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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 33-41

Understanding mental health in malaysian elite sports: a qualitative approach


Sport Psychology Center, National Sports Institute, Malaysia China Olympic Committee, China

Date of Web Publication14-Oct-2021

Correspondence Address:
Philip Lew Chun Foong
Sport Psychology Center, National Sports Institute, Malaysia China Olympic Committee
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-9409.328215

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  Abstract 

The attention in the society and rapid expansion of interest on the status and challenges of mental health among sporting athletes, especially in the elite sports setting, had increased exponentially. The present study was aimed to explore and gain a better understanding of mental health and psychological well-being of Malaysian elite athletes. It also provides insights into a broader aspect based on participants' personal experiences. A semi-structured interview was conducted for all 32 athletes (male, n = 16; female, n = 16) from a variety of sport: individual, team-sports; able-bodied, and Paralympic. Participants were aged between 19-38 years old (mean 25.69 years) from various ethnicity and religions. Six (6) themes (Personal understanding on mental health; Stigma of mental health; Symptoms, effects and sources of mental health; Coping strategies; Mental health and well-being support; Advice of athletes) and 19 subthemes were derived based on qualitative thematic analysis. Based on the analysis, subthemes, i.e. Presentation in mass media; Transition; Personal life-related issues; Performance expectation; Sporting environment are significant stressors causing mental health issues. The influence of spirituality and religion on the topic of mental health was also being highlighted. In conclusion, it is hopeful that the present study will stimulate interest and discussion in identifying methods and direction for both researchers and practitioners in bridging the theoretical-applied gap and offer effective supports to Malaysian athletes.

Keywords: Well-being, mental health, qualitative, elite sports, Malaysia


How to cite this article:
Foong PL, Sook Kwan RW. Understanding mental health in malaysian elite sports: a qualitative approach. Malays J Mov Health Exerc 2021;10:33-41

How to cite this URL:
Foong PL, Sook Kwan RW. Understanding mental health in malaysian elite sports: a qualitative approach. Malays J Mov Health Exerc [serial online] 2021 [cited 2021 Oct 25];10:33-41. Available from: http://www.mohejournal.org/text.asp?2021/10/1/33/328215

Submitted: 30-Oct-2020
Accepted: 20-Nov-2020
Published: 15-Jan-2021
Republished: 14-Oct-2021



  Introduction Top


There has been an increase of attention in the society and rapid expansion of interest on the status and challenges of sports athletes' mental health, with the publication of numerous consensus statement documents of the European Federation of Sport Psychology (FEPSAC; Moesch et al., 2018), International Olympic Committee (IOC; Reardon et al., 2019) and British Association of Sport and Exercise Sciences (BASES; Gorczynski et al., 2019). The outcome of the Annual International Think Tank organised by the International Society of Sport Psychology (ISSP) in Odense, Denmark on the 20-21 September 2018 and the consultation meeting of experts conducted in the European College of Sport Science Congress (ECSS) in Dublin, Ireland on 4th of July 2018 and the British Psychological Society's (BPS) Division of Sport and Exercise Psychology (DSEP) Annual Conference on 4 December 2018 in Belfast, Northern Ireland had established two consensus documents, that were published in the International Journal of Sport and Exercise Psychology (IJSEP; Henriksen et al., 2019) and BMJ Open Sport and Exercise Medicine (Breslin et al., 2019).

Definition of Mental Health

Mental health is defined as “a state of successful performance or mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity” (US Department of Health & Human Services, 1999, p. 4). It is also being highlighted by the World Health Organization (WHO), that mental health is “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014).

Mental Health in Malaysia

The 1996 National Health ad Morbidity Survey (NHMS) has estimated an increase in mental health prevalence among adults in Malaysia, pointing to the potential beginnings of a public health crisis. According to the 2015 NHMS, it was reported that the prevalence of mental health issues has increased nearly 3-fold, from 10.7% in 1996 to 29.2% in 2015. As the 2017 NHMS targeted the adolescent population in Malaysia, it was highlighted that one in five youths felt depressed, 10.5% had suicidal ideation, and 6.68% had attempted suicide. However, there is no data shown on athletes' mental health thus far.

