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Abstract
This study explores elite athletes’ experiences of psychotherapy administered by Swedish licensed psychologists or psychotherapists with and without specialisation in elite sports, addressing the research question: What do elite athletes experience as important for psychotherapy effectiveness when seeking treatment from a licensed clinical psychologist or psychotherapist? Five elite athletes (self-assigned women=4, self-assigned men=1; age range: 20–34 years) from three sports (fencing: n=2, handball: n=2, triathlon: n=1) volunteered to participate in interviews. All athletes had worked with more than one licensed psychologists/psychotherapist, either through a regional healthcare or an elite sports specialised clinic while being national or international elite sports level athletes. Data were inductively analysed by the use of reflexive thematic analysis. Trust and professionalism to the psychologist/psychotherapist were generated as an overarching theme. Themes created during data analysis included the psychologist/psychotherapist’s (a) understanding of elite sports and of both the person and the athlete, (b) psychotherapeutic behaviours or skills (ie, holistic problem assessment, communication, empathy, validation, confidentiality, therapeutic alliance, goal-oriented content and ability to tailor psychotherapy to the athlete) and (c) conditions for psychotherapy (time, accessibility and appropriate support). Participants expressed difficulties in differentiating between qualified and unqualified mental health support providers. Mental health services originating within the sport context were perceived to improve accessibility and the possibility of regular sessions. Mental health services provided outside the immediate sporting context, with the psychologist/psychotherapist not being overly involved in sports, was however perceived to enable a more objective and holistic assessment of both non-sport and sport-related concerns impacting on athlete mental health. We conclude that sports organisations must facilitate athletes’ access to psychological treatment, and additionally ensure that practitioners working with psychotherapy have professional expertise and are appropriately qualified. Sports organisations should also systematically evaluate mental health services to ensure quality and that they are up to date with best practices.
- Intervention effectiveness
- Psychiatry
- Psychology
- Qualitative Research
- Sports & exercise medicine
Data availability statement
Data are available on reasonable request. Anonymised data are available on reasonable request from the first author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Psychotherapy is considered a first-line treatment for athletes’ mental health concerns, but barriers (eg, stigma and confidentiality issues) in elite sport settings can make athletes hesitant to seek and use mental health services.
There is still limited empirical knowledge from the athletes’ perspective on how psychotherapy can be successfully facilitated in elite sport.
WHAT THIS STUDY ADDS
The psychologist/psychotherapist’s professionalism and trustworthiness were experienced as essential to successful psychotherapy. Psychotherapeutic competencies combined with an understanding of elite sport enable the consideration of both sport-related as well as non-sport-related issues that may individually or in combination affect athletes’ mental health.
Practitioners from different disciplines and educational backgrounds (eg, sports psychology consultants, psychologists and psychotherapists) offer psychological support in elite sports settings. The diversity of professional disciplines working with mental health makes it challenging for athletes to distinguish between qualified and unqualified mental health professionals.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Sport organisations need to facilitate access to evidence-based psychotherapy for elite athletes provided by qualified mental health professionals who understand the culture and expectations of elite sports.
