Mental Health Performance - What Athletes Need To Know Part IV. Addiction, Alcohol, Substance Use & How Sport Psychologists Help
About the Author
Ben Foodman is a licensed psychotherapist & performance specialist. He owns his private practice located in Charlotte North Carolina where he specializes in working with athletes to help them overcome mental blocks (the yips), PTSD, ADD / ADHD and achieve flow states through the techniques of Brainspotting & Neurofeedback. If you are interested in services, use the link here! Enjoy the article below!
Introduction: How Sport Psychologists Work With Athletes Dealing With Alcohol & Substance Use Issues
When athletes seek the help of sport psychologists and athlete counselors, they are usually trying to overcome trauma, mental blocks or what is more commonly known as the yips. This is largely because the environment of sports can be very punishing for athletes both physically and mentally. Whether this occurs through interpersonal relationship conflict, or verbal abuse from coaches, the reasons athletes deal with trauma will vary greatly depending on who you speak with. Unfortunately, a common negative outcome that many athletes suffer from as a result of trauma is excessive alcohol and substance use issues.
Because this is such a common issue, I felt it was necessary to use this issue of the Training Report to bring awareness to this conflict, and explore what athletes and their support system can do to help overcome this obstacle. In section I. I will review how sports impacts athletes that are dealing with alcohol and substance use issues. In part II., we will review some of the clinical terminology and science that helps us understand addiction. Finally in part III. I will review clinical interventions that athletes can turn to in order to start their journey of healing. With that being said, let’s begin exploring the content for part I.
Part I. How The Sports Environment Affects Athlete Addiction, Alcohol & Substance Use
When we think about the sports environment, there are many negative experiences that can come about from being an athlete. There are the ‘in-sport’ stress related experiences such as negative coaching experiences (e.g. verbal abuse, physical abuse, and sexual abuse), repetitive sports injuries (e.g. ACL tears, head trauma, concussions, broken bones, pulled or torn muscles), the negative social experiences such as fan abuse or letting teammates down, and then there are the difficulties with managing recovery. Then we have the ‘out of sport’ experiences that athletes can experience in conjunction with the ‘in-sport’ trauma such as interpersonal relationship issues, non-sport medical trauma (e.g. car accidents, getting sick), financial stress, social stress, having friends or loved ones die unexpectedly, or experiencing early child-hood trauma such as abusive parents, siblings, family members or being completely abandoned by those that were supposed to care for you.
We know that when athletes go through experiences like the ones previously mentioned, there is a predictable set of mechanisms in the brain that force individuals to seek safety, even if that safety mistakenly is through alcohol and substance use. In the book The Body Keeps The Score, Dr. Bessel Van Der Kolk explains how the mechanisms of the brain respond to trauma, which in turn can lead athletes towards using alcohol or other drugs to cope: the emotional brain has first dibs on interpreting incoming information. Sensory information about the environment and body state received by the eyes, ears, touch, kinesthetic sense, etc. converges on the thalamus where it is processed and then passed on to the amygdala to interpret its emotional significance. This occurs with lightning speed. If a threat is detected, the amygdala sends messages to the hypothalamus to secrete stress hormones to defend against that threat. The neuroscientist Joseph LeDoux calls this the low road. The second neural pathway, the high road, runs from the thalamus via the hippocampus and anterior cingulate, to the prefrontal cortex, the rational brain, for a conscious and much more refined interpretation. This takes several microseconds longer. If the interpretation of threat by the amygdala is too intense, and/or the filtering system from the higher areas of the brain are too weak, as often happens in PTSD, people lose control over automatic emergency response, like prolonged startle or aggressive outbursts.
