Behind the performance: mental health in sport and supporting elite athletes
By Dr Bradley Powell, Clinical Psychologist and Co-founder of Regal Private Therapy Practice, Harley Street, LondonSomeone can be performing well and still be struggling.
I have seen this in my clinical work with footballers, elite swimmers and people in other high-pressure, public-facing roles. From the outside, they may appear disciplined, confident and successful. Privately, they may be experiencing anxiety, burnout, difficulties with food, or uncertainty about who they are beyond their performance.
The research reflects this. A meta-analysis in the British Journal of Sports Medicine found symptoms of anxiety or depression in around a third (33.6%) of current elite athletes. In a UK survey of 143 elite athletes, 47.8% met the screening cut-off for signs of anxiety or depression.
Key points
Strong performance does not mean someone is coping.
Stigma is one reason athletes may not seek support.
Injury, deselection and retirement can affect confidence, routine and identity.
A Clinical Psychologist treats mental health difficulties; sport psychology focuses on performance.
Why do athletes struggle with mental health even when performing well?
Success on the outside can hide distress on the inside. Elite sport rewards being dependable, managing pressure and continuing to perform, which can make it hard to admit that something is wrong. The International Olympic Committee's consensus statement notes that athletes may not recognise or acknowledge symptoms, or may not seek support, partly because of stigma.
An athlete may worry about how seeking help will be interpreted, who will know, or whether it could affect how others see them. In therapy, I am interested in those concerns. What feels difficult to say? What does the person fear might happen if they admit they are struggling? Have they become so accustomed to pushing through that they find it hard to recognise their own needs?
We cannot assume that success tells us how someone is feeling, or that every athlete experiences their environment in the same way. Understanding the individual is essential.
What mental health difficulties do elite athletes experience?
My work with athletes has included supporting anxiety, addiction, suicidality, injury, burnout and identity following retirement. These experiences rarely exist in isolation. Anxiety about selection may lead someone to monitor their performance constantly. High personal standards may make rest feel uncomfortable. In the UK study above, dissatisfaction with one's sporting career was a significant predictor of both anxiety/depression and distress.
Psychological formulation helps us make sense of these connections. Together, we explore how the difficulty developed, what keeps it going and what might help. An athlete who becomes withdrawn, for example, could be experiencing low mood, fear of judgement, trauma-related avoidance or overload. Understanding what sits behind the behaviour helps us decide how to respond.
How does a sports injury affect mental health?
A significant injury can affect confidence, routine, relationships and a person's sense of who they are, not just their ability to play. The IOC consensus statement lists injury among the risk factors for depressive symptoms in elite athletes, and notes that mental health symptoms can increase the risk of injury and delay recovery.
Returning to sport is not guaranteed, even after successful surgery. A meta-analysis of 69 studies found that 81% of people returned to some sport after anterior cruciate ligament (ACL) reconstruction, but only 65% returned to their pre-injury level and 55% to competitive sport. Lower fear of reinjury and greater psychological readiness were both associated with returning to the pre-injury level.
Having ruptured my own ACL, I appreciate some of the disruption and uncertainty a significant injury can bring. I would not assume my experience mirrors an elite athlete's, but it made the relationship between physical recovery, confidence and participation personally meaningful to me.
Clinically, I am interested in what an injury means to the person. Alongside rehabilitation, they may be adjusting to a changed routine, time away from teammates or uncertainty about returning. Support involves making room for those reactions, rebuilding confidence gradually and finding sources of purpose during recovery.
What happens to an athlete's identity after retirement?
Leaving sport can mean losing much more than competition. Routine, relationships, recognition and a familiar sense of direction can all change at once. The IOC identifies retirement as a risk factor for depressive symptoms, and a UK-led review of 126 studies found that self-identity and social support were among the factors linked to how well athletes adjust.
In my work, I am interested in what the person misses, what they want to carry forward and what they would like to develop next. Therapy can provide space to acknowledge that loss without rushing to replace it, then explore interests, relationships and values that allow identity to broaden.
How do pressure and public scrutiny affect athletes' mental health?
For athletes in the public eye, distress can become entangled with concerns about privacy, reputation and professional identity. Fear about disclosure may make it particularly difficult to seek help. In my work, comment on social media can add to this pressure.
