Psychotherapy for athletes: when a coach and a sport psychologist aren’t enough

“At training I’m fine. The problem starts when I get home.”

That is how many athletes might begin when they one day find themselves sitting opposite a therapist. On the pitch, in the pool or on the track, everything works: they know how to focus, they know what to do, the coach is happy. Then they return to a quiet flat and can’t sleep. Or they fall out with their girlfriend again over something trivial. Or they sit in the car outside their parents’ house and don’t go in, because they know the first question will be: “So, what was your time?”

The sporting world doesn’t always have the right address for moments like these. The coach looks after form, the sport psychologist looks after the head on competition day. But who looks after the person who comes home after the match? In this post I want to explain the difference between a sport psychologist and a psychotherapist, when the right person to turn to is one or the other — and when it is neither of them, but a doctor.

First, something honest about myself: I am not a sport psychologist. I am a marriage and family therapist in training under supervision, and I am training in relational family therapy. I don’t teach techniques for better focus at the start line and I don’t prepare athletes for the Olympic Games. I work with people, their relationships and their distress — and athletes are people too, something the world of results tends to forget.

Mental toughness comes at a price

For a long time it was assumed that an elite athlete is, by definition, mentally tough. Who could endure all those hours of training, pain and pressure without being made of something special? This picture is partly true: athletes really do learn to bear effort and disappointment better than most. But the same picture has a dark side. If toughness is part of your identity, admitting distress feels almost like admitting you’re not a real athlete.

In 2019 the International Olympic Committee published an extensive expert consensus statement on mental health in elite athletes (Reardon et al., 2019). It was signed by psychiatrists, psychologists, sports physicians and researchers from all over the world. The message was clear: elite athletes are not immune to mental health problems. In some respects they are even more vulnerable — because of pressure, injuries, travel, public exposure and the fact that their whole life revolves around one single thing.

The same issue of the journal carried a meta-analysis summarising research on how common these difficulties are (Gouttebarge et al., 2019). Among current elite athletes, symptoms of anxiety or depression were found in around 34 per cent — roughly one in three. These are symptoms, not necessarily diagnoses, but it is a figure that makes it hard to keep pretending we are talking about exceptions.

And yet many athletes never seek help. Researchers who talked to young elite athletes about this named stigma as the main barrier: fear of what the coach, team-mates and selectors would think (Gulliver et al., 2012). When your place on the team depends on how others see you, admitting “I’m not doing well” carries a very practical risk too.

What a sport psychologist does

A sport psychologist is an expert in the psychological side of performance. With them, an athlete works on focus, on pre-competition nerves, on the routines that get them into the right state, on setting goals, on visualisation and on how to get back into the game quickly after a mistake. They can also help with communication within a team, with returning after an injury and with handling public pressure.

This is valuable work, and for many athletes it is entirely enough. If your chest tightens so much before the start that you can’t breathe, or your hands stop obeying you at the decisive moment, a good sport psychologist is most likely your first port of call. They know sport from the inside, speak the language of coaches and understand what a season, a training camp and peak form mean.

Their frame, however, is usually performance. The question that guides them is something like: how can this person show what they are capable of when it counts? They are often paid by the club, the federation or a sponsor — and although a good sport psychologist is always committed to the person first, the frame of the work is still tied to sport.

What a psychotherapist does

Psychotherapy has a different frame. At its centre is not the result but the person — with their whole history, relationships, wounds and questions. In psychotherapy, sport can be an important part of the story, but it isn’t its title. Here a conversation that begins with a bad season may, after a few sessions, turn towards a father who was only pleased after a win. Or towards the feeling that, as a child, you were only seen when you achieved something.

You’ll find a short explanation of what psychotherapy actually is in the knowledge base under psychotherapy, and I have described the difference between a psychologist and a psychotherapist in more detail in Clinical psychologist or psychotherapist: two roles we constantly confuse.

Psychotherapy isn’t about getting better at competing again — although that sometimes happens as a side effect. It’s about questions such as: why does a defeat pull the ground from under my feet, as if I had lost myself? Why do I feel like a stranger next to my partner when I’m out of season? Why can’t I rest without feeling guilty? Who am I once you take away the number on the start list?

