WH question 1 – Why is help needed?

Table 1 outlines reasons for why ‘help’ is needed and why ‘seeking help’ is problematic from the perspective of the player, based on themes from Woods et al. (Reference Woods, McCabe and Mistry2022), Gouttebarge and Kerkhoffs (Reference Gouttebarge, Kerkoffs and Krutsch2020), and the authors’ therapeutic work with professional footballers.

Table 1.

Players’ reasons for both ‘seeking’ and ‘not seeking’ help for mental distress/illness

Seeking help involves two key steps: disclosing a mental health issue and actively pursuing support. In the top half of Table 1, once a player has identified a problem, there are numerous reasons for getting help, including managing symptoms of anxiety and/or depression. There is also a recognised need to manage the experiential features of the illness (mood, thoughts, physiology), which will impact performance. Ford and colleagues concluded that untreated sport-related anxiety can ‘continue to have spiralling effects on an athlete’s performance. In short, sport-related anxiety can (1) have a negative impact on sports performance during practice and competitions, (2) lead to increased risk of injury occurrence, (3) delay and obstruct injury rehabilitation and the return to sport process, and (4) increase subsequent re-injury risk during post-rehabilitation practice and competitions’ (p. 210, Ford et al., Reference Ford, Ildefonso, Jones and Arvinen-Barrow2017).

Injury is a particularly significant issue. This is because a vicious cycle often emerges, with injured players developing MH symptoms, and those with MH symptoms becoming more prone to injuries (Bilgoe et al., Reference Bilgoe, Janse van Rensburg and Goedhart2024; Rogers et al., Reference Rogers, Tanka and Cosgarea2023). Beyond performance, distress affects other areas of life, causing fear, avoidance, hopelessness and self-criticism (James et al., Reference James, Medea, Harding, Glover and Carraca2022a). Footballers may also seek help upon realising their current coping strategies (drinking, over-use of medications/drugs, over-training) are exacerbating their distress.

In contrast, reasons not to seek help, shown in the bottom half of Table 1, include lack of faith in treatment, fear the treatment process might destabilise them further, and a culture of ‘toughing it out’. Players may worry about appearing weak, particularly if they fear there will be disapproval from managers, agents, team mates and family. The player may think the manager will be less likely to select them, worrying they are being seen as less competitive in high-stakes matches, and opening themselves up to ridicule from opponents, or fans on social media (Wood et al., Reference Wood, Harrison and Kucharska2017). While stigma exists in the general population, elite athletes face heightened pressures due to the competitive environment, micro-monitoring of performance, fears of de-selection, and concepts of hypermasculinity in the male game (Castaldelli-Maia et al., Reference Castaldelli-Maia, de Mello e Gallinaro, Falcão, Gouttebarge and Hitchcock2019).

Another factor is ‘learned behaviour’ from being members of footballing academies, (i.e. the stoical legacy of being part of an academy). Sothern and O’Gorman’s (Reference Sothern and O’Gorman2021) qualitative study examined the views of ‘category one’ academy players. They found young players were highly likely to hide both mental and physical difficulties in order to foster positive perceptions of themselves, and to avoid criticism and sanctions from coaches or parents. The young players were keen to maintain a positive identity of being a ‘resilient’ footballer.

WH question 2 – What types of help are available?

The NICE guidelines for depression recommend psychotherapies as the first-line treatment for mild to moderate depression, and the combined use of psychotherapy and anti-depressants for severe depression (NICE, 2022). Similar guidance applies to the various forms of anxiety disorders. It is relevant to note that care must be taken when administering psychiatric drugs to players owing to the numerous problematic side-effects as well as the need for a ‘treatment use exemption’ (TUE) assessment, under anti-doping regulations. TUEs enable players with a legitimate medical condition to use a prohibited medication or substance. These complexities highlight the importance of club staff understanding the evidence-based psychotherapies available to players.