A calm, respectful response matters. Support should give the person space to speak without judgement, alongside clear conversations about confidentiality, its limits and any safeguarding responsibilities. Where other professionals need to be involved, the athlete should understand why and, wherever possible, remain involved in decisions affecting them.
How can therapy be adapted for neurodivergent athletes?
My expertise in ADHD and autism also informs how I work with athletes. Communication preferences, sensory experiences, need for structure and ways of managing attention or emotion can all shape someone's experience of sport. Someone who appears disengaged may be overwhelmed. Someone who finds a change of routine difficult may need clearer information or more preparation.
Useful changes are often practical: agreeing how information is communicated, clarifying expectations or creating predictable opportunities to discuss concerns. The athlete's own account is central to identifying what would help.
Does an athlete need a sports psychologist or a clinical psychologist?
It depends on what the athlete needs help with. In the UK, "sport and exercise psychologist" and "clinical psychologist" are separate titles protected by law, and anyone using them must be registered with the Health and Care Professions Council (HCPC).
Sport and exercise psychologists typically focus on performance: concentration, confidence, routines and coping with competition.
Clinical Psychologists assess and treat mental health difficulties, such as anxiety, depression, trauma, addiction, eating difficulties and suicidality.
The two can work well together. If difficulties go beyond performance, or affect life outside sport, a Clinical Psychologist can help.
How can coaches and support staff help?
Coaches, clinicians, support staff and managers may hold different information and responsibilities. Psychological consultation can help a team understand a difficulty, consider risk and agree a consistent response, while respecting confidentiality. Through supervising colleagues and facilitating reflective groups, I have seen how concern for an athlete can evoke anxiety or an urge to act quickly. Reflecting on those responses helps colleagues think more clearly about what the person needs.
How can therapy help athletes?
Therapy gives an athlete time to be understood beyond their results. Our work might focus on anxiety, trauma, eating difficulties, self-criticism or burnout, developing a different response to pressure, adjusting to injury, or exploring life after competition. We agree the focus together and use evidence-based approaches suited to the person, such as cognitive behavioural therapy (CBT).
I value ambition and understand that sport may be one of the most meaningful parts of someone's life. My role is to help them understand their difficulties, access appropriate support and make choices that take their wellbeing seriously.
Frequently asked questions
How common are mental health problems in elite athletes? A meta-analysis found symptoms of anxiety or depression in 33.6% of current and 26.4% of former elite athletes.
Can a sports injury lead to depression? Injury is a recognised risk factor for depressive symptoms in elite athletes. Seek support if low mood, worry or withdrawal persist during recovery.
Is therapy confidential for professional athletes? Yes, within clear limits, such as a serious risk to you or someone else. These are explained at the start.
Speak to a Clinical Psychologist in London. If you are an athlete, or support one, contact Regal Private Therapy Practice on Harley Street to arrange a confidential appointment with Dr Bradley Powell.
If you are in crisis or worried about your safety, call 999 or go to A&E. You can also call Samaritans free, day or night, on 116 123.
Author Bio
Dr Bradley Powell is an HCPC-registered Clinical Psychologist, Chartered Psychologist, Associate Fellow of the British Psychological Society and BABCP-accredited CBT therapist.
He is the co-founder of Regal Private Therapy Practice in London's Harley Street medical district, supporting adults and young people, including elite athletes and individuals in high-pressure public roles.
References
Gouttebarge V, Castaldelli-Maia JM, Gorczynski P, et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. British Journal of Sports Medicine. 2019;53(11):700–706.
Foskett RL, Longstaff F. The mental health of elite athletes in the United Kingdom. Journal of Science and Medicine in Sport. 2018;21(8):765–770. doi:10.1016/j.jsams.2017.11.016
Reardon CL, Hainline B, Aron CM, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine. 2019;53(11):667–699.
Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis. British Journal of Sports Medicine. 2014;48(21):1543–1552.
Park S, Lavallee D, Tod D. Athletes' career transition out of sport: a systematic review. International Review of Sport and Exercise Psychology. 2013;6(1):22–53. doi:10.1080/1750984X.2012.687053
Health and Care Professions Council. Understanding the regulation of psychologists. 2023.