With athletes, certain themes often come to the surface that in other professions stay hidden deeper. Perfectionism, which was an asset at training but at home becomes an inner tyrant. Shame after a mistake that no subsequent win can erase. And a very narrow identity, which ties a person’s entire sense of worth to one single area.

When a doctor or psychiatrist is the right place to start

Before any of us begins with conversations, sometimes the body needs to be looked at. This applies to everyone, but to athletes in particular.

If you feel constant tiredness that doesn’t go away with rest, if you are losing weight without planning to, if injuries keep recurring, or if — for women — periods become irregular or stop, the first port of call is a sports doctor or your GP. For the condition in which an athlete takes in too little energy for their training load over a longer period, the International Olympic Committee introduced the term relative energy deficiency in sport (RED-S). It can affect hormones, bones, the immune system and mood as well (Mountjoy et al., 2018). Low mood that comes from this won’t be fixed by any conversation until nutrition is put right.

The right person is a psychiatrist when difficulties are so severe that they get in the way of everyday life: weeks without joy, persistent insomnia, withdrawing from everyone, thoughts of death, drinking or using substances just to cope. A psychiatrist can make a diagnosis and prescribe medication when needed. With athletes they also have to take anti-doping rules into account, which is one more reason not to handle this on your own. I explained who is allowed to do what in Who may diagnose, who may prescribe, and who leads the process, and the signs that mean a psychiatrist is the first step in When you need a psychiatrist first.

If you have thoughts that it would be better if you weren’t here, don’t wait for the next training session or the end of the season. In Slovenia, call 112, the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours a day).

What a coach cannot be

Many athletes confide in their coach. That is understandable: the coach is often the person they spend the most time with, sometimes more than with their parents. A good coach senses when something is wrong and knows how to help. But a coach has a dual role. They care for you and at the same time decide whether you play. That is why it is hard to tell them everything.

In psychotherapy we call this a dual relationship — a situation in which two people share two roles that get in each other’s way. A therapist who also picked the team could never truly be your therapist. That is exactly why it matters that therapy is a space that is not part of the club. There you can say that you are angry with your coach, that you are thinking of quitting, or that sport has become a prison — without it having consequences for your season.

This doesn’t mean the coach has to be shut out. Sometimes it is good for them to know you are in therapy, or for them to adjust something. But that is your decision, not their right. What you tell a therapist stays between the two of you, except in exceptional cases where there is a direct risk to life.

What therapy with an athlete looks like

Therapy with an athlete is not fundamentally different from therapy with anyone else. There may be more talk about the body, about schedules and about fitting sessions around training camps and competitions. The content, though, is often something like this (a composite conversation, not a real person):

“I don’t understand why I’m like this. I won, and in the evening I felt empty.”
“What did you expect to feel?”
“I don’t know. Relief. Joy. That it would finally be enough.”
“Enough for whom?”
A long silence. “For my dad, probably. Even though he wasn’t even there.”
“What would he have said if he had been?”
“That the start was poor.”

A sport psychologist hearing this conversation might ask how to help make the next start better. That is a legitimate question. In therapy, though, we are interested in something else: in the inner voice that says “not enough” even after a win, and in where it came from. Once a person recognises it as a voice they learned, not as the truth about themselves, they can begin to talk back to it differently.

In relational family therapy, in which I am training, we pay particular attention to how patterns from the family repeat themselves in other relationships — including the relationship with the coach, the team and the sport itself. Christian Gostečnik writes about how people unconsciously carry the emotional atmosphere they grew up in into new relationships. For an athlete, one of those relationships is often sport itself: a relationship in which love is conditional on results.

When sport is only part of the story

Behind every athlete there is a family that drove them to training, gave up holidays and invested money. Behind them stands a partner who sees them two days a month, and children who know the competition calendar better than their own birthdays. When an athlete gets into difficulty, it often shows up in these relationships before it shows up on the pitch.

So sometimes individual therapy isn’t the most sensible option, but a session with a partner or the family. A young athlete who has started skipping training is worth hearing together with their parents — not to blame anyone, but to see what place sport occupies in the family. A thirty-year-old athlete preparing for the end of their career may need a space where they and their wife can talk about what their life will look like when it is no longer all subordinated to the season. I wrote about this turning point in When the career ends: who you are when you’re no longer an athlete.

