To Phoenix, Ariz., psychiatrist Marjorie Shuer, M.D., the inseparability of mind and body, a tenet of modern biopsychosocial psychiatry, has a special meaning.

As a lifelong athlete, coach, and trainer as well as a researcher with a keen interest in the role of sports in physical and emotional development and mental health, Shuer knows that the swimmer on the last leg of a relay or the runner sprinting to the finish line is more than a well-oiled machine.

Trained as a child and adolescent psychiatrist, Shuer has brought to the profession her passion for sports and an academic interest in the psychology of injury and rehabilitation, drug use in sports, and psychiatric issues among young athletes.

Recently these interests brought her to the 1996 Olympic Games in Atlanta, where she was a medical officer in charge of "doping control"_the monitoring of drug use and abuse by athletes_for the kayaking and canoeing events.

The job kept her busy, but not too occupied to enjoy the games. Having been to the Olympics once 20 years before in Montreal, Shuer recalls the opening and closing ceremonies of the Atlanta Games as the most memorable moments.

"Packed with emotion" is how she described those moments. "You can see it on television, but it is never the same as actually being there in the stands."

Drug monitoring at the Olympics, as Shuer describes it, has advanced to a state of high sophistication since the mid-1970's, when athletes first were systematically tested at the international level for using anabolic steroids, which are used to increase strength, as well as other performance-enhancing agents.

Today, she said, winners of gold, silver, and bronze medals and randomly selected competitors who did not win are required to give urine samples directly after events.

Urine collection is "visualized," meaning that an official from the doping control unit has to be there to watch the athlete urinate, a precaution against drug users who might try to avoid detection by substituting someone else's urine or otherwise tampering with the urine.

Laboratory testing is blind_the identity of the athlete is unknown_and athletes are allowed to have a coach or representative with them during the collection.

It was Shuer's job to see that this highly regulated process conformed to the standards of the International Olympic Committee.

The Olympic Games are serious about detecting drug users, Shuer said, as is the United States Olympic Committee, which budgeted $1.5 million for drug testing in 1996.

Anabolic steroids are the most popular drugs among athletes, but laboratory testing_including high-resolution mass spectrometry_will detect almost any kind of substance, she said.

The experience taught her much, Shuer said, especially about the methods athletes can employ to avoid detection. It is a lesson that may inform her work with adolescents, she added, especially since drug-abusing teenagers can be fairly creative in their attempts to fool drug testers. She also observed that "visualized" urine collection could be problematic with youngsters who have a history of sexual abuse.

Sports and Mental Health

Her work at the Olympics was only the most recent achievement in a young career devoted to the intersection between sports and mental health. She was on the coaching staff of the United States Modern Pentathlon Olympic Development Clinic in 1980, chair of the historical committee on women's athletics at Stanford University from 1993 to 1995, a member of the Sports Medicine Advisory Council at Stanford, and a participant in the drug control program of the National Collegiate Athletic Association in 1994.

At APA's 1995 annual meeting in Miami, Shuer chaired the symposia "Athletic Injury, Loss, and the Invulnerability of Youth" and "The Athlete as Celebrity: Perks and Pitfalls."

She spoke to the American Academy of Child and Adolescent Psychiatry in 1993 on "Psychiatric Issues in the High School and Collegiate Athlete" and a year later on "Mental Health Characteristics of the Elite Athlete" and "Sports and Developmental Psychiatry."

Role in Sports

Shuer told Psychiatric News that she believes there is a burgeoning role for psychiatry in sports at the high school, college, Olympic, and professional levels.

Where athletes have turned to mental health professionals, it has mostly been to psychologists specializing in "performance enhancement."

Unaddressed, Shuer said, are a variety of issues related to athletes' larger well- being.

"In the early '60's psychologists were hired to give professional teams psychological batteries," Shuer said. "They shared the results with management who used them to make decisions [about who to place in competition]. . . .Shortly after that players unionized and said, 'No more.'"

While sport psychologists have stuck with specializing in performance enhancement, a "big void" has been left, Shuer said. Issues surrounding injury, rehabilitation, and retirement from sports are ripe for the attention of psychiatrists.

She cited the collegiate athlete confronted with retirement from competition: How does the competitor, having devoted a lifetime to the perfection of a single athletic skill and never having cultivated other interests or capacities, confront the end of a career?

Shuer is also interested in athletic attitudes toward injury and rehabilitation, a subject that intersects powerfully with risk for drug use.

"You have this milieu where to show any sign of weakness means that you are considered untough," Shuer said. "If you are not tough, then you lose the respect of your peers and your coach. Your own self-esteem suffers as well because there is this nagging question_are you really injured or are you faking it? Could you really push?

"No one wants to admit that they are injured or less than 100 percent in any way," she added, "and that includes psychological distress. Athletes will not come to you unless they are at the breaking point."

And it is at the breaking point that an athlete may turn to drugs.

Shuer said she is also very interested in the role of sports in the development of children, especially young girls.

Drawing on the work of psychologists Carol Gilligan, Ph.D., and Annie Rodgers, Ph.D., of Harvard, whose work has documented the powerful influence of socialization on young girls, Shuer hopes to study the way sports can help girls navigate the demands of growing up and the pressures of acculturation.

Shuer notes, for instance, that the passage of Title IX of the Civil Rights Act of 1972 has provided a whole generation of young girls the opportunity to participate in sporting events that were denied earlier generations. What, she wonders, has been the effect of that new experience on the ego development of young girls and their performance in other arenas?

Sometimes young girls, adept at sports, are subject to pressures and expectations not experienced by nonathletic peers, Shuer said. She described a nationally ranked teenage athlete whose parents believed she had a performance anxiety because of her superior performance in training compared with performance in competition.

The girl had minimal interaction with peers since she was training with athletes five years her senior. To further complicate the case, she was a year past menarche, and her coach was beginning to apply pressure for diet restriction since he wished her to revert to her prepubescent form.

Working with the girl, Shuer was able to discern that she did not have a performance anxiety; rather, her training required modification. With the help of her parents, those modifications were implemented.

Shuer was also able to work with the highly motivated parents to devise a strategy for letting the coach know that discussion of body image was unacceptable and inappropriate.

The case is an object study in the way the demands and pressures of early adolescence can be met, or exacerbated, by an athletic environment.

The study of these highly resilient athletes and their coping skills, Shuer believes, is a field of research and clinical inquiry ripe for psychiatric expertise.

She said, "I think one of the most interesting areas for psychiatrists is what happens to children at the crossroads of adolescence, and how participation in athletics can impact development through adolescence and young adulthood."

(Psychiatric News, October 18, 1996)