All of the previously mentioned trauma experiences are potential catalysts for alcohol and substance use issues amongst athletes. Frequently when athletes turn to drugs and alcohol to cope with the psychological stress that they are experiencing, they start off being able to be a ‘high functioning’ user. But as time goes on the stress inflicted upon the athlete’s body from both sport and alcohol/substance use will catch up with the athlete. Recovery times take longer, rest becomes more evasive, and most commonly athletes that use alcohol and drugs will socially isolate themselves from their teammates and/or coaches. There is virtually no scenario where this ends well for the athlete that is using substances. These athletes will become at increased risk for injury, early exit from sport, increased medical issues, and worst of all increase risk for completion of suicide. While all of this information is critical for athletes and their support system to understand, we need to go even deeper and examine the clinical features of alcohol and substance use issues.
Part II. The Science Behind Addiction For Athletes
The first place to begin understanding how clinician’s traditionally view these issues is through the DSM (Diagnostic Statistical Manual). Per the DSM, the following excerpt helps provide clinicians with a framework for starting to understand substance use issues for patients: The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. an important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment. Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. To assist with organization, Criterion A criteria can be considered to fit within overall groupings of impaired control, social impairment, risky use, and pharmacological criteria. Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed.
When we dive deeper into the DSM, we get a somewhat similar but also nuanced view of how alcohol use disorder is viewed amongst clinicians using the DSM: Alcohol use disorder is often associated with problems similar to those associated with other substances (e.g., cannabis; cocaine; heroine; amphetamines; sedatives, hypnotics, or anxiolytics). Alcohol may be used to alleviate the unwanted effects of these other substances or to substitute for them when they are not available. Symptoms of conduct problems, depression, anxiety, and insomnia frequently accompany heavy drinking and sometimes precede it. Repeated intake of high doses of alcohol can affect nearly every organ system, especially the gastrointestinal tract, cardiovascular system, and the central and peripheral nervous systems. Gastrointestinal effects include gastritis, stomach or duodenal ulcers, and, in about 15% of individuals who use alcohol heavily, liver cirrhosis and/or pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract. One of the most commonly associated conditions is low-grade hypertension. Cardiomyopathy and other myopathies are less common but occur at an increased rate among those who drink very heavily. These factors, along with marked increases in levels of triglycerides and low-density lipoprotein cholesterol, contribute to an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesia, and decreased peripheral sensation. More persistent central nervous system effects include cognitive deficits, severe memory impairment, and degenerative changes in the cerebellum. Alcohol use disorder is an important contributor to suicide risk during severe intoxication and in the context of a temporary alcohol-induced depressive and bipolar disorder. There is an increased rate of suicidal behavior as well as of completed suicide among individuals with the disorder.
Despite all of the information that is available on alcohol and substance use issues, what actually causes addiction or how addiction works is a highly contentious debate in the world of psychotherapy. In the book The Biology Of Desire, Why Addiction Is Not A Disease by Marc Lewis, PhD., the author goes on to highlight contested ideas on addiction in the following excerpt: Whether we construe addiction as a disease, a choice, a complex sociocultural process, self-medication, or a string of bad-hair days, we only have one brain, and it’s central to everything we do, everything we are. So a very important question is simply this: what does the brain do in addiction? But before trying to answer that question, we need to understand how brains change normally. In fact, brains are supposed to change. Brain change-or neuroplasticity-is the fundamental mechanisms by which infants grow into toddlers, who grow into children, who grow into adults, who continue to grow. Brain change underlies the transformations in thinking and feeling that characterize early adolescence. In fact, developmental neuroscientists estimate that ‘as many as 30,000 synapses may be lost per second over the entire cortex during the pubertal/adolescent period. Brain change is necessary for language acquisition and impulse control in early childhood, and for learning to drive a car, play a musical instrument, or appreciate opera later in life. Brain change underlies religious conversion, becoming a parent, and, not surprisingly, falling in love. Brains have to change for learning to take place. Without physical changes in brain matter, learning is impossible. Synapses appear and self-perpetuate or weaken and disappear in everyday learning. Learning alters the communication patterns between brain regions and builds unique configurations of synapses (synaptic networks) that house knowledge, skill, and memory itself. The connection between learning and brain change has been studied for more than a hundred years: it was reasonably well understood by the 1940’s, and the search for specific cellular mechanisms continues today.
