Finding a Mental Edge with Matthew Sacco, PhD

John Horton:

Hey, there, and welcome to , an extension of our popular Health Essentials Podcast. I'm John Horton, your co-host with Dr. Lauren Wichman.

Dr. Lauren Wichman:

Hi, John. Great to be here, and super excited about the conversation that we have planned today.

John Horton:

It really should be a great one. I know we had talked about doing this for a while, this whole ... if you're going to talk about sports, you're going to talk to athletes, you want to talk to them about how they can be their absolute best.

Dr. Lauren Wichman:

When it comes to performance, I mean, I say this a lot to my athletes — if we're really trying to maximize every single piece to be able to put that puzzle together, physical is a big piece, no doubt about it. Training-

John Horton:

…you spend all that time lifting weights. Getting bigger, faster, stronger, but you got to work upstairs too.

Dr. Lauren Wichman:

…mental is a huge piece of that, too. I think that's where hearing from Dr. Sacco on everything that he works with athletes on, day in, day out, to help maximize that, is going to be really, really interesting.

John Horton:

Yeah. I got to say, Matt Sacco, sports psychologist here was on our “got to get” guest list from the very beginning.

Dr. Lauren Wichman:

Not only is he awesome, but this topic is such a relevant and interesting topic to hopefully fill in our listeners on something that they may not have even considered, to be able to help them be their best.

John Horton:

Yeah. I mean, because we're all looking for that one little thing that can kind of put you over the top and make you just a little bit better. And it sounds like it might just be as easy as using your brain to get there.

Dr. Lauren Wichman:

Mm-hmm. Absolutely. I'm sure we'll touch on this a little bit, but whether it's on the field, in the classroom, in the office, there's so many different places that we all want to be our best. It'll be really interesting to hear from him on how we can approach all of those situations, where we know mental health and the mental edge is critical.

John Horton:

Absolutely. Let's tell folks how they can get there.

Dr. Lauren Wichman:

Let's do it.

John Horton:

Welcome to the podcast, Dr. Sacco. I can't tell you how much we have been looking forward to having you on with us.

Dr. Matt Sacco:

Thanks for inviting me. I'm looking forward to it. Anytime we can get a chance to talk about this stuff publicly and raise some awareness and things, it's a good thing.

John Horton:

Oh, definitely. And when we did our pre-podcast chat, I got to tell you, I was blown away by the variety of athletes that you work with on a daily basis. You see everyone from early teens, who need their folks to drive them to practice, to the professional athletes, who are probably rolling in with some fancy sports car, to old dudes like me, who are just trying to keep going. But despite that whole wide range of folks, it seems like everyone wants to know the same thing, and that's the secret to find that mental edge for their best performance.

Dr. Matt Sacco:

Yeah, you're right. That seems to be a starting point for many people. When they think of or they hear, especially the term “sports psychology” or “sports psychologist,” and historically, that performance enhancement piece is really what people have attributed to what we do in sports psychology. It's a really common question or statement that people come in with, regardless, whether the parents come in with it or whether it's, like you said, the weekend warrior thing. That is a huge element to what people ask about, for sure.

Dr. Lauren Wichman:

I think when it comes to sports in general, we spend so much time practicing and focusing on the physical aspect. I think, hopefully, at this point in time, more and more light is being shed on the potential benefits and how having that mental edge can take you to the next level, too.

Dr. Matt Sacco:

Yeah. It's a really neat progression even from my standpoint to see because ... especially as I mirror and relate to the practice that has been building over the years here in sports myself, one of the earliest conversations that I had with provider when I was being introduced or introducing myself — and at the time, most of my work was as primarily a health psychologist in general — and the comment was kind of more in the lines of, “It's great to meet you. It's great to have you here. We need a sports psychologist, though.” There's some truth to that in terms of understanding the differences between what different specialties, their expertise is. And so I did some, along the way, some specialty retraining in sports psychology and performance and really committed a significant chunk of my time to that, the educational foundations of that. But what really changed the conversation was the fact that putting that plate on an office door in sports medicine that said “Sports Psychologist,” the conversation became much, much less stigmatized for many patients.

Dr. Matt Sacco:

Again, seeing it, but also seeing that sports psychologist piece, the door literally and figuratively kind of opened up, and more people were willing to take that risk or that chance that they thought they may not have otherwise. So it's been really neat to see and then to see it grow to what it is now.

John Horton:

That's really neat to hear that sort of evolution and just kind of that healthy step forward that folks are kind of taking when it comes to approaching it that way.

John Horton:

Like Dr. Wichman said, what we really want to talk about today is finding that mental edge because anybody who competes, you want to be your best on certain days. And we've all been at the starting line of a race, or a game's just starting or something like that, you can feel it inside you. I mean, it's tangible. It's what people call butterflies or whatever it is.

John Horton:

So how do you work with people to find that balance between those normal butterflies, which sounds like are normal and human and kind of healthy, and that point where you are just kind of undoing all the good that you have coming into the event?

Dr. Matt Sacco:

Yeah, that's a really, really great way to describe that evolution as well. Some of it is starting with just some education, education that ... what is going on?

Dr. Matt Sacco:

Now, I'm fortunate with the group of sports providers that I work with that some of that conversation already occurs in the office with the likes of Dr. Wichman and our other primary care sports providers or orthopaedics — sometimes very directly, sometimes a little bit more like, “Hey, this kind of stuff affects what you're doing,” and then they kind of get to me.

