"At the End of the Day, It's Just a Sport."

On athlete mental health and what's unique about the sporting environment that gives rise to mental health concerns with Kelly Hee, licensed clinical social worker

There are two questions that I’m asked most often: Are you going to write another book? and What did you leave out of Up to Speed?

The immediate answer to the first question is “I don’t know.” I’m not opposed to it but I haven’t landed on an idea yet that I know will hold my attention and interest for 2-3 years. (I’m taking any and all suggestions!)

But when I think about the second question, I realize that there might be the seeds of an idea embedded somewhere in there. Because the thing that I wish I had more room to explore in the book was mental health.

Photo by Jeffrey F Lin on Unsplash

Sports and athletes can be an intense and highly-pressured environment that demands so much of athletes, both physically, psychologically, and emotionally. Yet, mental health is often overlooked and we’ve seen rising mental health concerns, especially among collegiate athletes.

• 70% of student-athletes report mental health issues, according to a 2022 study.

• 1 in 4 collegiate athletes reported signs and symptoms of depression with women reporting those symptoms more frequently.

• 38% of women athletes and 22% of men athletes in the NCAA report feeling mentally exhausted constantly or most every day

What’s going on? What is it about the sporting environment that gives rise to mental health concerns?

To get a sense of the factors at play, I talked to Kelly Hee. Kelly is a licensed clinical social worker and she works with the University of Hawaii athletics department where she’s helped build out mental service department for student-athletes. Kelly and I talked about the intersection of athlete identity and mental health.

Kelly Hee

Kelly

I am a licensed clinical social worker and I practice in both the states of California and Hawaii. Currently, I'm working with the University of Hawaii Athletics Department. Over the course of the last two or three years, we've created an entire mental health department specifically for athletes.

I also have a background working with eating disorders and specifically working with eating disorders within the athletic population. As a former athlete and someone who previously struggled with an eating disorder, I know how rampant disordered eating, disordered habits, and body image issues are within the population.

Christine

What sports did you play?

Kelly

I played soccer. I was a goalie.

Christine

I want to start a little bit broadly and talk about athlete identity. How do you think about and define athlete identity?

Kelly

I think about athletic identity like any other identity. It’s who we think we are, not just who we actually are, and how we believe we are defined. And what I mean by that is, if I was introducing myself to someone while I was in college, I might say, “I play on the soccer team” as like the second line after my name. Or somebody might say, “Kelly, you're the soccer player.”

Oftentimes with the identity piece, we become so reliant on it. I use the example of house on stilts or the legs of a table. Sometimes we are so reliant on one stilt, one leg of the table, one identity that if it’s no longer there—because of injury, retirement, or just no longer being on a team—our whole house or whole table comes crashing down.

When I'm talking about athlete identity with clients, we’re really working on trying to expand that one part of their pie chart. It’s an important part of their pie chart, but it does not have to be their entire pie chart.

Christine

How and when do these identities develop?

Kelly

It happens so naturally over time. Part of it is just our society's way of making something very simple. You play soccer. Great. You're the soccer player. That's how I identify you.

The more time you spend with something over the course of the years, and depending on your level of elitism and success in sport, it becomes who you are. If you started a sport at the age of five or six and play until you’re 22 or 23, that identity solidifies over the course of all those years. You’re part of the team. You go to practice. You travel with the team. Your friends are on the team. And especially if you play a single sport, a year-round sport, there's no room for anything else. It's just that.

Christine

Can you talk me through what you’ve seen in athletes that you've worked with when they become too dependent on this one identity?

Kelly

Team sports is an area where they set you up for success by saying, here's a group of people who will all have the same interests as you. You'll have something to talk about. You'll see each other every day. There's so much predictability and setup there. That’s helpful.

But let's say you've been the best on your team and you make it to this Division I team. Then something happens like an injury or you’re not chosen to travel with the team. We then see a downfall. We see isolation start to happen. We see shame start to happen because all of your friends, who are on the team, are talking about traveling or playing and you’re not a part of it. We see self-doubt and depression.

