Supporting The Mental Health Of Elite-Level Coaches Through Early Intervention

Current evidence indicates that elite-level coaches encounter a range of performance, organizational, and personal stressors that may influence or compromise mental health. With exposure to these stressors, supports need to be established to protect and preserve the mental health of elite-level coaches. Given the paucity of evidence available, this article proposes a number of considerations that should be taken into account when developing a mental health and rehabilitation framework for high-performance coaches. We argue that early intervention should be positioned at the core of this framework, to address the onset of symptoms prior to the emergence of a mental disorder or mental health crisis. Mental health screening and monitoring of coaches, the psychological safety of high-performance environments, the mental health literacy of coaches, and the tailored pathways to support are discussed. Beyond these strategies, it is proposed that rehabilitation and reintegration should be addressed to assist coaches who are currently experiencing mental ill health or have left their role due to mental health reasons. Although further research is needed to implement evidence-based strategies, it is recommended that a future mental health framework should incorporate the perspectives of coaches to ensure it is consistent with their needs and experiences.

][3][4][5][6] Elite-level coaches can be defined as individuals who operate as part of the management team or leadership group and regularly work to enhance the performance of athletes or teams competing at the Olympic, Paralympic, international, national, professional, or National Collegiate Athletic Association (NCAA) Division I level.These coaches are required to perform in rapidly evolving roles that comprise of multiple performance (strategic development, team selection, and management of assistant coaches or ancillary staff) 1,7 and non-performance related demands (e.g., extensive travel and lack of a social life), 8,9 all of which can lead to a lack of adequate life balance. 10From having to oversee the performances and well-being of athletes, 4 to representing and personifying the public face of an organization, 7 the highly demanding and timeconsuming nature of the profession can lead to coaches spending excessive hours working and ruminating about their role. 10,11In addition, research also indicates that elite-level coaches should be considered as "performers" in their own right (i.e., individuals who need to manage their own psychological state, leadership style, and standard of performance to influence competitive outcomes). 1,12][15] dual-continua model of mental health, 17,18 which asserts that mental health comprises two distinct but related phenomena: (i) the presence or absence of wellbeing (e.g., emotional, psychological, and social) and (ii) the presence or absence of a mental disorder (i.e., mental ill health).The model postulates that well-being refers to one's perceived quality of life, and reflects an individual's evaluation of their emotional (e.g., positive affect), psychological (e.g., personal growth), and social (e.g., contributions to the community, workplace, and society) well-being. 19When combined, these dimensions determine whether an individual is flourishing (high well-being), experiencing moderate mental health, or languishing (low well-being).Mental ill health, on the other hand, refers to the various symptoms and disorders associated with mental illness.This spectrum can be used to assess whether an individual is absent of symptoms or experiencing mild to severe symptoms of mental ill health.Given that this framework has been empirically supported in elite, university, and youth sport settings, [20][21][22] we argue that, to understand an individual's complete state of mental health, both symptoms associated with well-being and mental ill health should be examined.
Although the domains of well-being and mental ill health may overlap, an individual experiencing low well-being may not necessarily meet diagnostic criteria for a mental disorder.Conversely, those with a diagnosed mental disorder could potentially experience high levels of well-being throughout their day-to-day lives.Keyes' model is beneficial to researchers and practitioners because it provides a conceptual framework that can be used to categorize and distinguish between an individual experiencing low well-being or mental ill health (or both).Since research indicates that individuals who "languish" for prolonged periods are more susceptible to developing mental disorders over time, [23][24][25] this emphasizes the importance of providing early, timely interventions to halt the progression and development of mental disorders in elite-level coaches.Given the proliferation of research into the mental health of elite athletes 26,27 and the numerous mental health position statements that have emerged from this research, [28][29][30][31] it is critical that the field expand to develop frameworks that consider the mental health needs and challenges faced by elite-level coaches.

