On Monday, The Athletic published a special report into the case of Maddy Cusack, the Sheffield United player whose death in September left a sport in mourning. It is a heartbreaking story of a talented and popular footballer and the investigation into a family’s complaints about what they believe caused her emotional anguish.
The Cusack family submitted an official complaint that stated Maddy, 27, had described during numerous conversations how she felt marginalised and encountered “personal antipathy” from her manager, Jonathan Morgan, in what has been described by some former team-mates as a tough, divisive and often hard-faced environment. This had a devastating impact on her mental health and contributed to her taking her own life, her family believe, breaking her confidence at a time when she had the pressures of juggling her playing career with working for the club as a marketing executive.
Morgan says he tried to be a positive influence in her life and that it was completely unfounded to suggest their working relationship had contributed to her emotional anguish and, ultimately, her death. He says he repeatedly tried to help Cusack, making her vice-captain and putting her in touch with the club doctor when he suspected she was struggling with mental health issues. In a statement, Sheffield United said, “Promoting and supporting good mental health and well-being are both major considerations within the club’s EDI (equality, diversity and inclusion) working group.” An external inquiry, commissioned by the club, investigated the family’s complaint but found no evidence of wrongdoing.
Maddy Cusack in 2022 (Cameron Smith – The FA/The FA via Getty Images )
The case raises many questions, one of which revolves around the support networks in place for players across the women’s and men’s games.
More than 150 of the participants in the 2023 Women’s World Cup said they lacked mental health support, a figure described as “quite alarming” by Alex Culvin, head of strategy and research for women’s football at FIFPro, the global players’ union.
The maximum delegation size for each team at that tournament was expanded from 35 to 50 people to match the levels of care and support offered to those at the men’s World Cup the previous year, but it is not compulsory for federations to have a qualified mental health specialist on their staff. While sports and exercise psychologists are mandatory at Premier League academy level, they are not a required role for Premier League, Women’s Super League (WSL), English Football League (EFL) or Women’s Championship (WC) clubs.
“With that additional 15 people, you would expect the federations would have some mental health support for players,” adds Culvin. “Mental health becomes a big priority if 60 per cent of players said it was insufficient.”
The need for mental health support in football is not exclusive to the women’s game or football’s international stage. Everyone in the world has mental health, good or bad, just like they have physical health. Teams will have specialists focusing on physical health but coaches and players have told Dr Chris James, clinical psychologist and athlete sleep specialist at Sleep Athletic, a firm that analyses and advises on sleep in sport, that they feel mental health is treated as a “tick box” exercise.
“Clubs are still not fully aware of the true extent of mental health difficulties within football,” says James, who also works for a Premier League club as an external provider — a go-to person if any of the players, coaches, staff or their relatives are struggling with their mental health. “It’s through lack of awareness — it’s just not on their radar. That’s because of the continued stigma. Players feel reluctant to talk about their mental health difficulties. They’re worried about the perception of their team-mates, coaches and the public.”
Indeed, only 38 per cent of Premier League and EFL players and 26 per cent of WSL respondents said they would feel comfortable sharing concerns regarding their mental well-being with their clubs, according to a Professional Footballers’ Association (PFA) survey conducted throughout the 2022-23 season.
The demands on athletes in elite environments in which they are scrutinised, measured and judged have never been higher. The PFA survey reported almost half (47 per cent) of Premier League and EFL players revealed fears about being dropped were having an impact on their well-being, a quarter (23 per cent) of WSL players said money and contractual issues were causing stress and more than 40 per cent of WSL players said they had experienced online abuse, with general personal safety concerns a prominent issue in the WSL.
Some have spoken out. Tottenham Hotspur Women defender Molly Bartrip, Marvin Sordell, the former Bolton Wanderers and Burnley player who retired from professional football in 2019 at the age of 28, U.S. Women’s National Team defender Naomi Girma and Arsenal duo Beth Mead and Vivianne Miedema have all done so. They talked about panic attacks, anxiety, depression and suicide with The Athletic as part of Common Goal’s Create the Space mental health movement launched in November.
