Family Problems and Sports Performance
The Role of Couple's Therapy in Treating Athletes and Their Families
Eva C. Ritvo, MD; Ira D. Glick, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 9 - SEPTEMBER 2021
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In Brief: The incidence of psychiatric disorders and family problems in elite athletes is probably similar to that of the general population, yet, for a variety of reasons, athletes and their families rarely seek treatment. Athletic performance may be affected by problems in a marriage or home life, as in this case of a high-profile athlete whose wife abused medications and alcohol to cope with a depressive disorder and anxiety. Clinicians who treat athletes should be aware of family dynamics that may affect performance and be willing to suggest interventions, such as individual and marital psychotherapy, medication, or both.
Hardly a day passes without a media report of an athlete in trouble. The "trouble" is often connected to family problems such as spouse abuse, infidelity, substance abuse (including public intoxication), or chemical dependence. The stress of family problems (broadly defined and including "significant others") can affect the athlete's mental health and athletic performance. In general, the greater the problems and dysfunction at home, the greater the likelihood that athletic performance will be adversely affected. The reverse may also be true—a supportive home life may enhance athletic performance.
The literature "suggests that athletes, in general, show better emotional health compared with nonathletes, and the same is true for elite athletes. In that context, changes in mental health over time have also been associated with enhanced or impaired performance."1
Physicians need to take unique treatment approaches (ie, combining medication, individual psychotherapy, and couple's therapy) to improve couple and family interpersonal relationships in difficult situations. Although other examples may be found in clinical practice, we report one of the very few cases reported in the sports medicine literature. The stigma of psychiatric treatment among elite athletes means that very few regularly see a psychiatrist during their careers. Confidentiality issues, the paucity of sport psychiatrists, and the limited use of combination therapy (especially medication in addition to psychotherapy) are also factors that affect the low number of case reports.
Mrs B is a 32-year-old woman, married to a high-profile 31-year-old professional athlete. She was referred to us by her former psychiatrist. At the initial consultation, Mrs B was extremely anxious and a poor historian.
During the first several sessions, we learned that in the last few years Mrs B had experienced multiple stressors, including the death of a sibling. She subsequently developed an episode of major depressive disorder. She was seen by another psychiatrist for approximately 1 year and treated with a variety of antidepressants at adequate doses but for short periods only. Treatment ended because the psychiatrist found her husband "too intrusive" and the patient noncompliant.
At the onset of treatment, the patient reported the following:
•She felt "anxious" throughout the day but did not have panic attacks. The patient felt trapped in a high-profile marriage and unable to cope with the public pressures. She avoided public appearances and used alprazolam to "get through it."
•She was unsatisfied with her role as wife and mother. She felt "confined" in these roles and complained that she was losing out on her "ability to be herself." Her husband has two children from a previous marriage, and they also have one child together.
•She was obsessed with jealousy. Her husband attracted substantial attention from women at clubs, restaurants, and games. She questioned him about his level of involvement with them, and she suspected that he was having extramarital relations. She checked his phone and insisted on attending events with him to keep an eye on his activities, despite her mild social anxiety.
She was taking 40 mg of paroxetine hydrochloride daily and 1 mg of alprazolam three to four times a day. In addition, she reported chronic insomnia and was using zolpidem tartrate 20 mg at bedtime. She admitted to consuming four to six drinks of mixed alcohol an evening, once or twice a week, in social settings to "relax and have fun."
Psychiatric and family history. Three years ago, in the context of her sister's death, the patient was diagnosed as having major depressive disorder, but no history of mania or hypomania was noted. The depression resolved in the 6 months following treatment with psychotherapy combined with paroxetine and alprazolam. She denied any history of suicidal thoughts or intent. No history of violence in the couple's interactions was noted, but she reported that, on occasion, her husband became very angry with her and yelled. She did not feel he would harm her physically. Mrs B's mother has severe insomnia, but the patient did not report any other family illnesses.
Developmental history. She described a "happy" early childhood. She was born in Europe to an American mother and a French father. At age 11, her life abruptly changed when her parents divorced. Her father remarried and has had little contact with her or the family. Prior to his departure, she was "Daddy's little girl." When he left, the family's financial status changed, and her mother was required to work. The family relocated to the United States to be close to extended family. The patient would come home after school and take care of her sister until her mother returned from work.