Mental Ill Health in Elite-Level Coaches
Despite scant research to date, preliminary evidence suggests that elite-level coaches are potentially vulnerable to a range of mental disorders.Findings indicate that high-performance coaches experience symptoms associated with depression, 9,10,14,15,32,33 anxiety, 9,10,14,15,34 gambling disorders, 35 alcohol and substance abuse, 14,15,33 and eating disorders. 15,36reliminary evidence indicates that rates of mental ill health may range from 14% to 44% for depression, 9,14,32 40% to 44% for anxiety, 9,14 and 19% to 48% for alcohol abuse 9,14 in elite-level coaches (i.e., presence of symptoms).In addition to this, a range of studies have also identified several risk factors that may contribute toward mental ill health.For instance, having a family history of a mood disorder (depression), 32 managing an extensive list of stressors (anxiety and depression), 9,32 adopting ineffective coping strategies (anxiety), 34 coaching a team sport (adverse alcohol use), 9 and experiencing stigma towards help-seeking 33 (adverse alcohol use and depression) have been found to be associated with symptoms of mental ill health in elite-level coaches.Although further research is needed to confirm the prevalence and associated risk factors with larger cross-national samples (e.g., n >100), 26 these initial findings suggest that high-performance coaches may be at a greater risk of developing mental disorders when compared with elite athletes. 27e Need for Early Intervention One of the most effective ways to provide timely support to coaches is through early intervention.This strategy has been recommended by researchers for both elite and youth elite athletes. 37,38This stage of intervention reflects a period where the initial onset and presentation of symptoms has occurred, but the development (and sometimes diagnosis) of a clinical disorder is considered to be premature. 39Given the importance that timing plays in managing the exacerbation of symptoms, this period is perceived to be critical to suppressing the progression and maturation of a mental disorder. 402][43][44][45] Since there is a growing body of evidence to suggest that elite-level coaches may experience high levels of stress or burnout at some point throughout their career, 7,[46][47][48] approaches that seek to halt the development of a mental disorder or mental health crisis should be carefully considered.As a result, this article will discuss a number of factors that should be addressed when developing an early intervention framework for elite-level coaches.In adding to these, we propose strategies to support the recovery and continued care for coaches who are currently experiencing or have previously experienced mental ill health.This includes avenues to reintegrate individuals who have departed the coaching profession due to mental health reasons.

Early Interventions in Elite Sport
In an elite sports context, Purcell and colleagues 37 proposed an early intervention framework to support and respond to the mental health of elite athletes.The framework discusses four phases of involvement, including prevention, athletes identified as being "at risk" of mental ill health, early intervention for first episodes of illness, and specialist mental health care.Each stage incorporates a variety of strategies that can be used to assist elite athletes with diverse experiences of mental health.For instance, the prevention stage proposes that mental health literacy courses, individual development programs, and mental health screening and feedback can be utilized to support athletes prior to the onset of symptoms, whilst more specialized practitioners and treatments are required for acute and complex presentations.This framework also promotes and emphasizes the importance of considering aspects of the broader sporting "ecology" in the development or maintenance of mental ill health, including factors at the interpersonal level (e.g., team dynamics), organizational level (e.g., leadership or cultural practices within the club or code), and wider societal level (e.g., public scrutiny or social media abuse).This framework was developed to promote better support for the mental health of elite athletes, but may also hold relevance to elite-level coaches, particularly in relation to minimizing the myriad stressors that potentially operate as risk factors for mental ill health (e.g., lack of role clarity, job insecurity), 9 and promoting early detection and intervention (e.g., encouraging mental health helpseeking) 33 so that mental health crises are averted.

Early Intervention for Mental Health In Elite-Level Coaches Mental Health Screening and Monitoring
To identify coaches who may be at risk or currently experiencing a mental disorder, screening tools are an effective measure that can be employed to detect symptoms associated with mental ill health.In 2021, the International Olympic Committee developed the Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1) to examine symptoms of mental ill health in elite athletes. 49These tools were designed to provide mental health practitioners and members of an athlete's entourage (e.g., friends and families) with a set of guidelines that can identify and treat athletes who may be experiencing symptoms of mental ill health.The SMHAT-1, for example, uses the Athlete Psychological Strain Questionnaire (APSQ) to measure symptoms of athlete-specific distress.The APSQ evaluates an athlete's ability to self-regulate, capacity to perform, and proclivity to implement maladaptive external coping mechanisms to reflect and measure an athlete's level of psychological strain. 50,51APSQ items are not necessarily relevant to coaches, and a need remains to develop and validate measures that consider the unique stressors and symptoms experienced by this cohort.
Although the Coach Burnout Questionnaire 52 and Burnout Prevention Questionnaire for Coaches 53 have been generated to assess symptoms associated with burnout, it has been argued that these measures possess conceptual weaknesses (e.g., theoretical and clinical limitations). 54Academics and industry stakeholders would subsequently benefit from a robust tool that identifies high-performance coaches at risk of psychological distress and mental ill health.A tool of this nature could assist with early identification and provide opportunities to intervene before the development of a mental disorder or mental health crisis.Measures incorporated to assess disorder-specific symptoms within the SMHAT-1 may be a viable alternative during the interim (e.g., the GAD-7 for symptoms of generalized anxiety; PHQ-9 for symptoms of major depression).
Given the current sensitivity of disclosing mental health concerns in high-performance sport, screening processes should be ethically managed, ideally by qualified mental health practitioners or sports medicine physicians. 50Since coaching in elite sports is often accompanied by high levels of job insecurity and scrutiny, 55,56 coaches may be wary about potentially sensitive mental health information being shared with others in (and beyond) the organization, including those occupying board or management positions, given the potential implications toward their employment status and how they are perceived within the sport.For mental health screening to be effective as an early intervention strategy, coaches need to feel assured about their confidentiality and the ethical premise for screening (i.e., early detection and treatment for mental health concerns, rather than "screening out").
During the screening process, it is vital that timing is taken into consideration when assessing the mental health of high-performance coaches.Although screening can be delivered during standard competitive periods (e.g., preseason and midseason), 57 organizations and federations should also take specific periods when coaches may be at greater risk of mental ill health into account. 30For instance, coaches who are approaching or have recently experienced retirement may be at a heightened risk of developing symptoms associated with depression. 32Similarly, coaches who have been recently dismissed may also face periods of distress and uncertainty. 58Organizations and federations should be mindful of the various transitional phases faced by coaches, and that their duty of care should also extend beyond a coach's tenure.This may contribute toward coaches feeling a greater sense of organizational support, which may increase the likelihood of a coach returning to the role, in the event that they step away to manage an episode of mental ill health.