“On the outside, we can all look great sometimes, but some people are worse than others,” Mead tells The Athletic. “I could feel as bad as someone who (on the outside) looks 10 times worse than me. It’s important for people to check on each other and understand there’s a lot more to life than football. People forget that, sometimes, we are human beings — we still go through the same day-to-day things and have issues with friends and family, like everybody else.”
James thinks football has a poor understanding of mental health issues. In an address at a recent conference to a room full of people who were not psychologists, a Premier League club staff member said, “We’re all psychologists, aren’t we?”, when discussing the club’s mental health support.
“You would not say we’re all doctors,” says James. “That just shows there’s still this real lack of understanding of why specialist mental health care is needed. It’s still seen as not that important.
“There’s this thinking that you only really need to call upon it when players are severely struggling, which is such a ridiculous way of looking at it. It’s about prevention, low level, get in there early.”
Even if clubs have qualified mental health experts — some do not, often citing budgetary constraints — most operate externally.
“That creates its own issues,” says James. “It relies on a culture where the person feels able to go to the club and say I need support rather than having it embedded. It becomes this weird unspoken quiet thing that we don’t mention. That’s really unhealthy.
“As long as it’s separate, there’s something less acceptable about receiving support. Whereas if you’ve got an in-house mental health team in the way that you’ve got an in-house medical team, then it just becomes what we do.”
Mead believes a mix of external and internal support strikes a good balance. “We have a clinical psychologist at the club day in, day out,” she tells The Athletic. “But sometimes that’s not always the person you need. Sometimes you need someone neutral, outside of the bubble. Arsenal are very good at putting you in touch with people on a neutral level — and it might not always need to be in sport.”
Karen Carney’s government review into women’s football recommended that sports and exercise psychologists become mandatory in the top two tiers of the women’s game as of the 2023-24 season, so players had an identifiable route should they wish to raise any well-being concerns.
Although the government’s response to the review acknowledged the FA “has made a small number of changes to medical licence criteria” for this season — clubs have to have a player welfare officer, for example — it wrote that “the FA could have gone further” and were “disappointed” sports and exercise psychologists were not introduced as a mandatory role.
Vicky Jepson, assistant manager of Tottenham Hotspur Women, agrees a psychologist should be part of the licensing criteria for teams in the WSL and WC. “Molly Bartrip was so brave in telling her story but these girls need that because they’re exposed to more pressure than ever, with sold-out stadiums, TV and social media,” she says. “It has happened so quickly. The pressures of being in the squad, not in the squad, potentially going out on loan… there are all these what-ifs and uncertainties within this high-pressure game. The athletes and staff need that psychological support.”
Molly Bartrip has spoken publicly about her mental health (Eddie Keogh/Getty Images)
Describing the pressures that can be felt at the top level, one player, speaking anonymously to protect their position, described how players were addressed by a manager after a match. “We lost the game and he grabbed everybody in after the final whistle and called out one player to stand up in front of the group and he was like, ‘You’re f****** mentally weak. You’re not good enough to be here’.”
Provision in this area can vary greatly depending on the club involved. Some have sports and exercise psychologists, others do not. Some have daily wellness questionnaires monitoring sleep and physical condition, as well as weekly-to-monthly psychological forms to fill in. The club will then see if anything piques their interest.
James, however, feels “clubs are not asking the right questions”.
“If you don’t know which questions to ask and how to ask them, you don’t get the information that tells you what’s going on with the players’ mental health,” he says. A common misconception is the assumption that all must be well if players or staff are not coming forward to speak.
“We’ve got this tip-of-the-iceberg effect where they might be aware of a handful of players but there will be lots in the squad who don’t feel comfortable naming that they’re struggling.”
More beneficial ways, according to James, would be to ask direct questions about players’ struggles and be attuned to non-verbal signs. “They might seem quite despondent, labelled as difficult or not open to guidance,” explains James. “Other flags can vary from turning up late to training to a change in demeanour. It’s about learning to gently explore that in a way that feels non-blaming or non-judging.”