Introduction
Evidence-based psychological treatments (psychotherapy) are considered first-line treatments and are available for many mental health concerns (eg, anxiety, major depression and eating disorders)1–4 frequently reported among elite athletes.5–8 There are many evidence-based theoretical orientations to psychotherapy.2–4 Most therapeutic approaches include common factors like a strong professional alliance, therapist–client collaboration, goal consensus and empathy.9 Researchers suggest that common factors, interacting with specific factors (ie, treatment content or methods related to the psychotherapeutic approach), are essential components for change and psychotherapy effectiveness.9–12
Despite strong empirical support for psychotherapy for common mental health concerns within the general population,3 4 little is known about psychotherapy provided in the elite athlete population. Some scholars have raised concerns about the limited amount of mental health interventions developed for elite athletes.13 Others suggest, however, that the content in psychotherapy is not necessarily different if elite athletes or non-athletes are treated for the same condition.14–16 Instead, challenges may refer to prerequisites in elite sports settings. These can include diagnostic ambiguity or expectations put on the practitioner about special treatment, performance-before-health norms and requests for sports-related adjustments based on preferences from the athlete, coach or staff around.14 15 Elite sports environments can also introduce barriers that make athletes hesitant to seek mental health services like stigma in the sports culture, fear of deselection and concerns about confidentiality related to mental health staff in sports.17
Educational and licensure requirements to provide mental health services to athletes differ across countries.18 In Sweden, like many other countries, there are no formal educational requirements or licensure required to offer psychological support in sports settings. Non-licensed practitioners often work on consultancy basis adopting various titles (eg, mental coach, mental trainer, sports psychologist consultant and behavioural scientists) not regulated by law. In Swedish healthcare settings, on the other hand, the provision of mental health services involves professionals like psychologists and psychotherapists licensed by the Swedish National Board of Health and Welfare.19 Psychologists hold a 5-year university degree in psychology, including clinical psychology and basic training in psychotherapy, plus an additional year of supervised practice in healthcare to qualify for licensure.20 Psychotherapists are specialised in psychotherapy and come from various educational backgrounds, most commonly being psychologists, medical doctors with specialist training in psychiatry or social workers with basic training in psychotherapy. To qualify as a licensed psychotherapist, a 3-year (half-time) additional education in psychotherapy at advanced level is required after the undergraduate diploma, in combination with substantial psychotherapeutic work experience in healthcare.21 Both psychologists and psychotherapists are formally qualified to provide psychotherapy for healthcare purposes, are required to have patient insurance and are under oversight of healthcare authorities. However, they do not necessarily have experience working in high-performance contexts.
To date, sparse research has focused on elite athletes’ experiences of essential factors for psychotherapy effectiveness (ie, if the psychotherapy is successful towards meeting the athlete’s desired outcome). This study explores elite athletes’ experiences of psychotherapy administered by Swedish licensed psychologists or psychotherapists with and without specialisation in elite sports. More specifically, we address the research question: What do elite athletes experience as important for psychotherapy effectiveness when seeking treatment from a licensed clinical psychologist or psychotherapist?
Methods
Study design
A qualitative research design was employed. Sweden is a small country with a limited number of athletes at the national team level. To protect the participants anonymity, information that could reveal the athletes’ identity was omitted or slightly changed. Results are presented according to the Standards for Reporting Qualitative Research (SRQR) guidelines.22
Participants
Participants were recruited through various channels (eg, advertisement on social media, mental health clinics, players’/league associations and sports federations/clubs). All participants provided their written informed consent before data collection.
Inclusion criteria for this study were as follows:
Participants being ≥18 years and Swedish speaking.
Participants had received psychotherapy during the past 2 years by a licensed psychologist/psychotherapist through regional healthcare or an elite sports specialised clinic.
Participants had participated on a Swedish national team prior to psychotherapy, being ranked as a national or international elite sports level athlete for their age group.
Data collection and data analysis
A semistructured interview guide was used during the interviews, developed by the first and second author (online supplemental file 1). The first author is a licensed clinical psychotherapist and an associate professor in both psychology and sports sciences, also with extensive experience in applied sport psychology and psychotherapy in elite sports. The second author, at the time of data collection, was a final year student at a clinical psychotherapist programme with many years of experience working with applied sport psychology. Interviews were performed by use of digital tools (Zoom), were recorded and transcribed verbatim.
