Adolescent athletes and suicide: A model for treatment and prevention

Highlights

• A unique article which presents a model for treatment and prevention for adolescent athletes and suicide.

• The theoretical constructs covered are ones that are utilized when examining athletes such as perfectionism, fear of failure and social cognitive theory.

• Potential risk factors unique to the athletic domain are discussed and we offer models for treatment such as the traditional cognitive behavioral therapy, the transtheoretical model of change, motivational interviewing, mindfulness therapy and psychophysiological approaches.

Abstract

When examining suicide in the US adolescent population, subgroups are typically lost in the shuffle. We believe that subgroups are bound by unique characteristics and these distinguishing factors should be taken into clinical consideration. With that in mind, we provide the case that athletes be deemed a specific population and superfluous information regarding athletes should be thoughtfully integrated into treatment and prevention models when dealing with depression and suicidal behavior. This manuscript will be particularly useful for clinicians who have little or no experience working with athletes. We cover theoretical constructs often utilized when examining athletes such as perfectionism, fear of failure and social cognitive theory. We also introduce potential risk factors unique to the athletic domain and offer models for treatment such as the traditional cognitive behavioral therapy, the transtheoretical model of change, motivational interviewing, mindfulness therapy and psychophysiological approaches. The goal of this manuscript is not to explain a link between athletes and suicide- rather, our goal is to help clinicians who work with athletes or plan to work with adolescent athletes to build an expansive view of the unique culture related to the sporting domain. The coverage of risk factors and theoretical models are not meant to be comprehensive or exhaustive and the treatment suggestions are not intended to replace traditionally-accepted approaches to suicidality, rather to serve as an adjunct to a clinical approach when working specifically with adolescent athletes.

Introduction

Suicide among US adolescents aged 15–24 has recently moved from the third leading cause of death to the second leading cause (Hedegaard, Curtin, & Warner, 2018). However, examining athletes as a subgroup from the greater population would likely reveal a variation in these statistics, though specific statistics on suicide and adolescent athletes are not reported. Nonetheless, greater awareness and focus are placed on the mental health of adolescent athletes as evidenced by the representation of high-profile athletes such as Michael Phelps and Kevin Love at a recent National Children's Mental Health Awareness Day (May 4, 2017). In addition, researchers have begun to observe the relationship between athletic involvement and suicide. Initial findings revealed that athletic participation can serve as a protective factor against suicide. Involvement in sport was found to be associated with decreased instances of suicidal ideation in adolescents (Sabo, Miller, Melnick, Farrell, & Barnes, 2005) and improvements in quality-of-life for youth athletes (Moeijes et al., 2019) and collegiate-level student-athletes (Snedden et al., 2019). Although there is a strong association between physical activity and mental-health, the picture is not entirely clear as to why athletes, in particular, are less likely to attempt or commit suicide than the general population. Nonetheless, we argue that athletes be addressed as a distinct subgroup when dealing with the issue of suicide.

The framework from which competitive sports is set for the athlete is multifaceted and interacts uniquely with the development of one's identity and social standing, particularly with adolescent athletes (MacIntosh, Kinoshita, Naraine, & Sato, 2019). Arguments can be made that sport involvement enhances social aspects of one's life, but alternatively, athletic participation can also create unique challenges. The primary focus of this article is to identify key theoretical constructs that are uniquely associated with the psychological health of the athlete and suggest multiple theoretical frameworks by which the clinician might apply when working with athletes manifesting suicidal behavior or ideations. The information in this manuscript is not meant to be entirely exhaustive or comprehensive but was compiled to further inform the practitioner when working with adolescent athletes. Therefore, the information within should be considered merely a reference point and an adjunct to traditional approaches for working with adolescent athletes and suicide.