The patient remembers having lots of friends and being very social as a child. In high school, she was a "good girl" and did not drink or take drugs. She briefly attended community college but dropped out to work in an office. She had a boyfriend in high school and became sexually active at age 17. She had three long relationships and then met her husband at age 27. After a year of dating, she moved in with him, and they married after another year. His two children remained with their mother most of the time. He desired another child and she became pregnant. She reports increasing conflict in the marriage after the birth of their daughter. Her husband had expectations of her staying home with the child, and the patient felt overburdened by the responsibility.
Mental status exam. At the first interview, she was an attractive, well-groomed woman who spoke rapidly with a mild accent. Her mood was currently "good," but she reported a history of severe, sustained bouts of lowered mood episodes that lasted 2 to 3 months, once or twice a year. She appeared anxious and reported feelings of chronic anxiety. She was dramatic in her presentation. Her thoughts were logical and goal directed. No cognitive deficits or psychotic symptoms were found, and her sensorium was clear. She was not suicidal and had no thoughts of violence. Her thought content was centered on blaming her athlete-husband for some of her problems and symptoms.
Diagnosis. Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),2 the patient was diagnosed as having major depressive disorder (in remission), generalized anxiety disorder, mixed substance abuse (ie, alcohol, zolpidem, and alprazolam), chronic insomnia, and relational disorder.
The spouse-athlete accompanied his wife and was interviewed during several office visits. Although he had no psychiatric illness, he was diagnosed as having occupational disorder (ie, the focus of clinical attention is an interpersonal problem that interferes with work). Both parties had relational disorder (ie, interpersonal problems that interfere with their particular system and functioning as a unit).
Initial treatment for Mrs B consisted of individual psychotherapy, detoxification, and medication. The patient's anxiety, irritability, and jealousy were quite troublesome to her spouse. Couple's therapy was prescribed with weekly 1-hour sessions for both of them, and the patient was surprised that the athlete participated in sessions when he was in town and available. During these sessions, interpersonal issues were discussed and possible solutions were suggested.3 Marital system issues were addressed to rework how they related to each other and to make the system more balanced, equitable, and respectful. Individual treatment with a colleague was also recommended for him so he could address his "anger issues" and marital difficulties, but he refused. The therapist was in frequent telephone contact with the athlete to follow the progress of his wife's substance abuse treatment.
For Mrs B the marital issues addressed in therapy included her role as wife, her role as mother and stepmother, her role as a public figure, the stress of separations when her husband was out of town and her fear of abandonment, financial issues (ie, sudden wealth syndrome), jealousy—real and imagined—her sexual functioning (which had been impaired by medication), plans for additional children, and time with friends and family. Individual issues addressed included her loss of a sibling through death and the loss of her father through abandonment, relationships with her family of origin, substance abuse, self-esteem, resuming employment outside the home, medications, and her lack of sexual desire.
The patient and her husband were seen over the course of 4 years. The first year was extremely difficult as Mrs B reluctantly began to accept that she was abusing substances. The patient and her doctor worked together to taper the alprazolam, zolpidem, and alcohol use. Her doctor tried changing the prescribed antidepressant to increase her sex drive, but she felt only minimal improvement. Trazodone hydrochloride was added for sleep. Other pharmacotherapies were tried with limited success.
During the first year of treatment, it became clear that the husband-athlete was the primary caretaker for both his wife and their child. Mrs B's anxiety, substance abuse, and depression drained a considerable amount of his time and energy. When he would leave town to play in scheduled games or be gone for long days at practice, her condition would worsen as she became more anxious, stayed in the house more, and increased her use of alprazolam and zolpidem. She would repeatedly telephone him when he was away. When she was more symptomatic, he would be distracted during practices, and he reported that his performance deteriorated. He would then become angry with her, withdraw, and, at times, threaten divorce.
Over time, as her condition improved, he was able to travel and attend to his professional responsibilities with less distraction. He reported that his sports performance improved and their marital satisfaction increased, because he no longer saw her as a detriment to his professional success. His anger subsided, and this further increased her level of marital satisfaction. As she grew more secure in the relationship, her sex drive increased, and they both reported that their sex life improved.
