High performance conundrum: mentally, not so healthy

If music was as popular as sport in the Australian media, we’d read and see dozens of articles about mental health problems among musicians, artists and dancers.

But the mental health of musicians is largely buried in the mainstream media, which favours smash, bang and crash to shimmer and vibrato.

So it was surprising to find the two – athletes and artists – side by side in a research article published at about the same time as athletes were preparing for this year’s World Athletics Championships and the Commonwealth Games.

And this story is exemplified for sports fanatics by high jumper Nicola McDermott, who filled out her green-bound diary after every jump in the 2020/21 Tokyo Olympics, where she won a silver medal. More on that later.

As we pass the major football codes’ finals season, and await the beginning of the spring-summer performing arts calendar, it’s worthwhile comparing the two and examining some further discussion about mental health.

Psychologist Dr Courtney Walton, McKenzie Postdoctoral Research Fellow at Orygen and The University of Melbourne, has been studying the mental health of elite athletes for many years.

In the 2021 paper he led – “Nurturing self-compassionate performers”, published in Australian Psychologist – Walton and his co-authors state: “Performers, such as athletes, actors, dancers, and musicians, function within high pressure competitive and often hostile or critical environments. These individuals can be prone to a range of self-critical cognitions and behaviours which may make them susceptible to mental ill-health and psychological distress.”

It takes a moment of reflection to compare the performance pressures on an elite 100-metre runner or 3000m steeplechaser, and the lead violin or bass player in a rock’n’roll band. But these comparisons are lost to our popular conversation, buried in a media that’s sometimes accused of being obsessed about sport.

Writing in the Journal of Science and Medicine in Sport in 2015, Amelia Gulliver reported on a survey of 224 elite athletes (118 female, 106 male) from national sporting organisations in Australia:  “Overall, 46.4% of athletes were experiencing symptoms of at least one of the mental health problems assessed.

“Percentages meeting criteria for mental disorders were similar to previous epidemiological studies of both international athlete and community samples: depression (27.2%), eating disorder (22.8%), general psychological distress (16.5%), social anxiety (14.7%), generalised anxiety disorder (7.1%), and panic disorder (4.5%).”

There’s been some research done in a similar way on elite artistic performers. Professor Bronwen Ackermann, a musicians’ health researcher at the University of Sydney, has an interest in performing arts health that grew as a result of working with the Sydney Symphony Orchestra from 1995.

In 2014, Ackermann wrote a report in Frontiers of Psychology called “Sound Practice-improving occupational health and safety for professional orchestral musicians in Australia”. The survey examined eight professional symphony orchestras in Australia (377 musicians in total) and revealed that 84% of those surveyed reported having playing-related musculoskeletal disorder episodes. Of the 63% who returned hearing surveys, 43% reported hearing loss.

Ackerman said: “Female musicians reported significantly more trait anxiety (state anxiety passes when the threat fades, trait anxiety is part of personality) and depression than male musicians. The youngest musicians were more anxious than their elders; 33% met the criteria for social phobia, 32% returned positive ‘depression screen’ and 22% for PTSD.”

In 2016 Psychology of Music report titled “Symptoms of anxiety and depression among Norwegian musicians”, the researchers found psychological distress was more prevalent among musicians than in their total workforce sample. “Solo/lead performers, vocalists, keyboard instrument players and musicians playing within the traditional music genre reported the highest prevalence,” they wrote.

Amy Visser from the School of Health and Human Sciences at Southern Cross University, Queensland, said in a scoping review June 2021: “Professional popular musicians [our emphasis] are at increased risk of psychological distress, substance use problems, and suicide, yet little evidence is available on effective psychotherapeutic practices to address these issues.”

“Given the prominence of fear of failure, individuals often rely on self-criticism as a key motivational relating style.”

Dr Courtney Walton

Visser, herself a musician, might want to talk to Walton, who says in his report: “Individuals whose livelihoods are characterised by participation in performances which are inherently associated with competition, pressure, and comparison, may be at increased risk of mental ill-health.”

“Recent figures in Australia highlight the concerning rates of mental ill-health that are seen among elite athletes. While less extensively researched, artistic performers also appear susceptible to experiencing mental ill-health at high rates with an overlap in potential stressors clearly evident.”

Athlete versus Artist

Walton cites data from the Australian Institute of Sport, which suggests that compared to published community norms, athletes were more likely to report “high to very high” psychological distress (9.5% vs 17.7%, respectively). They’re also well above average for meeting the threshold for needing treatment for a potential disorder (19% v 35%). Approximately 34% of current elite athletes were shown to be experiencing symptoms of depression or anxiety, higher than many estimates of the general community.

Walton’s work suggests why athletes and performers might experience higher rates of mental health issues: “Performers may demonstrate hyper-competitive and perfectionistic behaviours and standards, distorted and narrow views of self and identity as well as high self-criticism, all of which are potential contributors to worsened mental health.”

He continues, pointing out that within competitive sports and the performing arts, performances have very real consequences to individuals, including role selection, sponsorship, contract renewal, peer trust/approval, and so on.

“Performances that are insufficient are often met with significant criticism from external sources such as coaches and teachers, media, and critics. Further, setbacks, disappointments, and failures are all potential triggers to an individual engaging in their own hostile self-criticism.

“Performers are required to constantly improve, and the reality of these contexts is that triggers to self-criticism are constant and often inescapable. Given the prominence of fear of failure, individuals often rely on self-criticism as a key motivational relating style.”