Mental Health Literacy
The beliefs and attitudes about mental health can play a pivotal role in early identification and responses to the initial onset of symptoms. 59It is critical that an earlyintervention framework considers and promotes mental health literacy in elite-level coaches.Given that there is some evidence to suggest that coaches possess lower levels of mental health literacy than other populations (e.g., university students and health care professionals), 60,61 educational programs need to be established and tailored to accommodate for the specific stressors and symptoms experienced by coaches.Despite the value of these findings, to the best of our knowledge, no research has explored the mental health literacy of elite-level coaches exclusively.We therefore argue that research is urgently needed to better understand how high-performance coaches perceive mental health, examining their knowledge and beliefs in relation to this.Not only is this important for coaches themselves, but given that coaches operate within an athlete's interpersonal network and have been identified as the potential "gatekeepers" to mental health supports, [62][63][64][65] attitudes that promote mental health and help-seeking can positively influence the management and perceptions of an athlete's mental health.
Although interventions have been developed to enhance the mental health literacy of coaches, 66,67 the focus has largely been directed toward providing support for their athletes.As a result, there is a need for interventions to focus on the mental health of coaches to ensure that these individuals are cognizant of their symptoms and behaviors, in conjunction with an awareness of when support may be required.Current mindfulness-based interventions have shown early promise in cultivating greater emotional awareness in high-performance coaches. 68,69Given these studies found that greater self-awareness led to improved mental well-being, mindfulness-based interventions could be incorporated as a potential strategy to enhance the awareness and identification of a coach's emotional state and mental health.Before the implementation of these strategies, however, further research is needed to confirm these findings with larger sample sizes and robust theoretical approaches.

Psychological Safety
Though initially developed as a construct outside of sport, over recent years psychological safety has garnered increased attention in sporting contexts. 70lthough there are major concerns about the conceptual clarity and application of this term, Vella et al. 70 recently provided a working definition of psychological safety in sport as "the perception that one is protected from, or unlikely to be at risk of, psychological harm in sport."Cultivating psychologically safe environments may encourage elite sportspeople to take greater interpersonal risks given there are fewer consequences attached to one's individual actions (e.g., raising issues or sharing sensitive information). 71reliminary evidence indicates that psychologically safe environments may contribute toward improved mental health (e.g., reduced anxiety) and performancerelated outcomes (e.g., team effectiveness) in sport. 70his has been qualitatively supported in a coaching context, where it has been found that Olympic coaches who were provided with the latitude to make mistakes reported reduced stress. 8iven that psychologically safe climates might empower individuals to disclose mental health problems and pursue mental health services, an early intervention framework should also consider the environmental supports that could be established to protect the mental health of elite-level coaches.Recently, Rice and colleagues 72 developed a psychometric tool to measure the perceived psychological safety of an elite sports environment.The Sport Psychological Safety Inventory (SPSI) utilizes three dimensions to examine psychological safety, including factors associated with mentally healthy environments, mental health literacy, and mental health stigma.This instrument may offer value to a prospective mental health framework, as the SPSI was validated with a sample incorporating elite sports coaches and highperformance staff.We therefore propose that organizations could use the SPSI to examine the perceived safety of a coach's high-performance environment.This assessment could be utilized to identify whether sporting organizations need to better support their coaches, in order to cultivate environments that encourage coaches to prioritize and manage their mental health.