Supplemental material
Data analysis was performed inductively by use of reflexive thematic analysis (TA)23 underpinned by pragmatic epistemology.24 Braun and Clarke25 suggested that the meaningfulness of themes in reflexive TA is a result of interpretative process and that the purpose and goals of qualitative research should guide decisions about sample size more than the number of interviews. The usefulness of data saturation in reflexive TA has also been criticised,25 26 and we adopted the concept of information power which focuses on the relevance of information obtained from participants. Fewer participants are generally needed if the sample holds relevant information,26 and in this study, we collected data from a sample with high specificity in knowledge and experiences of relevance to the study’s aim. After five completed interviews, we decided to terminate further data collection as the data were judged to be sufficiently rich in information to address the research question.
The first and second author performed the data analysis by following the procedures described by Braun and Clarke.23 27 28 In the first step, codes were identified in the interviews and initial themes were generated. Throughout the process of data analysis, the first and second author discussed the relevance of generated themes and worked to deepen the understanding of the underlying content. This process also included considering whether themes warranted separation, could be merged or reorganised to display the latent content more appropriately. During the data analysis phase, the first and second author also reviewed the interview transcripts several times to make sure that essential data were not neglected and to determine the alignment of themes related to the content in the data. These discussions continued until the authors reached a consensus on how themes could logically be organised within a thematic map. The themes were subsequently named.
Rigour
Following the guidelines suggested by Tracy,29 rigour was upheld throughout the phases of study design, data collection, data analysis and presentation of findings. Participants were selected if they fulfilled the predetermined inclusion criteria and were expected to contribute with meaningful experiences and perspectives. During the analysis phases, the authors put effort to ensure a close examination of data and to facilitate a robust organisation and interpretation of findings to strengthen the study’s conclusions. The authors were careful to report the results so they would contribute significantly to the existing body of knowledge. Finally, the third author undertook a critical review of the generated themes and how they were structured to ensure a coherent and meaningful presentation of the results.
Patient and public involvement
Patients or the public were not involved when this study was designed and conducted.
Results
Five elite athletes from three sports (fencing: n=2, handball: n=2, triathlon: n=1) volunteered to participate. The interviews averaged 39 min in length (range: 31–44). All athletes had worked with more than one licensed psychologists/psychotherapist because of experienced mental health concerns (eg, disordered eating, relationship problems, loneliness and psychological trauma) (table 1).
Interviewed participants and their experiences of psychological support/psychotherapy
Participants had experienced various types of psychotherapy (eg, cognitive–behavioural therapy (CBT), acceptance and commitment therapy (ACT), affect-focused therapy (AFT)), in different modalities and formats (eg, digital healthcare providers, primary healthcare, private clinics with specialisation on sports). Figure 1 displays the major themes generated: trust and professionalism, understanding, therapeutic behaviours and skills, and conditions for psychotherapy.
Research question (RQ) and summary of the results in a thematic map.
Trust and professionalism
Trust and professionalism were generated as an overarching theme, encompassing the athletes’ general experience of being understood, feeling that problems were taken seriously and the trust experienced in the psychotherapeutic treatment. The psychologist/psychotherapist’s expertise, together with the therapeutic approach, could directly influence the athletes’ willingness to engage with the therapy:
I was not forced but I was given a reason why we should do this exercise and how it can help me. It made it easier for me the first time. Just like the first time I tried to provoke a panic attack, we did it during a session, and I was really scared. But I did it because I trusted it okay, it is going to be tough, but [the psychologist/psychotherapist] is with me [Participant 3]
Understanding
The psychologist/psychotherapist’s understanding was another major theme generated and two subthemes were created: (a) understanding the elite sports context and (b) being understood as a person and an athlete.
The elite sports context
The psychologist/psychotherapist’s understanding of elite sports was important for how the participants perceived the effectiveness of their psychotherapy. It was vital for the psychologist/psychotherapist to have at minimum some knowledge of sports.
