Signal or Static: Differentiating Performance Hurdles from Mental Health Issues in our Inner Olympics
The 2024 Olympics and Paralympics just ended, but we can still hear the chatter about the mental fortitude required to be an Olympic athlete.
These conversations offer everyday people a chance to feel, for a moment, like an Olympian and join their mental journey through competition.
Our confidence builds with the athletes as their eyes and faces show laser focus. We can hear our own inner voices shouting positive mantras at us as we imagine the winning inner dialogue of the competitors.
The Unheard Voice
Despite much more conversation about mental health and athletics, most of the buzz has focused on the positive aspects and power of an athlete’s mind. This hides the notion that there are other voices of insecurity, doubt, and performance anxiety. These ‘other voices’ are unheard by those around us. The people they plague do not get interviewed, and those who do don’t admit that they hear these voices. But they are there.
We all have this unheard voice, whether we are managers, gardeners, teachers, surgeons, or entrepreneurs, and also as parents, children, and friends. This negative inner voice tries to creep in every time we try something new or try to win someone’s approval. ‘I wonder if my teacher thinks I am smart.’ ‘Does my manager even recognize my hard work?’ They also creep in because we are scared to fail others and ourselves. ‘What if I cannot make my deadline?’ ‘What if I am not as good as I and they thought?’ An oft-repeated statistic is that 80% of our thoughts are negative and 95% repetitive — we tend to focus on negative experiences more.
It can be hard to understand what this voice is saying. How we now process and listen to this voice has become complicated by the constant presence of and reporting about mental health in our society and inner circles.
It has become increasingly difficult to make a critical distinction for ourselves and others, namely, does this voice represent a mental hurdle most people face during a performance they care about or a much larger underlying mental health condition? How do we know if this voice is simply static to be ignored or a signal of impending concern? How do we differentiate between spotlight stress and systemic strain?
We approach these questions from our vantage point as parents and professionals who are individual contributors (as authors and surgeons), now training and leading (as team leader and surgical educator) others who are also individual contributors honing their craft. To support those in our care and under our responsibility, it is important for us to try to understand this complex distinction between a mental hurdle like the yips or twisties and a mental health issue like depression.
A First-Person Experience: Actions are the Manifestations of Anxieties
As a surgical trainee, fresh out of medical school, I had the surgical ‘yips.’ My op-ed in the Washington Post describes the yips:
when elite golfers, pitchers, cricketers or darts players, say, become unable to sink the short putt or let go of the dart — for no apparent reason. Pitcher Daniel Bard told the New Yorker of thinking in terror: “I don’t know where the ball is going.”
My inner voice had metaphorically paralyzed my hands, and I struggled. To the outside observer — my supervising physicians — I appeared hesitant and unsure, which is antithetical to being a surgeon. They didn’t realize that they were simply seeing the action that manifested the uncertainty created by a voice they couldn’t hear.
This is why Simone Biles's version of the surgical yips—the twisties—might have been misconstrued by the process, fans, and detractors alike. People were critical of what they saw, which was her opting out of the Olympics, “robbing” the world of her talent and perhaps her team of a gold medal. But they couldn’t hear the uncertainties her inner voice was speaking.
The yips and twisties for leaders, too, can be paralyzing. Unlike in sports and surgery, the twisties in management don’t result in the loss of spatial control but the loss of intellectual control. The inner voice of leaders introduces the possibility of loss of control or admiration, which many in power fear deeply. This state can lead to indecision, analysis paralysis, hesitation, or complete inaction, impacting their effectiveness and performance. This type of uncertainty can impair sleep, which can, in turn, worsen mental health conditions.
As I reflect on my experience with the surgical yips, I never saw them as a mental health issue. Surely, they created struggles that were mental in origin, but I viewed it then as I do now — a mental hurdle.
So, back to the original question… How did I know my inner voice was static noise and not a signal of something more?
Notably, my mental struggles only occurred in one setting. My voice was quiet at home and in social settings. I don’t recall feeling pressure outside the operating room. I could maintain relationships and take care of myself and my family. My actions in these settings didn’t suggest uncertainty, and I was fortunate I had a support system that helped press the mute button on my inner voice.