Pathways to Mental Health Supports
When developing a mental health framework for high-performance coaches, pathways to mental health supports should also be considered.Coaches are prone to symptoms associated with stress and burnout, 7,47,73,74 which, if ignored or otherwise neglected, could develop into more serious and persistent mental health symptoms or disorders.The provision of psychological or mental health services (e.g., by psychologists or psychiatrists) may play a crucial role in thwarting the exacerbation of symptoms.For instance, it has been found that help-seeking behaviors were positively correlated with levels of well-being in a sample of British coaches from a range of performance levels. 60One of the greatest threats to accessing mental health supports in elite sport, however, arises from stigma. 75Initial research suggests that some highperformance coaches may experience stigma towards mental health help-seeking, 33 with evidence indicating that coaches may avoid mental health services in the attempt to suppress and conceal what they perceive to be signs of vulnerability and weakness. 10Coaches may neglect treatment because of the common misperception that help-seeking is incongruous with the ideals of stoicism and mental toughnessdmisunderstood values that are commonly promoted and glorified in elite sport. 76,77To better support coaches, sporting organizations, federations, and governing bodies need to nurture high-performance cultures that destigmatize mental ill health and reposition help-seeking.Future research might examine the relationship between mental health and coaching effectiveness to leverage proponents of positive psychology, and evaluate whether performance could be employed as a "hook" to engage elite-level coaches with mental health practices and help-seeking.
Despite the presence of stigma, there may be contexts in which elite-level coaches seek to engage with psychological services. 15For example, Pilkington and colleagues 14 found that 35% of an Australian elite-level coaching sample had previously sought psychological treatment at some stage throughout their life.Although based on a limited sample size (n ¼ 78), given that more than one third of coaches reported seeking psychological treatment, this finding indicates a potential receptiveness toward mental health services.This may especially be the case in which mental health services are facilitated and paid for by the sporting body, as in the Mental Health Referral network funded by the Australian Institute of Sport, 78 and available to both high-performance athletes and coaches.As a result, we argue that further research is needed to understand the range of barriers and facilitators that influence mental health help-seeking in elite-level coaches.For instance, education and accessibility have been found to act as key barriers for elite athletes. 75Although there may a considerable overlap among athletes, coaches, and high-performance support staff, factors such as job security may play a larger role in a coach's consideration of support due to the threat and frequency of coach turnover. 79Researchers should subsequently seek to engage with coaches to understand their preferences for mental health help-seeking (e.g., how and with whom), and ideally co-design mental health services or frameworks to meet their specific needs.

Rehabilitation and Reintegration
Although it is critical to intervene at the earliest opportunity when symptoms of mental ill health arise, it is neither realistic nor appropriate to completely prevent experiences of mental ill health.Coachesdlike other members of the communitydwill be susceptible to episodes of psychological distress from general life adversity (such as relationship or financial difficulties or illness or death of loved ones), in addition to workrelated challenges and setbacks.Evidence-based psychological and pharmacological treatments exist for a range of mental disorders 30 and should be considered for elite-level coaches in accordance with clinical guidelines.Contextual issues (e.g., personal, social, environmental, and psychological) should also be factored into such treatments for coaches. 80For instance, to manage stressors, research suggests that high-performance coaches may be prone to using nonadaptive coping mechanisms such as alcohol consumption and substance use. 4,9,33,81Preliminary evidence indicates that elite-level coaches may engage in risky alcohol practices and substance abuse more than athletes and high-performance support staff. 14,15xploring treatments that promote adaptive coping could subsequently be a fruitful area for further research.These treatments should also consider whether a coach is still operating within their role or is no longer employed.This article stresses that the duty of care for coaches needs to be extended beyond their tenure, given the risks associated with transitional phases (e.g., retirement and dismissals). 32,56ince Keyes' model asserts that an individual can flourish (e.g., successfully achieving performance outcomes) despite the diagnosis of a mental disorder, we argue that sporting organizations must prioritize support and early intervention over dismissal or prolonged stand-downs for coaches experiencing an episode of mental ill health.This support is paramount if the high-performance sports industry wishes to maintain the best-in-class coaches.If elite-level coaches are fearful or apprehensive about the implications of a mental health crisis or disorder, stigma will continue to persist, and the desirability of the role may decrease, given there may be more stable, supportive, and appealing opportunities elsewhere.To ensure highquality leaders stay within the industry, coaches need to feel supported by their relevant organizations or federations, rather than isolated or detached.
For elite-level coaches who experience mental ill health, some individuals may feel it necessary to depart from the role. 10,33,82Evidence indicates that sufficient psychological recovery (e.g., psychological detachment and relaxation) 48,83,84 and taking time away from the high-performance environment 10,82 can lead to improved mental health outcomes in elite-level coaches.For those who take periods of leave for mental health reasons, however, appropriate protocols need to be established to ensure coaches return to psychologically healthy environments where they can perform their roles without being at risk of relapse if any contributing factors still persist.Currie and Purcell 85 have suggested that return-to-play guidelines adopting a traffic light system (e.g., red, amber, green ratings) representative of an individual's clinical condition would be a welcomed addition to the elite sports industry.These guidelines could emulate protocols put in place to assist athletes returning from significant physical injuries (e.g., concussion). 37Given that this is a broader area that could help generate parity between physical and mental health in elite sports environments, it is important that coaches remain part of the rehabilitation conversations and processes.