Psychological Demands in Sport

Pressures are unavoidable for the Olympic, elite and professional athletes due to increasing competitiveness at the international stage. High physical and performance demands present potential threats to athlete mental health. Olympic stressors included the stressors that mental performance consultants have observed athletes and/or teams encountering before, during, and after an Olympic Games. Those stressors include competition selection, performance expectations, long-term or repeated injuries, first Olympic Games, distractions, coach-athlete relationships, goal and motivation, as well as planning for the future or retirement (Arnold and Sarkar, 2015, Rice et al., 2016). A previous study has demonstrated significant levels of mental health issues among athlete populations in the UK revealing 47.8% of the 143 elite athletes met the cut-off for signs of anxiety/depression and 26.8% met the cut-off for signs of distress (Foskett and Longstaff, 2018).

Stress research shows that stress is an important contributor to depression and anxiety (Richards et al., 2016). Despite the fact that stress is the body's natural reaction to any kind of demand or threat when experienced at high levels, or over-amplified periods of time, it adversely influences mood, causes irritability, disrupts sleep patterns and affecting concentration. Just as physical training must be balanced with adequate recuperation to see progress, mental demands too must be emphasised with strategies to support psychological well-being. The limited research on mental health in sport has offered some insights into the challenges faced by athletes whilst also the consequences for, and on, mental health and well-being (Gulliver, Griffiths, Mackinnon, Batterham, & Stanimirovic, 2015; Hughes & Leavey, 2012; Rice et al., 2016). Research in Malaysia has shown that stressors such as problems at work, unhappy family relationships, and financial problems relate to depression (Rusli, Edimansyahm, and Naing, 2008; Kader Maideen, Mohd Sifik, Rampal, and Mukhtar, 2014). However, none of the above research focused on athlete populations.

Socio-demographic Factors of Mental Health in Malaysia

Previous studies conducted in Malaysia (Kader Maideen et al., 2014; Kaur et al., 2014; Rashid & Tahir, 2015; Tan & Yadav, 2015) have shown socio-demographical differences in mental health prevalence. For example, the number of mental health issues increased with age (Rashid & Tahir, 2015) but Tan &Tadav (2015) shown an opposite trend where younger age groups showed more risks. Different studies have shown either Chinese or Indian ethnics were more prone to developing mental health issues (Kader Maideen et al., 2014; Yusoff et al., 2014). Marital status and education level also played a role in determining the risk of getting mental health issues as according to Kader Maideen et al. (2015) and Rashid & Tahir (2014). However, findings from these studies are non-specific to sport samples, and it is difficult to interpret given that the above-researched samples were limited in terms of age group and geographical areas.


  Objectives Top


To date, there have been no reviews or research studies on the mental health and psychological well-being of athletes of any level (i.e. youth, elite) in Malaysia. The objective of this publication was (1) to gain a better understanding of the mental health and well-being experienced by the participants, (2) to provide some insight into the causes of mental health and well-being issues among the participants for a deeper understanding of their experiences.


  Methodology Top


Participants

A qualitative approach was being selected to provide a valuable platform in exploring the mental health epistemology and concept that are relevance in Malaysian elite sports setting. As this is a unique experience, the current study was designed to be descriptive and exploratory. In-depth semi-structured interviews were conducted with Malaysian athletes (N = 32; male, n = 16; female, n = 16), the mean age of 25.69 years (range 19-38 years), who are competing or formerly competed in elite-level from different types of sport: team-based and individual-based sports of para-sport and able-bodied events. The specific sport types are not named to protect the identity of the participants. As Malaysia is a multicultural society, the participants consisted of individuals from a variety of races (i.e. Malay, Chinese, Indian, indigenous) and religions (i.e. Muslim, Buddhist, Christianity, Hinduism, Others).

Interview Guidelines

The complete semi-structured interview guide for the first study was designed by the first author, which consisted of seven aspects: (a) the participant's understanding of the term 'mental health'; (b) the participant's opinion and/or experiences of the stigma of mental health; (c) the experiences of the participant in relation to mental health-related issues (e.g. have you experienced any mental health issues, in your life, training, during competitive career, or post-career); (d) identification of the symptoms and effects of mental health issues on the participant's well-being and athletic performance; (e) the sources of mental health issues; (f) coping strategies that were administered by the participant; and (g) participant's advice to the athletes who are experiencing mental health issues.