She had a sports orientation. And it was very good because I believe that it is most important to have some understanding of the demands that sports or elite sports put on you. And I think, compared to the first time, it was a little bit different because she did not really have that orientation, it was different because she did not actually understand how it is to be an athlete [Participant 5]
None of the athletes thought it necessary that the psychologist/psychotherapist had an elite athlete background. However, it was considered highly advantageous if the psychologist/psychotherapist had participated in sports at any level and was able to immerse into, and be curious about, elite sports to understand the ‘bigger picture’. All interviewed elite athletes described negative experiences of seeking mental health support from general healthcare providers, where the psychologist/psychotherapist lacked enough understanding about elite sports:
It used to be just general healthcare and stuff, and that has not really worked for me. It was like “why don’t you go for a walk?” but it is not quite the same thing. You train over 30 hours a week, and then just go for a walk [Participant 3]
In the context of mental health, however, the psychologist/psychotherapist not being overly involved in elite sports could also be perceived as beneficial:
I think you can even have some advantages by being outside the bubble, to be able to look at things more soberly. What I think you should try to understand is like, what demands are placed on these [athletes], what is required? [Participant 2]
The person and the athlete
Being understood as a person and an elite athlete was created as a pivotal theme. It involved being recognised for one’s elite sport identity, life choices, high ambitions and lifestyle, without facing scepticism or feeling alienated or deviant: ‘He understood my perspective exactly, and who I am personally, high achiever both in school and in sports’ [Participant 1]. Being understood also related to the person and the athlete being viewed as a whole, and not having to sacrifice an essential part of oneself to achieve well-being: ‘I think it is important to find that balance to achieve effectiveness in treatment. Dare to go a little deeper into what comes first, what the athlete, the individual, really wants’ [Participant 5]
Equally important was the ability to discern whether the origin of mental health issues was attributed to the sport, to external factors outside of sport, or a combination.
You must also be able to distinguish when it comes to feeling bad in, for example, sports. Yes, you can recognize that, but you should also be able to talk to someone simply as an individual, without in any way being seen as an athlete [Participant 4]
Therapeutic behaviours and skills
Central aspects pertaining to athletes’ satisfaction with treatment related to facets of the psychologist’s/psychotherapist’s therapeutic behaviours or skills: (a) conducting a holistic assessment of the problem, (b) communication, empathy and validation, (c) maintaining confidentiality, (d) fostering a strong therapeutic alliance, (e) structuring the treatment with clear and goal-oriented content and (f) tailoring the treatment to the needs of elite athletes.
Holistic assessment of the problem
A holistic assessment of the athlete’s problems by the psychologist/psychotherapist, not just isolating it to a sports performance issue, was important. For example, helping athletes understand how early life traumas, loneliness and/or long-term difficulties in relationships impacted them as individuals, and which also affected their athletic pursuits. Similarly, problems originating within sports could be generalised and negatively affect other areas of life, like their social lives and job.
I think I have problems that are not only related to sports, but also extend to my whole life and self-perception. It is a broader perspective [Participant 1]
In some cases, athletes had previously refused to acknowledge their problems, either to themselves or to others, because of the stigma attached to mental health concerns in elite sports. Some participants had not previously understood how issues outside of their sport could negatively affect their performance or how early experiences continued to impact their mental health.
I felt very bad in my life situation related to sports and everyday life, but the goal was not completely clear for me at the beginning. I wanted someone to talk to and move forward, what should I do, so the goal somehow became, like, established over time [Participant 5]
The psychologist/psychotherapist’s clinical knowledge and professional ability to conduct a holistic assessment on a deeper level were perceived to positively impact therapy results. For example, exploring an athlete’s background, life history, how the problems had evolved over time and their impact in different contexts, instilled trust in the psychologist/psychotherapist and improved athletes’ general self-understanding. Similarly, when the athletes learnt to manage their issues within sports, they also noticed improvement outside of their sport.
I would say it was what happened outside of sports that made me start performing well in sports again, to the point where I would even call it life changing. Many of the questions I have had in sports I have had in other contexts as well. But sport is what I am most committed to, and that is where the results show up much faster and it becomes ten times as visible [Participant 2]
Professional communication skills and empathy
This subtheme encompassed the psychologist/psychotherapist’s professional communication skills, which included the ability to listen and pose relevant questions that allowed the athlete to open up and feel safe in the session.