Researchers and clinicians have long understood that adolescents be treated different than adults. However, the difference between the brain of an adult and an adolescent is more than just a matter of life experiences, or lack thereof (Spear, 2000). Brain plasticity is extremely high during adolescence, which is critical for learning and adaptation, however, this level of plasticity also leaves the adolescent in a state of physical and psychological vulnerability (Arain et al., 2013). Research derived from the field of functional genomics along with imaging at the molecular level have established that the brain of an adolescence is still in an active state of development (Giedd et al., 1999; Konrad, Firk, & Uhlhaas, 2013). The active state of development is believed to be most salient between the ages of 10 and 24 years old. The interplay between puberty and the environment further interacts with the vulnerable neurocircuitry of the brain. This in turn influences sleep habits, dietary choices and even views on sex. Concurrently, the limbic system is undergoing substantial changes and is believed to influence emotional self-regulation and ultimately the ability to make decisions (Konrad et al., 2013). As such, the maturation of the brain during adolescence is undergoing a barrage of environmental influences and physiological changes including surges of myelin synthesis which affects cognitive processes. As a result, critical thinking and rational decision making is difficult for the adolescent due to the developing frontal lobes which are intricately involved in brain functioning at the highest levels (e.g., memory, language, judgement, problem solving) (see Arain et al., 2013 and Spear, 2000 for more on the maturation of the adolescent brain). Although the brain of the adolescent is going through dynamic developmental changes, the context of sport adds another layer of complexity. Therefore, it is critical to go beyond the general understanding of the adolescent mind and include the cultural aspect of sport to better understand the athlete.

Theoretical Constructs and Barriers.

In this article we highlight several relevant theoretical constructs as a means to develop a lens through which we can better understand and view the unique processes related to the athlete and the way an athlete thinks and operates. We begin with a general coverage of the interpersonal theory of suicide and then move to the family systems theory. We then cover theories widely applied in the sport sciences such as perfectionism, fear of failure and the social cognitive theory. This arrangement and presentation of theories are not intended to suggest or explain a linkage between adolescent athletes and suicidality- rather the intent is to create a lens through which one can gain a better understanding of the athlete and the unique facets associated with individuals who compete in sport, and second, to expand upon one's clinical breadth when working with adolescent athletes.

We would be remised by not presenting barriers that exist for adolescent athletes who seek or require therapy. The most obvious barrier is the lack of services available to young athletes. Furthermore, beyond the lack of services, most coaches and parents are not trained or made aware of the subtle signs that indicate a young athlete may need therapeutic treatment in relation to suicide. However, socially constructed barriers may be the strongest of all impediments to overcome. The social environment through which athletes are immersed often nurtures a sense of “toughness” which on the field-of-play, for instance, can serve as a benefit. Yet, the tough mindset can often discourage help-seeking behaviors to avoid the impression of appearing “weak.” Understanding these barriers is a critical first step in establishing a sound treatment and prevention model for adolescent athletes. We provide further discussions in relation to these barriers throughout the manuscript.

Joiner's interpersonal-psychological theory of suicide is widely used to assess suicide risk (Fitzpatrick et al., 2009). Within this theory, three major characteristics of individuals are identified that are likely to elevate suicide risk including: (a) acquired capability to inflict lethal self-injury, (b) perceived burdensomeness, and (c) thwarted belongingness (Joiner, 2005).

Acquired capability addresses an individual's capacity to hurt themselves. This is not limited to self-injury or prior suicide attempts but can also include confronting fear-provoking situations. As a population, athletes are at a higher risk for injury than the average person, and those who have a higher tolerance for discomfort and pain are at an even higher risk for suicide (Pennings & Anestis, 2013). Discomfort and fear-confronting is associated with many aspects of sport and athletes are encouraged to “get comfortable being uncomfortable” and to embrace pain and to push through it. For example, wrestlers embracing the common practice of extreme calorie restriction in an effort to cut weight; soccer goalies throwing themselves in front of a ball anticipating the fall to the ground; gymnasts performing without regard for the high risk of potential bodily harm; or the repeated collisions of football players week after week. Although perceived as noble, the frequency by which athletes willingly endure pain, may result in an increased tolerance. Notably, higher levels of discomfort and pain tolerance are associated with increased suicide risk (Franklin, Hessel, & Prinstein, 2011).