Procedure

Each participant was contacted by e-mail and provided information pertaining to the objectives of the study. Specifically, they were being informed that the study emphasised on exploring their experiences and understanding of mental health-related issues. All the participants in this study volunteered to provide their subjective experiences and opinions on the objective of the study. Each of the participants was provided with informed consent forms that outlined the purpose of the study and ensured their confidentiality and demographic data was being collected. Informed consent was obtained from all the participants, with data processed anonymously. Ethical approval was not sought as these interviews were comparable to those they would routinely provide as part of their official duties as national athletes (Winter &Maughan, 2009). Each participant took part in a semi-structured qualitative interview at a venue and time convenient to them. The interview was moderated with the semi-structured interview guide, and participants were encouraged to express themselves freely (Patton, 2002) to stimulate discussion and obtain the relevant information on the topic. Furthermore, in enabling participants to relay their personal and experiential insight, the interviewer stayed with the responses provided by the participants and follow-up questions, related to psychosocial considerations and clarification on specific statements mentioned, was asked to deepen the understanding of their experiences (Kvale & Brinkmann, 2009). The interviews lasted for a mean of 39 minutes. All the interviews, which occurred face to face, were digitally recorded and transcribed verbatim producing 285 double-spaced pages of data.

Data Analysis

Qualitative rigour was addressed by interviewing Malaysian athletes from a wide range of sporting experiences, types of sports, race, and religion, which provided in-depth raw data that was used to generate the result (Patton, 2002). The data were analysed inductively through the 6-step approach of thematic analysis outlined by Braun and Clark (2006, 2012), to identify and group units of meaning related to the themes relevant to the experience and context of mental health in Malaysian sport. The interview transcripts were repeatedly read to familiarise with the content and becoming immersed in the data (phase 1). After familiarising with the key messages, initial codes were created upon comparison of their perspectives and views on the meaning of the data (phase 2). Patterns of meaning within each interview transcript were examined, identified, sorted and grouped together to develop themes (phase 3). The developed themes were further reviewed and revised. A discussion was made on the possibilities of discarding existing themes or establishing additional themes (phase 4). Both authors provided input to review themes numerous times prior to agreeing on the final themes. The themes were organised into descriptive categories and allocated names that defined the content (phase 5). Finally, a report of the thematic analysis was produced (phase 6). To ensure the findings covered the range of all the athletes' experiences in a meaningful way, an iterative process was conducted throughout data analysis, where, during any phase, themes generated from the data were revisited and re-examined, to ensure better understanding and better fit of the results presented (Srivastava & Hopwood, 2009). To enhance trustworthiness, each participant was presented with a copy of their transcript verbatim and provided the opportunity to clarify, reflect, and elaborate on the information that they had mentioned during the interview (Patton, 2002).


  Results Top


A narrative analysis of the interview transcripts resulted in a final thematic structure (see [Table 1]) consisting of six major themes that reflected on the participants' experience in mental health issues. These were: personal understanding of mental health, the stigma of mental health, symptoms, effects, & sources of mental health, coping strategies, mental health & well-being support, and advice of athletes.
Table 1: Major and Sub Themes of Participants' Experiences in Mental Health Issues

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Personal Understanding on Mental Health

This theme captures the literacy of mental health among the participants.

“Whenever I heard about 'mental health', despite knowing the exact definition for the term, I have a tendency of linking it to crazy and insanity.”

A number of the participants did mention that they tend to associate the term “mental health” with negative thoughts, mental illness, and mental disorders. 25% of the participants (n = 8) commented that mental health is an absence of mental disorders (e.g. depression, eating disorders). 75% of the participants (n = 24) highlighted that it is a state of well-being of an individual in being productive and coping with challenges in his or her life.

“Mental health is a normal experience of life, experiencing mood and emotion.”

Majority reflected that they have a better understanding of the term, due to the effort of the sport psychology practitioners in providing insight during psycho-education sessions and effort of government agencies through the dissemination of information through media.

“Through regular discussions and information sharing with our sport psychologist, the athletes, including me, understand better regarding mental health and its impact on our life and performance.”

“The topic of Mental Health is once a taboo, people just keep it silent. They don't want to talk about it, cause some do not know about it, while others treat it as a taboo. Since the start of the year, more posters on mental health were provided by the MOH (Ministry of Health). It also helps when we are able to seek support from our mental coache (sport psychologist) when we need it. It's very important.”

The statement provided by one of the experienced participants, who has competed in three Olympics, made this subtheme particularly insightful:

“In my opinion, the term 'mental health' is not negative in nature. Asking people regarding their mental health, should be treated similarly like when you are asking others about their physical health.”

