Psychosocial factors impacting performance health

Whilst we may have previously considered the brain and body and separate entities, it is no longer viable to do so; the research is now clear that the brain plays an important role in moderating risk factors associated with injury and illness, and, from a performance standpoint, it is often psychological factors that most differentiate the performance of elite athletes on competition day.

Research also continues to help us understand mental illness and altered mental health states in elite athletes. Just as we wouldn’t expect an athlete to perform at their best if they had the flu or a torn hamstring, we can’t expect them to optimally perform if their mental health is not supported, even though, in some cases, the symptoms are less visible and obvious.

In this article, I explore the role psychological and psychosocial factors play in injury and training response, and touch on common mental health issues in athletes.

» Learn more: This article is part of Craig Pickering’s Performance Health Series. Part 1 discussed the concept of performance health, part 2 reviewed leading injury models, part 3 explains load and load measurement, part 4 looked at immune function and support, and part 5 looked at nutrition and energy intake.

Psychosocial factors and sports injury

As discussed in the article on injury models, there is a well-established model, updated over the years, which supports the idea that psychosocial factors, and the athletes interpretation and response to those factors, influence the risk of injury. A recent meta-analysis, for example, reported that stress responses was associated with injury rate, with weaker relationships existing between a history of stressors and coping ability.

The proposed explanation here is that stress, particularly prolonged stress, may alter the function of a variety of networks in the brain, altering internal communication of information, reducing affect and cognitive abilities. The knock-on effect to sport is that the athlete has a reduced capacity to accurately calculate the risk of various movements (e.g. a tackle in rugby), which exposes them to a greater number of situations in which the risk of injury is increased.

The ability to respond more favorably to stress, and become more resilient, can be developed in athletes—and this may have important implications when it comes to reducing the risk of injury. Returning to the meta-analysis mentioned earlier, the overall effect size of psychosocial-based interventions aimed at reducing injury risk was -0.63, which indicates that they have a medium overall effect in the reduction of injury risk. The interventions used in these studies include mindfulness, psychological skills training, and cognitive behavioral therapy, suggesting that a variety of methods may be effective—and supporting the use of these interventions in athletes who appear to have high levels of stress—either acutely (e.g. important competition, life transition) or historically (e.g. history of abuse of trauma)—and an increased response to those stressors.

Psychosocial factors and the response to load

The effects of psychosocial extends well beyond injuries. Most importantly, it has a huge impact on how we adapt to training. Research is starting to give us a much clearer understanding on the relationship between psychosocial factors and the response to training load. For example, in a cohort of 135 undergraduate students who underwent a 12-week resistance training program, participants who reported lower levels of stress had significantly greater improvements in both bench press and back squat 1RM improvements than those in the high stress group. Similar results have been reported in terms of aerobic fitness improvements following training. Building on this further, negative life events have been shown to negatively influence performance (in this case, running economy) and recovery in athletes, and also increase the risk of developing overtraining syndrome.

Mental health and wellbeing in athletes

Elite athletes are also normal people, and, as research suggests, are generally as susceptible to mental health issues and illnesses as the general population. As you might expect, there are periods within an athlete’s career where sporting-specific factors may acutely increase their risk of experiencing a mental health crisis, including poor performance at an important competition, de- or non-selection, injury, and retirement. Athletes may not seek help for their mental health issues due to the stigmas associated with such a crisis, as well as the fact that sports stars are supposed to be tough and resilient, and, especially in team sports, there is often a “macho” factor. Closely linked to the article on nutrition and RED-S, eating disorders, disordered eating, and body dysmorphia are potentially higher in athletes, particularly in aesthetic and weight-dependent sports, although not all studies support this increased prevalence.

Like any health issue, mental health issues increase the chances of the athlete missing their performance goal, and so mental health optimization and well-being is an important part of athlete performance management. A large part of this comes with reducing the stigma associated with mental health—and, with more sports stars, both past-and present, opening up about this, we’re moving in the right direction—as well as a breaking down of barriers, real or perceived, that get in the way of athletes seeking help. As a coach, it’s important to create an environment free from stigma, and for governing bodies to support coaches and athletes in optimizing their mental health.

A recent paper, published in Sports Medicine – Open, provides a framework for supporting elite athlete mental health. At the bottom of the pyramid is the foundation of preventative measures, comprised of (a) enhanced mental health literacy, (b) focus on holistic athlete development, including non-sporting career and personal development goals, and (c) mental health screening of athletes. Following on from this initial broad base, more specific and specialist care is required for athletes with a mental health issue, which should be supported and managed by experts in this field.

Quantifying athlete stress and mental wellbeing

Given how important athlete mental health and wellbeing is, including the acute psychological response to a stressor, there is clear scope and importance for coaches in being able to better understand the current status of their athletes in regards to these factors. As always, there is the option for a low-tech approach; regular, non-threatening conversations with your athletes to better understand their life loads away from the track, as well as gaining insight into their feelings towards any major upcoming events or competitions. This only works if your athletes can be honest with you, and so being approachable is important here, and it’s only worth doing if you use the information you receive to actually make changes!

For a more moderate-tech approach, there are a number of questionnaires that have demonstrated reliability and validity when it comes to quantifying the current stress status of an athlete. Perhaps the most useful of these is The Acute Recovery and Stress Scale (ARSS), a survey allowing you to better understand both the recovery and stress status of your athlete – killing two birds with one stone. Other potential tools include the Life Events Survey for Collegiate Athletes and the Recovery Stress Questionnaire for Athletes.


Based on the research explored in this article, it’s clear that:

  1. Increased psychosocial stress can increase the risk of both injury and illness in athletes.
  2. Increased psychosocial stress can blunt the expected training adaptations from a training intervention, and negatively influence post-exercise recovery.
  3. Mental health status and illness can also have a substantial influence on athlete wellbeing and performance, with rates of mental health issues at least as common, and in some cases more common, in elite athletes when compared to the general public.

As such, as a coach it is important to consider, and perhaps quantify, the psychosocial state of your athletes, and use this information to inform decisions around training load. Furthermore, the development and cultivation of positive psychological traits, such as resilience, and improving the stress management techniques of your athletes should place your athletes in a better position to thrive in terms of performance. Whilst often under-considered in favor of physiological load, psychosocial load (and stress) is a crucial part of the jigsaw for coaches to consider when it comes to keeping their athletes’ injury-free and performing at their best.