The way he spoke. I think he was very professional, yet very accommodating and pleasant. Both in the conversations and around it was like… I never felt any negative feelings or anything. He helped me. I felt that I could share things, which is also quite important [Participant 1]
When participants perceived the psychologist/psychotherapist to have inadequate communication skills, they reported poor experiences (eg, not being understood, not understanding the meaning of psychotherapy). In fact, it was a significant reason for distrust and discontinuation.
Like last time, I felt that we talked a past each other a bit. I felt like I brought up a question and did not quite get the guidance I was hoping for. It had somewhat of the opposite effect /…/ That was probably the main reason why I did not ask for another session. I feel like these conversations do not calm things down or make things more organized or anything [Participant 4]
Central to this theme, and recurrently emphasised in the interviews, was the psychologist/psychotherapist’s ability to express empathy, validate the athlete’s experience and normalise without being judgemental, dismissive or negatively question the athlete’s experiences.
I got empathy for my problems and empathy for feeling bad. As I previously mentioned, it feels like many other psychologists were almost judging you for feeling bad, which makes you feel almost like a bad person for feeling that way. But now it was more like this happened because of [X] and [X]. You get some support from the fact that it is okay to feel this way [Participant 2]
Conversely, when the athlete did not experience empathy and validation, it was described as potentially exacerbating the problem: ‘It was the feeling of being alone in this little bubble of isolation, and I tried to break out of it, but it did not work, so it kind of reinforced the feeling of being alone and isolated’ [Participant 4]
Therapeutic alliance and confidentiality
Participants emphasised the importance of the therapeutic relationship. A good relationship encompassed a sense of collaboration, with the athlete being fully involved in decisions and the treatment process. In addition, it was appreciated if the psychologist/pyschotherapist took time to understand and get to know the athlete.
We are in this together, you know. I get to express what I find difficult and then it is integrated into the treatment. It is not like there is a pre-defined concept of how we have done things with everyone else. Instead, it is all about you, and if you have a problem, we will come up with a plan that is specific to you [Participant 2]
Being able to trust confidentiality, not always found in elite sport culture, was expressed as central to the therapeutic alliance, where the knowledge that the psychologist/psychotherapist was licensed and legally bound by confidentiality provided a sense of security for athletes.
The question of confidentiality, always asking for permission, like, "Can I share this with a coach or something?" And be clear that what is said and done here stays between us. So I do not feel a lot of worry about it, but I can understand that it [worry] exists [Participant 5]
One athlete described the opposite situation, where a non-licensed sports psychology consultant worked with several people on the athlete’s team, and the athlete felt uncertain about confidentiality.
The awkward thing that he often had others who were people I was talking about, which is something he is probably good at. But it also meant that the person on the team I had problems with had her session right before mine. She left and then I went in [Participant 1]
Structured, concrete and adapted for elite athletes
The psychologist/psychotherapist ability to structure the overall treatment, and individual sessions to be goal-oriented with concrete exercises was important for athletes. They also preferred clear content that could be evaluated in relation to the treatment goals. Several athletes highlighted the importance of therapy mirroring their athletic training by being organised, concrete and explicit and giving a sense of forward progression.
But it is about practice and homework, like getting something each time that you need to take with you to the next session. In that way it creates a clear goal. And I, as an athlete, like that, knowing exactly what I need to do. Like incorporating it a little bit, like it is a training program. But this time it is for the soul [Participant 3]
The psychotherapy being perceived as structured, clear and evaluable was also closely aligned with the athletes’ experience of the psychologist/psychotherapist’s ability to tailor the therapy to them as elite athletes and align the work with the sport’s conditions and goals.