In some settings such as dance and aesthetic or weight-dependent sports, factors such as body weight and image come into play, with individuals in these environments more sensitive to perceived demands on their body weight and shape. Other factors that are especially relevant include financial difficulty and job instability, social media or audience abuse, and exposure to significant injury.

Self-criticism – strength or weakness?

Elite sports and performing arts are environments in which self criticism is often seen as a strength – the abilities to tough it out, overcome emotions and ignore mental pain are highly regarded. In sport, being tough on yourself might be seen as a way to be tougher than your opponent. This is probably where sports and music divides: musicians rarely have an opponent.

On the other hand some athletes view self-compassion as a weakness, with one telling quote in Walton’s work: “Most people who are like that don’t go as far in sports because they’re too easy on themselves.”

So, is self-compassion an antidote for performer distress?

Walton says in his report that, “contrary to common misconception”, self-compassion is not simply accepting mediocrity, and may offer performers a way to encourage their efforts and pursue their goals in ways that are supportive, as opposed to being hostile and attacking.

“In the sports context, self-compassion may be considered by some to be the antithesis to mental toughness; however, other researchers have described how athletes actually see self-compassion as critical in the development of mental toughness, for if they did not use self-compassion, they would struggle to move past moments of adversity.”

A psychology intervention suggested by Walton enables the performer to “explore and possibly discover any fears or resistances they have towards self-compassion.

“One possible difficulty here is the environment in which the performer operates, with potentially contrasting voices from coach or teacher. Athletes for example, are known to engage with self-compassion more readily when it is normalised within the performing contexts by teammates.”

Of course, fear of self-compassion is more widespread than that.

“Absolutely, for whatever reason, many of us feel an intuitive recoil from the idea of providing compassion to ourselves,” Walton told Cosmos Weekly. “It’s typically something we’re not good at doing. Much of this stems from misunderstandings on what self-compassion really is.”

“However, we know from much of the literature that more resistance to compassion for ourselves is typically associated with worse mental health outcomes. We might assume that those in highly competitive contexts are particularly resistant to these ideas, though to this point research has not suggested this is clearly the case. In fact, many athletes can see the benefits of self-compassion for both health and performance.”

Walton says in his experience, individuals with blocks or resistance to being more self-compassionate can speak to this easily – often describing the ideas as feeling “yuck” or “wrong.” Walton says that many in this cohort reckon they don’t “deserve” the compassion. We can measure such resistance using the Fears of Compassion Scales.

Self-compassion may be considered by some to be the antithesis to mental toughness; however, other researchers have described how athletes actually see self-compassion as critical in the development of mental toughness.

Dr Courtney Walton

“It often takes some time to help individuals come to terms with what compassion is, so that we’re speaking the same language,” Walton says. “A helpful strategy, in response to resistance, is to identify compassionate and non-compassionate ways of responding to a loved one’s distress, and identifying which are perceived to be more or less helpful.

“My experience is that most people have a lot of wisdom when it comes to giving compassion to others – we just need to help them turn it inwards.”

The performing arts link is really fascinating … why isn’t there as much research into artists’ mental health?

“I’m not sure,” says Walton. “The performing arts are clearly a unique context with a range of risk and protective factors for mental health. Many of these overlap with sports, for example opportunities for abuse or harassment, concerns with body image and disordered eating, financial and role insecurity, injury, identity foreclosure, and early retirement… the list goes on.”

“Learning to engage self-compassion is likely helpful for a host of these. While some research certainly does exist, it’s unfortunately a long way from the large literature base in elite sport, for now. There is plenty left to do to understand how we can best support those who work within the performing arts.”

Given widely accepted perceptions of elite performers – that they’re somewhere on a scale between good egg and aggressive narcissist – was this research difficult?

“The hardest thing about doing this kind of research is reaching elite populations,” Walton says. “Elite athletes are a tricky group to conduct research with for a range of reasons. Their context and traits are often quite unique, and as such research with more recreational levels of sport may not be informative to make conclusions about those at the highest level.”

Was there an “aha” moment?

“I can recall my first aha moment during my Masters, [when I was] learning about self-compassion from Australian leader in the field, Dr James Kirby. When he described the role of social comparison and self-attacking on mental health in the general population, I knew this would be incredibly relevant to sport and performance. I’ve been lucky enough to collaborate with James on a few projects now and look forward to many more to come!”

Jumping barriers

So, what about Tokyo Olympics high-jumper Nicola McDermott (She married Rhys Olyslagers in April 2022 and now competes as Nicola Olyslagers). She’s still jumping well. She’s been writing notes about her feelings in her journal after every jump. Exhibiting, quite literally, self-compassion.

But the final word must go to the under-reported musicians.

In the home of country music in Nashville, Tennesee, a research team from the Vanderbilt University School of Medicine, Nashville, surveyed health problems of more than 14,000 musicians whose details were on the Electronic Health Record (EHR) database.

The team conducted the first and largest study to date to identify the medical diagnoses associated with musician patients in an EHR context.

It replicated previous associations of musician status with medical problems and, counter-intuitively, identified a number of protective effects by observing diagnoses such as cardiovascular disease, respiratory failure, and renal failure. These, the study found, were less common in musicians than in controls, in line with literature indicating that active musical engagement has similar health benefits to athletic engagement.

Which is worth a round of applause on its own.