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Mindful Healing

Overcoming the obstacles and stigma of mental health issues takes a team of allies

By Jassim Kunji

A runner crosses the finish line, pumping his fists in the air in triumph. A basketball player nets a last-second buzzer beater to dramatically turn the game on its head. A quarterback hoofs the ball down the field to complete a spectacular touchdown pass. Impeccable specimens of the best the human race has to offer. This is what champions are supposed to look like — steeped in the glory and adoration of success.

There are some trade-offs, of course: The pressure to succeed, the extra scrutiny and a large time investment all come with being a student-athlete. But those are only minor sacrifices, not nearly enough to outweigh the benefits — at least, from an outsider’s perspective. A fan might question why a student-athlete would be unhappy. How could he or she not love such a wonderful life? Even if student-athletes have problems, aren’t they supposed to tough it out? Isn’t that part of the deal for glory?

The amassed spectators demand their gladiators mask any weaknesses and fight on. And the scrutiny of expectant observers does not end at the arena walls. It is present in the pack of reporters waiting outside, in the hallowed halls of university campuses, and sometimes even the very homes of the athletes themselves.

Who would not be happy living the life of a student-athlete?

A lot of people, it turns out.

There has been a growing recognition among college administrators across the country that student-athletes are in no way immune to mental health issues. In fact, there is a realization that student-athletes face a host of unique stressors that can negatively impact their mental health. Issues such as depression occur just as frequently among student-athletes as among the broader student body — and there may be a greater risk of underreporting due to the competitive nature of athletics and the athletic mentality.

“Just because they’re athletes doesn’t mean they don’t suffer from the same things as regular students,” said Ron Chamberlain, a sports psychologist at Washington. “Then you add in additional stressors on top of that, and it can bring out tendencies.”

Chris Carr, a sport and performance psychology counselor at St. Vincent Sports Performance in Indianapolis, shares this opinion. Carr sees student-athletes as having a set of unique stressors, although the amount of stressors they face are not always greater than that of other students who may have their own commitments, such as part-time jobs. Still, student-athletes have to deal with issues exclusive to athletics, such as feeling pressure to perform well while receiving a scholarship. Most students will be able to access student counseling centers, but Carr believes that to properly address the mental issues that student-athletes deal with they need a professional resource specific to them.

Rather than preventing mental health issues, many of the characteristics innate in collegiate athletics actually may cultivate vulnerability to some mental health problems. The emphasis in athletics on being strong and soldiering on, combined with the monolithic perception of athletes on campuses, carries the potential to compound mental health issues.

 

ONE STUDENT’S STORY

At 6 feet, 6 inches and 295 pounds, Will Heininger cuts a formidable figure. Now working in the investment industry, Heininger was a four-year letter winner during his time on Michigan’s football team, where he graduated in the winter of 2011. In conversation he is cheery and outgoing, fitting the image of a successful student and football player. It is less apparent that Heininger was depressed for months during his time on campus.

Heininger grew up in Ann Arbor and always dreamed of playing for the Wolverines one day. He was living that dream; everything was going smoothly. Then the symptoms of depression set in after the summer of his freshman year.

BEHIND THE NUMBERS

With the sensitivity that surrounds issues of mental health, data can be difficult to obtain. Much of the relevant data on mental health issues for student-athletes does not even exist.

“The data on mental health issues among college student-athletes, and even elite athletes generally, are lacking,” said Tom Paskus, principal research scientist for the NCAA. “The data are difficult to obtain because you’re dealing with issues that student-athletes are hesitant to discuss and with privacy issues related to medical confidentiality.”

Paskus and the NCAA research staff are making attempts to widen the net, trying to get student-athlete identifiers added to the American College Health Assessment, among other efforts. But most of the data he has to work with currently is drawn from the SCORE and GOALS surveys conducted by the NCAA. It is an imperfect measure due to the problems of self-reporting and the infrequency with which they are conducted. But they do unearth some startling statistics.

31% of male Division I basketball players agreed with the statement, “My coach puts me down in front of others.”

39% of Division I female basketball players strongly agreed with the statement, “My coach can be trusted.”

12.7% of FBS football players in Division I described the effects of participating in college athletics on their mental health as “somewhat negative or worse,” and 8.1 percent were dissatisfied with the treatment they had received for mental health issues.

42% of current student-athletes described themselves as being “very happy.”