All 20 Premier League clubs have first-team and academy player care leads, while every club must ensure that all age groups, including first-team players, receive an educational session of between 45 and 90 minutes on mental and emotional well-being on an annual basis. Clubs must also devise a mental and emotional well-being action plan and designate an individual as its mental and emotional well-being lead. In 2020, the Premier League signed up to the Mentally Healthy Football Declaration, committing to make mental health a key priority at all levels of the game. The EFL’s four-year partnership with Mind, the mental health charity, concluded in 2022 but the league has continued to work alongside them to deliver a mental health action plan. Every EFL club at academy category one to three also employs a full-time head of player care.
Premier League, WSL and EFL players (via the PFA) and WC clubs have access to a network of more than 200 specialist counsellors from the Sporting Chance Clinic (an organisation offering mental health and well-being support for sportspeople), and a 24/7 support helpline. But it is the duty of clubs, as their employers, to ensure they provide adequate well-being support for their players and staff.
Initial points of contact, such as in-house player welfare officers, are important but it is not a protected title, meaning people without relevant qualifications can take on this role.
“A lot of informal mental health support might be happening on the treatment bench or the training ground — informal chats,” says James. “There’s lots of good work that happens in that way. Players may not want to go near me (as a clinical psychologist) but they’ll talk to their physio quite happily about all their stresses. It’s not making the physio into a mental health professional, but it’s helping them learn what to do with that conversation. That’s the thing that’s missing.”
But what happens when a coach or player needs specialist input and who is there to support them through that process?
The FA’s player care lead works with WSL and WC player care and well-being staff, safeguarding representatives and, where applicable, sports psychologists. They also have doctors and referral pathways at each club for clinical services.
But one player The Athletic spoke to, on condition of anonymity to protect their position, described a scenario where she and her team-mates were offered support by a well-being lead who worked predominantly on the men’s side of the club. That person did not realise the players were part-time and had other jobs, and so those involved were left thinking, in the player’s words, “‘How do you expect this person to help us? Because they clearly don’t know what the issues are’.”
Carney’s review, published in 2023, addressed such issues. “Players highlighted barriers to accessing mental health support, including a lack of awareness of where to find support and fears of the repercussions on their footballing career,” the review read.
Former England midfielder Karen Carney led a review on women’s football (Michael Regan/Getty Images)
“I didn’t feel comfortable expressing how I felt in case it jeopardised my position in the team,” one former player told the review, a view shared by many current and former professionals.
These players’ words in 2023 echo how Sordell felt when he tried to take his own life in 2013, although he believes football is in a better place to help players with their mental health compared to a decade ago.
“Looking back, people didn’t necessarily know how to deal with it, what to do, what to say, whether to ignore it, whether to address it, where to send me to,” he told The Athletic. “That’s dangerous. People dealt with things in the way they best saw fit without necessarily having the understanding, the tools or the capabilities to deal with it.“
Sports and exercise psychologists, according to James’ experience, are often expected to provide mental health input at football clubs. There is a lack of understanding about the difference between sports and exercise psychologists and clinical psychologists.
“Clubs think the word psychologist means everything,” he says. “They’re treating sports psychologists as being able to treat mental health issues. That’s not their specialism at all. Equally, it is really unclear how and when sports psychologists should refer on to clinical psychologists.“
Sports and exercise psychologists are experts in performance and motivation enhancement. They help athletes and teams understand, develop or change behaviours, mental processes, and improve general well-being, in the context of sport. They can provide support and advice for managing stress and anxiety relating to sport.
Clinical psychologists, meanwhile, are regarded as mental health experts and are called upon by the courts when they need an expert opinion about a mental health issue. They tend to hold very senior roles within the National Health Service’s operations and are experts in psychological therapies.
“It’s not about clubs deciding which they need,” says James. “Sports and exercise psychologists and clinical psychologists bring very different types of expertise, but all underpinned by a deep understanding of human psychology — clubs need both working in a highly collaborative way.”
One psychologist embedded into a team is not going to fix every problem. But creating a culture where people can talk openly with someone qualified to help is seen as fundamental to the future of footballers’ mental health.
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(Top photo: Getty Images; design: Eamonn Dalton)
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