injury form e.g. Alan Smith. In 2006, he suffered a dislocated ankle and broken leg after blocking a shot from John Arne Riise. Speaking to the Daily Mail he is quoted saying “I’ve never been the same player since my Antonio Valencia – style injury”. Although physically healed, he admits there are mental scars such as fear that have subconsciously altered the way he plays.

To conclude, low levels of self-confidence can occur pre- and/or post-injury. When making decisions regarding the athlete’s treatment you should always ask for their input to maintain their confidence levels. However, remember before deciding on treatment, all parties involved should be in agreement. Goal setting and mental training methods are effective in maintaining confidence levels, especially when physical practice is limited. Finally, once an athlete returns to competitive action, follow-up tests must be carried out measuring confidence levels to eliminate any chance of re-injury.

Article

There are many physical and psychological benefits of exercise, so it might seem paradoxical that there is also a risk that, at really high levels, excessive exercise may produce negative effects, including an unhealthy addiction to it. What is Exercise Dependence? A psychologist called William Glaser was the first to differentiate between a negative addiction […]

There are many physical and psychological benefits of exercise, so it might seem paradoxical that there is also a risk that, at really high levels, excessive exercise may produce negative effects, including an unhealthy addiction to it.

What is Exercise Dependence?

A psychologist called William Glaser was the first to differentiate between a negative addiction and what he called a “positive addiction” to exercise.

Positive addiction is characterised by an individual’s love of an activity which has a positive impact on their physical and psychological wellbeing. The “positively addicted” individual is able to control their exercise participation and schedule it around other important aspects of their life.

In contrast, Glaser described a negative addiction as a compulsive need to exercise that takes priority over an individual’s health, relationships and other interests. If they miss a workout, a negatively addicted exerciser will experience unpleasant emotions, such as depression and guilt, as well as physical symptoms like insomnia.

Since Glaser’s first insights into exercise addiction were published in 1976, several terms have been used to describe the phenomenon, including exercise dependence or obligatory exercise.

Broadly speaking, exercise dependence occurs when an individual performs any type of physical activity at such high frequencies or durations that it becomes difficult for them to stop or reduce the amount of time they spend exercising, even if they are injured or have other commitments. When so much time is devoted to exercise at the expense of other areas of life like work or relationships, the behaviour becomes abnormal or dysfunctional [1].

Primary and Secondary Exercise Dependence

In primary exercise dependence, an individual is addicted to exercise for reasons associated with simply doing the activity. For instance the compulsive runner for whom running has become an end in itself rather than a means to an end (such as training for a marathon or to get fit) [2]

In secondary exercise dependence, the key motivation is to control and manipulate body composition. The problem is typically associated with individuals who have a fear of becoming overweight and who do excessive amounts of cardiovascular activities to burn calories. But exercisers who want to increase the size of their physique or have a fear of losing muscle might also be at risk for developing a dependence on their workouts [3]. In secondary dependence, an eating disorder or steroid abuse is likely to be present too.

Am I Addicted to Exercise?

Just because you work out a lot and are strongly committed to keeping in shape, doesn’t necessarily mean that you are, or are at risk of becoming, exercise dependent. In fact, the prevalence of true exercise dependence is relatively low within the general population.

A psychologist called Veale [2] has proposed a set of clinical standards for diagnosing the disorder, which are based on similar criteria for substance dependence. Drawing upon Veale’s criteria, there are some key differences between those who are strongly committed to exercise, and those who are dependent on it [4].

  • Committed exercisers might feel annoyed by a missed workout but will not suffer extreme symptoms if they are unable to exercise. Addicted exercisers will experience strong physical and psychological withdrawal symptoms such as depression, anxiety or insomnia

Ask yourself: Do I get irritable, moody or angry when I miss my workout?

  • People who are dependent on exercise will continue to exercise in spite of injury or known physical or mental health risks (like runners who continue to run with painful shin splints). Committed exercisers understand the need to heal and recover.

Ask yourself: Do I exercise against medical advice or when I am injured? Have I already suspected that I exercise more than is good for me, but not been able to stop?

  • Commitment to exercise will give you feelings of satisfaction, enjoyment and accomplishment. Dependency can often leave you feeling dissatisfied or unhappy even at high levels of exercise.

Ask yourself: Am I doing more exercise this year than I did last year just to feel ok?

  • Committed exercisers organise exercise around their lives, but dependent exercisers organise their life around exercise, at the expense of other commitments such as work or family life.

Ask yourself: Have I ever considered that I am risking my job, relationship or health because of my exercise routine? Is exercise dominating my life so much that when I am not doing it, I am thinking about it? Am I having more arguments about the time or money I spend on exercising?

How much exercise should I be doing?

Healthy levels of exercise have an anabolic (tissue-building) effect on the body, but excessive exercise, whether it is a conscious decision or a habit you are finding hard to stop, can have a catabolic (tissue-destroying) effect on the system. The amount of exercise and fitness training you can healthily sustain will depend upon your goals, fitness levels and the time you can devote to training. Speaking with a qualified personal trainer will help you plan a programme that will not only challenge you but also includes adequate recovery intervals.

Recovery time is an important aspect of physical training and without it you are likely to eventually experience physical symptoms, such as muscle or joint damage, prolonged fatigue, and be more prone to infections. Don’t ignore physical symptoms just because you want to keep exercising: consult a physiotherapist, sport injury specialist or your GP.

If you are keen to continue exercising when you are rehabilitating from an injury, a qualified strength and conditioning coach can help you structure a routine that will allow you to repair the current damage whilst continuing with appropriate levels of physical activity.

What to do if you are concerned that you or someone you know is exercise dependent

The research does demonstrate that it is possible, although relatively rare, for some people to become dependent on exercise in ways that have a negative impact on their wellbeing. The problem is starting to receive more attention, helping psychologists understand more about how exercise dependence might develop, how to identify it, and prevention or treatment options.