The stigma of Mental Health

This theme encompasses the stigma of mental health in areas of (1) labelling and discrimination; (2) gender stereotyping; and (3) representation in mass media.

Labelling and Discrimination

“I told the management team that I am facing some mental health issues. They asked me to not fake my condition and put in more effort to overcome that feeling. I felt even worst after disclose my situation with others.”

Some participants mentioned their personal experience of seeking assistance on mental health issues. However, the existing stigma created a label to discriminate the individuals who required help and could make the situation become worst.

“observe my team mates struggling with their life. I have seen her crying and I wanted to help, but the people around me pulled me aside. They said that she is an attention-seeker and only wanted people to feel pity about her.'

Gender Stereotyping

“I am a male, therefore I need to look strong. Even if I am struggling, I will not say it out.”

60% of the male participants reported their reluctance to seek support for their mental health or disclose mental health problems to loved ones. Whereas all the female participants are willing to seek assistance for their mental health issues, however, 50% of them often worried about the reaction of others towards their problems.

“If I encounter difficulties, I will go and seek for help. Despite I am worried that others will think that I am weak and emotional, just because I am a female.”

Representation in Mass Media

Social media, e.g. Twitter, Facebook, Instagram, is viewed as an integral component in an individuals' daily life. Participants shared that frequent use of social media can cause the development of mental health issues, e.g. anxiety or fear, when used too much or without caution. The impact of their image on social media will influence their self-esteem, according to several of the participants:

“The media portrayed that I am mentally weak, and always break down at the wrong moment. I am very worried that I will be scrutinised if I don't do well.”

“I am afraid that if I claimed that I have mental health issues, the fans will hate me and turn their back on me.”

Symptoms, Effects and Sources of Mental Health

This theme describes the symptoms, effects and sources of mental health experienced by the athletes, in areas of (1) clinical; (2) subclinical; (3) personal life related; and (4) sporting performance related.

Clinical

Two (2) participants described expressing clinical symptoms that required them to receive clinical support from health care professionals, e.g. psychiatrist and clinical psychologist. They were diagnosed by qualified practitioners according to the recognised criteria, categorised in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Both participants are willing to disclose their conditions and experiences:

“Due to the demands of my sport, I had quite chronic eating disorders, and was placed on medication by the psychiatrist.”

“severe depression after the lost of my father during an accident, and led to depressive mood disorder. Currently working with a clinical psychologist, upon the referral of my sport psychologist and psychiatrist.”

Subclinical

66% of the total participants (n = 21) reported experiencing mental ill-health symptoms that are not severe enough to meet diagnostic criteria, e.g., irritability, negative thoughts, feeling unusually tired, feeling hopeless, feeling sad, being frequently on the verge of tears, having difficulty focusing, feeling unmotivated, and wanting to be left alone. Among the statements presented by the participants are:

“I have consulted with counsellor for feeling like not in the mood of doing anything.”

“facing challenges in focusing when I am completing a task, which affected my emotion”

“occasionally, I feel like I am want to be alone, feeling irritated by everything and everyone, but I will be back to normal functioning, after a few days.”

All the participants acknowledge that the symptoms will diminish after a few days, and is not long term conditions.

Personal Life Related

Majority of participants highlighted that this sub-theme is the most significant stressors of mental health issues. The managing transition was mentioned as a crucial factor in mental health, as participants have high tendencies of experiencing negative thoughts and emotions as a consequence of not being able to adapt to transition in sports.

“I am struggling balancing my academic and my sports career. I am trying my best to manage, but I am afraid that I might fail everything.”

Some reflected on the potential struggle of transition difficulties with an identity crisis.

“After retiring from sports, I felt very stressful in making that transition from sporting world into the corporate working industry. I don't know what I am at the moment.”

Sporting Performance Related

All the participants indicated that they faced with sporting performance-related issues occasionally. The unpleasant thoughts, mood and emotions may affect their mental health and the psychological status during training and competition. The pressure of performance and fulfilling the expectation of themselves and others are the common stressors of the athletes.

“Happy to make it to the senior team, however I am facing difficulty in maintaining the standard of performance required”

“The more I try, the more nervous I become. I know that I can play well, however I am too stressed up and will perform badly every time during competition.”

Coping Strategies

This theme emerged from participants' description of coping strategies of mental health issues. Sub-themes within this major theme included personal, social, and environmental.