The last 2 years of her treatment focused on increasing her coping skills and rebuilding a life for herself outside of his sports career. Her substance abuse stopped. As their child grew older and entered school, she was better able to handle her role as a mother and become a more effective parent. Her husband continued to desire another child, and marital therapy was restarted for several months to help him accept her desire not to have any more children. Subsequently, she was seen for individual treatment, and he participated on occasion as needed.
Comprehensive treatment that combines medications, individual therapy, and family therapy may improve quality of life for patients, their marriages, and their families. If the spouses are athletes, their athletic performance may improve as they are able to dedicate more attention and energy to their sport and less to caretaking. As such, we wish to emphasize the importance and the benefits of comprehensive treatment for mental disorders, not just for athletes but for their families as well.
Our patient's course of treatment involved both psychotherapy and medications, targeted to each of her axis 1 disorders (table 1). The athlete required supportive psychotherapy as well. Underlying the multimodal treatment regimen was ongoing, repetitive psychoeducation that served as the glue to keep the patient and her spouse in treatment (ie, improved compliance) by helping them understand the symptoms and diagnosis, as well as the treatment required for both of them.
Our review of the literature found no case reports on elite athletes and limited mention of this type of problem or current treatment options. Begel,4 in his classic overview article, noted that a family-systems perspective has been applied in some clinical situations. Baum5 discussed a variety of issues in her article on sport psychiatry and mentions family therapy as being a useful treatment, but provides no examples. Glick and Marcotte,6 in an article focused on psychiatric aspects of basketball, included a detailed section on family processes as they affect performance and vice versa. Glick and Horsfall1 have a detailed section on discussing the treatment of the family and significant others. Likewise, Kamm7 described evaluating the family, implying that understanding the family would be useful in understanding athletic performance.
Hellstedt8 has written a very comprehensive report of family-based treatment of the athletic family. That review focuses exclusively on the family unit—not the athlete—and does not cover athletes who have family members with axis 1 disorders. In this context, one of us (IDG) has recently summarized the data on the added benefits of adding psychotherapy to medication for certain psychiatric disorders.9
Obviously, a single case cannot be the basis for a guideline or algorithm. However, solid evidence in the scientific literature suggests that adding psychotherapy to medication improves outcome over medication alone for some disorders.9,10 An axis 1 disorder in an athlete's spouse or immediate significant other is not a rare occurrence in our experience. As such, we suggest that combined therapy may not only be necessary, but should be mandatory in some clinical situations. For example, the presence of individual psychopathology, couple's disorder issues, and substance abuse in one or both partners usually requires medication plus individual and marital psychotherapeutic intervention and rehabilitation (eg, Alcoholics Anonymous, Narcotics Anonymous).
We must mention a number of caveats. First, the improvement in the husband's athletic performance may have occurred independent of treatment. Second, it is not at all clear which part of the treatment equation was most crucial. We argue that each modality was necessary but would have been insufficient by itself. Third, it is possible that if the spouse-athlete were more motivated to participate in marital therapy, the wife may not have needed the other modalities. Likewise, if the wife's response to medication had been more robust, and she had been more compliant with initial treatment, she may not have used alcohol and sedative hypnotics to cope, and perhaps her husband's performance would not have declined. It is our impression that individual therapy alone or marital therapy alone would have been inadequate to treat the multisystem problems that were present. Lastly, it is possible, but unlikely, that without treatment Mrs B's illnesses, disorders, and marital problems would have improved on their own over time.
Athletes and their families are involved in many complex interpersonal issues. Family issues may affect athletic performance; therefore, when a problem arises, it is necessary to treat both the athlete and the spouse or partner and other important family members. In this case, both individual therapy and couple's therapy alone were not sufficient, nor was medication alone, although we now have effective medications for many axis 1 disorders. Combined treatment for both mood and anxiety disorders and including the significant other are part of a successful treatment plan. A more controlled series or more case reports are needed to provide data to guide treatment decisions.
Dr Ritvo is an associate professor in the Department of Psychiatry and Behavioral Science at the University of Miami School of Medicine in Miami Beach, Florida. Dr Glick is a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California. Address correspondence to Ira D. Glick, MD, 401 Quarry Rd, Suite 2122, Stanford, CA 94305; send e-mail to [email protected].
Disclosure information: Drs Ritvo and Glick disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.