76% of Division I football players agreed that they felt a sense of belonging on campus. Among Division I women’s basketball players, 77 percent reported the same feeling.

67% of former Division I student-athletes considered themselves “very happy.”

Heininger said a contributing factor to his depression was his adjustment to a new life at home after his parents’ divorce, which occurred when he left for college. He kept himself busy, avoiding free moments that would fill with negative thoughts as he stared off into space and faced the dreadful specter of personal failure that others couldn’t imagine in a Division I football player. When he returned to Michigan as a sophomore, he carried his depression with him, although the return to the activity and normalcy of university life helped him stave it off more effectively than at home. Heininger at first tried to combat his depression with the same single-minded determination that had brought him success both as a student and an athlete.

“That athletic mindset got me so far, so I tried to attack it that way. It just made it worse. I felt like I’d failed because I couldn’t beat it myself,” he said. “Sometimes I just sat on the couch and cried.”

That carry-the-burden approach is often seen by sports psychologists.

“It’s this athlete’s mentality that has allowed many of them to succeed at this level,” said Carmen Tebbe, associate director of academics and student life at Oklahoma. “But it doesn’t work well in this area, and can actually be very unhelpful.”

Heininger decided to ditch the solo approach and began to reach out for help. “I’d been able to do everything myself, my whole life. Eventually I realized that this I couldn’t do,” he said.

He confided to his mother first, a step he found worthwhile, though difficult. “After that, my favorite thing every day was coming home and talking to my mom,” Heininger recalled. But that alone was not enough to bring him out of his depression. It was not until he began to use the resources available at Michigan that he truly made progress on his path to recovery.

Heininger had previously been reluctant to confide in his teammates or coaches because he feared the stigma attached to mental illness.

“I had an irrational fear that I’d be weak in their eyes, that they’d see me as unstable, someone they couldn’t trust,” Heininger said.

He also worried about how it might affect his reputation outside the team. Data indicates that student-athletes — particularly men — place high stock in their identity as athletes. In a 2010 NCAA study of current student-athletes, 76 percent of male athletes charted a high athletic identity, while only 63 percent indicated a high academic identity.

“There’s some amount of celebrity, where students don’t understand that athletes are like them. Some people don’t think of athletes as human; they just see them for what they do and their success on the field,” Heininger said. “The more athletes define themselves by what they do, the more susceptible they are.”

But he did eventually open up to his coach, experiencing a self-described breakdown in his office.

“It wasn’t so much courage that finally made me come forward; I was just so sad I didn’t care,” Heininger recalled.

That is when he found out about the support services available to him and began to have therapy sessions with Barbara Hansen, an athletics counselor at Michigan.

Once he started therapy, Heininger began to better understand depression. Rather than an indictment of himself, he began to recognize its true causes.

“It’s chemicals of the brain really; it’s not anything that’s a representation of you,” he said. “But there’s so much misinformation out there. Most people don’t really understand depression. I didn’t either.”

He also found that instead of being stigmatized, there was an outpouring of support among his friends, family and teammates. Heininger said that contrary to what he imagined, almost everybody was “super receptive” and helpful.

According to Hansen, it is often more of an internal perception with student-athletes than actual negative judgment from their peers. Nonetheless, this self-perceived stigma sometimes prevents them from coming forward.

HELP ON CAMPUS

Universities currently provide for student-athletes’ mental health in one of three ways. Many universities provide their students with counseling services, which student-athletes can use. Other universities provide liaison services with off-campus psychologists to provide care for student-athletes. The third method, exercised by an increasing number of universities, is to have mental health providers dedicated to working exclusively with student-athletes.

“In the past five to 10 years, most universities have come to recognize the importance of mental health in athletics, and every year there are more and more jobs opening up in the area,” Tebbe said. “It’s a huge issue, and growing.”

STRESS FACTORS

While all college students can feel stress, student-athletes are at risk of additional unique stressors.

Shared Stressors
• Relationship issues
• Family issues
• Financial concerns
• Formative age of development
• Time concerns

Unique Stressors
• Media scrutiny
• Effects of winning and losing
• Issues of celebrity

RED FLAGS

Chris Carr, a sport psychologist at St. Vincent Sports Performance in Indianapolis, has previously worked with the U.S. Navy, the Columbus Crew professional soccer team, the U.S. Men’s Alpine Olympic Ski Team and the USA Olympic Diving Team. He says the key indicator of depression is when individuals deviate from their normal behavior. Some forms this can take are:

• An individual withdraws and isolates himself or herself from others;
• The mood of an individual appears flat and unenthusiastic;
• An individual begins to have issues with substance abuse;
• The sleep patterns of an individual are disturbed;
• An individual’s personality changes to become atypical compared with how he or she normally acts;
• An individual shifts suddenly from being introverted to extroverted or vice versa.