It's like you lose all of those coping mechanisms all at once. I'm not going to call my friends. I'm not going to share how I'm feeling. It's this natural spiral down of choices that gets you stuck in a place you don't want to be.

But instead of spiraling down, we can spiral up. I have the choice to isolate or I have the choice to call my friends who aren’t athletes. I have the choice to go home and stay in my room. Or I have the choice to hang out with these people anyways. It’s a prime opportunity for mental health skills to kick in.

Christine

How do you see athlete identity and eating disorder identity intersect and interplay with each other?

Kelly

The first thing that naturally comes to my mind—and this might raise some eyebrows—is ego. It's success and ego.

We may not be known as the athlete or the soccer player or even as the person with the eating disorder if we're not “successful at it.” Once we become successful at it, it becomes your identity. We claim it and that's when it's hard to let go. It provides us with a sense of security, a sense of safety, a sense of predictability—all of these emotional supports, just like the athlete identity does.

Because eating disorders come in all body shapes and sizes, they often hide in plain sight in sports. So the most "successful" eating disorder can be disguised as the most "successful" player. That makes the athlete identity and the eating disorder identity so deeply intertwined, because they feed off of one another at times; while also battling each other at other times.

If I don't have my eating disorder, does my house come crashing down? Or if I don't have those behaviors of over-exercising, what else do I have to keep my house up?

When someone has an eating disorder identity and an athlete identity, they have two really strong stilts holding up their house, but maybe they're both unhelpful or unhealthy. If they don't have either of them one day, their house comes crashing down even further.

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SIDEBAR

Pro runner Molly Seidel won the bronze medal in the marathon at the Tokyo Olympics. Seidel has talked openly about her mental health issues, including an eating disorder. In a recent Runner’s World article, she talks about how she was throwing up in the airport bathroom a few days before she stood a top the podium.

A couple weekends ago, she ran a solid race at the Chicago Marathon and she discussed her race on a recent episode of the Ali on the Run podcast (~17 minutes into the interview). She also talked about how she’s in a much better place mentally. But still, going into the race, she wondered whether or not she’d be able to run well without her eating disorder.

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Christine

You referenced that there seems to be a pretty high prevalence of disordered eating and eating disorders among the athlete population. Why haven't we done more to stem these behaviors, especially knowing the consequences?

Kelly

Our country is success driven and when it comes to sports and competition, most people will be success driven. I think there tends to be this idea of “at whatever cost.”

If we were to say something like, Okay, your sport, you need X amount of strength, which means you need X amount of focus to get that strength and X amount of self discipline and hard work. If any of the those things cause mental health, stress or some disordered thoughts, does our country just say, well, we don't need the same amount of success? Or do we say, too bad because we still expect success?

I think a shorter way of saying that is: If we cared too much about people's mental health, we maybe wouldn't get the same physical outcomes. So are we prioritizing the human? Are we prioritizing the gold medals or the championships?

There are certain sports that are doing more about it and they're still expecting greatness. It’s something I've noticed more in the running community where they are more supportive of athletes who are struggling and saying, take time off if you need it so that you can be a top performer.

That stuff is really incredible to see, to say they can be both. We can prioritize mental health and then prioritize competing and winning.

Christine

What is it about the athlete population or the active population that does make it so ripe for these behaviors to take hold?

Kelly

I think that’s such an interesting piece. When we look at eating disorders or any mental health issue—say substance abuse, gambling, etc.—risk factors could be trauma, abuse, maybe genetic factors. When we look at those things, we’re like, oh, those are bad.

But when we look at sports, the focus on exercise isn’t inherently bad. But it can be a risk factor for somebody to say, I'm going to compete and try to beat the person next to me or be better than the person next to me and I'm going to use exercise as that tool.

Or health. It's not inherently bad. But some of these things can be a risk factor because of the possibility of somebody turning the volume up too high on those factors.

Disordered eating in men can be called, "bro science," right? Do this diet. Gain this way. But people aren't looking at eating disorders as much in those those populations. It doesn't mean it's any less disordered.