If you are concerned that your exercise routine is having a negative impact on your life and preventing you from meeting other commitments, if you are experiencing feelings such as anxiety or depression when you are unable to exercise, or if other people have expressed concern that you are losing too much weight through exercise, your should seek the advice of a qualified psychologist.

Speaking with a psychologist can help you understand the extent to which exercise might be controlling your life rather than being a source of wellbeing, and explore the underlying reasons why you are exercising at such high levels. You can find a qualified psychologist at www.bps.org.uk.

About the Author

Helen O’Connor is a sport and exercise psychologist, in training with the British Psychological Society. She established her psychology consultancy in 2009 and works individually and in groups with adults and teenagers who are looking for support to make healthy lifestyle changes, such as increased physical activity.

Article

Last year several newspapers reported the failure of a randomised controlled trial to identify any additional long-term benefit of ‘facilitated exercise’ over and above conventional care (such as counselling and medication) for people with depression (Chalder et al., 2012). These findings were reported with dramatic headlines such as ‘Exercise “of no benefit” in fight against […]

Last year several newspapers reported the failure of a randomised controlled trial to identify any additional long-term benefit of ‘facilitated exercise’ over and above conventional care (such as counselling and medication) for people with depression (Chalder et al., 2012). These findings were reported with dramatic headlines such as ‘Exercise “of no benefit” in fight against depression’ (Metro, 6 June 2012) and consistently failed to mention important aspects of the research

But, before we stop bothering to encourage our depressed friends, family or even ourselves, to be more active, we should look at what the results really tell us, and what they don’t, about exercise and depression.

Media reports were particularly misleading because it appeared that the effects of exercise upon depression were tested. In fact the only difference between the intervention and control groups was that the intervention group received additional advice and encouragement, delivered using a motivational interviewing (MI) approach, to find and participate in locally available opportunities for physical activity. The intervention group was not given an exercise programme, and nothing prevented the control group from learning about the potential benefits of exercise from other sources, or from exercising.

Whilst the intervention group did report exercising slightly more than the control group, the findings showed no significant differences between the groups for depression symptoms (most participants reported improvements) or antidepressant use at four, eight or 12 months. The take-home message being that ‘advice and encouragement to increase physical activity is not an effective strategy for reducing symptoms of depression’.

However, the study’s authors also point out that although their intervention did increase physical activity ‘the increase may not have been sufficiently large to influence depression outcomes’. Similarly, a BMJ editorial emphasised that patients in both groups were receiving high quality care and 25 per cent were already meeting Government exercise guidelines at the start of the study, so there may have been ‘little room for the intervention to make a difference’ (Daley & Jolley, 2012).

What the study also didn’t tell us is:

  • Whether there were any differences between those who were more physically active, and those who were not, irrespective of intervention group
  • Whether there were any differences between those who were taking antidepressants and those who were not
  • How access to local opportunities differed according to participants’ socioeconomic status
  • Whether there was a dose effect of exercise frequency or intensity upon depression symptoms (e.g. dog walking versus aerobics)
  • Whether there are beneficial temporary effects of physical activity on depression symptoms during or immediately following an activity
  • Whether intervention adherence (attendance at guidance sessions) resulted in adherers exercising more than non-adherers or controls
  • Whether intervention success was affected by how well the treatment model was followed and delivered.

We must absolutely understand the evidence base for both the behaviours we recommend, and the interventions we use to support those behaviours, which is why rigorously conducted RCTs are essential. But, whilst we strive to protect the reputation of our discipline following recent incidents of scientific misconduct, we should not forget how important it is to also report our findings responsibly – people are not only mislead by falsified data. Just don’t get me started on ‘Chocolate “as good for you as exercise”‘ http://bit.ly/qTab16.

This article was first published online here

Helen O’Connor is a sport and exercise psychologist in training with the BPS. She established her psychology consultancy in 2009 and works individually and in groups with adults and teenagers who are looking for support to make healthy lifestyle changes, such as increased physical activity. Twitter @psycurious.

 

Article

n 2013, it is impossible to go into any workout facility and not see the majority of the exercisers with headphones in or to walk into a team’s changing room and for it to be silent. Music plays an influential role in our society and the world of sport and exercise is no exception. Advances […]

n 2013, it is impossible to go into any workout facility and not see the majority of the exercisers with headphones in or to walk into a team’s changing room and for it to be silent. Music plays an influential role in our society and the world of sport and exercise is no exception. Advances in technology have made music more accessible and more prevalent than ever making it a part of our daily lives. But how do we know what kind of music is most effective to our training and performance? This is a guide for appropriate and effective music to listen to before, during, and after exercise or sport performance.

Pre-Task Music

 Music is often used by athletes before an event, game, or match. Michael Phelps is a prime example of this as he has often been shown with his headphones on before swimming each of his Olympic races. Phelps has stated that before he swims he listens to music that motivates him and that has lyrics he can relate to. These are just a couple of the reasons why athletes use pre-task music. Laukka (2013) found that elite athletes’ other motives for using music before an event are to increase pre-event activation, positive affect, motivation, performance levels, and to experience flow. The research done in this area has been primarily on the effects of stimulative and sedative music pre-task. Karageorghis, Drew, and Terry (1996) found that listening to stimulative music prior to a grip strength test resulted in increased grip strength relative to the control. It was also found that listening to sedative music prior to the test resulted in lower scores. Other studies have shown that listening to music before performing can increase or decrease arousal depending on the type of music (Eliakim, Meckel, Nemet, & Eliakim, 2007; Yamamoto et al., 2003). Yamamoto et al. found that slower music lowered arousal during the listening period and that faster music elevated arousal. While Eliakim et al. found that stimulative music increased heart rate, which is an indicator of increased arousal. This is evidence that music can be beneficial to a pre-performance routine as far as preparing the body for its upcoming sport. However, it is important to note that pre-task music is not as relevant in an exercise context as it is in a sport context because people do not generally get too anxious about exercising like they do sport performance (Karageroghis & Priest, 2012a).