The author continues: Whether repairing the damage caused by a minor stroke or altering emotional processes in the wake of trauma, neuroplasticity is at the top of the brain’s resume’. To repeat: proponents of the disease model argue that addiction changes the brain. And they’re right. It does. But the brain changes anyway, at every level: gene expression, cell density, the concentration and location of synapses and their fibers, even the size and shape of the cortex itself. Of course, neuroscientists who subscribe to the disease model must know that brains change with learning and development. So they must view the brain change that accompanies addiction as extreme or pathological. In fact, they would have to show exactly that in order to be convincing. They would have to show that the kind (or extent or location) of brain change characteristic of addiction is nothing like what we see in normal learning and development, or even in the more extreme transitions people go through when they fall in love or have children. But that’s where they step onto thin ice. The kind of brain changes seen in addiction also show up when people become absorbed in a sport, join a political movement, or become obsessed with their sweetheart or their kids. The brain contains only a few major traffic routes for goal seeking. Like the mina streets of a busy city, the same routes get dug up and paved over time and time again, no matter who’s in charge. Brain disease may be a useful metaphor for how addiction seems, but it’s not a sensible explanation for how addiction works. What I love about this excerpt is both the heavy emphasis on discussing neuroscience mechanisms and how this complicates traditional ideas of how we understand addiction. And while this can complicate our approaches, it also frees athletes and sport psychologists to utilize new approaches to help individuals overcome these issues. So what are some interventions that can potentially help?
Part III. How Sport Psychologists Can Help Athletes Overcome Alcohol & Substance Use Issues
There are many different approaches that sport psychologists can use to help athletes overcome these issues. But when athletes are deciding what the best approach is, there are several considerations that must take into consideration when seeking treatment: first, athletes should make sure that the individual they are working with is a licensed psychotherapist who has specialized training and licensure to provide interventions for addictions. In many cases, this may mean that athletes will not be working with a sport psychologist or a mental performance consultant, but that won’t be a problem as the primary issue is ameliorating the issue of alcohol and substance use and not necssarily focusing on sports performance outcomes. Most sport psychologists and athlete counselors don’t have this specialized training in addiction. Second, the clinician should have additional training in trauma-informed psychotherapy interventions that have a heavy emphasis on somatic-based interventions. Examples of this include EMDR (Eye Movement Desensitization & Reprocessing), Brainspotting, Somatic Therapy, Neurofeedback, Biofeedback, etc.
It is not enough for a clinician to list that they are ‘trained’ in one of these interventions. The clinicians ideally need to be certified in one or several of these approaches. Finally, the athlete needs to make sure that the clinician is either working with a medical doctor that specializes in addiction and psychopharmacology (a psychiatrist or a sport psychiatrist) or that they are collaborating with a doctor that the athlete chooses to have in their corner. If athletes have their own doctor that they prefer to work with, then it would be most optimal if they facilitate release of information between their doctor and the substance use specialist. Working through addiction can be one of the most challenging obstacles that an athlete faces, but with the advances in brain science in coordination with the new interventions that are available, there is more hope than ever that individuals can overcome and beat these problems! Finally, even if the athlete does not feel that the first clinician or even the second one is the right ‘fit’, don’t give up! Finding a therapist that has the right combination of training and social connection can be a journey, but is well worth the investment once they are correctly identified!
Note To Reader:
If you are an athlete reading this segment of the TRAINING REPORT, hopefully this content was helpful! I put the Training Report together because I felt like many of the discussions on issues such as the Yips/mental blocks, strength training & other subject matter on athlete performance concepts were really missing the mark on these ideas (e.g. how trauma is the direct cause of the Yips). If you are interested in learning more, make sure to subscribe below for when I put out new content on issues related to sport psychology & athlete performance! Also, if you are looking to work with a mental performance specialist, you are in the right place! USE THIS LINK to reach out to me to see if my services are the right fit for your goals!
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