It speaks to the fact that eating disorders aren't really in any way about food. It’s about the reason why we turn that volume up—what it does for us and what it provides us. That might be a sense of success, accomplishment, confidence, security, safety, all of those things.

Then we look at the elitism of some of these athletes and how much more they are in the spotlight and how much more pressures is put on them.

Even something like the NFL Combine. Looking at the photos of the outfits they have to wear over the years, they're just getting more and more naked and it’s getting more and more televised. Nobody wants to feel insecure in their body when it's on ESPN and all of these people are doing fantasy football and judging them online. Of course not.

Christine

That's the piece of it that drives me a little bit nuts is the body surveillance and commentary online and how insidious it is.

Kelly

Surveillance is such a good word for it.

Christine

We make so many assumptions and associations based on what someone looks like. Because it's the body we see, we assume that body composition, size, and shape must be tied to performance and success.

Kelly

Body surveillance is such a powerful word. There's a commercial going around where they replace all the female athletes with male athletes during interview. They tell them to do a twirl or ask them ridiculous questions but they’re asking Russell Westbrook and his reaction is, “What the hell?” They switch it back and say we would never talk to male athletes like this, but it's so prevalent to say, “Wow, she's looking a little heavy. She's looking a little slow.”

It’s so harmful from a mental health standpoint, from a disordered eating standpoint, from a body image standpoint.

I've noticed there's a big difference in sports commentary. I watch college football. They will say some things about student athletes, but it's like the minute they turn pro, then there’s no holding back. For whatever reason, it's like, “You make million dollars? Well, then I can say whatever I want to you.”

Christine

That's such a big piece of the dehumanization that happens to athletes. When they’re on this higher level, they’re there to win gold medals and to perform well. Who cares what you’re going through?

Kelly

Okay, go back even further. Let's think about the Olympics in general where a lot of sports and athletics came from.You think about the scene from the Gladiator, right? I'm going put you in here. You are our entertainment. Live or die.

Of course, we're so far from that, but are we?

Look at professional basketball and some of the fans are closer than the actual bench. And they are physically they're getting into it. You see people just like being aggressive towards these players.

I know people will say it's their job, but at the end of the day, it’s just a sport. I think people lose sight of how much we are impacting the actual players and the actual humans with all the pressure and intensity that we put on this game.

Christine

How we can make the shift from you are just an athlete, my entertainment, to recognizing that folks are human beings? Do you think things are starting to shift in that realm?

Kelly

I think that there’s starting to be less stigma and athletes themselves are finding a platform for their own voice. Kevin Love was a big person to do that. Simone Biles and Naomi Osaka. Michael Phelps. People with big platforms are using those platforms to say, “Hey, chill out. We're humans at the end of the day. We're people just like you.” And that has started to chip away at it.

One of the things that also comes to my mind is positive commentary. Sports broadcasters have so much power in setting the tone. That's a huge place to start.

I now watch track and it's been really cool to hear the track commentators because they are so positive. I remember the commentators so perfectly used Nikki Hiltz’s pronouns. There wasn’t even an “Oops, let me correct myself,” but they used their pronouns effectively, appropriately and respectfully. The only other time I've heard that so far is in the NWSL. But that's where those small things mean so much when it when it comes to respectful commentating.

Christine

I'm a huge fan of Kara Goucher and it's been so fun to listen to her because she's so excited when she's commentating. And that translates. She’s someone who knows the sport so well, knows these athletes. But it’s also her love for the sport that comes through.

Kelly

I do think that there's something to be said for former athletes as commentators. Obviously, they’re not the only ones who can do it, but I think of Julie Foudy. She's a great, positive commentator.

Those things do make a difference. It’s not always directly correlated with body image but it’s the fact that there's a neutrality on that platform.

Photo by Jeffrey F Lin on Unsplash

Christine

I want to bring it back to the work that you're doing at the University of Hawaii. Over the last couple of years, we’ve seen more student athletes speak up about the athletic environment at their schools, the team environment, the coaching—for good or for bad. I’m curious how you've seen this shift happen and how students are thinking about mental health issues.

