Behind the mask: demedicalising race and mental health in professional football
Authors: Michael Bennett
Journal: The Lancet Psychiatry (2020)

The deaths of Gary Speed and Dalian Atkinson, both professional footballers, have raised concerns about mental health in professional football, a sport with which I have been involved all my life, first as a professional player (for Charlton Athletic and England Youth) and later as a counsellor and researcher in my role as Director of Welfare at the Professional Footballers Association of England and Wales (PFA). Football continues to treat mental health as an area of both stigma and taboo, and, despite the growing emergence of women in the game, male domination of the sport is reflected in the prevalence of masculine codes of deflection. In addition to toxic masculinity serving as a barrier to open discussion about mental health, the sport's silence on the role that racism plays in poor mental health of footballers also hinders progress. High-profile campaigns (including Heads Up and their partnership with the Football Association, and Mind's partnership with the English Football League) have helped to spotlight mental health issues. Carmondy and colleagues1Carmody S Murray A Borodina M Gouttebarge V Massey A When can professional sport recommence safely during the COVID-19 pandemic? Risk assessment and factors to consider.Br J Sports Med. 2020; 54: 16Crossref Scopus (82) Google Scholar suggest that 16% of a sample of 1034 male players reported symptoms of depression during the COVID-19 period, but with no reference to racism. Similarly, Rice and colleagues2Rice SM Purcell R De Silva S Mawren D McGorry PD Parker AG The mental health of elite athletes: a narrative systematic review.Sports Med. 2016; 46: 1333-1353Crossref PubMed Scopus (606) Google Scholar found more than 2279 global studies in mental health in sport that focus on stress, self-esteem, and depression, but again without any attention to racism as a causal factor. The lack of analysis of racism is primarily because these studies are mostly quantitative, and are profoundly incurious about the diversity and lived experiences of professional footballers. As a consequence, players are falling victim to a biological, symptom-based approach that is largely ignorant of the crucial structural factors underpinning players' mental health issues, particularly for Black players, who make up 30% of professional footballers in England and Wales. Current constructs of mental health do not look at the social factors that shape the experiences of Black men inside the structures of professional football. The dominant biomedical model neglects the person-centred approach that focuses on people's lived experience. Such an approach is crucial to demedicalise mental health in sport, to empower Black professional footballers, and to use their interpretative, authentic, first-person voices as the basis for a transcultural model to mental health. Together with colleagues, Brownrigg,3Brownrigg A Burr V Bridger A Locke A 'You shut up and go along with it': an interpretative phenomenological study of former professional footballers' experiences of addiction.Qual Res Sport Exerc Health. 2017; 10: 238-255Crossref Scopus (9) Google Scholar an ex-professional footballer, has used an interpretative, phenomenological, analytical method to explore the unmedicalised voices of professional footballers. This approach is a challenge to the sports psychiatry model that tends to deny complex transcultural issues facing Black players, using instead an oversimplified, categorical, symptom-driven, diagnostic approach.4McCabe T Mintry AD Case studies in sports psychiatry. Cambridge University Press, Cambridge2020Google Scholar From three PFA wellbeing conferences in 2017–19, it was apparent that the voices of professional players and the complexity of their experience were being oversimplified and medicalised. For Black players, this is a loss of a recognised cultural reality: an Afrocentric reality. Thus, as suggested by Fernando,5Fernando S Institutional racism in psychology and clinical psychology: race matters in mental health. Palgrave Macmillian, London2017Crossref Google Scholar professional football has become another area in which mental health has been made into a scientific measure of the need to assimilate into westernised spaces. The danger is that the lived world of Black professional footballers is made captive to medical forms of diagnostic categorisations and is hidden behind what could be called, adapting Fanon's6Fanon F Black skin, white mask. Pluto Press, London1967Google Scholar metaphor, a sports medicalised mask. Consequently, Black professional footballers find themselves obliged to communicate their needs through medical conditions whose definitions were developed outside of their heritage. Mental health in professional football is associated with the currency of a physical injury; the focus is on function and fitness to play, not holistic wellbeing. The effect of this medicalised model denies the reality of the lived experience of racism in professional football, as expressed by crowds at games and on social media. For Rhoden7Rhoden WC Forty million dollar slaves: the rise, fall, and redemption of the Black athlete. Broadway Books, New York City2010Google Scholar, this situation is tantamount to a new form of mental slavery in the sport. There is growing evidence of the detrimental outcomes of this approach. King,8King C Offside racism: playing the white man. Berg, London2004Google Scholar who heads the Black and Asian Football Coaches Association, reveals being diagnosed with schizophrenia following physical abuse from a white coach. There are parallels, too, with the racialised gender silencing described by Powell,9Powell H Hope: my life in football. Bloomsbury Sport, London2016Google Scholar in which Black women are stereotyped as aggressive, "uppity," and less collaborative than their white female counterparts, and need a platform to share their lived worlds of racism and sexism. Understanding the lived experience of Black players is essential not only to inform a theory of racism, sport, and mental health, but also as a basis for developing more effective interventions. We have started to do this in the PFA, employing a person-centred, transcultural model that builds on the first-person, lived experience of professional players. This approach leads, in turn, to the construction of novel strategies for players' mental health, which are especially important during the ongoing COVID-19 pandemic. A holistic and culturally relevant strategy is the basis of best practice not just in sport, but in any area of mental health care. In conjunction, the issue of racism in sport is gaining increasing prominence in the light of the Black Lives Matter movement. Our emerging mental health intervention strategies in the PFA aims to focus on more effective player-centred practices, in which mental health is defined from players' lived experience. This is an exciting prospect. If we can get it right in football, maybe we can get it right in other areas of sport; and if we can get it right there, maybe we can get it right in society as a whole. I declare no competing interests. The views expressed in this Comment are not necessarily those of the PFA.