It’s inevitable that things will go awry for athletes from time to time. Setbacks will happen - both on and off the pitch. The question above highlights two distinct types of setbacks that can occur in sport – those that occur during a particular performance (e.g. hitting several bad strokes in a round of golf, missing free throws in basketball), and those that can build across a series of performances (e.g. a soccer team having successive defeats). There are some overlaps, and also some distinctions, in how an athlete can best be supported with these two types of setbacks.

With both types of setbacks, athletes’ can get tangled up with their mind’s critical judgments about their performance and their ability to cope under pressure. For example, they may have to deal with self-critical thoughts such as: “You’re a choker” or “You’re not as good as you think”. When an athlete dwells on thoughts like these, their attention switches away from the performance environment to being much more self-focused. This can in turn increase the likelihood of further setbacks because the athlete is less responsive to important cues in their environment. An athlete that I worked with recently summed up this vicious circle when he said: “You can get lost in your thoughts, then you end up judging yourself for getting lost, and then you end up even more lost”. The occurrence of setbacks can also trigger memories of the athlete’s past setbacks or worries that similar setbacks will occur in the future. The net outcome of these consequences is that the athlete is not fully oriented to the time and space where the action is taking place.

Strategies that allow athletes to draw their attention back to the present moment can be very helpful for dealing with setbacks that occur during a particular performance. In the Flexible Mind approach (https://www.flexiblemind.co.uk), which myself and colleagues developed, we highlight how the use of phrases such as “Notice, Refocus” or “Be here now” can help athletes to acknowledge the judgments that their mind might be making and bring their awareness back to the present moment. In a recent podcast, Dan Carter, the former New Zealand rugby player, spoke about how he would use phrases such as ‘What’s my next task?’ and particular physical actions (e.g. pushing his toes into the front of his boot) to help him switch his attention back to the external environment after he missed a penalty kick (https://tinyurl.com/mrxd94c4). In a similar vein, former Ireland rugby captain Paul O’Connell has spoken about using phrases such as “Win the moment in front of your face” to anchor himself in the present moment (https://tinyurl.com/3kmta7bz).

Regarding setbacks that have occurred over a series of performances, it will be important to review technical and tactical elements of the athlete’s performance. No attempt of psychological work will compensate for technical and/or tactical flaws with performance. To help manage the psychological consequences of a series of setbacks it can be helpful for athletes to reconnect with their ‘purpose’ – what is it that matters enough to the athlete to participate in the sport and to endure the setbacks? From a psychological perspective, it will be important for athletes to make choices that are motivated by an intention to move towards that sense of purpose, as opposed to moving away from further setbacks. This is the difference between playing to win vs. playing not to lose, playing with freedom vs. playing with fear. Supporting athletes to embody their values in how they act and the choices that they make (e.g. doing things conscientiously, supporting others during difficult times, demonstrating good leadership etc.) can be a helpful way of supporting them to move towards their purpose.

The Flexible Mind approach, like ACT approaches more broadly, recognises that critical comments have the potential to impact on athletes’ performance, as well as their mental health and wellbeing. Whilst athletes can’t control whether criticism is directed their way, they can exercise choice in how they respond to it. The question makes mention of helping the athlete to ‘…ignore negative comments…’. Importantly, however, the Flexible Mind approach does not recommend that athletes should try to ignore/avoid/suppress experiences. This is because doing so can paradoxically intensify the impact of those experiences. As the French philosopher, Michel de Montaigne once said - “Nothing fixes a thing so intensely in the memory as the wish to forget it”. So, although there is a lot of talk about “blocking out the noise” in high performance environments, this might be hard to do in practice. The Flexible Mind approach instead places emphasis on helping athletes to develop a courageous willingness to be open to the experiences that they are having – leaning into them rather than away from them. It’s like the approach a down-hill skier takes – rather than leaning back and recoiling away from the descent, the skier maintains balance and momentum by leaning forward into the descent. Proactively developing mindfulness skills can assist with building openness to the breadth of current moment experiences. This work will involve ‘showing up’ to the challenging emotions that can arise when criticism comes our way and utilising strategies to help bring kindness to the upset (more details about that in the response to Question 4).

Another important strategy for dealing with unconstructive criticism is to change the way in which we relate to the ‘audio’ that other people create about us. Do we buy into those stories as facts? Or can we connect with them in a different way? It’s like being in a club and the DJ plays a track that you don’t like. Unfortunately, we don’t get to choose the tunes the DJ plays. If we were to try to tell ourselves not to listen to the tune – we would be even more aware of it! Rather than blocking out that ‘noise’, the Flexible Mind approach supports the person to allow the tune of criticism to play (knowing that it will come to an end) and to keep doing what matters. In the case of the club, this could include connecting with the people around you, whereas in sport this would be about remaining engaged with coaching staff and trusting the process.