Dr. Matt Sacco:

But that educational piece is important because it normalizes what you're describing there, John. It normalizes that you're going to have some of these physiological experiences, and that really starts a conversation. The idea here is not about ... you can use the term “mental edge,” it's not about trying to make those feelings and those experiences go away. And I'll often make a joke, and it's … anybody who's ever said that to an athlete or if it's a coach or something, “When you step onto the field,” that stuff … “You step over that line, it's got to go away, you got to leave all that.” It doesn't work.

Dr. Lauren Wichman:

No. Not at all.

Dr. Matt Sacco:

It just doesn't. I try to do that in a way to not put somebody in a position where they're now contradicting and arguing with a coach, but a recognition that feeling is normal and we're not trying to make it go away. We're not trying make it-

John Horton:

…you can't just swallow that nervousness, huh?

Dr. Matt Sacco:

…right. Like I said, the train there has already left the station. You're already experiencing that physiology, and it is not about trying to help someone become fearless or ultra-motivated or just push through this, because that does not work. It's much, much more about learning how to function inside of that space. But we do have to find that pocket. We do have to find that space that you can function in, and that's kind of the foundation of where I start.

Dr. Lauren Wichman:

And I think sometimes it even comes to we ... when they're in that space, they're at the point where they're like, “I need to not only function, but I need to excel. I'm on the free throw line and the game's on the line and I got to be able to make this shot.” Or, “I've got to hit this putt in this golf outing that means everything.” I think that space can kind of hit you and you don't even realize it. I'm sure when we're in that space to be able to not only perform but exceed expectations.

Dr. Matt Sacco:

Correct. I'm a very visually kind of oriented person. So I do speak a lot in terms of the way I see it, but that description there, it's really ... and athletes are in some of these maybe more high-pressure or feel like they're under pressure types of situations. Our brain, it really does want to operate and zoom out. I've never quite made sense of the term “zoom out.” It really does want to zoom out to this really, really, really big picture because it's getting overwhelmed with processing. All of it gets overwhelming.

Dr. Matt Sacco:

And when we talk about maybe the differences between many of the athletes that we see and what maybe constitutes someone more in that elite space, that elite performer or elite athlete — and athletes and performers, very similar — they're able in those moments to maintain that focus, that hyper-focus on often what are those very, very, very seemingly small controllable details. And unless someone has kind of experienced that, sometimes people talk about being in that flow state of things, it's hard to describe because being overwhelmed changes our entire physiology.

John Horton:

Yeah. So how do you find that balance? That sounds like what you're looking at here. You know you're going to have some nervousness, you know that nervousness can get to the point where it tips you over the edge and you kind of melt down. You got to find that sweet spot right in the middle. What can athletes do in that moment to try to get in that zone where they need to be?

Dr. Matt Sacco:

Well, I think what to do in that moment is really reliant or contingent on everything that you're doing from a preparation standpoint before that because, early in work with many of the athletes that I see, that's the conversation which is ... and it mirrors sports. If you show up on game day not having practiced for a week, or I'll sometimes embellish it even further: If a team shows up the first day of the season and coach says, “Hey, welcome everybody. We'll see you in a month when we have our first game.” People laugh at that. Because no way in your right mind would you think that you're going to do OK on that first game if you haven't practiced.

John Horton:

Coaches are going to love you for this. You know that because they always emphasize practice.

Dr. Matt Sacco:

You got it. It's the same process, and some of it is setting those expectations. You can't expect, then, whatever tool or whatever skill or whatever we talk about to be useful for you, if you haven't been working on it, because that's when you're in that moment and getting that feeling of being overwhelmed. You're not going to have the practice and the skill enough to have essentially that muscle memory, like we talk about in sports or the processing. Practice gives you that ability in sports to ... a coach can say, “All right. Wait, stop. Stop here. Let's do it again. No, stop here. When this person's here, do this, that.”

Dr. Matt Sacco:

And so eventually, you see so many different scenarios that on the field, on the court or whatever it is when you're competing, that processing all of those details is done. There's a recognition, and you respond.

Dr. Matt Sacco:

Same thing with some of these skills, and it's got to start with the practice of it. Learn it, practice it, then when you need it, you'll have that experience and it will be helpful. But it's really challenging. It is really challenging for a lot of folks.

Dr. Lauren Wichman:

I feel like, too, the opportunity to maybe practice some of the skills we may touch on here next comes up probably more frequently than we realize. It doesn't always necessarily need to be just on game day. We have our student athletes, who could really use a lot of these techniques and skills before a test or anybody in the workforce who's got a big meeting, a big presentation. A lot of these techniques and skills, that practice will come in handy in more facets than just the athletic sphere.

John Horton:

I got to be honest, I do that sort of stuff before the podcast because you want to get in that zone. It's not quite game seven of the World Series, but I try to channel that every time.

Dr. Matt Sacco:

And Dr. Wichman, what you said. It's a great kind of conversation to have for a lot of athletes, especially when you talk about it in terms of, you can use these skills in other situations, which means you also then ... they seem like they serve more than one purpose. So then, the ability to practice and see some benefit is not limited to this very specific finite sports skill. And that's how, of course, the competence in it builds. Their confidence can be built, and it's with routine practice.

