November 12, 2012

Baseball Therapy

Assessing the Risk: Hamilton, Greinke, and Mental Health

by Russell A. Carleton

Printer-friendly

Contact Author

If you'll excuse me for a moment while I put on my other hat.

'Tis the season for free agency and, as always, attention turns to the top end of the class. This winter, teams may bid on a former Most Valuable Player in Josh Hamilton and a former Cy Young winner in Zack Greinke. Like any free agent, both come with their positives and negatives, but certainly, they are among the few free agents who can dramatically change a team's chances of success next year (and beyond). And they will be paid accordingly.

But this year, there's a new wrinkle to assessing free agents that has not often been (publicly) discussed. Both Hamilton (substance use) and Greinke (depression and anxiety) have battled mental health issues in the past. And in many of the free agent ranking lists and other reviews of this year's class, these issues have been mentioned, although the level of sophistication with which they have been discussed has ranged from the humble "I honestly just don't know" to laughably amateurish. All free agents have risk associated with them, but while there's a backlog of data on how to assess physical injuries, this is one of the first times that major free agents have (publicly) had their mental health histories be part of their free agent narratives.

I'm not an amateur. In real life, I have a Ph.D. in clinical psychology (hence my column name, "Baseball Therapy"). I think it's time that we had a professional discussion about mental health and what it means for this year's free agent class.

Let's dispel some myths
First, let's start with a few important facts. Zack Greinke and Josh Hamilton are not the only major-league players who have battled against mental illness. This isn't a case of "I know something you don't know." (I actually don't.) It's a matter of statistics. There are 30 teams with 25-man rosters, so that's 750 major leaguers. The National Institute of Mental Health estimates that more than one quarter of adults in the United States have a diagnosable mental illness during the course of a calendar year. It's possible that rates are lower for major leaguers, but even cutting that rate in half, that's nearly 100 players.

Second, people hold a lot of myths about what a mental illness is and looks like. No, it is not the same thing as "hearing voices." Blessedly, that's rare (although I wish it were rarer). It is also not a matter of being weak in some way. There are real neurochemical problems that underlie most mental illnesses. If anything, I would suggest saluting someone who manages to get through a day even when his own neurochemistry is working against him.

Third, mental illness is not something to giggle about. If I make jokes about people who had cancer, people would be horrified. Yet, it's okay to make jokes about "crazy people." There's a stigma around mental illness in United States culture. One of the major public health problems of our time is working against this stigma so that people feel comfortable getting the help that's out there for them. Mental illnesses are hard to beat, but they have a cause, symptoms, and treatment, and people can recover from them. I'm living proof.

What's the Risk?
With that said, mental illnesses are not easy to overcome, and like any injury, they can recur. Teams who are thinking about signing either Zack Greinke or Josh Hamilton need to factor in that risk when they consider what offers they might make. In the same way, they will be considering Mr. Hamilton's injury history (he has had trouble playing 150 games over the past few years) and the fact that Mr. Greinke is a pitcher (which is a risk factor for injury unto itself). Before I delve too deeply, I should point out that I have never met nor spoken to either Mr. Greinke or Mr. Hamilton, so I don't know their exact situations (nor have I sought this information... there are certain questions that you don't ask). I'm basing all of this material on what's been publicly said and my professional experience and knowledge of the literature on the subject.

Greinke, Anxiety and Depression
Zack Greinke has been diagnosed as having social anxiety disorder, as well as depression. This isn't surprising, as depression and anxiety are often found together. One theme I've noticed in the coverage of Greinke's battle is how little people understand social anxiety, mostly taking the form of comments that Greinke wouldn't be able to pitch in a "big market" (read: New York). If he had a bad outing, the common narrative goes, the attendant media would jump all over him. (Did anyone notice that he spent the second half of the 2012 season in the noted small market of Los Angeles?)

Greinke will have a bad outing at some point (because all pitchers do). He might even have a rough couple of weeks along the way. And no matter where he plays, there will probably be a sportswriter who calls him on it or fans who boo. I want you to memorize this sentence: social anxiety disorder (SAD) is not about being overly sensitive to what other people say about you. Social anxiety is about the irrational fear that you will do or say something horribly embarrassing in front of others. We're talking about something that is internal in its origin. It's not about needing to have thicker skin when people are critical. In fact, people can develop SAD even if no one's been particularly harsh with them. It's also not about the size of the audience. For someone with social anxiety, it can just be the thought of someone else being there.

It's possible that what triggered Greinke's SAD was related to his pitching. It's also possible that it had nothing to do with baseball. Remember that while we often see these men only in their roles as baseball players, they also have lives to live. To my knowledge, Mr. Greinke has chosen to keep the details of his struggle against anxiety and depression private (and that's his right), so before you write him off as damaged goods on the mound, consider that you're dealing with variables about which you know not.