However, when there is no mute button, and the negative inner voice becomes audible in various settings, it becomes an issue. For example, when an inner voice has the ripple effect of preventing an accountant from balancing their personal checkbook.
Distinguishing between signal and static may seem obvious. Still, the boundary between these situations is often blurry at best — and making the right “diagnosis” is imperative to helping the “patient,” in this case, the inner voice listener. We cannot help but wonder if this is due to overexposure of the word “mental health?” The use of this word has had an incredibly positive impact by bringing mental health concerns to the forefront of public awareness. But like anything, over time, people become desensitized to the effect. Numb to the once sensationalized discussion. Its use then expands and suddenly applies to more experiences that may be a mental health issue- but may not.
The Inner Voice in Families
For parents and children, the dynamic of performance anxiety and mental health issues can present differently but remains just as significant — the models we set as parents shape how kids manage themselves and others.
Parents often place high expectations on themselves and their children, which can create environments where performance anxiety quickly takes root, especially at a time when everything is reported on social media.
Parents may experience performance anxiety in their role of raising children, similar to how leaders experience it in managing teams. They might worry about:
- Am I a good enough parent?
- Why might my child be underperforming?
- Am I providing my child with the right opportunities?
- What if my decisions negatively impact my child’s future?
These doubts and fears create the “parenting yips” or “twisties,” where parents may second-guess their choices, overreact to their children’s struggles, or become overly protective. Anxiety, much like in leadership, can result in indecision or excessive control, both of which can affect the parent-child dynamic and might not get to the root of what is actually happening for both parties.
Children often internalize the expectations of their parents and society, and this can manifest as performance anxiety in various areas of their lives — academically, socially, or even in family settings. Many of our kids feel watched, much as a new surgeon might. Voices in a young head might ask:
- Does my parent think I’m doing well?
- Am I smart enough or talented enough to meet their expectations?
- What if I fail and disappoint them?
- What will I tell or whom, and what will I blame if my performance does not meet expectations?
Like adults, children develop an “inner voice” that echoes these concerns. If not addressed, this voice can lead to withdrawal, perfectionism, or reluctance to try new things for fear of failure.
The Mental Health Hammer: Risks of Over-Diagnosis
While the growing awareness of mental health is a positive development, there is also a risk of over-diagnosing common experiences as mental health disorders.
When we label temporary struggles, such as performance anxiety or momentary self-doubt, as clinical conditions, we risk pathologizing normal human emotions. This can lead to unnecessary interventions, reduce individual resilience, and create a culture where people feel they need external solutions for challenges that might otherwise be resolved through support and personal growth.
More importantly, over-diagnosing dilutes the attention and resources that should be focused on those facing chronic or severe mental health conditions.
In this way, we may inadvertently shift our focus from building coping mechanisms for everyday stress to treating natural experiences as illnesses, blurring the line between normal stressors and true mental health disorders.
Honing our Ultrasonic Microphone for Inner Voices
Much as bat fans and farmers use an ultrasonic microphone to make bat sounds audible to the human ear, we can use more low-tech tools to make the inaudible accessible.
Create an Open Dialogue
Like leaders in the workplace, parents can encourage children to share their inner voice by asking, “What’s on your mind?” or “Are you feeling worried about something?” “Tell me your concerns.” Listening without judgment creates a space where children feel safe discussing their doubts. Beyond that, it offers a chance for your struggling colleague to read aloud their once quiet inner voice.
My surgical mentor didn’t do anything extraordinary to help me overcome the yips. His approach was ordinary- he listened. He wasn’t afraid to talk to me about the issue. He forced me to talk through my uncertainty and ensured I understood that the future would look brighter after I leap over this mental hurdle. My mentor was right. Doubt and insecurity seem insurmountable inside one’s head, but speaking them aloud can turn almost any mountain into a molehill. More importantly, by listening, he was able to understand my problem. And when we share, we might also learn that others had the twisties and yips at some point. The skill building is for outside actions and inside voices.
Whether talking to your child or a professional colleague, try to allow these conversations to arise organically, whether walking to the bus or over lunch. Being too formal can re-create the uncertainty that one is trying to address.