Dr. Matt Sacco:

I say this very frequently, especially to parents. There is not probably a single more useful skill than you can teach a school-aged kid than the ability to learn how to self-soothe through breathwork, because that hits exactly on ... oftentimes, in school, where they're faced with something, an academic challenge, like a test or something and with some practice, they feel like they're able to control some of that nervousness from spiraling. And if their physiology stays in a healthier space, it prevents that breakdown of that long-term memory retrieval pathway, which when people have extreme test anxiety, they go blank. Then, they start to have that confidence that this actually can work. And young people don't always say it that way in their brains, but it feels better. They feel more in control. And if we can get people to start doing that in these other situations, then of course, ramping up the intensity, it might need a little bit more of an advanced skill or we might need to build more complexity to it, but it all starts at a real basic level.

John Horton:

Yeah. That's so great because you always hear people say, “Take a deep breath.” And it sounds so cliché, but yet, it sounds like when you are in those situations, that is exactly what you should do. I mean, Dr. Sacco, what is that actually doing to us, to our bodies? When you do that, you take that second, like you said, a soothing technique and just focus on your breathing. Take a deep breath. What's going on then that lets us focus better on the task at hand?

Dr. Matt Sacco:

Yeah. And I can speak in the generalities of it, and Dr. Wichman, you certainly can, if you share some more of the physiological info to it.

Dr. Matt Sacco:

I often will say, as our breath goes, the rest of our physiology will follow because it's really the only piece of what is a controllable, and it's not always in control, but when we think about it, we can change it. We shift to these deeper, more ... filling our lungs more, the diaphragmatic breathing, eventually, the heart rate and the blood pressure, things will start to slow down. We just call stress hormones and the reactions to the body — when we're stressed in that fight-or-flight, everything gets pushed to the core, to their survival systems.

Dr. Matt Sacco:

And John, that's what you were saying before about the butterflies, that stomach feeling ... I work with a lot of retired professional athletes and they all joke about there's always somebody throwing up in a locker room before a game, and there's a physiological tie to that because our body is basically saying, “Well, what good is that meal that I just ate if I'm going to be dead in two minutes?” From a very survival standpoint.

Dr. Matt Sacco:

So when our resources get pushed to the core to survival, the things that we don't need to survive are typically the things ... talk about fight-or-flight, the things that help us function, like long-term memory or the ability to process information, that stuff shuts down. So the big picture is, if we can get that breathwork — because you can control it — things will start to slow down.

Dr. Matt Sacco:

But back to what we said before, if you don't practice it, if you don't do the 15, 20 minutes of a very focal kind of process, then your body isn't going to have anywhere near the reaction because it still takes ... even with some deep breaths, it's not instantaneous. It's going to take several minutes at the very least to see this really significant shift in physiological change.

Dr. Matt Sacco:

So if you take a couple deep breaths and you don't have this strong reaction, they're like, “Oh, my gosh, it worked.” Well, there are reasons for that, but the confidence piece is usually what helps carry people through that.

Dr. Lauren Wichman:

The concept of fight-or-flight is totally spot on. I feel like every athlete, high school, college or the pros have all been in that situation. And I think it's so crazy to think about and hear from your perspective, too, with the professional athletes that you've worked with, for some of our listeners to hear that, like, “Hey, they may be performing at the highest, highest, highest level, but they aren't immune to this either.” They are working at these skills and working at this craft, just like all of our other youth athletes are.

Dr. Matt Sacco:

Absolutely. And in many cases, they never really have given a lot of in-depth thought to why that's happening because it's such a common occurrence, a common stereotype, where people hear about it. It's like, “Oh, they're nervous.” Or whatever. And it never really rises to the level for many people to do anything about it because they get sick, they throw up whatever. Especially the people that are competing at those high levels, they've managed to operate despite that and get in the game and play. It never really hits the radar as, “Hey, wait a minute. I wonder if there's something I can do about this because” They just move on.

John Horton:

It's part of their routine, it sounds like. This is what I do. I throw up before a game.

Dr. Matt Sacco:

Correct. It's important, as you said, Dr. Wichman. It's important for young people in particular to recognize, one, that this is really a very, very common, in most instances, it is a part of the normal physiological process that the body undertakes in a stressful situation. It's normal. That it's something that we can improve on, we can work on, we can get better at. But it's nothing that is out of the range of what we might expect to see. It's probably got its roots in this, maybe that threshold has been crossed between “I can function within this space” to maybe it's getting in the way now.

Dr. Lauren Wichman:

Right. I'm thinking, too, obviously, butterflies are normal, but if we can minimize everybody from having to throw up before games, let's do this. Can we imagine what level we could get to if we didn't have to deal with that? So I think that's where hearing from you could be so helpful in strategies and things that you recommend to all the athletes that you work with, too.

John Horton:

Yeah. Not throwing up would make the locker room a little more pleasant ahead of the games, too, I'm thinking.

Dr. Matt Sacco:

However, those that have those little superstitions that if we break that, then if they end up losing the game, we may have just shot a hole in their entire theory of what was working. It's about recognizing that there's a space that you operate really, really maximally at. And butterflies, that nervousness, excitement: normal. Cross into anxiety, and it gets in the way of your ability to operate at a high level. And that's kind of that little nuanced space for a lot of people, of finding where that is.