Music can also be used as a tool to regulate pre-competitive emotions. Bishop and Karageorghis (2009) found that young tennis players listen to music at least two hours a day on average, and that it usually takes place while they are travelling, preparing for competition or training, in their bedrooms, or working out in the gym. They also established that these athletes listened to music in order to achieve five broad states: appropriate mental focus, confident, positive emotional state, psyched-up, and relaxed. Bishop and Karageorghis came to this conclusion by having the tennis players keep a daily one-page diary for two weeks that consisted of open ended questions about what they had done that day, their tennis performance, what music they listened to, and how it made them feel. From this, they were able to create a new model for selecting effective pre-performance music. In the model, there are five determinants of emotive music. Extra-musical associations with significant others, places, and past events is at the top because that was found to be the most important according to what the young tennis players put in their diaries (Bishop & Karageorghis, 2009). Overall, it was found that all of the music selected by the young tennis players were tracks they were very familiar with, which again shows the importance of personal preference because if the athlete does not know the song that is supposed to be preparing them to perform it will be much harder for them to connect with it.

In-Task Music

The majority of the research done in the area of using music in sport and exercise has been focused on the use of asynchronous music, or background music, while training or exercising. It is best used when the goal is to either enhance mood or distract attention away from a monotonous or repetitive drill, such as gym workouts or when practicing specific skills (Karageorghis & Terry, 2011). Several studies have been conducted on the effects of music during endurance tasks, and the general consensus is that music does increase endurance (Crust, 2004; Crust & Clough 2006; Priest & Karageorghis, 2008). Crust (2004) and Crust and Clough (2006) examined the effects of motivational music on an isometric muscular endurance task which required participants to hold a weight extended directly from their body at shoulder level. In both studies, it was found that muscular endurance lasted longer when the participants were listening to music than when they were not. Crust also found that the endurance was greatest when participants were exposed to both pre-task and in-task music. Crust and Clough’s study was unique in that it used a drumbeat condition and a motivational music condition. It was found that the participants’ endurance was greater while listening to the motivational music than the drumbeat. These are important findings that can be directly applied to athletes and exercisers wishing to increase their isotonic muscular endurance.

Synchronous in-task music is used for different reasons and often accompanies repetitive endurance tasks such as running and cycling (Karageorghis & Priest, 2012b). Synchronous music has been found to increase ergogenic effects more than asynchronous music. When athletes train to music, they tend to work harder for longer (Karageorghis & Terry, 2011). Karageorghis and Terry found that 400-metre runners improved their time trial by half a second on average when they synchronised their strides to music compared to when they used no music. This is useful but it is essential that the tempo of the music is only one or two beats faster than the athlete’s usual speed. Having those extra one or two beats can make a big difference as Karageorghis and Terry demonstrated with the 400-metre runners.

Post-Task

Post-task music is something that is still in the early stages of research as there have only been two studies done on the topic (Jing & Xudong, 2008; Savitha, Mallikarjuna, & Chythra, 2010). Both of these studies demonstrated that sedative music yields the fastest recovery time from exhaustive exercise, compared to stimulative music or no music. Sedative music aids in lowering of heart beat and blood pressure as well as perceived exhaustion (RPE). However, both of these studies had several methodological flaws that should be addressed. For example, they used the Borg RPE Scale to measure perceived exhaustion during the recovery period, which is not what it is intended for. There are clearly benefits to listening to sedative music while recovering from exhaustive exercise or a particularly tough training session, but this is an area that needs to be researched more thoroughly so that these benefits can be more fully understood.

In summary; before exercise or sport listen to music that is familiar and motivating to you, during exercise listen to music that is slightly faster than your usual exercise speed or use background music to distract yourself from a repetitive task, and after sport or exercise it is beneficial to listen to music that is slow and sedative to aid your body in recovery.

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It is common to hear music blaring in sports stadiums and a frequent sight at events, such as the Olympics, is to see athletes ‘psyching’ themselves up with their headphones pre competition; but how useful is music in aiding performance? Music often evokes certain feelings or memories with people, for example, your first dance at […]

It is common to hear music blaring in sports stadiums and a frequent sight at events, such as the Olympics, is to see athletes ‘psyching’ themselves up with their headphones pre competition; but how useful is music in aiding performance?

Music often evokes certain feelings or memories with people, for example, your first dance at a wedding will always remind you of your partner and that day, or a song on an advert will remind you of that product the next time you hear it. Musical association with feelings and memories can help you prepare for competition.

Michael Phelps, 18 times Olympic Gold Medalist, is renowned for listening to music until just before diving in the pool. Not only will this allow him to listen to the music that mentally prepares him for competition, but it also allows him to block out the sound of the crowd and removes distraction from his ideal competitive mental state.

Music choice will ultimately depend on the individual, as a song that evokes the feeling of apathy in one individual, may inspire motivation in another. Athletes’ specific song choices are not directly important, it is the emotions and feelings they create that are key to producing the perfect competition mindset.

The perfect competition mindset will vary depending on the sport, but generally involves:

  • Confidence in ability
  • Positivity
  • Emotional stablility
  • Feelings of control
  • Mental alertness
  • Motivation

Listening to the same playlist before every competition should help to ensure that the correct competition  mindset is achieved everytime. The songs then will not just have their individual associations with certain feelings, but the whole playlist will induce the ideal feelings and emotions.

“In training build ups for major races, I put together a playlist and listen to it during the run-in. It helps me psych up and reminds me of times in the build-up when I have worked really hard, or felt good. With the right music, I do a much harder workout” – Paula Radcliffe, Marathon World Record Holder.