I think in general, as an athlete, and when you get to a certain level, you tend to be a bit rigid and you want things to be very specific and clear as a way to move forward. It is also very important, even if the goal was not very clear at the beginning, that it must become clear over time. Just sitting and talking… It has to lead to something specific that we are working towards [Participant 5]
The participants, however, had varied experiences regarding how well psychologists/psychotherapists managed to tailor the therapy to their individual needs or situation as an elite athlete: ‘I was simply told that you better quit or give up, you should not compete. It has more been at that level, so there has been zero adaptation’ [Participant 3]. Some did share positive examples where the psychologist/psychotherapist had managed to adapt the therapy well or referred the athlete to somebody more knowledgeable: ‘Then sports came into play a little more than I had anticipated, and at that point she wanted to pass it on to someone else’ [Participant 4].
Conditions for psychotherapy
Session length, accessibility and appropriate support
This theme encompassed several external conditions necessary for successful psychotherapy. First, the session length needed to be long enough for the athletes to explain and process their problems. In addition, the psychologist/psychotherapist had to be accessible with the ability to schedule regular, recurring sessions with the athletes.
Ideally, I would like to have a psychologist connected to the team, because sometimes, when you talk maybe once a week or every two weeks, a lot can have happened in that time. But you cannot always bring up everything in the conversation. So the only negative would be that sometimes you would like to have sessions more often [Participant 5]
Athletes highlighted the difficulty in knowing where to find professionals with adequate experience and knowledge about psychotherapy for elite athletes. The participants’ sports organisations were often not helpful, many had no agreement or connection to an appropriate psychologist/psychotherapist. As a result, it was a challenge to discern where to go, as many consultants advertise their services as mental health without having the necessary qualifications or licensure.
It is complicated to understand the jungle of mental coaches in sports psychology. Who does what, who is what, who can do what /…/ I find it very challenging. Even when I Google it is like, what is the difference between a therapist and a psychotherapist and all these… [Participant 1]
Two of the interviewed athletes described experiences of ending up with a mental coach/sports psychology consultant when they needed clinical psychotherapy. This led to unsuccessful interventions, not targeting the underlying problems: ‘It ended up that I felt worse, but I did not contact him because what I was experiencing was not related to me doing sports’ [Participant 4]. Additionally, working with someone who offered overly superficial psychological support had sometimes delayed getting the proper care for their mental health needs.
I acquired methods to use in different situations during competition or training. But more profound work, it was not. /…/ It feels like something has ultimately changed now, it is different with [the psychotherapist]. I was like, damn, why did not this happen four years ago? [Participant 1]
Discussion
This study explored elite athletes’ experiences of psychotherapy effectiveness and provided unique insights about their experiences with different mental health providers. Trust and professionalism in the psychologist/psychotherapist were prominent in the athletes’ reports of psychotherapy effectiveness, irrespective of the delivery’s modality (eg, face to face, online) or the psychotherapeutic approach (eg, CBT, ACT, AFT). Corroborating previous findings in non-sport settings,9 12 our results indicate that the therapy process itself, including common factors such as the therapeutic alliance between the therapist and the athlete, plays a critical role in the athlete’s engagement in psychotherapy. Professionalism, therefore, does not only encompass knowledge of specific techniques or methods, but also the psychologist/psychotherapist’s ability to motivate and involve the athlete in decisions, as well as creating appropriate and safe conditions to facilitate successful results. Moreover, the study’s results suggest it is important to perform a holistic assessment of the athlete’s mental health concerns (eg, the life history, sports experiences, general predisposition to mental health concerns) beyond problems that directly impact sports performance. There are currently several brief, symptom-based screening tools available to support evaluations of athletes’ mental health (see Mountjoy et al30 for a summary). Clinical judgement, including the knowledge and experience of psychiatric diagnosis, however, is essential to appropriately interpret the assessments’ scores and to determine how, for example, biological, cognitive, behavioural, emotional, social and cultural factors can influence athletes’ mental health concerns.18
Clinical, research and practical implications
In psychotherapy, like other health services, evidence-based practice is considered a core competency of mental healthcare.31–33 An alarming finding in this study was that participants expressed difficulties differentiating between qualified and unqualified mental health providers, lacking support from their sports organisations in contacting qualified psychologists/psychotherapists. Athletes and coaches cannot be expected to know what mental health services are needed or the root of their mental health concerns. Our results suggest that athletes can perceive licensed psychologist/psychotherapist who are qualified to provide psychotherapy for healthcare purposes to lack enough understanding of elite sports. On the other hand, non-licensed practitioners with an experiential or educational background primary in sports do not have professional psychotherapeutic qualifications. The findings, therefore, suggest that practitioners need to be equipped with multiple clinical and sports-related competencies, which encompass both professional knowledge and skills in psychotherapy and appropriate knowledge and experience about the conditions found in elite sports. More research is needed to understand what specific competencies (ie, knowledge and skills to deliver mental health treatments to an acceptable standard for anticipated effects34) mental health practitioners need to effectively provide mental health services to elite athletes.