John Horton:

When we were talking about tips and things like that, I know, when we talked to you ahead of this, you brought up some examples that were fascinating to me. It seemed like it brought a tactile approach to it. When you're in these situations, if there's ... you mentioned baseball pitchers, and they do things on their mitts. So that way, when you're in that stressful situation, you feel a knot on a string or something, and it kind of helps bring you back down. That's very much, it seems, like a learned sort of thing that you have to do and just kind of practice, very much like what you were saying.

Dr. Matt Sacco:

That's a strategy and that's a tool across many sports that I use and help people with. The tactile components or that touch component to it, I think, is so important because one, it's not often that people focus on that. The addition of information coming in from one of our other sensory channels, and one that isn't necessarily focused on in the same way, can really, really help from a focus standpoint. Again, a pitcher's a great example. Baseball, softball. You're on the mound, you're in the circle. There's lots of sounds, there's lots of sights, there's lots of visually things happening that you're processing. There's all these different things going on. Smells, all of that.

Dr. Matt Sacco:

And the point here is, it has to be used very, very intentionally for it to work. Whether it's, like you said, a knot — baseball, softball mitts have knots on the laces, so that's not enough — it has to be that one knot, that knot that we tie specifically for this, that knot that when you touch it is paired with practice exercises that are rooted in the grounding, the physiological relaxation. So the moment that that person either seeks that out — that's often why I tell people it has to be intentional that you seek that out — and with that practice, it is a tactile sensory input for that sense of calm. If you have some other phrases, whatever, but it allows a different way to activate that relaxation, rather than relying on, “OK, deep breath.” Or “Tell myself something.” Or whatever. The tactile one requires ... it's a different input channel, it's a different intentional channel, and it's something that, for a lot, find very helpful, and nobody has to know about it.

John Horton:

Yeah. It's an emotional support knot is basically what it comes down to.

Dr. Matt Sacco:

Absolutely. It is absolutely something where people can touch and just get that ... we create the grounding or the relationship with it very intentionally — and it has to be something that works for the athlete, it has to be personal — and then it's something that ... it is there and they use it, it's a tool and it helps them stay in that space.

Dr. Lauren Wichman:

I like the idea even that you had shared before with that tendency to zoom out in big moments, that knot keeps you zoomed in. You can see it, you can touch it, that's what it's for. Keep you engaged, keep you locked in, not considering the crowd or the circumstances that may be influencing the potential for your performance.

Dr. Matt Sacco:

Correct. I really encourage people to really try this, and it can be in any way that works for you. I keep a stone, a little pebble, something in my pocket. I tell people ... obviously, you're not on the field, it's a little different. People say, “What about a coin or something?” Well, no, it's got to be something that ... if you put your hand in your pocket, if you're going to go do a presentation, you're going to go do a talk, and you put your hand in your pocket and there's a quarter there or something … now maybe you never have change in your pocket and it might work. But if it's something that you touch it and it has that like, “Oh, that's what that is.” It changes the whole dynamic. It refocuses things in that sensory channel and you're right — with all the other stuff that could be coming at someone, that's really one way that requires no internal dialogue. It requires no other reminder. When you do it and practice it enough, that hit is like a tactile boom. There's no higher-level processing that's required because you've been ... you really do have to practice it and use it as a tool, and it works really well.

John Horton:

That's such a great tip, leaning on that in those moments and doing it. But I'm also drawn to your whole thing that it has to be practiced. How much of this then also becomes routine? Obviously, we're in Cleveland here. If you're of a certain age here, we all grew up watching Mike Hargrove adjust his batting gloves like 800 times before he got in the box, and I'm guessing his gloves were not that loose. It was just kind of his routine every single time, and it kind of becomes what you do. How much of that can also be used to get yourself ready and focused and ready to be your best?

Dr. Matt Sacco:

A lot of it. In my experience in working with athletes, there are some sports that seem to be more prone to a lot of those, the superstitious, those routines. I will distinguish, though, between when someone has a very specific routine that they do on game day that is a little bit more expanded, where, “OK, I get up and I do this and I do this and I do this.” So that part of the lockstep getting to the game. Or if it's school-age athletes on the bus doing some things intentionally from a routine and a structure at certain points to start to remind your body — remind yourself that you're beginning to shift toward that higher level of competition, so that it's not a shock to the system.

Dr. Matt Sacco:

Some people stumble on that just on their own because that's kind of what they've done. That is different in setting it up, structuring it and staying with that. And then, as you're describing with those ... maybe some of those things that are superstitious. If people are doing it intentionally, like “I do this because it helps me” versus “If I don't do it then ... I struck out, I did it.” That's why, because I didn't do it exactly this number of times. Try to manage those things. But routine and repetition, what helps people feel comfortable and focused is a very, very important part for many athletes of maintaining that, that kind of staying in the zone and being prepared to perform.

Dr. Lauren Wichman:

In my college soccer days, I can fully attest to that superstitious/just routine to kind of get you in the right mindset to perform on game day. Anything, from the night before meal to the pregame playlist to the lucky hair scrunchy. It's really funny, because all of those things that I used in my college soccer days translated right over to a med school test, right after I finished retiring. It worked like a charm. But I get what you-

John Horton:

…that lucky hair scrunchy came with you to the exams. Is that-

Dr. Lauren Wichman:

…it did. It did. That it did.

Dr. Matt Sacco:

That's awesome.