The type of music listened to pre competition will not only depend on the individuals’ personal choice, but also on the sport they compete in. For example, a golfer needs to be very calm and relaxed, where as a boxer needs to be confident and aggressive. The music that will create these contrasting states will more than likely be opposing genres; the golfer is more likely to listen to classical music, whilst the boxer is more likely to listen to upbeat rock music.

However, not all sports are individual. Whilst listening to headphones and blocking out distraction would work well for a tennis player, if the members of a football team all listened to different music on headphones, their team spirit would suffer. This could lead to a reduction in the quality of performance. To ensure team camaraderie prevails, speakers should be used for pre competition playlists; professional teams may benefit further by playing pre competition playlists over their stadiums’ loud speakers, which would also hype up the crowd. Used in the correct way, music can optimise performance.

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Depression within Cricket has hit the headlines in recent years with many household names such as Andrew Flintoff, Steve Harmison and Marcus Trescothick opening up about their own experiences and battles. One study suggested that the suicide rate among English test cricketers over the years is almost double that of the UK’s male population. The […]

Depression within Cricket has hit the headlines in recent years with many household names such as Andrew Flintoff, Steve Harmison and Marcus Trescothick opening up about their own experiences and battles. One study suggested that the suicide rate among English test cricketers over the years is almost double that of the UK’s male population. The media spotlight surrounding the issue has triggered a response from the Sport, with organisations such as the Professional Cricketers Association (PCA) launching initiatives such as the Mind Matters tutorials to educate players about the possible risks and coping strategies.

The real question though is why is this the case? Is it something about the sport that is triggering such incidences? Or is it more likely to be a reflection of the type of personalities that tend to take up the game? There is no concrete answer.

Let’s firstly look at characteristics of Cricket that could be deemed as risk factors for the onset of depression. In professional Cricket, time away from home can be a huge issue for some players, with as much as 44 weeks of the year being spent in hotel rooms. The huge amount of time spent alone on tour, as well as the time in the field, whilst waiting to bat etc. provides perfect opportunity for introspection, or analysis of one’s thoughts and feelings, which can therefore also lead to rumination, which consists of persistent negative feelings. Studies have shown strong correlations between both introspection and rumination and incidence of depression.

On top of all that, there’s then the pressure of a game that is quite unique in its need for individual performance within a team game. Individual performance is tangibly measured and compared through the use of batting and bowling statistics, with averages and number of runs scored or wickets taken regularly being used as performance indicators. This is much more objective than most other sports, for example football, where a player might not score a goal, but it can still be subjectively perceived that he had a good game.

In other words, poor performances are harder to hide in Cricket. This is capable of creating a huge amount of self-induced pressure; wanting to contribute to the team, pressure on one’s self to do well, and a high fear of failure. It can also create insecurity, with the constant worries of whether one’s contribution is being valued and the questioning of one’s own ability. If you play an individual sport, and play poorly, that’s one thing; you may feel that you’ve let yourself down. If you have a poor individual performance in a team game, you may not just feel that you’ve let yourself down, but also your teammates, your captain, your coach etc. So in a game where individual performance is so easily measured, this can be a huge issue.

All of these things, or a combination of them, are capable of leading to depression as they encourage risk factors such as self-criticism, rumination and anxiety. However, each sport has its own pressures and every career has its own pressures that it would be equally reasonable to suggest as risk factors for depression. So maybe there is an argument for the side of the story that suggests the high incidence of depression is due to the tendencies of the people who play the game. It could be construed that it is a certain way in which these pressures are being handled that eventually leads to depression.

It is possible that Cricket attracts a large proportion of people who are prone to a large amount of self-analysis, as there is plenty of opportunity to analyse technique and performance. This also lends itself well to striving for perfection, or aiming to avoid imperfection, which also has links with a high fear of failure and depression.

It could just be that a combination of the two, the nature of the game and the tendencies of the people that play it, that when brought together cause such devastating consequences.

Whichever it is, or even if it’s both, Cricket’s leading organisations need to continue to take this seriously, even as the media attention dies down, and continue to put in place strategies and support networks for its players, for both prevention and management/cure. In the mean time, hopefully the opening up of former players will encourage current players struggling with such issues to open up too, and not suffer in silence like many have before them.

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How do athletes become elite players in their chosen sport? Is it their innate talent or do they train every hour of every day to become an elite player? It is often said that ‘practice makes perfect’ and to a certain extent this is true, the more you practice a skill the more likely you […]

How do athletes become elite players in their chosen sport? Is it their innate talent or do they train every hour of every day to become an elite player? It is often said that ‘practice makes perfect’ and to a certain extent this is true, the more you practice a skill the more likely you are to master this skill. However, too much practice can be debilitating and can in some cases cause the breakdown of an athlete.

Perfectionism is considered to be a personality characteristic that reflects an individual’s obsessive pursuit of exceptionally high standards and overly critical appraisals of performance (Hewitt and Flett, 2001). Perfectionism can stem from three areas; self-orientated perfectionism, other orientated perfectionism and socially prescribed perfectionism (Flett and Hewitt, 2005). Self-orientated  is striving and demanding absolute perfection from the self, other orientated is demanding the best from those around you, whilst socially prescribed is the belief that the people around you demand that you are perfect. Perfectionism has been described as multidimensional with adaptive (good) and maladaptive (negative) characteristics that affect athletes in different ways. The positive outcomes of perfectionism are high levels of performance that are reached by setting goals to strive for. However, this high performance level is difficult to maintain as the goals that are set by the athlete are excessively high and very difficult to reach. When they are not met it leads to the negative characteristics of perfection which include harsh self-criticism and intense focus on personal and interpersonal inadequacies (Frost et al., 1990).