Personal

Participants highlighted that psycho-regulation techniques, such as breathing exercises and cognitive reconstruction, are useful in managing anxiety and uncomfortable emotions.

“Take deep breaths, breathe in for 5 seconds, hold the breath for 3 seconds, and gently breathe out for 7 seconds. I can feel calmness surrounding me, my heart rate becoming slower and my thoughts becoming clearer.”

Yoga and meditation were also being introduced as effective practices for reducing the symptoms of mental health issues. Online applications, e.g. Headspace, can also be administered as a personal coping skills to tolerate, minimise, and deal with the stressors in life.

“I love using Headspace on my handset, as I can follow the instructions of the app, and conduct my mindfulness training at anytime, anywhere that I want. I felt more relaxed and centered, after completing the activity.”

Social

Participants from team sports specifically indicated that social support is an important factor that has a positive effect on mental health.

“The feeling that we are able to share with the group. Being together to spilt the burden. He/she will not be suffering alone, as we will be there to support him/her through the process.”

Majority of participants echoed that a strong social support network is often identified as a key component of a solid relationship and enhances psychological health. Social support motivates individuals during moments of stress and provides them with the vigour to overcome obstacles and even thrive.

“When I am stressed, or encountering mental health issues. It is a great comfort to know that I have my support team to be there for me. They are my pillar in the wind, and although they might not be able to help me with everything, but at least I have more courage to seek help and overcome the challenges.”

Environmental

Some participants felt that changing a new environment is helpful in promoting psychological well-being.

“I once felt that I am too stressed up, and everything is not going for me. I discussed with the coach on taking a few days off, to visit some new places and to clear my head. After coming back from that short break, I felt revitalised and regained the motivation to train harder.”

Participants echoed the establishment of a supportive sporting environment is important in association with ideal mental health.

“I feel more relaxed and less stressful when the training environment is peaceful and encouraging. I always perform better during competition when I train in this environment prior to a major tournament.”

Mental Health and Wellbeing Support

This theme encompasses the availability of mental health and well-being support in areas of (1) types of support; (2) quality of support; and (3) challenges faced by support providers.

Types of Support

Among the most effective types of support mentioned by the participants, was the words of encouragement by a role model. Many participants highlighted the Olympian swimmer of the United States of America, Michael Phelps and his famous interview, where he opened up regarding his struggles on mental health issues during his illustrious sporting career.

“I was so touched when I watched that interview. Especially when Michael said that 'I still go through times that are very challenging. I do break down and maybe have a bad day, where I'm not in a good mental state. It's Ok not to be OK.' If the greatest athlete of all time also faced with this kind of problem, and manage to handle it, I am able to do it too.”

Spirituality and religion play an important role in the maintenance of mental health and personal well-being of Malaysian athletes.

“Whenever I experienced any difficulties or negative symptoms, I will pray to God. Eventually I felt peace in my life and regain the purpose to carry on with my task.”

Relationship with significant others, e.g., parents, spouses, family members, coaches, teammates, is integral in providing ample support on mental health issues in sport.

“My parents are always there for me. Whenever I am sad, disappointed, they will always be there to support me and tell me that everything will be alright.”

Quality of Support

Each participant expressed their personal view of the quality of support on mental health issues in Malaysia. Overall, on a Likert scale of 1 to 10, 1 being lowest (poor), and 10 being highest (satisfy), majority of the athletes who had received mental health support reported a mean score of 7, which indicated a reasonably satisfactory rating.

Challenges Faced by Support Providers

The three (3) key aspects that were highlighted by the participants: competency of a practitioner, confidentiality, and building rapport with the provider.

“the practitioner is not paying attention and did not manage to help me at all. I felt even worst after consulting him/her.”

“I am not confident in sharing information with (the person). I do not trust him/her. I am afraid that he/she will share everything with my coaches.”

“The practitioner do not understand me at all. He/she fail to comprehend what I've been through and the amount of sacrifices that I made to become successful.”

Advice of Athletes

This theme emerged from participants' description of coping strategies of mental health issues. Sub-themes within this major theme included: (1) voice out, seek help, (2) establishing a social network, (3) creating mental health awareness in sports, (4) de-stigmatisation of mental health, and (5) effect of spirituality and religion.