Dr. Lauren Wichman:

A lot of times, whatever it takes for people, as long as we can kind of find that healthy balance. But at the same time, if there's a way that we can maximize that. Let's maximize the butterflies. Let's give you that extra energy through doing that routine to be able to help you feel, just like you said, Dr. Sacco, really confident in what you're doing. We'll take that, for sure.

Dr. Matt Sacco:

Correct. And confidence, that genuine bona fide confidence comes from having some success with whatever it is that you're doing, it's not enough to try to have that ... just telling oneself, “I can do this. I've got this.” If it's not led to success or if you don't have other similar things that you can tie, that you can prove to yourself that you're capable, that can be a challenge. As I said, you do have to have some success, you do have to have some ... whatever that looks like in the task to then feel like, “OK, it's not a miracle. It doesn't mean, well, now I've got this.” It means, “All right. Well, now I can draw from some experiences because I did this before.” And that's hard because it's a process.

John Horton:

We were talking earlier about the whole visualization techniques, which I think everyone talks about, and you were very much like, “Yes, there is power in those, but there are limitations.” Like I said, I can think about dunking a basketball as much as I want, and those thoughts are not going to get me over that 10-foot rim. So how do you balance out using that sort of technique or this positive reinforcement and thinking it through to, I guess, meeting the realities and not overstepping?

Dr. Matt Sacco:

Yeah. I'd say that those visualizations, rehearsals, imagery, all that, they're tools. They're tools and they should be used just like that. They are tools, and the more tools you can have in your toolbox to approach things, the better. People I work with have probably heard me use this example a lot as well, but it's kind of like at home. Most people have that drawer in their kitchen somewhere that's got stuff in it. Let's say you want to put a nail in the wall to hang a picture. You open that drawer and you look and there's one of those adjustable wrenches, those crescent wrenches. You're like, “Well, that'll do it.” And you grab it and you go and you can put the nail in. And that wrench, you could put a screw in, you could open a bottle. You could use it for a bunch of different things.

Dr. Matt Sacco:

However, if you open that drawer and there's also a hammer. You say, “Well, yeah. That's actually way more appropriate and efficient for the job.” And these skills are the same way because, eventually, what you start to do through practice is figure out for yourself as an individual, which ones seem to work for me and in what situations. It's like making sure you have the right screwdriver for the screw that you're trying to put in. The right size wrench.

Dr. Matt Sacco:

So those kinds of things, visual cues, rehearsal, mental imagery, are absolutely tools that go in there, but it would be no different than if they were the adjustable wrench and you're relying on it and they work. Grossly, they can get you some benefit, but they're going to come up short, especially with very specific tasks that might require a little bit more fine-tuning. A little more finesse, a little more specificity. It just doesn't work. And so they're tools, and that's how I would approach them.

John Horton:

And it sounds like with this, you need to be flexible. Like you said, you can have these great tools, but they're not always necessarily going to work. If you set up this great routine, that's fabulous, if you can follow it. But then one day, the bus is running late to wherever you're going, and all of a sudden, you don't have that hour that you usually like to prep for your game, and you've got to speed it up. It sounds like you have to be able to mentally make that adjustment and have that in your toolbox, too. There's no one right answer, but it sounds like you try to work with people to find multiple solutions, depending on the situation.

Dr. Matt Sacco:

Absolutely correct. Psychological rigidity is something that usually shows itself quite quickly. And this is something — and Dr. Wichman, you've probably seen in practice — when you're talking with a patient, it doesn't matter what it is, there's that rigidity that comes out or that inflexibility, like, “Wait a minute. Something's making it very, very difficult.” And that rigidity, when somebody approaches with that, can make it very difficult. Those are also going to be the people who have already experienced a lot of chaos or challenge in their ... when things change, those are the ones that you see on a bus full of kids that just, they just can't kind of recover or rebound.

Dr. Matt Sacco:

Psychological flexibility, and that term that we hear a lot now, that “growth mindset” — someone that looks at it and says, “OK, well, all right. Well, let me see what I can do.” Versus, “I can't do that.” I mean, that's an oversimplification, but that idea of being flexible, forward-thinking. “OK, this happened. What can I do to try to navigate through whatever it is?” Those are the most favorable characteristics when it comes time for people being able to adjust and adapt that you could come up with. And it shows itself in so many ways when you work with people.

Dr. Lauren Wichman:

I feel like, too, when it comes to performance within sport, a lot of the athletes that are able to adapt to a specific situation, if they have those tools in their toolbox or if that's something that they've just ... a skill they've acquired throughout their life, they're able to perform better. They're able to be those clutch performers within a specific situation. And I think, for people who maybe haven't had that much experience, they're looking for ways like, “OK, well, how do I get to that level?”

Dr. Lauren Wichman:

One thing that we're always really curious to hear from your perspective is how possible is it for people to really learn some of those flexibility, adaptability, willingness to accept and use some of those skills? How possible is that, would you say?

Dr. Matt Sacco:

That is a really, really, really good question. I mean, the short answer is: It's very possible. And I think that the signs that you might look for, that might give you an idea of where someone might be on that kind of continuum, first and foremost, if you're ... specifically as a sports med doc, if you're in the office talking to someone and you make the suggestion or the offer to go and possibly see the sports psychologist, I don't know, some people reflexively might ... the difference between that reflexive versus ... they say, “Sure, sure, sure.” And then, they never schedule or whatever, that's helpful information.