It is difficult to predict whether perfectionism will exhibit positive or negative outcomes for an athlete. There are various aspects that impact on this which include coping styles, self-esteem and performance success and failure. In terms of coping styles, those with maladaptive coping styles (e.g. avoidance and emotion focused) are more likely to be exposed to the most severe negatives of perfectionism including depression. Avoidance coping involves the athlete ignoring stressful situations and not dealing with a problem whilst emotion focused coping involves actively dealing with the negative thoughts such as fear. Athletes who have adaptive coping styles (e.g. problem focused coping), are more likely to be able to deal with setbacks effectively as their coping style targets the problem directly so that they can move quickly past it (Hewitt and Flett, 2002). Self-esteem is another area that often has a negative effect on an athlete as those with low self-esteem are more likely to be dissatisfied with their performance, give low self-competence ratings and be concerned about their mistakes (Gotwals, Dunn and Wayment, 2003). Whether a perfectionist perceives themselves to be a success or a failure is also important. Perfectionists are also more likely to see failure in an objective way. This means that their view of the performance is severely distorted and if they don’t win, it is seen as a failure. This is because they don’t see improved performance (e.g. last time they finished the race 6th, this time they finished 3rd) as a success and they don’t take mitigating circumstances (e.g. injury) into account.

An example of perfectionism in sport can be seen in former England rugby international fly half Jonny Wilkinson, who was widely regarded as the best goal kicker in world rugby at his peak. This kicking ability was obtained through hours and hours of practice – “maybe I’ll hit four in a row and just miss the fifth one… Instead of being satisfied with that, I won’t allow myself to leave until I’ve hit five… An hour and a half later – and having missed loads of appointments and left myself runningcompletely late – I might do it” (Wilkinson, 2009).  His perfectionism was caught between his drive to be the best and his fear of letting people down. After winning the 2003 Rugby World Cup his career took a downturn as the next 2-3 years where dominated by numerous groin injuries, which in his eyes, was down to his exhaustive kicking regime. This is a perfect example of the different effects that perfectionism can have as Wilkinson’s need to be the perfect player got him to the peak of his career, but was also his downfall as he pushed himself too far physically and experienced burnout, in his body and his mind. Wilkinson describes his desire for perfectionism as both unattainable and “unhealthy”. After fully recovering from his physical injuries and reassessing his mental approach, he is far more relaxed and is not so hard on himself when things don’t go his way, part of which he puts down to his new found faith (Wilkinson, 2009).

When perfectionism turns negative, which according to various research in the area it almost always does, burnout is an area that becomes very important. It has been described by Raedeke and Smith (2004) defines burnout as a multidimensional construct that is caused by emotional and physical exhaustion with a reduced sense of accomplishment and caring towards sport participation. The links between perfectionism and burnout have been shown by various research. Appleton, Hall and Hill (2009) found socially prescribed perfectionism to be strongly and positively linked with burnout. Socially prescribed perfectionism defines the perceived pressure from those around you to be perfect and can lead to burnout in such a way that athletes often lose their desire to play sport as they feel they are not doing it for themselves but instead for those around them. Perfectionists are known for setting high standards and goals but when these are left unfulfilled the athlete can once again risk burnout as they then try harder and harder to reach these standards and goals by pushing themselves too far physically and mentally.

The standards and goals that athletes set themselves define the elite from the normal player and often have a positive influence on their careers. However perfectionism can take this to a new level which can have dangerous affects on an athlete and their career. It is important that coaching staff familiarise themselves with the characteristics of perfectionism so that they can identify it early on and avoid these negative outcomes for the athlete.

 

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About 18 months ago a high court rulingdeemed lengthy gym membership contract tie-ins unfair. This may well have been one reason for the recent increase (in the UK at least) of several low-cost/no-frills gym groups. For too long gyms have happily taken our joining free and monthly standing order whether we do or don’t use the […]

About 18 months ago a high court rulingdeemed lengthy gym membership contract tie-ins unfair. This may well have been one reason for the recent increase (in the UK at least) of several low-cost/no-frills gym groups.

For too long gyms have happily taken our joining free and monthly standing order whether we do or don’t use the gym, and until now those who don’t use the gym haven’t been able to get out of the contract easily. It is my guess that the majority of people who do try to cancel their contracts are those ‘New Year Resolution’ January-joiners: new exercisers who have not yet developed a regular fitness routine or habit, and who just don’t use their membership enough.

50% of people who begin an exercise program will drop out within six months the majority of which in the first 2 weeks of a new exercise program (Dishman, 1991)

Even with all the best intentions, a new exerciser often has difficulty staying with a program. Their life isn’t yet geared up to accommodate a new fitness regime, and they have several competing lifestyle habits and some unhelpful beliefs about their own exercise ability, all of which can interfere with their desire to be more active.

If people exercise consistently, for long enough, good habits have a chance to form, which hopefully improves their fitness and health across their lifespan. But it takes a long time for a new habit to form, especially something like exercise that isn’t usually done daily.

Recent research suggests that it might take 66 or more regular repetitions for habitual exercise to develop (Lally et al., 2010)

That’s about three months if you are going five times a week, five months at three times a week and longer if you don’t make it that often

If gyms want to stop people cancelling their contracts, then, rather than dishing out the usual uninspiring gym induction and leaving them to their own devices, they must think seriously about innovative ways they can encourage new members to start and maintain a new exercise habit and learn to enjoy the gym so that they see it as an essential cost they are happy to incur.

How might gyms, fitness trainers or exercise class leaders do this?

  • Establish trust

Gyms can be daunting places for new members, and people like to feel that they matter. Make new members feel part of your club by trying to learn people’s names and using them, and encourage receptionists and other staff to do so too. In a class environment, this can also help people feel like an important part of a “team” and more likely to return. Welcome people back after an absence.