Voice Out, Seek Help

Most participants highlighted the experience of noticing that other individuals have the tendency to isolate themselves when they faced with mental health issues. 90% of the participants (n = 29) commented on the importance of having the courage to speak up regarding their struggles and seek assistance from professionals.

“Most people do not want to say that they require help, or they have problems. At times, by seeking help, the issues can be managed better, and you will know that you are not alone in facing all the problems.”

Establishing a Social Network

The importance of having a strong social network is highlighted by 78% of the participants (n = 25). Early detection of the symptoms and providing support were among the positive factors of social network that contributed to better mental health among athletes in Malaysia.

“My parents, teammates, coaches, support staffs will always be there for me, whenever I am feeling stressed up and hopeless in my sporting pursuit. I do experience some depressive symptoms at times, however just being close to my team, I feel more relieved and provided me with the courage to overcome challenges.”

Creating Mental Health Awareness in Sports

As identified in the other subthemes, participants indicated a reasonably satisfactory rating on mental health support. Majority of the participants acknowledge the importance of the impact in awareness work on mental well-being that was conducted by the sports psychology practitioners at the National Sports Institute of Malaysia (ISN) and the campaigns conducted by government agencies, e.g., Ministry of Health of Malaysia.

“Mental health has become a commonly discussed topic and the ISN sport psychologist provides us with ample information regarding mental health and how to enhance the mental well-being in sports. They are also very sensitive towards early detection of symptoms and helpful in support us with our problems, such as referring to professional help. In my opinion, early detection is key to reduce the damage being done by mental health issues or illness.”

Almost one third (1/3, 10 people) of the participants highlighted the needs to expose the younger athletes on mental health-related topics and provide them with resources to cope with the pressure of transitioning from youth to senior level in the future:

“At a younger age, I am not being exposed to mental health information. I do not know what to do when I experience some of the symptoms. I am ashamed when others managed to be fine, except me. It created a fear in my life, especially when I am a junior athlete, training with the senior squad for the first time. With more exposure and guidance, I am sure I would have cope better during that challenging moments.”

De-stigmatization of Mental Health

In the earlier theme of the stigma of mental health, participants commented on the effect of labelling and discrimination, gender stereotyping, and representation in mass media. In this subtheme, all participants expressed the importance of de-stigmatising of mental health, especially among the sports cohort.

“Seeking help for mental health issues or problems, doesn't mean that you are weak. It actually shows a high level of self-awareness and courage, to know that you want to get better, and you require support. Experiencing mental health issues is not a problem, not seeking help when you require it, that's a major problem.”

However, they perceived that it is also one of the most challenging tasks in promoting mental health and changed the perceptions of others towards the issues.

“Parents, coaches, team mates, associations and those responsible parties in Malaysia sports should understand the importance of mental well-being and be sensitive in those issues. When athletes voice out that they are facing mental health problems, it is not that they want to find excuse, or seek for attention. They really require help and sending an SOS to those who are willing to listen to them.”

Effects of Spirituality and Religion

Only two (2) participants acknowledged that they are atheist, as the remaining thirty (30) participants (94%) identified that spirituality and religion plays an important role in the management and maintenance of mental health issues in Malaysia. As Malaysia consists of multicultural and multi-confessional society, therefore strong spirituality and religious beliefs are among the common denominator among individuals:

“Besides working with a sport psychologist, I also tend to share my worries and seek guidance from my ustaz (Muslim religious teacher). He provides me with guidance on my issues.”

Participants agree that spirituality and religion play a central role in the processes of reconstructing a sense of self and recovery. The beliefs also provide meaning to an individual's life and capable of establishing a harmonious correlation among an athlete's personal lives and sporting career.

“Praying is part of my routine. I do it regularly and it provides me with comfort and strength. With that belief, I know that I am capable of becoming better and stronger, no matter facing with mental health issues, or challenges in my sports.”

Being a role model

Participants acknowledge the positive influence of role model in managing and creating awareness on mental health issues. Having a role model as a reference point and being a role model to others are common factors that are highlighted in this subtheme.

“Watching the interview by the greatest swimmer of all-time Michael Phelps on national TV and reading NBA superstar, Kevin Love's article on The Players' Tribune, regarding their struggles with mental health issues. They provided me with comfort and warmth, knowing that I am not the only one experiencing those episodes. They are my role model, and knowing that even the best sports athletes are not invincible and without any problems at all. They are human, and they do face with challenges too.”