It can also help to volunteer a personal experience — “when I started writing cases at Harvard Business School, I got totally stuck in a project, worried I would never make it out of the tunnel. I often feel that way, but now I know I will make it out.”
Listen with Intention
Making it possible for someone to speak without being strategic about how to listen to them is promoting a monologue, not a dialogue for discovery. We can improve outcomes by being more explicit about three dimensions:
a) Once I engage the other in conversation about their inner voice, what will I be listening to (which characterizes and interprets the nature or purpose of the message’s intentions)?
b) What will I be listening for (which characterizes and interprets component elements of the message itself)?
c) Where will I be listening from (which processes the incoming information through multiple filters)?
The first two are inherently influenced by the listener’s perceived role in the dialogue and the goals such a role should entail (which may not be at all what the speaker needs or expects of the listener). Simply put, the listener should be conscious of the nature of the intention. Why one is paying attention (which will be shaped by our own inner voice) will determine how one pays attention and what one is paying attention to. The third shapes the filtering.
In the medical field, the history of present illness relays the symptoms shared by the patient. Symptoms are sensations or feelings reported by the patient. What the doctor sees are signs—observable characteristics. The symptom is what a patient reports: “I have a headache.” The doctor observes the sign: “The patient presents with a nail sticking in her head.”
Making the inner voice not only audible but also worthy of respect enables the signs and symptoms to come together for a potentially better history of “present illness” and, hence, a more appropriate therapeutic, parental, and managerial approach.
Model Healthy Responses
Managers, supervisors, and parents can model how to manage their own performance anxieties by talking openly about their challenges and how they address them. This shows reports and children that these feelings are normal and manageable.
In surgery, this means being explicit with the junior surgeons before the upcoming surgery that you remember the uncertainty they are feeling. Taking the next step to show how you manage it now can be useful. For me, taking 5 minutes to sit quietly before each surgery accomplishes this goal and models a technique for uncertainty reduction.
As a parent, showing your child how to create space from a tense situation can help them regain control of their emotional uncertainty.”
Recognize the Signs of Punctual Struggle vs Pattern
It’s important for supervisors, colleagues, and parents to observe any changes in the behavior of others in their care or training that may indicate more than just a passing stressor.
A child withdrawing from social activities, losing interest in hobbies, or showing persistent anxiety might signal that they need more help. An employee struggling to meet job expectations might also experience a change in behavior or affect. They might need very different conversations and referrals to supportive resources.
Winning Gold in Understanding The Inner Voice
Just like the Olympians we admire, we all face moments where our inner voice can either propel us forward or hold us back. The difference is that while Olympians’ struggles with uncertainty are sometimes broadcast and analyzed on a wide stage, our personal battles often go unheard and unseen. But, they do stand in the way of running the races of our lives.
We tried to show that actions were manifestations of uncertainty to suggest that if you learn to look, you can identify anomalies in actions or decisions. While this doesn’t mean you can hear someone’s inner voice, it does allow asking about what their voice is saying.
As leaders, parents, and individuals, we must learn to listen closely — not only to our inner voices but also to the subtle signals from those around us. Whether supporting a colleague through a mental hurdle or guiding our children through a moment of self-doubt, the key is creating space for these voices to be heard. And then, like a coach helps an athlete push through a difficult moment, we can offer that same support to the people we lead, nurture, and care for.
In the end, overcoming these mental hurdles is not about silencing the inner voice but about understanding when it’s a signal worth addressing. Like the greatest Olympians, we need to find balance — between listening to the doubts and pushing beyond them, between understanding what is punctual versus what is chronic, signal versus static.
In doing so, let us always be cautious not to jump to conclusions. True resilience lies in this balance—recognizing when we need help and when we just need to push through.
Please tell us about your twisties and yips and how to support others!
Compiled by Carin-Isahel Knoop and Doctor James Naples. Carin is the co-author of Compassionate Management of Mental Health in the Modern Workplace and head of the Harvard Business School case writing team. Jim is an Ear-Nose-Throat Surgeon and Educator at Beth Israel Deaconess Medical Center/ Harvard Medical School. He is the residency program director there and an advisor to Harvard Medical students.