What's the risk? About 50 percent of people who have an episode of depression have a second one within five years. Social anxiety disorder is a little harder to shake, with about 80 percent of folks having another episode. This, however, is not the chance that he will suffer a debilitating episode such as the one several years ago that led to him taking time off from and nearly quitting the game of baseball.

The good news is that Greinke has received treatment and, according to published reports, responded well to anti-depressants. My guess is that he's also seen a counselor. Standard treatment for social anxiety and depression is something known as cognitive restructuring. (For the initiated: yes, I was trained in CBT). When you recognize the anxiety or the depression happening, you figure out the triggering thought and then evaluate whether that thought is true. As an example, if the thought is "I'm going to throw a bad pitch and this will be the end of the world," the first part of that sentence may or may not be true (at some point, everyone throws one that they want back), but the second part is clearly false. My hope is that Mr. Greinke has built up his skills in restructuring his thoughts. If he has built up these skills and he has a recurrence, it will not be as deep or severe.

There is risk that Greinke will have another episode of depression and anxiety, although seemingly he's been living (and pitching) well over the last few years. Within the limits of my knowledge, I don't have great concern about Zack Greinke as a free agent.

Hamilton and Substance Abuse
Let's clear one thing up: if you're going to give Josh Hamilton crap about the decisions that led to his problems with drugs and alcohol, then give him equal credit for the fact that he sought out treatment and has gone to great lengths to maintain his sobriety. Hamilton reportedly travels with no cash in his wallet, as he fears that this will trigger him to use again. He has an accountability partner with whom he travels. Yes, it's a little odd, but for a moment, appreciate the story of a man who has to work that hard for his sobriety and wants to stay away from alcohol and drugs that bad.

Hamilton has had a couple well-publicized incidents when he slipped up in his sobriety, although to his credit, he was able to catch himself and things went no further. But those incidents probably went a long way toward making some GMs nervous. Somewhere between 40 to 60 percent of people who have abused substances have another episode of substance abuse in their lifetime. Not surprisingly, those who have supportive relationships with others, who believe that they can stay away from using (and believe that this will do them good), and have high levels of coping skills are more likely to abstain. Those who suffer from depression are more likely to have a relapse.

The problem with substance use is that it alters the structure of the brain. Most illicit drugs work by stimulating the brain to produce large amounts of a chemical called dopamine that clings on to specific sites in the brain (receptors) in the "pleasure center" of the brain (nucleus accumbens). The feeling that it produces is intense, and it's overwhelming for the brain. So, the brain says "Well, if that's what's going to happen, I need to get rid of some of these receptors so that it's not so intense." (This is known as down-regulation.) This is why people who struggle with addiction often take larger doses of the drug to try to produce more dopamine to get as much coverage as they can on the remaining receptors. But of course, the process feeds back on itself, and the brain down-regulates further.

The brain also makes other structural changes to adapt for the fact that apparently, there will be large doses of this drug coming in. When a person stops using, the brain is still wired to expect the same doses of drug, and the nucleus accumbens is less able to produce happy feelings. People often fall back on drugs because it's the only thing that gives them any sort of happiness. Over time, the brain will repair itself, but that process takes much longer than the initial changes. This is why recovery from substance use is a one-day-at-a-time process. Your brain is with you 24/7, and you have to live with those structural changes all day. This is also why relapse is often sudden and unexpected.

Hamilton does have several protective factors in his favor. He's made structural changes in his life to make sure that he doesn't have opportunities to use drugs. Those aren't fail-safes, but it shows that he values his sobriety. He's found a church that he likes. Whether or not you agree with his theology, a religious group is a very good support system to help in times of emotional stress. My hope is that he attends some sort of a support group, such as Alcoholics Anonymous, to help him. But I'm sure that even Mr. Hamilton would point out, there will always be stress and temptations in his line of work.

For one, United States culture is awash in substance use. Don't believe me? Is that coffee in that cup next to you? Men in United States culture will often try to assert social status by out-drinking one another. At the grocery store that I go to, there's half of an aisle on one side that stocks bread. There are two full aisles devoted to alcohol. For people who are responsible and moderate drinkers, this isn't a problem, but imagine if you were someone who had to fight for your sobriety every day.

On top of that, Mr. Hamilton's job requires that he travel frequently, away from his support systems and frankly, when you have an annual salary that is eight digits long, finding a drug dealer isn't going to be a major undertaking. So, yes, Josh Hamilton will need some very specific handling, particularly on the road. He'll also need very close monitoring over the life of his contract. In assessing the risk of Josh Hamilton relapsing, a GM should be aware that there is a non-zero chance, and that's part of the package that comes with signing him. The good news is that his chances are lower than average and the more supports that are put in place (which he has shown a willingness to embrace), the more likely it is that he will stay sober. My sincere hope is that wherever Mr. Hamilton ends up this offseason, it’s in a situation where his team is as committed to helping him maintain his sobriety as he appears to be.

Russell A. Carleton is an author of Baseball Prospectus. Follow @pizzacutter4
Click here to see Russell's other articles. You can contact Russell by clicking here