Dr. Matt Sacco:

The person that comes into the door, even skeptical, then we can start that process. It definitely is possible because it's always ... I always start my root with skills because it doesn't matter if someone believes that they work, it doesn't matter if it's like they buy into it per se, that will affect how much they practice, for sure, and how committed they are. I usually have people keep a notebook and track things, so that we can talk about hiccups, what works, what doesn't, whatever.

Dr. Matt Sacco:

That's evidence to how much they put into that. But if they're practicing the skills regularly, whether they feel like it makes a difference or not, if they're doing it physiologically. They're going to be gaining some control and some confidence in this. So the answer is: It's very, very possible.

Dr. Matt Sacco:

I also am very mindful, and this is something that I think in ... just from a societal standpoint, what we see with social media and everything's videoed and shows from every age. We've got this elite athlete at this age and this elite ... I'm also very, very mindful that we have to consider where someone is developmentally in life.

Dr. Matt Sacco:

It's a different conversation with the 12-, 13-, 14-year-old and what I might expect and what they might, from a brain development standpoint, be able to even do versus the 25-year-old, versus the young person who's just got their first semester as a freshman in college. It may seem similar, but brain development plays a huge role in the capacity for certain skills are … I mean, young kids are very emotionally driven. So trying to give them ... let me go into this long, drawn-out conversation about how to improve your internal dialogue and it's like, they just don't have the equipment. And so we have to be mindful.

Dr. Matt Sacco:

But I think sometimes, we do see that adults expect young people to be at a place that developmentally they're not, and that's where some of that frustration could come in. So I try to be very mindful of where someone is before I think about, “OK, what are we going to do?” But it doesn't matter when it's breathing.

John Horton:

You had mentioned before, too, even the stigma around this. And even just now, you're saying when people come into the office, sometimes they're a little skeptical. Where are we now in this acceptance of mental health being something that you need to incorporate into your sports routine? It can be as important as all the physical aspects we talk about, the lifting, the muscle building. You got to get your head in the right spot also. Where are people at with accepting that, and do you still see it as something that's growing?

Dr. Matt Sacco:

I'll start by saying, I wish we were further along. I'm also often surprised — and I can draw from conversations that I've had with many either professional or retired professional athletes who are 40 years old and up, just as kind of a cutoff here — and when I'm working with them, if I'm doing an evaluation, getting some history about, some mental health history, or I'll ask, “OK, at any point, have you ever worked with a therapist, a psychologist, a counselor?” Whatever, just to get some history. And I'm often pleasantly surprised to hear the number that have had ... and say, “Oh, yeah. I worked with a psychologist when I was with this team.” Or “I worked with a psychologist for that.”

Dr. Matt Sacco:

And many times, it is beyond just the performance and the skills and the mental skill stuff, that they've worked with them because things were going on. So when I hear that, I know that it's been done and that people have had those experiences when I might not have been quite ... I might not of come up with a number that said, “Wow, people have actually been doing this.” I think it's there. I do think there's still a pretty sizable stigma, especially in certain age groups, men, gender-specific it's-

John Horton:

…you feel like you have to tough it out and sometimes, using your noggin to figure things out isn't always ... it can be a really good thing.

Dr. Matt Sacco:

Yeah. That we're socialized as men, the “tough it out” is the tool, that is the adjustable wrench that we go to. That's it.

John Horton:

Right.

Dr. Lauren Wichman:

Yeah.

Dr. Matt Sacco:

It's disproportionate, even in my practice in sports, it's disproportionately female athlete that comes in, that takes the referral, that comes in and then sticks with it for a while. We work on that, a lot of the community outreach, the things ... working with teams and just kind of putting face with name and letting people know a little bit about what it might look like helps. And if I can just get them to recognize that, “Ooh, this could actually maybe help performance.” Then, we've got a step. But it is hard.

Dr. Matt Sacco:

The expression, you don't know what you don't know, and you also, not necessarily willing to jump into it if you're uncertain. And historically, it might be something that would've been used as leverage or proof that you're weak or whatever it is. So we have work to do, but we're in a lot better place than maybe I would've said several years ago.

John Horton:

Yeah. Dr. Wichman, I know you work with a lot of teams. Do you find that there's more of an acceptance when you even maybe talk to some young athletes about, “Hey, maybe talk to somebody about this, try to work some of this stuff through.”

Dr. Lauren Wichman:

I would say definitely. Especially when I am potentially making a referral over to Dr. Sacco and I'm trying to frame this as something that they could ... I usually try to frame it as a way that they can realize that, “Oh, this is something that could help my performance.” I'm not necessarily sending them over because it's like, “Oh, I think this would be ...” When I'm trying to frame it, I usually try to also normalize that and say that ... we send a lot of our athletes over. We have many athletes that talk to sports psychology on a very regular basis. It may just be checkpoints, it may just be techniques. It's not necessarily something that you have to go for once a week for the rest of your life, where this is going to be something that is quite an undertaking, but really, it's learned skills. It's talking to somebody that knows exactly what they're doing and what they've helped athletes get through time and time again, and seeing if there's something that you can pick up on to enhance the way that you perform out on the field.

Dr. Matt Sacco:

And appreciate hearing that, too. I think that's exactly why the practice that they've built in sports in the last couple of years works so effectively and most of it is ... of course, some of the skills stuff. Most of the impact, the additive value comes from the conversations, the relationships as this multidisciplinary team approach that ... I mean, I work with PT, if somebody's struggling, walk down the hall and then see one of the primary care sports providers or they'll come over.