Conclusion
There is growing recognition that elite-level coaches, who operate in the same high-performance and outcome-focused environments as athletes, might also be susceptible to the same mental health difficulties their athletes face.Empirical research evaluating the mental health of elite-level coaches, however, is still in its infancy.This article has subsequently proposed a range of factors that should be considered when developing a framework to support the mental health of elite-level coaches (Table 1).Although these measures reflect the distinct stressors experienced by coaches, as well as the unique contexts they operate within, a greater body of evidence is needed to inform and develop a prospective framework.At present, little is known about the extent to which elite-level coaches experience mental ill health, as well as the various risk and protective factors that operate at the individual, interpersonal, organizational and societal levels.Current research also generally reflects the mental health experiences of coaches who identify as men.Much like the broader representation of gender in the field of sports psychology, 86 future research is required to explicitly consider gender differences and potentially other forms of diversity, including race and disability (e.g., para-coaches).For instance, given the underrepresentation of women coaches within elite sport, 87 further research should evaluate the gender-specific stressors and risk factors that may influence the mental health of coaches who identify as women (e.g., managing hypermasculine cultures). 88o develop a mental health framework that could provide coaches, practitioners and organizations with a set of guidelines to manage coach mental health, researchers need to better understand how elite-level coaches experience mental health.Researchers should also investigate theory-based strategies and interventions that could be employed to protect coaches from mental ill health (e.g., compassion-focused approaches are relevant in sport and currently being trialed with coaches). 68,89,90Alongside evidence-based practices, future mental health frameworks should incorporate co-design processes that ensure the mental health help-seeking and intervention preferences of coaches are considered and incorporated.Without such knowledge and engagement, mental health services or frameworks may not be "fit for purpose" and therefore risk redundancy due to a lack of potential relevancy and suitability.
Beyond the contents of a framework, timing is also a critical aspect to consider.Elite-level coaches are not immune to high levels of stress and periods of burnout, which necessitates the need for early, timely interventions to prevent the onset of mental ill health, or at least the worsening of existing symptoms.For those who do experience mental ill health, supports and treatment plans need to be established, so that coaches To understand the beliefs and attitudes that elitelevel coaches hold toward mental health and help-seeking.
To cultivate highperformance environments that protect coaches from mental ill health, support openness and connection, and encourage individuals to seek mental health services.
To provide elite-level coaches with pathways and access to evidencebased mental health supports and services.

Recommendations
In the absence of a coachspecific mental health screening tool, the SMHAT-1 could be used as a guide to assess general mental health symptoms and disorders in elite-level coaches (e.g., anxiety and depression).
Given mental health literacy has not been studied exclusively in elite-level coaches, research is needed to better understand coaches' beliefs and attitudes toward mental health and help-seeking.Mental health literacy levels could be examined using the Mental Health Literacy Survey. 89ture research should examine how elite-level coach's perceive psychological safety in their high-performance environments.The SPSI could be used as a measure to assess and benchmark psychological safety in coaching cohorts.
Since preliminary evidence indicates there may be an appetite for elite-level coaches to engage with psychological services, tailored referral pathways and mental health services should seek to optimize coachspecific support (e.g., how and with whom?) e6 are provided opportunities to recover within their role.It is also incumbent upon sports organizations to offer rehabilitative support after a coach departs from their role.From a sustainability perspective, offering psychological support to an individual even if they are no longer coaching, may potentially have lasting impacts in retaining these "bastions of leadership" within the high-performance environment.A mental health framework for elite-level coaches should subsequently address ways to support coaches beyond their tenure.

Table 1 .
Early Intervention Recommendations