Perceived burdensomeness refers to the belief held by the individual that they are a burden to their loved ones (Joiner, 2005). They often believe their family and friends would be “better off without them” and it is this type of thinking that contributes to suicidality (Van Orden, Lynam, Hollar, & Joiner, 2006). For young athletes, this could occur in any situation in which they believe they are no longer an asset to the team. Additionally, perceived burdensomeness to their family and non-teammate friends must be assessed.

Thwarted belongingness addresses the idea that social support acts as a buffer against suicide risk. As such, those whose basic psychological needs are met may be less likely to consider suicide and engage in suicidal behavior (Britton, Van Orden, Hirsch, & Williams, 2014). Conversely, according to Joiner (2005), if one is feeling isolated or receives little support from loved ones, suicide risk increases. As such, the individual's relationship with teammates and other peers should be assessed as well as family dynamics. And if the relations between the athlete's peers and/or family are deemed positive and supportive, then such relationships may serve as a protective factor against suicide (Britton et al., 2014; Fitzpatrick et al., 2009). However, if such relationships are absent, maladaptive, or insufficient, suicidality is likely to increase (Van Orden et al., 2006).

The application of Bowen's family systems theory (Bowen, 1978) to both the athlete's family life and team can illuminate several important factors in preventing adolescent athlete suicide. Looking at any group through a family systems lens reveals patterns present in the group that could be a potential focal point of future treatment.

The first major aspect of the family system is self-differentiation, which refers to an individual's ability to separate their self-concept from the family of origin, or even a team. It is likely that this self-differentiation becomes more evident or prominent as adolescents begin testing the boundaries of their freedom and roles must be re-examined (Koopmans, 1995). Those with low self-differentiation require affirmations and validation from their family or team more than those with high self-differentiation (Kerr, 2000). Differentiation is crucial to connect emotionally with people outside of the group, and to make decisions according to one's own desires, not based on relationship pressures (Charles, 2001; Kerr, 2000). Therefore, it is likely that an athlete who perceives his or her self-concept outside of their team or family is likely to more successfully cope with any sort of stress like an injury or rejection from the team without relying on others for emotional well-being. Additionally, through the multi-generational transmission process, individuals often have similar self-differentiation levels as their parents and seek out partners with similar levels to themselves (Kerr, 2000).

One way to conceptualize teams using family systems theory is as a series of interlocking triangles. These triangles could negatively impact an athlete because the nature of a triangle is to create an “odd man out” (Kerr, 2000). If the individual starts to feel as though they have been left out by their friends, this could lead to loneliness and in some cases, suicidal ideation. This same idea could be applied in the family home, often with the child and the two parents as a triangle.

If an adolescent's triangle or family relationship becomes too strained, he or she may employ emotional cutoff to ease some of the tension, but the emotional turmoil in the relationship remains. Kerr (2000) noted, often those who emotionally cut off family or friends look to other relationships to meet their needs, which further strain those relationships in turn. For example, if an athlete were to emotionally cut off his father and look to a coach to meet a paternal need, then it may create familial tension and is unlikely to succeed long-term.

Family projection processes may also lead to a propensity for emotional difficulties in the adolescent. If a mother, for example, often needs approval from others, she may constantly give the child positive affirmations, such as “job well done.” Where in adolescence, the athlete no longer receives this approval so constantly, he or she may seek approval from peers, teammates, or coaches, leading to low self-differentiation. The athlete may also inherit or develop perfectionist tendencies leading to a constant state of dissatisfaction with their performance. Kerr (2000) further posits that any number of emotional difficulties, or strengths, may be passed on.