American gymnast Simone Biles rocked the Olympic world this week with her announcement that she was withdrawing from two critical, gold-medal-potential events because of a mental health issue.

Biles’ move came on the heels of a similar announcement weeks earlier from Japanese-American tennis great Naomi Osaka, who withdrew from the French Open after her own mental health struggles.

In a subsequent essay for Time Magazine addressing the situation, Osaka wrote: “It has become apparent to me that literally everyone either suffers from issues related to their mental health or knows someone who does. The number of messages I received from such a vast cross section of people confirms that. I think we can almost universally agree that each of us is a human being and subject to feelings and emotions.”

Even before the games, public pressure had been building on Biles, 24, who has won every all-around competition since she was 16 and is considered the greatest gymnast of all time. She said as much on Instagram Monday, writing that she feels she has “the weight of the world on my shoulders at times.”

Dubbed “GOAT” (for “greatest of all time”) for her superior performance, Biles even received a special GOAT emoji attached to her Twitter hashtag on the social media platform. She has been the smiling face of NBC’s coverage of the Tokyo Olympics for months leading up to the Games.

Add to that the fact that the Olympics were delayed by a year because of the coronavirus pandemic, even as Biles and all the world’s Olympians continued to train, only to arrive to competition spaces devoid of live spectators, and you’ve got the makings of the ultimate dystopian novel. But this is all real.

UVA Today reached out to Nicole Ruzek, a clinical psychologist who heads Counseling and Psychological Services at the University of Virginia, to talk about the latest headlines and how they relate to students at UVA – especially incoming first- and second-year students, who are about to experience a new phase of life.

Q. The announcements by Biles and Osaka to withdraw from competition because of mental health struggles are groundbreaking and have been met with lots of support from the general public. What was your reaction upon hearing this, as a clinical psychologist?

A. I think that in both of those situations, the situation is pretty complex, because you are talking about young adults who are faced with enormous amounts of pressure and in highly unusual circumstances, who undoubtedly are facing a lot of stress. And so it would be somewhat expected and normal to be feeling that pressure. It’s not surprising, especially at such a young age and with so many eyes on you, to feel not only under stress, but probably to develop a good amount of anxiety around that. All the pressure that’s put on these young athletes makes the situation ripe for them to be challenged in this way.

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Speaking more specifically to your question about how it feels to me that they’re speaking out about that experience and their own mental health concerns, it really reflects a larger cultural shift around how people are both talking about mental health and then seeking support for mental health in different ways, through health care or medical care or psychological care. To me, it feels in line with this larger cultural shift that’s been happening, I think, for the last decade or two.

Q. Living through the pandemic added tremendous pressure and trauma to athletes and to people in general. It feels like the world has changed and that now, more than ever, people are prioritizing their mental health in ways that they hadn’t in the past. What do you think?

A. I think the pandemic has only heightened our awareness that the world can change very, very quickly and that what we experienced as normal one day can change the next day and feel very different. So, this level of uncertainty, I think that people have had to learn to adapt to and cope with, has been challenging.

Specifically with these athletes, one thing that caught my attention was when organizers said there were no longer going to be live audiences; it creates a pressure cooker for a person when they’re not experiencing that positive reinforcement from an audience. And in some ways, that parallels all of our experiences when we were isolated or in lockdown and we weren’t having social experiences in the same way. People may have felt very lonely or anxious or depressed as a result of not having that human contact. I think there’s that connection piece that is critical to human flourishing, and when it’s not there, people start to feel like things are really off and then perhaps need a break.

Q. You’ve said you’ve seen people become more open to discussing mental health issues in the last 10 to 20 years. Why is that?

A. I use that time span because I’ve become a clinician for about that amount of time. What I’ve witnessed, working within the context of college student mental health, is that during that time, there’s just been a much broader acceptance of mental health diagnoses and concerns as being legitimate issues that can be successfully treated. There’s just more awareness and acceptance that you can seek help for these things and the treatment can be very effective. What I’ve seen over my time in this career is increases in demand for mental health services.

With those increases, we’re just learning more about all the things that people have probably been struggling with for a long time without seeking help. But now we’re much more aware of the experiences that people are having. And that’s really wonderful, because we’re able to help people to feel better.

But again, I think the pandemic only heightened people’s awareness around this by having a lot of time, either isolated or not engaging in a lot of activities, becoming more aware of mental health concerns that may have preexisted or were exacerbated by the pandemic or developed as a result of it.

Q. In an interview, Biles said she was suffering from a phenomenon in gymnastics called the “twisties” – a mental block where your brain and body feel disconnected. It happened during her vault on Monday, and she said she felt “lost in the air” and that she was worried she might hurt herself. What are the psychological issues at play here?