It is important to recognise that in the short-term perfectionistic striving can deliver improvements in performance. This can serve to reinforce the belief that this is the only way to proceed. Many athletes are all too ready to sacrifice self-care in the pursuit of perfection. Over-time ‘maladaptive perfectionism' can develop, and the research evidence suggests that this can have adverse consequences on performance and both physical and mental wellbeing. Paradoxically, it can be the case that less can be more, and that quality rather than quantity of effort can be crucial. Elite environments can be harsh and uncompromising at times, and people can internalise a harsh and uncompromising attitude towards themselves. Whilst self-criticism can sometimes serve to motivate us to work harder and/or direct our attention to problems that need to be addressed, high levels of self-criticism are also associated with low mood and feelings of worthlessness.

In recent years, strategies aimed at helping people to enhance their ability to be self-compassionate and kinder to themself have been developed. Higher levels of self-compassion are associated with higher levels of wellbeing and a superior ability to deal with adversity in sport (https://tinyurl.com/2p95h9ae). An important potential obstacle to tackle in supporting athletes to develop self-compassion may be their misgivings that being kinder to themself will lead to complacency. There is no evidence to support this belief. Self-compassion is not about letting yourself off the hook, it’s about taking good care so that you can get the best out of yourself. In a world where emphasis has been placed on making ‘marginal gains’ to improve performance, the potential benefits of increasing an athlete’s margin for self-compassion should not be underestimated. Athletes are not superhuman, they are humans who can do super things. Like all humans, athletes will experience difficult times both inside and outside of sport. During such times, it will be important to support the athlete to recognise their shared humanity and respond with kindness. Helping the athlete to repeat the following phrase will be an important first step: “I am going through a difficult time. All people go through a difficult time. May I respond with comfort and kindness”.

The identity of athletes can be very closely entwined with the development of their careers. In the 1990s the psychologist Britton Brewer proposed the term athletic identity to capture the extent to which a person identifies with the role of an athlete and the degree to which they prioritize attention to sport relative to other aspects of life. High levels of 'athletic identity' have been shown to be associated with high levels of training commitment, and higher levels of performance. On the other hand, high levels of athletic identity have been associated with athletes engaging in several adverse behaviours including overtraining and refusing support when it is needed. Furthermore, when involvement in sport is stopped due to illness or retirement, those with high levels of athletic identity are prone to experiencing reduced self-esteem and increased low mood. The scaffold of sport-related focus and routine that has maintained the person’s sense of self is no longer there, and an overwhelming sense of loss (with accompanying feelings of sadness and yearning) can emerge.

The Flexible Mind approach and Acceptance and Commitment Therapy (ACT) approaches more broadly, can help athletes who are transitioning out of sport due to injury or retirement. By practicing ACT related strategies, athletes can build a willingness to be present and open to feelings of loss, so that they can process this pain rather than investing time and energy in trying to avoid it. ACT also places a specific focus on helping people to notice the ‘stories’ that their minds generate about their lives. The use of the term ‘stories’ here is not intended to trivialize, nor dismiss the concerns that the athlete might be experiencing, rather it is about helping the athlete to recognise that they are the author of their life and that they don’t have to become trapped by a particular story. Instead, as one chapter closes another begins. The focus that ACT allocates to helping people to clarify their values and commit to actions that are consistent with those values will be helpful in this regard. It is likely that many of the values that helped to inspire and motivate the athlete during their sporting career (e.g. working as part of a team, being committed and conscientious, an openness to learning and innovating etc.) will be important for helping to guide the choices that the athlete can make as they move on from competing in sport. The ACT practitioner will work collaboratively with the retiring athlete to explore what other contexts will provide an opportunity to be true to their values.

Eating disorders are conditions that are characterized by disturbed patterns of eating. This can include restricting the intake of food, consuming large amounts of calories in one sitting (referred to as ‘bingeing’), forcibly removing food from the body (referred to as ‘purging’) using laxatives or by making oneself sick, and/or engaging in excessive amounts of exercise. Examples of eating disorders include: anorexia nervosa, bulimia nervosa, and binge eating disorder. The rates of eating disorders in athletes are higher compared to the general population. As with the general population, female athletes are at higher risk than males. To date, there has been a lack of research that has followed athletes longitudinally through their careers to determine what the specific risk factors for developing eating disorders are. It is likely, however, that a combination of biological, psychological, and socio-cultural factors contribute to the increased risk. Research has shown that rates of eating disorders are higher in particular types of sport. For example, sports that require athletes to be below a particular weight (e.g. weight-divisions in boxing, weight classes in rowing), sports that highlight low body weight as a means to maximize efficiency (e.g. cycling), and sports that place emphasis on the aesthetic aspect of sporting performance (figure skating and gymnastics) are all associated with an increased risk of eating disorders. Yulia Lipnitskaya, the Russian figure skater who won Olympic Gold in 2014, has spoken about her struggles with anorexia nervosa (https://tinyurl.com/y2czz34k). In addition to ‘eating disorders’, athletes can also experience what is referred to as ‘disordered eating’ – characterized by abnormal patterns of eating (e.g. anxiety associated with particular foods, skipping meals, frequent dieting), which do not meet the full criteria for an eating disorder. The rates of disordered eating amongst athletes are also higher than in the general population.

