A sports medicine update to American basketball

Open AccessA sports medicine update to American basketballContributions and changes from abroad and implications for sports medicine and psychiatryIra D. Glick and Davide ZaccariaIra D. GlickIra D. Glick, MD, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 2, Scenic Way, San Francisco, CA 94121, USAiraglick@stanford.eduhttps://orcid.org/0000-0002-8518-0893 Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA Search for more papers by this author and Davide Zaccaria Department of Research and Digital Innovation, Università degli Studi di Bari, Italy Search for more papers by this authorPublished Online:May 10, 2023https://doi.org/10.1024/2674-0052/a000045PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreThis article updates our previous papers on psychiatric aspects of basketball, which had the aim of providing diagnostic and treatment implications for physicians doing Sports Medicine and Sports Psychiatry. Using articles from the sports media and from clinical experience, we update that broad overview from the European perspective. That is focusing on those athletes born in Europe or who have arrived in the U.S. born in Africa via Europe, who have in important and new ways changed the American game. As such, this is the first paper that details the European perspective for athletes, athletic teams, leagues, countries, and the sport itself. These athletes have changed the nature i.e. style, psychology, and medical-psychiatric aspects of this American game – changes which Sports Psychiatrists need to be aware of to improve treatment efficacy.In 1989, one of us (IDG) wrote the first paper on “psychiatric aspects of basketball” with the aim of providing diagnostic and treatment implications for physicians doing Sports Medicine and Sports Psychiatry [1]. In that paper, we described “mental health,” physical health, and the psychiatric aspects of the game in three related areas/issues: 1) individual, 2) team, 3) community and country. We wrote:“Basketball is enjoying wide popularity and growth today for a variety of reasons – not the least of which are the facts that it fulfills individual and family needs and helps to bridge the gap between individuals of different countries and different races. It is a sport that requires the combination of skill, strength, intelligence, and mental health in a unique, challenging and creative way.When basketball ‘goes right,’ it can do much to develop psychological awareness of others, physical skills, and the ability to think quickly and decisively. It can also go wrong – not only for an individual player and/or their team, but also for the community/country at large – when players are improperly used for the sports organization’s own ends” [1].Our objective in that paper was to lay out the symptoms, problems, illnesses that athletes present for diagnosis, treatment and long-term management. It was aimed not only for physicians – but also for the trainers working closely with the athletes. Somewhat surprisingly, it was used by coaches, administrative staff, agents, and basketball leagues, including the National Basketball Association (NBA) and Women’s National Basketball Association (WNBA). In part, based on the feedback we received, we updated this paper in 2018 [2], focusing on the then new “mental health” services available – with a focus on issues, problems, and psychiatric disorders like substance use disorders, personality disorders as well as diseases with a genetic etiology like anxiety and depressive disorders, attention deficit disorder and schizophrenia.Subsequently, we searched the literature. To the best of our knowledge, we were unable to find articles discussing how the American game has changed secondary to what European players brought to America. We have found papers, which in a more general way describe diagnosis and treatment of athletes globally playing a variety of sports [3, 4].In this article written for those practicing Sports Medicine – we update that broad overview, with a focus emanating on, and from the European perspective. We try to make clear that European players have changed the psychology, psychiatric aspects of the sport to make what we believe increases the complexities of the mental game in the context of the physical, raw athletic play of the American game. We focus on those athletes born in Europe or who have arrived in the U.S. born in Africa that grew up and/or played in Europe and then came to the U.S., via Europe, who have in important and new ways changed the American game. As such, this is the first paper that details the European perspective for athletes, athletic teams, leagues, countries, and the sport itself. By way of example, last season (2022), Nikola Jokic won his second successive NBA Most Valuable Player (MVP). Furthermore, for that award there were other, very close and worthy choices including Luka Doncic, Joel Embiid and Giannis Antetokounmpo – all of whom have changed the nature i.e. style, psychology, and medical aspects of this American game. In short, players like these have changed the psychology of the game, resulting in changes to both the physical as well as the mental health of athletes.BackgroundAs some sports lovers say: “B-Ball is life,” and as Life it continues to grow and evolve. We have made giant footsteps as a sporting civilization since James Naismith created basketball. At that time back in 1891, it was viewed as a way of spending time. Still, nowadays, it is viewed almost as a “revolution in major sports competition” having great global popularity roughly equal to football/soccer. Simultaneously, focusing on the NBA, we see that the number of foreign players continues to grow. Starting the 2022 season, 109 foreign-born players were under contract with NBA franchises (approximately 25% of all players) [5]. We now see flashy and spectacular plays that fans love, even from the European players, who were once considered “wooden-legged, silk-hands, skinny, white people.”Well before 1989, the contacts between Europe, especially Eastern Europe, were almost nonexistent. As it happened, the Eastern part of Europe was the area with one with the largest basketball cultures globally, excluding the United States. From the early years at the Melbourne Olympics in 1956 to the Seoul Olympics in 1988, we observed several forces collide in the world of basketball: first, in the United States with their Team USA Basketball, and second being the Yugoslavian national basketball team and national teams from the Soviet Union. These teams, and how they played, created a new European basketball culture based on the Eastern European states as the model. In short, it was a different way of thinking and strategizing. At the same time, Team USA developed the culture of what some understood as a more athletic and a more individually focused team, starting from the earliest Olympics. The toughest encounters were games with these two above colossi competing against each other.From the US point of view, European players were viewed as anything but “athletic athletes.” Likewise, there was a different point of view in Europe that still flourishes among older observers as, “just business, they want to entertain “athletically” to sell a product to some fans. That’s not basketball, that’s some sort of a circus.”Changes in American basketball via Europe and AfricaHow did things change? In