“If an athletic trainer notices that an athlete is withdrawing into themselves or displaying other indicators, they should reach out to them and try to determine whether there is a possible mental health issue,” Carr said.

Noel Bauman is one of those recent recruits. Hired as a sports psychologist at Virginia two years ago, Bauman works within the athletics department and is on call at all times. He said that the continuity gained by contacting the same person is a benefit offered by a full-time psychologist.

Bauman said that when student-athletes go to a counseling center or an off-campus practice, they are not guaranteed to get the same person every time.

This lack of familiarity results in lower rates of referral than with the presence of a full-time sports psychologist. Bauman witnessed a shift occurring once he fully established himself.

“When I first got here, most referrals were from coaches, trainers and other support staff,” he said “Now most referrals are coming from other student-athletes, and the vast majority of people that come in now are actually coming in by themselves.”

Chamberlain has seen a similar effect, estimating that between 80 and 85 percent of his clientele see him of their own volition. It makes sense, considering the work he puts in to familiarize himself with the student-athletes.

“It takes awhile to build relationships, to build relationships of trust. So it’s really important for me to be a visible part of the athletic environment so that they see me as a normal person in their daily lives,” he said.

According to Chamberlain, it is difficult to get student-athletes to visit a psychologist who is only available a few hours a day. If a full-time sports psychologist is not available, he sees a strong relationship between the athletics program and counseling services as crucial.

However, most universities do not have full-time licensed sports psychologists, and sometimes the idea itself faces resistance.

Carr has dealt with coaches who assumed that having a full-time psychologist on staff increases the number of mental issues present. In actuality, the psychologist is simply helping to recognize and treat issues that already exist.

Oftentimes, the first issue that sports psychologists deal with on the job is convincing coaches that a psychologist should be there in the first place. Bauman quickly established an educational program for coaches at Virginia so that they would understand what his job entailed. They quickly embraced his role.

Outside of hiring a full-time sports psychologist, a large part of improving the mental health of student-athletes is based on fighting the stigma of mental illness.

“There has always been a stigma of ‘You’re supposed to be mentally tough, not emotional’ in athletics, and it’s gotten in the way of a serious look at the problem,” said Chamberlain of his 17 years of experience in Division I athletics.

The challenge for counselors and psychologists is how best to normalize mental health. One approach is to draw comparisons between mental illness and physical, visible injuries. The idea builds upon the reality and seriousness with which physical injuries are treated in sports; mental issues deserve the same treatment.

Carr said that, just like a muscle tear, no one wants a mental issue to occur. But when it does happen, it should be recognized and treated appropriately. Hansen’s favored analogy involves a dentist. “In an ideal world, it would be nice if it were viewed as ‘Oh I’ve got a cavity that needs to be taken care of, I’ll go to the dentist to get some help with that,’” she said.

Another angle to take is to consider mental health as a continuum, rather than having negative and positive extremes. That way, student-athletes are not seen as being either unwell or well. Rather, the emphasis is on improvement.

Tebbe prefers a strength-based approach, reversing the negative connotation of illness by characterizing her help to student-athletes as learning new skills to help reach their potential.

Such an approach is well within the scope of sports psychology, which encompasses a wide range of issues. For Carr, sports psychology does not deal with purely positive or negative issues. Rather, it provides a continuum from developing a winning mental attitude to counseling.

 

PURGING THE STIGMA

There remains much work to be done to eliminate the stigma of mental illness, and it remains a very real and concerning issue — not just among psychologists and counselors, but among student-athletes themselves.

“When I met with the student-athlete advisory committees, the committee members mentioned student-athlete mental health as a pressing concern,” said Dr. Brian Hainline, who assumed his position as the NCAA’s first chief medical officer in January 2013. “I had a similar experience when I met with athletic trainers from member institutions and conferences.”

Hainline’s appointment has resulted in an increased emphasis on student-athlete well-being as a whole, and in particular mental health concerns.

Hainline questions why mental illness is stigmatized as a weakness when it is as biologically driven as any other condition.