  • Build confidence: Make it do-able

People are more likely to stick with their programme if it is fun and convenient and if they can gradually build up their confidence in what is often quite an intimidating environment, especially for people who aren’t happy with their body image. The better a person is able to perform a task, the more confident they feel about their ability to do it in the future (and the more likely they are to actually do it again).

So don’t just trot out the usual gym induction and programme of 60 minute weight and cardio workouts to be done three-five times per week. Studies show that people are less likely to continue their programme if they exercise at higher intensities too soon and long workouts are also associated with higher drop out rates. Personal trainers and members of staff who do the gym induction program might benefit from taking a step back from the “science” behind what gets the best or fastest results, and realise that their new clients might not get any results at all if they don’t start off with shorter, more enjoyable workouts that are within their abilities. This might produce slower physical results, but psychologically you are laying the foundations for some positive attitudes, self-belief and self-confidence about exercise in your clients.

Encourage new members to try out several classes on the timetable and find something they enjoy. Ideally, run some specific taster classes just for new members in January so that they can experiment with other novices in a pressure-free environment, rather than feeling intimidated by existing cliques and experienced members in the regular classes.

Remind new members that there are likely to be some times of the day that are better for them to workout and that they should experiment with different classes at different times. If membership includes access to multiple branches find out which are closest to your members’ home and work, and create a monthly email of the class timetables for both to encourage them to find something they can fit in: reassure them that even a 30 minute session on the cross-trainer at lunchtime will benefit their health.

  • Monitor progress and goals

Many new exercisers join the gym to lose weight but the danger of measuring success using one single outcome goal is that there is plenty of scope to feel disheartened when the scales don’t move as quickly as they would like. This can lead to a spiral of negative thinking (“what’s the point, I am still overweight”) that can discourage them from sticking to their program.

There are so many other potential markers for improvement that can help people feel positive about their progress. Previously sedentary members who come to the gym even once or twice a week are likely to see measurable improvements in bleep tests, a timed kilometre on the treadmill, their recovery time, taking fewer breaks during an aerobics class, and even body composition. The latter helps people see how they are gaining more muscle and losing fat, even when there is no change in weight or size.

So think about taking a range of non-weight-related measures when you welcome new members, and scheduling regular progress updates each month (or even more often) during their first year of membership. This can keep motivation up and reinforces their continued effort. Even better, encourage them to set a new goal for each measure for the next progress session (improve my timed kilometre by one minute; lose 1% more body fat etc.).

Hopefully now that gyms have to be more flexible about contract cancellations they will think instead about how they can encourage new members to become lifelong members by improving their initial gym experiences to foster new healthy habits.

Helen O’Connor is a sport and exercise psychologist, in training with the British Psychological Society. She established her psychology consultancy in 2009 and works individually and in groups with adults and teenagers who are looking for support to make healthy lifestyle changes, such as increased physical activity. Follow @psycurious

This article was first published online here

 

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An estimated 1.6 million people suffer from an eating disorder in the UK– 6.4% of the adult population, and the prevalence is even higher amongst athletes. Key Features of Anorexia Nervosa: Symptoms, Causes and Treatment Eating disorders are popular topics in the media and are frequently the focus of television programmes such as Supersize vs. […]

An estimated 1.6 million people suffer from an eating disorder in the UK– 6.4% of the adult population, and the prevalence is even higher amongst athletes.

Key Features of Anorexia Nervosa: Symptoms, Causes and Treatment

Eating disorders are popular topics in the media and are frequently the focus of television programmes such as Supersize vs. Superskinny and Dana: the 8 year old anorexic (Clifford, 2008). Widespread interest in anorexia nervosa can be understood by the bewilderment of how any human could starve themself and lose the instinct to keep themselves alive. With the highest mortality rate of any psychiatric disorder, lack of understanding of anorexia extends to health professionals. One hundred and forty years after the disorder was first established as a ‘nervous loss of appetite’, biomedicine still fails to adequately define, explain or cure anorexia.

Whilst anorexia remains mysterious, the criteria for a diagnosis are stringent: refusal to maintain normal body weight (<85% expected weight), fear of gaining weight, disturbance in self-evaluation of weight or shape, and amenorrhea. The significant revision of criteria for the next version of the Diagnostic and Statistical Manual of Mental Disordersdemonstrates how current criteria are totally inadequate. The removal of amenorrhea as a criterion from DSM-5 highlights the increase in ‘manorexia’. Whilst the female to male prevalence of anorexia is 11 to one there has been a 66% rise in male hospital admissions for eating disorders in the last decade.

Other behavioural, cognitive and emotional signs of anorexia include missing meals, excessive exercise and perfectionism, some of which have been proposed as alternative diagnostic criteria.Recent research has identified auditory hallucinations, impaired ‘set-shifting’, and psychological inflexibility as additional symptoms. However, considerable underlying heterogeneity means it is difficult to reduce anorexia to a psychiatric tick list which would identify all those suffering.

Unfortunately, DSM-IV criteria fail to identify the majority of those affected by anorexia. Whilst sufferers may display a buffet of disordered eating symptoms, many cannot access treatment because they do not meet the diagnostic criteria. For example, West Sussex Family Eating Disorder Service does not treat sufferers when the diagnosis of anorexia is unclear.

The cause of anorexia has been attributed to everything from genes, low birth weight, and abnormal neurotransmitters, to insecure attachment, unresolved trauma, and media ideals. Whilst professionals accept that there is no single cause of anorexia, this medicalisation has resulted in an assumed underlying pathology. This isolates those with anorexia as abnormal, disregards personal experiences, and ultimately prevents sufferers from recovering as social and moral individuals. Instead those with anorexia are treated as cognitive cripples fixable with drugs and Foucauldian-powered regimes.

Treatment programmes for anorexia are largely unsuccessful. Clinicians’ disregard for the uniqueness of each individual’s suffering has resulted in treatment plans which may actually replicate conditions that cause the disorder.