A. That sounds a lot like a dissociative experience, which typically comes in experiences of trauma, when you’re faced with a situation that is overwhelming your nervous system. It’s really an adaptive response of the body so that you’re not fully experiencing whatever that pain or traumatic event might be. I don’t know if there’s any real connection between that and what these athletes are experiencing, but obviously, they put their bodies through tremendous amounts of pain and stress in order to do what they do.

Nicole Ruzek is the director of UVA’s Counseling and Psychological Services. (Photo by Dan Addison, University Communications)

It’s interesting to think about “What if you get stuck in that [mental] place?,” and sometimes people with trauma do – they get stuck in a dissociative place and lose a connection with their body, which then leads them to have other symptoms that are difficult to manage and then hopefully they get treatment from there.

Q. Do you think Biles’ and Osaka’s decisions to go public about their struggles on the world stage represents a sea change in athletics going forward?

A. I think what it reflects, again, is this larger cultural shift toward accepting that people do struggle with mental health issues. They’re just as serious, if not more serious at times, than physical health issues, and just like when an athlete experiences a physical injury and needs to take a break, they can also experience a mental injury and need to take a break.

My hope is that there’s more awareness and acceptance that these athletes at times may become aware of their limits. And if they are listening to their bodies and paying attention to what their bodies are telling them, it will help them understand the limitations and be able to know when they’ve had enough and when it’s time for a break.

Q. For those who have not experienced anxiety or panic attacks, can you describe, clinically, what happens in the brain and body? Biles said in the hours before she took the floor in Tokyo that she was shaking and could barely nap. “I’ve never felt like this going into a competition before,” she said.

A. Because I am not a neuroscientist, I am probably [better] qualified to describe the experience of having a panic attack or anxiety, rather than what is going on in the brain.

There are various ways that people experience them. For some people, it’s very physiological and they’re feeling their heart rate increasing or they’re sweating or shaking or having difficulty breathing, usually tightness in the chest. Some people even feel like they’re having a heart attack or a stroke and seek medical attention at the emergency room, because it feels that intense. And then there are lower-level panic attacks, where people might just become really tearful or experience a little bit of physical discomfort. But it feels much more like an emotional or mental event, where thoughts are racing or where they’re unable to connect with their thoughts fully. It’s a very common experience for people who become overwhelmed in different situations.

Data shows that there has been an increase in rates of anxiety over the last 10 years or so. In talking with various colleagues doing the work that I do, people are having some of those symptoms re-entering life after the pandemic, after having spent a lot of time alone.

On the flip side of that are some people who are re-entering and feeling a lot of relief and actually feeling less of those symptoms, because they’re able to re-engage again and connect in ways that they couldn’t before.

Q. Speaking of re-entering society after the lockdown, what advice do you have for incoming first-year students, as well as second-year students who are going to have a completely different experience from 2020?

A. I read something recently in an article written by a psychologist, who talked about really thinking about what things that you valued pre-pandemic that you couldn’t do as readily. So, during the pandemic, what things did you lose that you want to have back in your life? That might have been social engagement with peers; know that that’s something that’s important to you, that you want to make that a part of your life again because it feels good and it adds value to your life.

Then also think about what things changed during the pandemic that you want to keep. Maybe you didn’t put as much pressure on yourself to be involved in every activity or to go out with friends every night because you couldn’t. That may have felt really relieving in some ways … for students to not have to feel totally plugged in in every moment. So, think about how you can integrate maybe a slower pace or less of those things that were mostly stressful and just added more challenges to your plate.

What things do you want to bring with you and what things do you want to leave behind?

Q. These students are moving into a new phase of life. What are the resources for those who may experience anxiety or other mental health issues while at UVA?

A. My main piece of advice is – maybe like these athletes in some ways – to listen to your body, pay attention to your experience, understand what your stress levels are and when they start to get too high, to engage supports or take care of yourself so that you don’t become completely overwhelmed.

UVA is a highly competitive University, and we have students who are remarkably smart and have often put a lot of pressure on themselves to get into the University. So, recognize that they’re not alone, that many are coming in with these experiences.

Also, connect with others. This is where I found that the reduction in stigma around talking about mental health issues has been extremely valuable. You have peers starting to talk more with each other about their vulnerabilities, about their difficulties, and then can support one another and also normalize that.

I think it’s also important to acknowledge that it is a new transition, and any time we go through a transition it’s stressful, even if it’s a good transition.

If you’re feeling stressed, don’t wait to reach out to Counseling and Psychological Services. There are a number of other resources within Student Health and Wellness, beyond the counseling center as well, like WahooWell, which is a great resource where students can just sit down and have a talk about their well-being and get some advice on things they can do to increase their well-being while they’re at the University.