The gap between the treatment of mental and physical health has proved disconcerting to Hainline. He said he has witnessed a disparity in the reimbursement rates from insurance companies, and even instances where it was more difficult to obtain treatment for a mental health issue than an unnecessary surgery.

In addition to the appeals of the student-athlete advisory committees, there has been another indicator that the mental health of student-athletes warranted additional scrutiny. Two studies conducted by the NCAA — Growth, Opportunities, Aspirations and Learning of Students in College (GOALS) and the Study of College Outcomes and Recent Experiences (SCORE) — collect information from student-athletes on a variety of subjects.

The GOALS study surveys current student-athletes, while SCORE’s purpose is to collect data from former student-athletes.

A ROAD MAP FOR ACTION

In September, the NCAA joined nine other athletics and professional associations in announcing a set of recommendations for recognizing and referring student-athletes with psychological concerns – believed to be the first collaboration of its kind on the issue.

The nine guidelines issued by the interassociation task force were designed to provide a clear road map to address the mental challenges student-athletes face, according to Timothy Neal, assistant director of athletics for sport medicine at Syracuse and chair of the task force.

“The probability of encountering one or more student-athletes with psychological concerns within an athletic department is a certainty,” Neal said. “Our goal is to immediately address and care for the student-athlete with the best protocols in place.”

The announcement was hailed as a major step to addressing the issue of student-athlete mental health, which in recent years has prompted athletics programs to devote more resources to psychological support.

The guidelines were presented as developmental steps for athletics programs to institute a plan for recognizing and referring student-athletes with mental health concerns.

They included addressing mental health concerns during preseason exams; scheduling routine referrals for evaluations; developing good relationships with the campus athletics department; and being aware of and taking preventative measures for the possibility of suicide.

Hainline said that although the purpose of the GOALS and SCORE surveys was not to search for mental health issues, they did unearth certain trends that were a cause for concern.

In response, the NCAA has launched a number of initiatives.

One of these is increased collaboration between the NCAA Sport Science Institute and the NCAA’s research department in order to use the information collected as a foundation for a more extensive study on student-athlete mental health. Also, a new post-doctoral research position has been created with a mandate to focus on student-athlete mental health. And in November, the Sport Science Institute will host a mental health task force to explore the issue.

At the moment, the emphasis is on obtaining information, with Hainline characterizing the efforts as “a foundational step.” The data collection will draw upon a combination of anonymous surveys in addition to injury and surveillance data collected by the Datalys Center for Sports Injury Research and Prevention. The hope is to improve on current NCAA student-athlete mental health data and to allow for a more educated program to improve recognition and treatment of mental health issues.

In the meantime, heightened sensitivity among athletics departments would help to combat mental illness, Hainline said. At the moment, most universities lack sports psychologists, instead providing counseling services through student affairs. An informal query about five years ago placed the number of universities with in-house sports psychologists at around 20, with an additional 70 universities contracting with sports psychologists through the athletics department or other divisions. In the approach that the NCAA’s Sports Medicine Handbook puts forth, psychologists are to be incorporated into a multidisciplinary approach. However, Hainline said, “we don’t legislate how member institutions manage student-athlete mental health issues.”

But legislation may not be necessary given the reactions Hainline has observed. The issue strikes a chord throughout the community. Hainline has been encouraged by the openness and eagerness among athletic trainers and physicians.

Of course, a lot of it has to do with being provided the right information.

“The more people are educated, the more people are aware of an issue and understand how to deal with an issue,” Hainline said.

 

A HEALING HERO

After his own experience as a student-athlete suffering from mental illness, Heininger decided to use the knowledge he gained to help other people experiencing mental illness.

Initially he applied his new understanding of the nature of depression and why people experience it to help his father, who had been experiencing some issues at the time.

Heininger also presented Michigan’s 2013 Mental Health Advocate Awards in February, which are given to graduate and postgraduate students across the country who advance de-stigmatization and improved awareness of mental health issues. Heininger continues to advocate for better mental health himself, driven by a desire to help others who may be experiencing the same struggles he did.

“I believe in it — if you save one life you’ve done well,” he said. “I want everyone in the world out there to know that mental illness is a disease, which means that there are professionals who can help you get better. In my ideal world, there is zero stigma associated with mental illness. None.

“Everybody would go to therapy, and there would be nothing wrong with it.”

It may be a dream at the moment. But with the effort being put forth, it may become reality.