“… love the idea of being a role model for other athletes in Malaysia who face with mental health issues or struggling with their mental well-being. I have experienced it before, in my life and in my sporting career, and I am eager to help them overcoming it too. You are not alone, everyone goes through something. I want to help you to get help, if you are willing to.”


  Discussion Top


The findings of the current study provide a meaningful contribution to the research of mental health and psychological well-being of athletes in Malaysia. Based on the qualitative analysis on the understanding of the athletes towards mental health, it was observed that representation in mass media, transition, personal life-related issues, performance expectation, and sporting environment are significant stressors in the prevalence of mental health issues among Malaysian athletes. The athletes also highlighted the influence of spirituality and religion on the topic of mental health, as it provides a sense of belief, increasing self-awareness and creating a calming effect to the symptoms of mental health issues. This influential factor also emphasises on the athletes' understanding of the integration of dimension in the cognitive, emotional, behavioural, interpersonal and psychological facets of an individual.

Majority of the participants acknowledge the importance of the impact in awareness work on mental well-being that was conducted by the sports psychology practitioners at the National Sports Institute of Malaysia (ISN), who are the primary psychology service provider to the national athletes. Through the implementation of multiple methods (e.g. surveys, monitoring, assessment, observations, psycho-education workshops, discussion sessions), the practitioners manage to encourage help-seeking tendencies among athletes and obtain a deeper understanding on the complexity of mental health in sports.

The increment in awareness campaign and distribution of information on mental health by the Ministry of Health of Malaysia enhance the exposure of the individuals towards the topic. The ministry also launched a handbook, titled The Mental Health Book (accessed at https://www.myhealthmylife.com.my), which contains advice on how to recognise the early warning signs and symptoms of mental illness, and how to manage the ailment. It is written for easy-reading and supplemented with visuals, emphasising on the four (4) common mental disorders, namely depression, anxiety, bipolar, and schizophrenia. Collaboration by the ISN sports psychology practitioners with the government agencies (e.g. Health Ministry) and non-governmental organisations (e.g. Mental Illness Awareness and Support Association; MIASA) will be beneficial for emphasising on the importance of mental health in Malaysia, specifically in the sports setting.

As highlighted in the studies of McGannon, Schinke, and Busanich (2014), and Ryba, Stambulova, Si, and Schinke (2013), cultural awareness and cultural competence are acknowledged as key elements of effective practice and delivery of sport psychology to address the requirements of individuals from a culturally diverse nation. As Malaysia is a multicultural society that includes three (3) major ethnic groups: the Bumiputra (68.8% of the total population of citizens), Chinese (23.2%), Indians (7.0%) and Others (1.0%), therefore sport psychology practitioners should be aware and competent in the idiosyncrasy and uniqueness contexts between cultures, when fulfilling the role of managing mental health issues. The interview conducted for the qualitative study also consisted of athletes from a wide range of race and religion, which is a representation of the ethnic groups in Malaysia.

Initiating a consensus document on the mental health care in Malaysian sports setting, underlining the diversity, multicultural, and multidisciplinary standpoint would be a valuable resource for athletes, coaches and key stakeholders on the support on the mental health of individuals involved in sports. Establishing a standard operating procedure (SOP) in handling mental health-related cases and guidelines on managing referral cases to access mental health services, e.g. clinical support for individuals with clinical symptoms, are also highly recommended. Besides athletes from able-bodied events, this current study also includes the insight of para-sports athletes. As highlighted by Swartz et al. (2019), only seven (7) publications addressed Paralympic athletes specifically on their mental health. Therefore, there is a need for identifying the differential stressors experienced by the para-sports athletes, effective coping strategies, stereotypes on individuals with disabilities, and impact of the experiences on the individual's mental health.


  Conclusion Top


It is hopeful that this current study will stimulate interest and discussion in identifying methods of conducting relevant research in the mental health of athletes, increasing the awareness of mental well-being in sports, and bridging theoretical to the applied practice in sports. More work in the applied setting to emphasise on educating athletes and family members about mental health with strategies and skills in handling stress and maintaining well-being; observation and recognition on behavioural shift; breaking the stigma about mental health to speak out and look out for assistance; as well as preventive measures for athletes. Further studies should be conducted to generate more comprehensive findings in the process of providing a supportive contribution to the athletes' psychological well-being of thriving in a highly pressured sporting environment and their personal life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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