Cognitive behaviour therapy (CBT), particularly Beck’s cognitive therapy (CT; Beck, Reference Beck1976), is the most widely used form of psychotherapy in the UK and considered the gold standard psychological treatment (David et al., Reference David, Cristea and Hofmann2018). In relation to football and UK sports in general, the dominant form of CBT is rational emotive behaviour therapy (REBT) rather than CT. This is partly due to some key academic practitioners championing the role of REBT, believing that working with the concept of ‘irrational beliefs’ bridges ‘performance and MH’ effectively (Jordana et al., Reference Jordana, Turner, Ramis and Torregrossa2020; Turner, Reference Turner2022; Turner and Bennett, Reference Turner and Bennett2018). This group of practitioners, mainly sports psychologists, have produced an impressive body of work in support of their views (Turner et al., Reference Turner, Jones and Wood2023). A comparative review of the differences and similarities between REBT and Beckian CT from the perspectives of these academic practitioners has been published recently in this journal (Young and Turner, Reference Young and Turner2023). Other CBT approaches available to athletes (schema therapy, acceptance and commitment therapy, etc.) have been described in a book edited by Turner et al. (Reference Turner, Jones and Wood2023). In relation to football specifically, Nesti, who has worked with a number of English Premier League teams, recommends the use of existential psychotherapy (Nesti, Reference Nesti2014; Nesti and Ronkainen, Reference Nesti, Ronkainen, Tod and Eubank2020). An adapted version of the Power Threat Meaning Framework has also been described for players (James et al., Reference James, Morris, Johnston and Glover2022b). Like REBT, the latter is a trans-diagnostic approach, avoiding the need for diagnostic labelling.

One of few studies on CT in footballers showed it was neither popular nor known about, with only 8% of players aware of CT and just 4% able to describe it (Wilkins et al., Reference Wilkins, Sweeney and Zaborski2020). However, when informed about such therapies, players expressed that such support should be available to all footballers, with a preference for one-to-one, face-to-face sessions over group or online formats (Wilkins et al., Reference Wilkins, Sweeney and Zaborski2020). The lack of awareness is partly due to limited effort in distributing material to them, but also reflects the shortage of published studies on psychotherapy in football (Ekelund et al., Reference Ekelund, Holmström and Stenling2022). Other studies have shown that even when players request psychological support, access remains a challenge. For example, a study by Junge and Prinz (Reference Junge and Prinz2019) found only a third of female professional players seeking psychotherapeutic support received it.

Beyond formal therapies, less structured options are support groups and counselling approaches, as well as self-directed support such as bibliotherapies, therapeutic animations, online courses and case studies. FIFPRO (2024) have produced a website providing MH resources for professional footballers. The English FA addresses MH issues within its Equality, Diversity and Inclusion program (‘A Game for All’) and in its ‘Kick it out’ campaign; the latter tackling racial discrimination for players, coaches, and fans. A Game for All outlines three key strategic EDI commitments under the headings – Lead the Change, Be the Change, and Inspire the Change. Within these titles the FA supports wellbeing initiatives that: promote EDI training sessions; tackle online abuse; identify and sanction discriminatory practices, etc. The over-arching aim is to deliver initiatives that enable individuals from across gender, ethnicity, disability, faith, and LGBTQ+ communities to fully participate in football at all levels.

WH question 3 – Who can provide the help/treatment?

Footballers seek help from a range of non-clinical and clinical sources – partners, family members, friends, managers, coaches, team doctors, sports psychologists, player care staff, safeguarding officers and other support staff (James et al., Reference James, Turner and Reicheltunder review). Weber et al. (Reference Weber, Bos and Clancy2021) interviewed 22 club doctors in Australian Rules Football about their roles in managing MH issues. The doctors felt they needed to have an executive role in the treatment of players, having specific roles with respect to: screening, prevention, assessment and treatment, duty of care, case coordination, communication, and confidentiality.

In UK football clubs, in addition to the medical doctors, the club’s sports psychologists have a clinical/coordination role as well as their performance-related work. Indeed, sports psychologists have the competencies to undertake MH screening and low-level treatments (within their professional competencies). Nesti believes that sports psychologists should have a more important role in managing the MH of players, but notes their training is heavily biased towards ‘performance’ rather than therapy (Nesti and Ronkainen, Reference Nesti, Ronkainen, Tod and Eubank2020). A review paper by Feddersen et al. (Reference Feddersen, Champ and Littlewood2025) examined the perceptions and knowledge of coaches and sport scientists (physiotherapists, strength and conditioning workers) regarding the work of sports psychologists within football academies, including their MH input. The researchers found there was a lack of knowledge and appreciation of the benefits of having psychologists as part of multi-disciplinary teams (MDTs). This was in part due to the fact that psychologists had only recently been employed full-time within teams; thus there was scepticism about their added value (McGinty-Minster et al., Reference McGinty-Minster, Champ, Eubank, Littlewood and Whitehead2023). There were also historical and cultural features that disadvantaged many of the psychologists’ contributions, owing to the fact most had not previously played football at a professional or semi-professional level. Indeed, playing football to a high level was greatly valued amongst coaches in the elite clubs, with many of the senior coaches coming from footballing backgrounds (Hanin, Reference Hanin2007). It was noteworthy that the sports science staff were not similarly disadvantaged because many had played football, but more importantly they were seen as providing technical skills and inputs. In contrast, it was viewed that the psychologists were working with concepts (confidence, mental toughness, fear of re-injury) which were very familiar to the ‘footballing’ coaches from an experiential standpoint; thus the coaches often regarded themselves as ‘experts by experience’ in such areas.