I, along with the other authors of the Flexible Mind book, have made the session guides for the approach and associated audio files freely available to those who are interested to use them (https://tinyurl.com/2p97ha25). We hope that these will be helpful for practitioners and coaches interested to use an ACT-informed approach to promote wellbeing and performance in young athletes. Although not specifically developed for athletes, Joseph Ciarrochi and Louise Hayes have done great work to tailor ACT approaches for use with adolescent populations. Their recent book ‘Your Life, Your Way: Acceptance and Commitment Therapy Skills to Help Teens Manage Emotions and Build Resilience’ (https://www.thrivingadolescent.com/yourlifeyourway/) would be well worth checking out.

Dr Tobias Lundgren and his colleagues recently published the results of a randomised controlled trial of an Acceptance and Commitment Therapy (ACT) intervention for elite level ice hockey players (https://tinyurl.com/4xfdmfed). The trial was comparatively small – recruiting 34 junior elite ice hockey players. These players were allocated to either an ACT group intervention or a waiting list comparison group. The ACT intervention consisted of four weekly group sessions that were between 30–45 min duration. Those who received the ACT intervention demonstrated levels of objective performance (including goals, assists, and taken shots) and ratings from coaches (about the players’ performance, focus and commitment) that were higher than those achieved by players allocated to the comparison group. Importantly, the coaches doing the ratings did not know whether the players had received the ACT intervention or not. Although the superior ratings by the coaches were maintained at 3-month follow-up, this was not the case for the objective performance measures. Although these findings are encouraging, further research recruiting larger numbers of people and comparing ACT to another active form of intervention will be important for further evidencing the effectiveness of ACT in elite sport settings.

Over the last 50 years, Cognitive Behavioural Therapy (CBT) has been shown to be effective in supporting people who have been experiencing a range of difficulties with their mental health and wellbeing. It is a talking therapy that helps people to understand how their thoughts, emotions, physical sensations, and behaviours are connected. A key underlying principle for CBT is that negative thoughts and feelings can trap people in vicious cycles. CBT helps people to examine whether there is evidence to support the negative thoughts that they might be having about themselves, other people and/or the world around them; explore what alternative (less negative) thoughts they can generate; and engage in behaviours that might help to give rise to more pleasant emotions. It is highly structured and equips people with strategies that they can use in day-to-day life. However, CBT will not be to everyone’s liking, nor will it necessarily resolve the challenges that a person is experiencing.

Acceptance and Commitment Therapy (ACT) has evolved out of the cognitive behavioural tradition. Like CBT it is interested in a person’s thoughts, emotions, physical sensations, and behaviours. Unlike CBT, however, ACT therapists tend not to label these experiences as being ‘positive’ or ‘negative’. ACT instead recognises that these experiences can serve important functions in particular contexts but not others. Difficulties can emerge when we don’t adjust our ways of responding to meet the demands of the situation that we find ourselves in. ACT approaches (such as The Flexible Mind) aim to boost what is referred to as ‘psychological flexibility’ – the ability to notice the breadth of current experiences that we can have; be courageously willing to make space for our mind’s ‘stories’ about life and accompanying thoughts and emotions, and our ability to commit to actions in line with our values. In short, psychological flexibility allows us to be more Present and Open and Do what matters (the Flexible Mind approach refers to these three aspects as The P.O.D. of psychological flexibility). This can equip athletes to respond to the challenges that they experience with a range of behaviours that are influenced more by what truly matters to them, than by wanting to avoid difficult thoughts and emotions. If we are hardwired to experience challenging emotions why not have them in pursuit of a sense of ‘purpose’ and the values that bring this purpose to life? Unlike CBT, ACT does not encourage people to weigh up the evidence for thoughts or to substitute those thoughts for different thoughts. Instead, ACT helps people to use strategies that change the relationship that they have with their thoughts and emotions so that these are not a barrier to doing what matters. ACT does not pretend to cure all ills, nor will it be for everyone, but it is an approach that is being increasingly used in high performance environments to good effect.