Dr. Matt Sacco:

So there's this knowledge that we are all actually ... it's more than we just say that we work together. We can have conversations and we'll talk about it and of course, do all of this with permission from the patients. And most of the time, they love to know that, and say, “Hey, can I reach out to or can I talk to this person?” And they're like, “That's great.” It enhances what all of us do because it really builds upon this idea that it's this care team, and there's so many athletes, our team. That team idea resonates with them.

Dr. Matt Sacco:

You can put a referral, maybe if you talk to a sports psychologist, that they have to go somewhere else, it breaks down and so it's easier. And I really do, I believe wholeheartedly, and I've seen it from our primary care sports providers, our athletic trainers, our physical therapists, the surgeons, especially our sports-specific providers, is that, just as you said, we send a lot of people there. It's acute focus. It's not long-term, and they figure that out. It is exponentially more powerful.

Dr. Matt Sacco:

I don't really think I could imagine building a practice like this, this effective, and actually make a go at it in a place like this if it wasn't with the ... not just verbal lip service support, but you can tell that the sales pitch and the belief is that this can work and patients feel that. They feel that this is genuine and that we're all really wanting them to get better. It's just so much more effective.

John Horton:

Now, Dr. Sacco, so much of this, it sounds like, is very individualized with people. We always like to give our listeners some kind of concrete things they can take into their life, into their sports, in this instance, to kind of help. So what would just be a few things you would kind of suggest if people are looking for ways to get that mental edge to just hit their absolute peak performance?

Dr. Matt Sacco:

So I think first of all, what I would just kind of highlight again, is that the idea that athletes are very, very, very familiar with the concept of spending thousands and thousands and thousands of hours training, lifting, running. So much of it is quantitative. You work hard, you get results, you get faster, you get stronger. We can put a number to that. Even injury recovery, you go to PT and they're checking your range of motion.

Dr. Matt Sacco:

One of my own kids right now, I'm dealing with that with recovery from surgery and my knee's at this and I can do this. And it's like those numbers stick. However, we aren't accustomed to and spend almost historically nothing or limited on the training of the brain, if you will. And the brain is what controls all of it.

Dr. Lauren Wichman:

Mm-hmm.

John Horton:

Yeah.

Dr. Matt Sacco:

So we think about the connection, this isn't a leap, this isn't about a separate ... your brain is doing all of this. So if we can understand that there's some training that can be done there and also a recognition that as athletes from young ... as you grow, you get older, you start to compete in higher levels of sports, the physical differences that exist between athletes ... hang out in some youth sports and you watch a 5-, 6-, 7-seven-year-old or younger soccer game and kids are ... you might see a kid who seems a little more coordinated and is running circles around them and kids that are falling over. That highlights it.

Dr. Matt Sacco:

But as we get older, those differences get smaller. We step up further and further and further … what begins to separate people is often the ability to gain some skills or to manage to control more of that mental aspect of it because physically, the gap is so small and you can only get so strong, you can only get so fast. Watch the Olympics and the times, and they're slicing stuff at the hundredth of a second, and that beating it by a hundredth or a world record by ... you watch the line at the Olympics that they're trying to catch, that is misleading because what it takes to get that change is, it's not physically at that point.

Dr. Matt Sacco:

So the emphasis that if you start to work on it now, that those are going to be the kind of things that will help distinguish you, separate you, and make you better and more prepared, or the best version of yourself that you can.

Dr. Lauren Wichman:

Do you have any quick-hitter tips for parents of these athletes in helping them help their child navigate the mental edge side of sports?

Dr. Matt Sacco:

Yep. Yep. I chunk it into developmentally young kids, elementary, first and foremost. The amount of time that we often see people dedicating to the skills and the practice is too much. Developmentally, their brain has to do other things to get those skills. They're going to get them. And so giving them those opportunities to still be a kid, to play, and that kind of stuff is very, very, very, very important. Kids know what competition is.

Dr. Matt Sacco:

When a kid hits that growth spurt at 12, 13, 14, whatever it is, those skills that worked in the 12-year-old body before it grew six inches. Listen, you got to figure it out again. So I think there's this idea of being patient, being patient, especially younger. And the most important thing is that the kid wants to keep coming back and wants to keep playing because then, they can get better because if they're still playing, they can get ... but if they don't, that's a problem.

Dr. Matt Sacco:

And as parents and as adults, it's tough when you're inundated with these comparisons and see that this kid's doing this, this kid's doing that. So sometimes, it can be a matter of again, being patient, taking a step back. If you have questions, just as many of you do, send people my way. I will often say, if you have questions, if you want to know about ... I've learned a ton in my years of being a parent at this point, my oldest is 15. I'm like, “Oh, I have people down the hall, sports providers.” And Dr. Lewis is my go-to, like, “Oh, hold up.”

Dr. Matt Sacco:

And developmentally, when they can recognize, no, that's normal for a kid to have this issue, to have this pain or that. Go to the experts and not Google, not ChatGPT. Go to the experts and ask. That's where you start. And then, from there, you can develop a plan. If one skill, breathing, diaphragmatic breathing, a few minutes, started as a routine, and it will really, really be helpful, and everybody can benefit from it.

John Horton:

That sounds like the breathing technique is one of the biggest things. And we've covered that on the Health Essentials Podcast, and various things, just that whole mindful breathing. As simple as it sounds, it sounds like that's where the solution kind of starts for all of this, getting your mind and body ready to just really rock whatever it is that you're doing. Yeah.

