“Plastics,” Mr McGuire famously said to Dustin Hoffman’s character Benjamin in The Graduate. What did he mean? Was he suggesting that to be successful Benjamin should find a niche? Or have we only now mastered the concept of a niche, subdividing fields into narrow areas of alleged expertise. Did he mean plastic surgery? I wondered. If so, was he going to be a breast guy? A hand guy? A face guy? Or had Mr McGuire meant actual plastic, and if so, in what niche? PCBs? Saran wrap? Wheels? Bottles? Toys? Packaging?
A niche is a way for us to package, or market, ourselves. The thinking is that it may help us attract patients. The theory is that a niche signifies expertise, which ultimately would benefit a patient. What is a niche, how is it done, and is there a purpose? According to Merriam Webster, niche is a “place, employment, status, or activity for which a person or thing is best fitted.”
Developing a professional niche takes passion, perseverance, and a body of knowledge that is unique. In psychiatry, a heightened knowledge of and sensitivity to a particular area has the potential to benefit our patients. Although in theory we can all bring that tabula rasa and empathic connection to our patients, we do gain instant credibility if our experiences resonate with those of our patients.
There are a number of well-established niches in psychiatry, from forensics to addictions to LGBT. What are the origins of a niche, particularly in psychiatry? You may find your niche if you have been imprinted by a charismatic mentor, such as an eccentric but charming professor of neuropsychiatry, who ignites an enthusiasm for study in an area of research or practice. Or perhaps by an uncle with bipolar disorder, who will afford you a unique sensitivity to and an insider’s expertise on mood disorders. Could the budding forensic psychiatrist be sublimating his desire to go to law school?
Sports psychiatry is a niche that took root 22 years ago, when 4 psychiatrists came together and started a group for those who shared this interest. The group has since grown into an international organization called the International Society for Sports Psychiatry (ISSP) (www.TheISSP.org) with over 100 members from Europe to South America to Japan and Australia. The ISSP has become an allied group of the American Psychiatric Association (APA). Every year at the APA annual meeting, members of the board meet. There are scientific sessions, the ISSP presents a symposium on a timely topic in sports psychiatry, and featured athletes present their histories.
Sports psychiatry distinguishes itself from the well-established field of sports psychology. While our interventions often do affect sports performance positively—and performance problems may in fact be the presenting complaint—our primary goal is not performance enhancement per se, but rather a focus on psychopathology. Some illnesses may have been present before the person became an athlete or the potential may have been there. Perhaps there is a genetic predisposition to, for example, bipolar disorder. Similarly, it is not uncommon to make a diagnosis of new-onset schizophrenia in a young high school or college athlete, given the demographics of the illness.
Involvement in sports may exacerbate some existing illnesses; for example, an anxiety disorder might be exacerbated by the unique pressures of athletic competition. Other psychopathologies may be engendered through the sport itself: an eating disorder in a gymnast or anabolic steroid abuse in a body builder.
There are unique considerations when choosing pharmacological interventions. It is vital to attend to adverse events that may impair athletic performance, such as a tremor induced by lithium, or weight gain secondary to an antipsychotic. In addition, sports psychiatrists must be mindful of prescription medications and must keep in mind the banned substances list for each sporting body. A common example: drugs perceived as having performance-enhancing properties, such as psychostimulants for ADHD. The rules vary from one governing body in sports to another, but a therapeutic use exemption may be available for an athlete after a careful review of his or her history.
What qualities might a sports psychiatrist have? Most of us who are drawn to the field have been athletes, and we are no strangers to the discipline, single-mindedness, and competitive spirit required to succeed on the field. This resonates with our patients.
Dr Baum is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and is in private practice in Chevy Chase, Md.