In male athletes, distress often doesn’t show as sadness but as irritability, withdrawal or more alcohol after matches. I wrote about how depression hides behind anger and silence in Depression in men: anger, withdrawal and silence instead of tears.

Exercise: who am I when I’m not training?

You can do this exercise tonight. You need a sheet of paper and fifteen minutes when no one will disturb you.

1. Draw a circle and divide it like a pie into slices showing how much of your sense of who you are each area takes up: sport, family, partner, friends, school or work, other. Don’t think about it for too long — your first impression is the most honest.
2. Look at the slice taken up by sport. What would happen to you if that slice disappeared tomorrow? Write down the first sentence that comes to mind, even if it seems exaggerated.
3. Write down three qualities that others say you have and that have nothing to do with results. For example: that you are reliable, that you can make people laugh, that you notice who on the team has gone quiet.
4. For each quality, ask yourself where else it shows up, besides sport. If nothing comes to mind, that is valuable information, not a failure.
5. Choose one small thing you will do this week simply because you enjoy it, not because it will make you better. And notice what happens inside you — whether guilt, restlessness or perhaps relief appears.

If the exercise brings up strong anxiety or emptiness, that isn’t a sign you did it wrong. It means you have touched something important that deserves more space — perhaps a conversation with a professional.

You may feel there will be plenty of time for exercises like this later, when your career is over. But identity isn’t built in a hurry at the moment you need it. Athletes who keep some piece of themselves outside sport during their career tend to cope better with injury or with the end later on. Brewer and colleagues (1993) described this as a double-edged sword: a strong athletic identity supports commitment, but becomes a vulnerability when sport stops.

Where this doesn’t apply

It wouldn’t be honest to claim that every athlete needs psychotherapy. They don’t.

Not every dip in form is a psychological problem. Sometimes the reason is overtraining, poor sleep, a cold that drags on, or a training plan that isn’t well designed. Then you don’t need a therapist, but a coach who adjusts your load and a doctor who checks what is going on with your body.

For many things, a sport psychologist is entirely enough. If your difficulty is clearly limited to competition — nerves at the start, a block when taking free throws — and otherwise your life is going well, working with a sport psychologist is more focused and quicker. There’s no need to look for deeper wounds where there aren’t any.

Therapy cannot fix a harmful environment. If a coach humiliates you, shouts or crosses physical boundaries, that isn’t a topic for therapy but something to report — to the federation, the club and, in more serious cases, the police (113 in Slovenia). Therapy can help you recognise such an environment and find the strength to speak up, but it cannot replace the responsibility of those who should be protecting you. If you are under eighteen, turn to your parents or another adult you trust.

Timing matters too. In the middle of preparing for a major competition may not be the best moment to open up deep family questions. A good therapist will talk with you about what is possible now and what can wait — and that isn’t avoidance, but respect for your rhythm.

How to choose the right professional

When you look for help, it is worth asking a few simple questions. What training do they have? Are they under supervision or registered with an appropriate professional association? How do they work — with individuals, couples, families? Have they ever worked with athletes, and how do they understand the pressure you carry?

None of these answers matters as much as the feeling you have after the first few sessions. Research on psychotherapy has shown for decades that the quality of the relationship between therapist and client is one of the most reliable predictors of a good outcome. If you don’t feel safe with someone, it is perfectly fine to look for someone else. What matters isn’t whether the therapist is a fan of your sport, but whether they are interested in you as a person.

That is how it works with me too: if it turns out at the first session that what you mainly need is work on performance, I will refer you to a sport psychologist. If it turns out that the body needs looking at first, to a doctor. That isn’t a rejection. It is part of good help.

What to remember

• A sport psychologist works on performance — focus, nerves, routines. A psychotherapist works with the person — relationships, distress, identity.
• Around a third of elite athletes experience symptoms of anxiety or depression; mental toughness doesn’t protect against them.
• With tiredness, weight loss, recurring injuries or severe distress, the first port of call is a doctor or psychiatrist.
• Therapy is a space outside the club where you can say even what you can’t tell your coach.
• If you have thoughts of death, don’t wait: in Slovenia call 112, 01 520 99 00 or 116 123.