Dr. Matt Sacco:

You need to be skilled with that to be able to build into more of those complex things. It's not an oversimplification. You have to have a mastery of that, though, if you really do want to, then build up to those precise things where you're saying, “OK, now that I've slowed down, now that I can get access to some of that higher level stuff that I need.” But if you can't, then it's going to be really setting someone up to be really frustrated because these other higher-level things — imagery, visualization, cues — they're not going to be able to learn them as effectively and they're not going to work if you haven't managed targeting that physiological piece.

John Horton:

Well, we've covered an awful lot today. So I think we're all going to, one, start working on our breathing, and then start going into all these other things that you've been talking about. If we're just going to wrap things up here, final thoughts for people: If they want to go searching for this mental edge, to really just excel as much as they possibly can, where do you recommend they start? What's the first step to take?

Dr. Matt Sacco:

So first step, and I'll loop back to what I just said a minute ago. Go to the people that know, lean on the people who have an understanding of this. Depending on what age group we're talking here, depending on that. I think it's very, very important to take this holistic approach, make sure that you have good general physical health, work with your pediatrician, your primary care, because it's really hard as a psychologist to think that I can make much difference if there's something going on that medically or physically is keeping somebody from reaching their potential.

Dr. Matt Sacco:

I think, from a psychology standpoint, there are differences, in terms of sports psychologists who are licensed psychologists in the state. Whatever state it is, someone who's licensed who provides more of those complex care things, also has the experience with mental health and all that kind of stuff. There's that piece. There aren't as many as there are nowadays with what we see as more of the performance consultants and the coaching, those things that not necessarily don't require that very specific licensure or the training might be a little bit more, a wider range of types of training.

Dr. Matt Sacco:

So being mindful of that and looking ... I say if you're really questioning or you really try to find the licensed folks, there are psychologists in practice, licensed psychologists that may not have even the specialty retraining in sports and performance who are also, though, very, very, very, very, very skilled and competent with some of these breathing exercises. Or the stress management or the things that. Most of us in psychology build a lot of our coping with clients upon that. So those folks are great as well for a broader application, but go to the experts. Just go to your primary care, go to your sports provider. Start with those folks. If they're outside of our system, they really need to start seeing somebody in our sports, so that I know that ... I rely very heavily on our sports providers to help me understand if this is someone who's in a position to ... healthy, well, or other things, but start there and get involved in a team of people who you, you have a good feeling or have a good reputation about being helpful. And then from there, just invest, just go with it and give a little college try, as they say. Really commit yourself. And I can't check on that, but if you've committed yourself and you're doing the work, then it'll work.

John Horton:

All right. Well, that sums it up pretty well. Dr. Sacco, I can't thank you enough for coming in. Every time I talk with you, I always feel like I learn a ton. I try to carry your words with me whenever I'm out doing things. I got a half-marathon I'm going to be hitting pretty soon. I'll try to keep some of those positive thoughts in my head as I'm chugging through those miles.

Dr. Matt Sacco:

Absolutely. Don't wait until the day of that marathon to start using those things. Commit yourself to the practice now and it'll work. But anytime anybody is interested in having conversations about psychological well-being, mental health and that, performance, it's a great exposure and maybe opens the door for somebody who may have been on the fence about, “Should I or should I not give this a try?” And so it's worth it if somebody hears something that they value.

Dr. Lauren Wichman:

Thank you so much for coming on the podcast, and thank you so much for being such a great interdisciplinary partner for us over in sports and exercise medicine, orthopaedics. We really appreciate it. So thank you.

Dr. Matt Sacco:

Absolutely. Anytime. I appreciate ... it is a team. It works a lot better when we're all genuinely pulling in the same direction.

John Horton:

We're going to take you up on that. Thanks a lot. Thanks again, Dr. Sacco. See you soon.

Dr. Lauren Wichman:

Bye.

Dr. Matt Sacco:

Bye.

John Horton:

So Dr. Wichman, I know we were excited to have Dr. Sacco on just to start exploring this concept. And I got to tell you, that was way more in-depth than what I even thought we were going to go to. I learned so much from that conversation.

Dr. Lauren Wichman:

I feel like we covered so many different facets of what's involved with the mental edge. And I feel like one of the big pieces is just the relatability with this. Whether you're youth, whether you're college, whether you're elite pro athletes, everybody is thinking about this. It applies to everybody, which is really great.

John Horton:

Yeah. And the thing that really struck me is his comment that this all can be learned. We think that there's just people who have that clutch gene. They always come through. And so much of it is just in training yourself and preparing yourself, to just calm your mind and really focus on the task at hand. And you can learn that if you put in the time and the dedication and the practice just to get on point.

Dr. Lauren Wichman:

There are a few skills that we can kind of home in on, things that we can develop to stay zoomed in. I love that concept because it's so easy to think about how if you're in that moment, coming, zooming out, looking at the stage, looking at the circumstances. That could be really, really nerve-wracking. But he's got tools to put into our toolbox to help us stay in the moment.

John Horton:

Yep. And you want to grab the right one. You got to leave that handy wrench. You don't need that when you got to hammer something in.

Dr. Lauren Wichman:

Let's get the hammer. I love it.

John Horton:

Well, if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, play hard and be well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.