The importance of confidentiality related to mental health services was expressed by participants. Lack of trust in mental health services, for example, if athletes fear negative consequences (eg, not being selected to the team) if sensitive information reaches coaches or administrators,17 35 can result in early termination of psychotherapy and make athletes hesitant to contact a mental health specialist.17 Sports organisations must ensure that practitioners are appropriately qualified, that athletes can trust fundamental premises like confidentiality and provide conditions that enable mental health specialists to work professionally. Given that some psychiatric conditions commonly reported among athletes (eg, depressive symptoms or disorders5) are related to increased suicide risk,36 37 the consequences of neglect or inappropriate mental health support can be fatal. Sports organisations have a responsibility to systematically evaluate the quality of mental health services offered and ensure they stay up to date with best practices and national healthcare regulations.
Limitations and trustworthiness
This study is limited to five interviews with Swedish elite athletes with a predominant female sample, with only one male athlete included. Despite a small number of participants, the interviews were information rich and provided unique insights into the elite athletes’ experiences and reflections on working with psychologists/psychotherapists. To increase the credibility of our data, we used a semistructured interview guide developed by two of the authors who are well acquainted with the Swedish elite sports context. The author team is also experienced in clinical psychology/psychotherapy and sport psychology, which ensured that multiple perspectives informed data collection and analysis. To enhance transferability, detailed descriptions of the Swedish context are provided. Educational and licensing requirements for mental health professionals (eg, psychologist, psychotherapist), as well as sports systems, vary across countries which may limit transferability. Because of ethical considerations, we decided to limit detailed information that could reveal the identity of the athletes. Consequently, researchers and practitioners should interpret these findings within an appropriate cultural and contextual framework. The dependability of our research was ensured through a transparent description of the research process while confirmability was strengthened by the third author’s critical review.
Conclusions
Swedish elite athletes experience trust and professionalism, understanding, therapeutic behaviours and skills, and conditions for psychotherapy as important for psychotherapy effectiveness. Mental health practitioners should acquire professional competencies in clinical psychotherapy and an understanding of elite sports to tailor psychotherapy to the specific needs and circumstances of the individual athlete. Sports organisations must facilitate athletes’ access to qualified mental health professionals and systematically evaluate and ensure the quality of mental health services offered.
Data availability statement
Data are available on reasonable request. Anonymised data are available on reasonable request from the first author.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Swedish Ethical Review Authority (Dnr 2021-06529-01). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank the elite athletes who volunteered to share their experiences of psychotherapy.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @CarolinaLundqv1, @DrDavidSchary
Contributors Guarantor: CL. Substantial contributions to conception, design: CL and JW. Writing the draft: CL. Data collection: JW. Data analysis: CL and JW. Editing the manuscript critically for important intellectual content: CL and DPS. All authors approved the final version of the manuscript for submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.