Anorexia Nervosa in Sport 

Constructing anorexia as a biocultural disease eradicates the Cartesian dualism of modern medicine. Anorexia as a social matter is supported by the increased prevalence of anorexia among athletes. The performance, ascetic and virtuous dispositions often found in those with anorexia, combined with aesthetic, aerodynamic and weight-categorised pressures, may prime athletes for anorexia.

Despite the high prevalence, identifying anorexia is even more challenging in a sporting environment with symptoms being dismissed as a benign form of the clinical syndrome. The similarities between the traits of ‘good athletes’ and those with anorexia, and the reinforcement of dieting by coaches, further complicates diagnosis and treatment.

Questionnaires, such as the EDE-Q, can been used to identify anorexia among athletes. Whilst viewed as valid instruments to assess eating disorder psychopathology, self-report measures are subject to social desirability bias and faking good. Denial may also be used by athletes in an attempt to disguise the severity of their suffering.

It should be noted that psychometric measures of anorexia predominantly include negative self-statements (e.g. ‘I feel guilty after eating’) which may foster self-criticism – a key predictor of anorexia. This can also inspire athletes with anorexia to live up to the symptoms of their diagnosis. However, positive psychology measures have been developed (e.g. Body Appreciation Scale) focusing on sufferers’ strengths rather than their symptoms.

Instead of relying on questionnaires, coaches need to be aware of any disordered eating behaviour which could indicate anorexia, as well as athletes’ emotional and psychological state. Knowledge of the female athlete triad is especially important for anyone working with young women in sport.

Reducing the taboo around eating disorders in sport is crucial in preventing athletes suffering from anorexia from getting abandoned.  Educating coaches and parents on preventative strategies is key in reducing risk factors and encouraging sufferers to seek treatment.

Preventative strategies include:

  • Advocating health and wellbeing
  • De-emphasizing body weight
  • Using role models with healthy body weight
  • Referring athletes with disordered eating to a specialist
  • Dispelling myths that ‘thinner is better’
  • Make disordered eating a health and safety issue rather than a coaching issue

Practical Challenges of Anorexia Nervosa in Sport and Appropriate Support Interventions 

Recovery from anorexia is challenging, especially for athletes. Because it is considered normal for an athlete to pay meticulous attention to their diet and weight, anorexic behaviours may be justified to family as part of the athlete’s training programme, preventing early intervention and delaying recovery.

Sport Psychologists play a key role in identification of anorexia, but a referral should be made to specialists (ideally with the athlete’s consent) so the athlete has the appropriate support from a multidisciplinary team, which can provide nutritional support, psychological therapies and medical check-ups. Whilst some clinicians advise that athletes can only train if they comply with treatment, whether sport withdrawal is necessary for recovery in anorexia is debated. Resource intensive treatment does not necessarily improve prognosis of anorexia, therefore empowering the athlete to take control of their own recovery, with trusted support and expert advice, may be more effective unless their physical health is at risk.

During the athlete’s recovery, coaches need to prioritise the person over their performance, and treatment teams need to see the sufferers’ strengths not just their symptoms. An athlete’s recovery should not be seen purely as getting rid of problems, but in seeing beyond the anorexia to the passions that give meaning to their life. Therefore continuing to train can be helpful for athletes in recovery, encouraging weight restoration, reducing body dissatisfaction, and helping athletes to develop a positive sense of identity.

Athletic participation can also be protective against the development of anorexia, especially in non-elite sport. Adapted Physical Activity, dance therapy, and yoga can be usefully integrated into treatment programmes for anorexia. Therefore, exercise not does not necessarily increase the risk of anorexia, but can actually be a tool for healing.

In conclusion, anorexia is mysterious and unpredictable. Its diagnostic criteria are currently being revised.  Despite the high prevalence of anorexia in elite athletes, the sporting environment and pressures makes it difficult to identify and treat. There is no one-size-fits-all treatment for athletes with anorexia. A holistic approach, offering, psychological, emotional and spiritual support is essential in helping the athlete to realise that the anorexia need not starve them of their sporting hopes, but that they can be strengthened through suffering. Empowering the athlete to apply their sporting discipline and anorexic asceticism to recovery allows them to use their struggles to reconstruct life’s meaning, to transform fear into faith, and to thrive.

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According to recent research it appears that professional footballers are in fact real human beings, with real emotions and accordingly, a capacity for mental health problems. Although the domain of Sport Psychology is primarily performance optimisation, while counselling/psychotherapy focuses on optimising people’s well-being, the two don’t- and shouldn’t- exist in total isolation from one another. […]

According to recent research it appears that professional footballers are in fact real human beings, with real emotions and accordingly, a capacity for mental health problems. Although the domain of Sport Psychology is primarily performance optimisation, while counselling/psychotherapy focuses on optimising people’s well-being, the two don’t- and shouldn’t- exist in total isolation from one another. They are by no means mutually exclusive, and indeed often sport psychologists work in conjunction with or at least refer onto mental health professionals. By helping someone to work through the difficulties they’re going through/have gone through, and any unhelpful thinking patterns that may have developed as a result, it can also aid performance in various ways, like, for example, unclogging valuable working memory resources.

In order to help people with any difficulties, we know that opening up and talking things through is a necessary- and often sufficient- condition.  This is certainly the case for mental health problems; whether mild and transient or more severe and long-lasting, half the battle is feeling able to talk openly about what’s going on. Narrowing this down to men, it becomes three-quarters of the battle- owing largely to evolutionarily hardwired conceptions of men’s role as ‘hunters’, with any of talk of feelings revealing ‘weakness’. For male athletes, working in an environment where ‘weakness’ equals ‘failure’, this becomes nine-tenths of the battle. In football, where changing rooms are abound with macho-driven banter, where a spade isn’t so much called a spade as an ‘absolute tool’, the fraction gets pretty close to becoming a whole number.

