Simone Biles Shines Light on Mental Health in The City of Lights

With the conclusion of the 2024 Olympic Games, Simone Biles returns home after leading the U.S. Women’s Gymnastics Team to victory and winning four medals (three gold and one silver) including the gold medal in the individual all-around competition. In doing so, she completed her successful comeback from a painful episode at the 2021 Olympics in Tokyo in which she had to withdraw because of “mental health issues” and cemented her legacy as the greatest gymnast in history.

Source: Courtesy of Jeffrey Lieberman

Mental Health of Competitive Athletes

But Simone’s legacy will also include bringing the mental health of competitive athletes to the public’s attention and calling for more to be done to support this critical aspect of their development and well-being. Biles’ athletic talent had long been apparent as she ascended to GOAT status in the women’s gymnastics universe, but it was how she responded to the dire situation in which she found herself in Tokyo and then managed her recovery that revealed Biles’ courage and strength of character. In Tokyo, she faced the maw of the media with dignity and poise, explaining that the reason she withdrew was that she had lost awareness of her body’s position in space while performing various exercises—a condition known as the “twisties.” She realized that apart from this impairing her performance and dragging the team’s scores down, she would risk serious injury.

Biles' exit was given added resonance because it was followed eight weeks later by champion tennis player Naomi Osaka’s controversial withdrawal from the French Open for similar mental health issues. Two young, gifted female athletes of color reacting very differently to similar if not identical situations dramatically illustrated how athletes are left on their own to manage the psychological demands that come with competitive sports at the highest levels. Moreover, they have to contend with a public that is not always sympathetic to the sacrifices and pressures these elite athletes must endure. Osaka was accused of being unprofessional and wanting special treatment, and Biles was called a “quitter” and selfish for taking a spot on the team thereby depriving another candidate of the chance to compete at the Olympics, not to mention her teammates of an opportunity to win the gold medal. Among her critics was the then-Senate candidate, now newly nominated Republican vice-presidential candidate, JD Vance, who said on Fox News that “it reflects pretty poorly on our sort of therapeutic society that we try to praise people, not for moments of strength, not for moments of heroism, but for their weakest moments.”

It took Simone two years to recompose herself following the Tokyo experience before resuming training for what would be her triumphant comeback. I was overjoyed to see her glorious recovery as I had vicariously experienced her painful experience in Tokyo and her mental challenges in her comeback in the following way.

Six months after the Olympics, I was invited to attend a conference and discuss the effects of stress on the brain, mind, and competitive performance with Simone and her former coach Val Kondos Field. We took the stage before a packed audience of financiers and entrepreneurs eager to know how to compete in their respective fields of endeavor more successfully. I knew that I was not the reason for their attendance and rapt attention, but was pleasantly surprised at their astute questions and comments.

I began by explaining how we learn mental and motor skills through a conscious intellectual process of procedural learning based in the frontal lobes of our cerebral cortex and through repetition inculcate the learned techniques into mental routines, which are transferred to sub-cortical brain structures (basal ganglia and hippocampus) where they can be readily, even automatically, retrieved on demand without thinking. To execute these mental processes most efficiently, our minds must be clear and focused. If we are preoccupied, anxious, or distracted these psychomotor processes cannot be orchestrated efficiently.

The "Twisties"

Simone confirmed that this is what happened to her. So much weighed on her from her past and present (born to a drug-abusing mother, three years in foster care, raised by her grandparents, sexually abused by Dr. Larry Nassar the official USA Gymnastics physician, daunting expectations that she led the USA team to gold, again) that she couldn’t focus her concentration on the routines she had endlessly performed. She explained that for her to execute the gyrations, tumbles, spins, and flips comprising her program with precision timing, she must constantly be aware of her body’s position in space while performing her routine. To not have this constant awareness infused her with the frightening realization that she was developing the “twisties.”

I explained the term twisties referred to the loss of bodily awareness or proprioception. This is a sensory modality (comparable to hearing, seeing, smell, etc.) that relies on mechanosensory cells (think mini-gyroscopes) embedded in muscles, tendons, and joints to send a steady stream of information to the brain. This sensory input automatically signals your brain where your arms, legs, and other body parts are and is acted upon without conscious thought. For these data to be received, to be interpreted, and guided motor schemas with the precision required by elite gymnasts, the mind must be uncluttered by anxiety, worries, and other distractions. If one has too much on their minds, even with conscious effort, they cannot perform optimally. Simone recognized this in the preliminary events and said she "didn’t feel right.” As she progressed through the events, this got worse, not better, and she realized that she couldn’t perform at the level that her teammates expected and even more importantly would risk serious injury.

The phenomenon of twisties is specific to gymnastics but has equivalents in other sports (“choking” in tennis, the “yips” in golf, or just cracking under pressure). All of these entail anxiety or worries interfering with the physiologic functions required by the sport’s specific type of motor actions. Their whimsical names belie the serious nature of the phenomenon, particularly in gymnastics. It’s one thing to miss a putt in golf or a double fault in tennis. However, a mistake in gymnastics when flying through the air twisting and turning at break-neck speed (pun intended) can result in serious, possibly life-altering or threatening, injury.

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In making this comeback, Simone did what few athletes have been able to do (like tennis players Monica Seles, Jennifer Capriati, soccer star Abby Wambach, swimmer Ryan Lochte, and football player Johnny Manziel; the jury is still out on whether Naomi Osaka will regain her winning form), make a successful comeback after a potential career-ending incident occurred and do so on the most exalted and visible stage of athletic competition.

Not every athlete can be expected to have Simone Biles’ talent, courage, and character to meet the challenges and overcome the adversity that comes with competition at the highest levels. Therefore, oversight organizations of the various sports have a responsibility to do more to support the mental health needs of their members. If an athlete sustains a physical injury, they are ministered to by legions of orthopedists, physical therapists, and trainers, whereas for mental difficulties, they are on their own and must fend for themselves. Simone’s inspiring story can bring not just awareness but also action on the part of athletes and sponsoring organizations, and it will add to her astounding legacy.