The other staff offering support for wellbeing issues within clubs are the members of the player care team. This team have responsibility for many of the non-sporting aspects of a player’s time at a club, such as welfare and personal developmental aspects. In addition, members of the player care team get involved in many of the operational and practical features (assisting with housing, transport issues), enabling footballers to perform with minimal distractions. In addition to providing support from within the club, external help can also be accessed from general practitioners (GPs), counsellors, clinical psychologists and psychiatrists. There are also a number of specific organisations, such as Sporting Chance, who offer bespoke packages of therapy (www.sportingchanceclinic.com). In extreme cases the player may be required to attend a residential clinic for a period of time.

While professional assistance is vital, elite athletes often turn to family, friends, and coaches for support (Gulliver et al., Reference Gulliver, Griffiths, Christensen and Brewer2012). While there are clearly benefits obtained from speaking to non-specialists, it may also be inappropriate. For example, Mazzer and Rickwood (Reference Mazzer and Rickwood2014) found there were concerns amongst coaches that their input could potentially undermine their athlete’s MH. A helpful review of the area concerning the role of sports coaches in promoting athlete MH was undertaken by Bissett et al. (Reference Bissett, Kroshus and Hebard2020). A product of their review was a list of 26 activities athletic coaches could undertake to promote good MH. The three key themes identified were: to promote a culture that supports MH; to help identify and connect ‘at-risk’ athletes to appropriate services; and to support those in treatment. However, the research also recognised that in order for coaches to undertake such roles, they required supervision. Such supervision could potentially be provided by sports psychologists, although an article by Kelly and colleagues noted sports psychologists felt that they would require extra training both to provide psychological support to coaches and to enable the coaches to support others (Kelly et al., Reference Kelly, Thelwell, Barker and Harwood2018).

Selecting the appropriate ‘helper’ is evidently difficult for players. Owing to stigma, trust and confidentiality issues some footballers may obtain help outside of the club, often without the club’s knowledge. The employment of unvetted and potentially unqualified ‘therapists’ is highly problematic and could potentially lead to worsening MH (Curran et al., Reference Curran, Parry, Hardy, Darling, Mason and Chambers2019). It is relevant to note that in elite (Category 1) academies there are safeguarding features that prevent the employment of unqualified professionals. Indeed, the FA stipulate that starting the season 2025–26 all Category 1 departments must employ a full-time (or equivalent) HCPC registered psychologist (Barraclough et al., Reference Barraclough, Grecic and Harper2024). Of note, such standards are not required for men’s or women’s ‘first-teams’ in either the Premier, EFL or women’s leagues.

A further issue regarding the selection of MH providers from an EDI perspective (Equality, Diversity and Inclusion) is the inability of many MH and wellbeing professionals to speak multiple languages. While English may be regarded as the lingua franca of footballers in Europe, personal experience has shown that many foreign players struggle to express their MH needs effectively and confidently using a second language. An additional query regarding ‘who provides the help’ is the matter of the gender of the MH provider. In the general literature it has been shown that female college students often feel more comfortable self-disclosing to female therapists (Landes et al., Reference Landes, Burton, King and Sullivan2013). The broad consensus of this body of research is that organisations (such as football clubs) should ideally enquire about a client’s preferences about the gender of the therapist prior to therapy and, if possible, cater to the client’s preference.

WH question 4 – When is the best time to get assistance?

Many mental illnesses get worse if not treated early in the onset of the disorder; there are a number of reasons for this. Firstly, the person’s thinking will become more negative, exacerbated by reduced concentration, motivation and poor quality sleep, leading to self-criticism and withdrawal (James et al., Reference James, Medea, Harding, Glover and Carraca2022a). Secondly, the player may develop ‘bad’ habits such as avoidance, hyper-vigilance, and overthinking – known as safety-seeking behaviours – that make future treatment more difficult (Thwaites and Freeston, Reference Thwaites and Freeston2005). Unfortunately, accessing help in a timely manner may be difficult if (i) their club has not set up a pathway for the management of their difficulties (Purcell et al., Reference Purcell, Gwyther and Rice2019; Purcell et al., Reference Purcell, Pilkington, Carberry, Reid and Gwyther2022), or (ii) there is an overly demanding schedule of football fixtures and travel pressures. Players may also fear that treatment will destabilise them when they are ‘barely coping already’ and delay seeking help until the season ends – a costly decision psychologically (Pillay et al., Reference Pillay, van Rensburg and Ramkilawon2024).