Since the tragic suicides of Robert Enke and more recently Gary Speed, the issue of mental health in football has risen in profile. The key question is, though: are players feeling more able to talk openly about their problems? It’s a question that relates to closely interwoven issues like stigma, lack of knowledge about mental health problems, transparency, and availability of professional support.

To get an insider’s take on this question I spoke with Mickey Bennett, a former player at Charlton and an England under-19 international, who now works as a counsellor working predominantly with professional footballers (having set up his own company, Unique Sports Counselling). In April this year the Professional Footballer’s Association (PFA) announced the launch of the national network of counsellors for all PFA members, meaning that any players who have joined the PFA can access the support of a sports counsellor in their region of the country. Alongside Tony Adam’s Sporting Chance Clinic, Mickey Bennett initiated this scheme as a result of the growing recognition that more specifically tailored counselling support was required for football pros (both current and former). The network echoes measures taken in Germany after the death of Robert Enke.

Mickey talked to me about why he became a counsellor:

‘I’ve been working with the FA for five years now [as a counsellor]. I’ve experienced some stuff myself in terms of injuries and a fear of not being the player I expected myself to be, playing the bills, and all that stuff… At the time unfortunately I didn’t have anyone I could talk to about the way I was feeling, so that’s where it came to mind that I’d like to give something back by being a counsellor.’

In order to promote players’ understanding and recognition of mental health issues, the PFA commissioned the production of The Footballer’s Guidebook: Life as a professional footballer and how to handle it, which was given out to all professional teams across the country. Mickey contributed towards the guidebook, which was written by Susannah Strong, a mental health journalist.

‘When the Gary Speed situation took place it kind of nudged everybody, as everyone went ‘What’s this all about? Why did he kill himself?’ Then mental health awareness was raised. Also, the PFA made the footballers guidebook. A combination of the guidebook and Gary Speed’ death made people aware, and the phone started to ring, and then it continued to ring- because [players] now identified what depression looked like, what anxiety looked like, what stress looked like, and could recognise it in themselves and could say ‘Yeah, I’ve had that’, and they came forward.’

Mickey told me he met fifty-four players for counselling last year. As he was having to drive around the country to do so, it became clear that a national network of counsellors, where players could access support more locally, would be crucial to accommodate the number of players seeking help. As Mickey says, ‘We have to make sure we have things in place to support the guys who are coming forward.’

The fact that people are coming forward at all marks pretty good progress in terms of players recognising the need for psychological support. Part of this has come from the way the message about mental health has been put across. With mental health already stigmatised in society, tailoring this message to footballers with care is also important:

‘It’s all about education. When I do my talks with clubs and players, I tell them that ‘if you have a hamstring injury, you go to the physio and get treatment. If you have a mental health issue, you just go and do the same thing. It’s no different.’ That’s how we try to break it down for them’.

Mickey is an ex-pro himself, having played 72 times for Charlton as well as having stints at Wimbledon, Millwall and Brighton among others.  Although he emphasises it’s not necessarily the case that if you haven’t played the game professionally, players won’t respond to you, he acknowledges it certainly makes things easier:

‘Ultimately, I think it helps. If you’ve played the game, you have a better idea of what players are going through. It’s made the transition much easier for people to talk about what they’re going through, because I’ve played the game…

‘When they come to see me, their jaws drop, because I think I go against the whole grain of what a counsellor looks like; I ask them [what they were expecting] and they say, you know, ‘glasses, shirt tie, pen, middle-aged man, a couch’. When I turn up with casual gear, chilled out, an ex footballer who’s just relaxed and being myself, I think it breaks down the barriers for them.’

I asked Mickey what kind of themes often come up when working with football pros (whether current players, ex pros or young aspiring players- all at a range of levels)…

‘Most of the time you have the transition of leaving the game. That’s the big issue. Basically, players who’ve been in the game for X amounts of years, have been in the bubble, and are told ‘You have to come out the bubble’. They’re on their own. That’s massive for footballers…

‘You have some players who are depressed with the pressure of football, the financial side of football, marriage problems… All kinds of issues arise throughout the game; there’s not just one issue- anger, stress, anxiety, depression…

‘People think about footballers: ‘Well why are they having problems?’ Well, they’re human beings like everybody else.’

On the issue of the macho culture of football, Mickey told me:

‘It’s macho, of course. I’ve had a few players who’ve come forward because their wives called on their behalves because of that macho image- that pride stuff that gets in the way. For men in general, it’s one of the last things they want to do- go for therapy- so it’s bad enough, but football being a macho sport makes it even more difficult. But again, by making people aware of what it is we [PFA counsellors] do and how we do it- if we keep putting that message out there- it will remove that stigma.’

Mickey told me about his own experiences as a player and how speaking with someone like himself, as he is now, would have made such a big difference to his game. As a promising young player who had made it into the England under-19 team, in 1991, at the age of twenty-one, he injured his cruciate ligament. Having been catapulted into professional football from playing with his mates in the park at sixteen, his ‘whole world came crashing down’. He did recover physically, but he told me ‘mentally I don’t think I fully recovered because I went into matches thinking ‘If I get tackled, it could be the tackle that finishes my career.’ So I went into games at 75%.’

If Mickey were to speak with himself as a twenty-something year old…

‘I would have told myself that medically the injury’s fine- in fact it’s stronger than it was before; you just need to go out there and go play. And ‘what are your fears?’.. Then at least you’re talking about what doubts you have rather than keeping it inside…

‘You might have financial problems in the background at home, you might have marital problems, knee injury problems…etc; but you’re still expected to perform on a football pitch. It’s difficult, because you’re carrying those things around with you, whilst trying to play football as well.’

So, as sport psychologists are only too aware, sport- and football alike- is heavily reliant on mental processes. Promoting openness about mental health is therefore key not only to helping players manage everyday life, but performance as well.