a companion paper, now under review in a sports magazine online, we have described in detail the origins and history of European basketball – the athletes who made or did not make American teams, their early development and training as kids, the conferences, countries, teams and leagues in which they played, and most important, how they changed the American game [8]. There is an old saying, “There is nothing so constant as change.” From that paper, we summarize some of these changes – acknowledging that these are broad, generalizations, yet for the medical objectives of this paper, they provide a grounding for the sports physician to understand and prescribe interventions in the context of both the psychology and the physical aspects of their European countries.Previous articles have delineated 1) how American basketball has changed, 2) how athletes – both men and women – are more diverse and think/play differently and 3) some of the diagnostic and treatment issues are now different and require a different approach [6, 7].Here we summarize with the following generalizations (and of course there are exceptions to generalizations):•European players are more focused on learning individual fundamentals, and a bit less on “athleticism.”•European training systems are more egalitarian, focused on the team rather than the individual from the players from four decades ago.•Foreign “big men” have improved their shooting skills and their footwork for both self-creating and creating for others on the perimeter, rather than mostly playing with what has been described as brute strength in the post.•European players are more focused on controlling the “rhythm and tempo” “slowing things down,” compared to others who have developed skills at speedily moving aggressively and athletically to the basket.•Europeans are known for being tough defenders, all in the context and facilitated by European rules, which allow more physical contact. Even so, they are still seen by some as less capable of individual defense than US players.Other players, coaches or sports writers may have contrary views. There is very little data or expert sources to rely on. The point here is that European players have created changes in America basketball. As such, these changes have had significant effects on the “psyches” of most players. Sports psychiatrists need to be aware of changes such as these and of rule changes.Implications for the sports physicianGiven the above, modest changes in the game, the work continues to be – how best to help the athlete play and stay healthy before, during and post career. First, it is crucial to understand the changes that have occurred in the American game and what this means for the athlete and their teams. Then integrate your understanding of them into medical-psychiatric practice. Second, note that “depression and anxiety” are often what are called “presenting symptoms”: Actually, what athletes mean when they say they are depressed or anxious is that they are asking for help to deal with A) team issues (“They don’t throw me the ball or don’t like me”), B) problems (“I don’t get enough playing time or I’m not being paid enough”), C) illnesses like Diagnostic and Statistical Manual V (DSM) anxiety or depressive disorders as well as D) life issues, i.e. being a rookie or facing or having troubles in retirement [8]. Worse still are prejudices or biases – “I’m Russian, but my teammates blame me for the war.” These issues have to be understood, diagnosed and managed by physicians and by therapists, working with brain-mind issues.This involves both practicing quality psychopharmacology as well as integrating individual, family and group psychotherapy into treatment, depending on the diagnosis and situation. Therapy sometimes has to be provided by physicians familiar with the player’s culture. Athletes commonly have preferences or biases about the physician or therapist being of the same age, gender, or race – although there is no solid scientific evidence that these factors importantly affect treatment outcome [6]. Having said that, the sports physician should be aware that cultural factors to varying degrees may affect outcome [6].In summary, the sports physician needs to be able to, and competent to, provide evidence-based interventions for the medical and psychiatric disorders/illnesses they manage – e.g. antidepressants for major depressive disorder, antipsychotics for psychosis, etc and know how to integrate the different types of psychotherapy with medication. Given the changes we describe, A) the more physical the play, the more orthopedic problems may result and B) the more rapidly the interactions with teammates, the more challenging it may be psychologically, i.e. creating anxiety for some players. That might lead to cognitive difficulties like disfunctional anxiety or disorders like GAD or dysthymia [4, 6, 8, 9].ConclusionFrom our perspective and opinion, American basketball has changed and is on the right path to develop and build a strong combined and integrated culture of European, African, and American style of play. It is based in part on changing past negative attitudes about European players as well as integrating positive changes. We note continual development of thoughtful play and a “feel” for the game, which can’t be taught, but can be learned at a young age. European basketball is more open at this time to send young players overseas. With the globalization and the spread of information made possible by social media, watching the NBA on a daily basis becomes possible and challenging to existing styles and current play. European players coming back from America and playing with their national teams now show an increase of skills. All this has given birth to a new way of team-play both in its technical and physical aspects. As such, structurally we see the birth and development to stardom of players like Giannis, Doncic, Embiid, Kristaps Porzingis and others, perhaps best illustrated, like the 19 year old, French prospect Victor Wembanyama – the probable next first pick in the NBA Draft and one of the most highly hyped prospects of all time.We believe the bottom line for the sports physician – basketball competition has changed from “winning at any cost” to competing to win, but working together to improve life for the athlete, leagues, tribes, communities, cities and countries that the teams represent. We’re all in this together to advance civilization. And it’s up to us across continents to work together as well as for the sports physician to provide the crucial medical and psychiatric help to achieve these new goals.References1 Glick ID, Marcotte DB. Psychiatric aspects of basketball. J Sports Med Phys Fitness. 1989;29:104–12. First citation in articleGoogle Scholar2 Glick ID, Geigerich M, McDuff D. Basketball. In: Glick IDKamis DStull T, editors. The ISSP manual of sports psychiatry. New York: Routledge Press; 2018, 186–96. First citation in articleGoogle Scholar3 Claussen MC, Gonzalez Hofmann C, Schneeberger AR, Seifritz E, Schorb A, Allroggen M, et al. Position paper: Sports psychiatric care provision in competitive sports. Dtsch Z Sportmed. 2021;72:316–22. First citation in articleGoogle Scholar4 Reardon CL, Hainline B, Miller Aron C, Baron D, Baum AL, Bindra A, et al. Mental health in elite athletes: International Olympic Committee consensus statement. 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