Kelly

What's unique about our department is that it's a combination of both performance/mental skills training, and general mental health for athletes. It’s a holistic view because you can't have one without the other. We prioritize student athletes being the best athlete but also being the best and most supported human at the end of the day.

Mental health is a hard thing to break into with coaches and the NCAA in general. A lot of coaches wouldn't have thought that they or their athletes need this help.

It’s been so cool because this generation is cool. Therapy is so normal to them. It's part of their lives. Maybe they haven't gone to therapy, but maybe their mom does or somebody they know does.

Our ability to open doors purely based on this generation and their acceptance of mental health and mental well being has been amazing. The student athletes teach the coaches and help the coaches break the stigma.

The athletes know this and want this. It’s been such a cool thing to witness them say, “Hey, we don't really have a stigma. We're cool with it.” The coaches say, “Is that helping? Then sure, let's keep doing it.”

Christine

When most of us think about mental health within a sports context, we think of sports performance and mental fitness. How do you make yourself mentally tough? Can you talk a bit about how your model is more holistic?

Kelly

The first thing we talk about is sports performance. How are we going to make these athletes better? And the answer is that we make them better athletes by making them feel supported, feel safe, feel more balance, feel like better humans. That shows up on the field or the court.

For so many people, the only way they're surviving is by holding on to an unhealthy crutch. How much better could you actually be if you didn't have that crutch?

We have to understand that the mental health affects physical health. If I'm using an eating disorder, then I'm not going to be at my top physical abilities. If I'm using substances or drugs or alcohol, I'm not going to be able to show up nearly as much as I could without it. So we have to think holistically because one clearly affects the other, no matter what.

Christine

You had a pretty supportive administration that brought you in to start this program at the University of Hawaii. I'd imagine at some other universities that buy-in might not exist. Do you have any advice for people who are trying to integrate this focus on the whole human and not just the student athlete within their athletic departments?

Kelly

That's a great question. Finding a community of people who believe in what you believe in truly helps. When I was hired, we had an athletic director named David Matlin, and he, the head team physician, the assistant athletic director all believed so fully in mental health. They wanted to figure out a way to do it and prioritize it. We trust each other enough and know that we're doing this for our student athletes through and through.

It’s harder to go against the grain and try to convince people. Finding your hub and finding your community of like minds is key so that you can make moves together rather than feeling like you've got to make these tidal waves on your own.

I do think we need to change the way that other mental health providers focus on this as well. I think there's a big part of the community that says sports performance first and foremost. I hope that at some point, we can say sports performance AND mental health rather than one or the other.

Christine

Knowing that not every school has resources for this and not every student athlete might have someone that they can turn to, do you have recommendations for good resources for people?

Kelly

The Players’ Tribune is a great resource. The Hidden Opponent is a great resource. Sidelined USA is a great resource for injured athletes and people who are retired or sidelined by their injuries. I love Common Goal because soccer but it’s a good resource too. And these are all just for general mental health topics and maybe validation.

When it comes to eating disorders, NEDA is a great resource to find providers.

The hard part is, especially if we're talking about athletes, mental health, and eating disorders, there's not a lot of us that focus on this niche. That's part of my goal. Not to take my own business away from myself, but we need more providers that want to treat this.

Christine

There’s also Athletes Mental Health Foundation. It’s an interactive platform for athletes, parents, and coaches to learn how to most effectively integrate mental health into athletic systems and provides tools and resources for how to respond and address athletes’ mental health needs. I know that they're also putting together a directory of therapists and counselors who work in this area.

{Disclosure: I’m on the Board of Athletes Mental Health Foundation.}

Kelly

I love that. Athlete Ally is a good one. We didn't really talk about this but how people in the LGBTQ community may not be seen or validated. That's a big risk factor for eating or eating disorders as well.

Christine

Kelly, this has been such a great conversation. Thank you so much for taking the time to speak with me.

Kelly

Thank you!

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Thank YOU for being here too.

Christine