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Mind, Body and Sport: Potential barriers to accessing mental health services

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness

By Ken Chew and Ron Thompson

Over the past decade, research and reports from university counseling centers have suggested that students are generally using mental health services at a much higher rate. They are displaying higher levels of distress and psychopathology, and their overall coping and adaptive skills are not as well developed as in prior generations.  

Research has repeatedly demonstrated that having access to mental health services has a number of positive benefits, which include reduced risk for behavioral problems and suicide and better overall academic outcomes, including better grades, higher retention rates, and reduced overall liability for the colleges and universities. Further, students who use counseling services generally have higher graduation rates than students who never seek counseling.  

Historically, the perception has been that student-athletes are more well-adjusted than non-athletes and are therefore less likely to struggle with mental health concerns at the same level. Further, studies have shown that participation in sport at the high school level and before acts as a protective factor that leads to more pro-social behavior.  

Nevertheless, as students-athletes move into the collegiate environment, they become at increased risk for issues related to alcohol abuse, aggression, injury and other negative behaviors. More and more, mental health professionals and individuals who regularly work with college-level student-athletes are acknowledging that they may actually be at greater risk for mental health concerns because they have the same risk factors as non-athletes, while also dealing with the pressures related to sport participation. Despite these additional stressors, student-athletes continue to use mental health services at a much lower rate than non-athletes.

Because student-athletes are often perceived as being higher functioning and have a variety of resources available to them to be successful both academically and athletically, it can be difficult to recognize when these individuals are distressed versus just having a bad day. As a result, it’s often not until performance drops or there are recognizable behavioral problems that there is even an awareness that the student-athlete may be struggling. However, that initial recognition and getting the student access to a mental health professional may be challenging because of a variety of barriers that limit or prevent access.

In an effort to improve student-athlete use of mental health services, it’s important to briefly discuss some of the barriers that may make access challenging. These generally fall into three fairly broad categories:  

  • Student variables
  • Barriers associated with service provision
  • A general misunderstanding of the difference between mental health counseling and mental health performance

Student variables

The most common student-related factors that may affect entry into or follow-up in counseling include the stigma around counseling, a desire for a quick fix rather than wanting to go through the process of counseling, fear of change, resistance related to feeling as if they are being made to go versus choosing for themselves, embarrassment, limited time, uncertainty of why they’re being referred, and confusion about what counseling is.  

Of these, the most noteworthy is the stigma related to counseling, which is common to both student-athletes and non-athletes. In fact, stigma is often perceived as the most significant factor preventing people from seeking counseling or being referred.

This especially holds true for student-athletes who may be taught from an early age that they need to persevere and push through pain or discomfort to be successful. The concept of being “mentally tough” actually conflicts with the very concept of counseling, which may require opening up to another person about any perceived weaknesses or things that the individual may be struggling with.  

Nevertheless, it’s important to note that the stigma associated with counseling has been lessening over the past decade, and students in general are seeking services at much higher rates than in the past. In fact, approximately 1 in 4 young adults between 18 and 24 are dealing with some form of mental illness; and it’s estimated that approximately one-third of students entering colleges and universities at this time are coming in with some prior counseling experience or having been on medication for a diagnosed mental health condition.  

Source of service provision and culture

Barriers related to service provision and culture are sometimes the most difficult to navigate because there are so many potential variables that may have an impact, many of which may have developed over time or may be related to institutional structure. Two of these potential barriers in particular are source of service provision, and historical/cultural barriers.  

With regard to the source of service provision, there are currently three major ways that mental health services are provided to student-athletes: (1) counseling centers, (2) positions within athletics, whether dedicated or shared with counseling, and (3) outside consultants. All of these have benefits and barriers.  

Counseling centers. The most common source of mental health service provision to both student-athletes and non-athletes comes from university counseling centers. The benefits of counseling centers are that they typically offer a variety of specialties or service providers, an increased level of privacy, and independence from pressure from athletics administration. Also, counselors are able to easily consult with each other on difficult cases.  

Despite these benefits, the biggest limit is the fact that most counseling centers don’t have psychologists who are trained specifically to work with student-athletes or are aware of sport culture. Additionally, access to services may be slow or difficult during busy times of the year, and there may be pushback from centers that believe that student-athletes are given preferential treatment. Also, hours of availability are often limited, and communication issues between counseling centers and athletics may limit referral. Unfortunately, at many institutions, there has been a historical rift between counseling services and athletics that only has served to add to the challenge of getting student-athletes proper counseling.  

Positions within athletics. Over the past decade, more universities have been moving to a model in which athletics has a dedicated in-house psychologist or a shared position with a counseling center. These positions provide greater flexibility in terms of overall access, and having a person familiar to the department increases use as well as referral.  

Additional benefits may include reduced concerns about higher-profile athletes being identified as being in counseling, consistency of treatment with the sports medicine team, increased availability to consult with or provide training to coaches and athletics administration. Having an in-house person also allows for greater awareness of the culture around athletics at a particular institution, which may be useful in helping student-athletes adjust or work through related pressures.  

Though the benefits may seem great, there are a number of challenges with these positions as well. These may include limited professional support, a high level of demands on a single clinician, limited resources, potential pressures from athletics administration or sports medicine, and professional resentment from other clinicians on campus who may not fully understand the position.  

Also, there can be confusion over whether the student-athlete is being referred for psychological counseling, which centers on helping people who are struggling with personal or mental health concerns and helping them get back to a normal or healthier level of functioning, or sport psychology/mental performance services, which focus on developing optimal performance in relatively well-adjusted individuals.  

Outside consultants. The third method of service provision is the outside consultant who comes in on a part-time basis. The primary benefit of this kind of position is that the athletics department can hire a person with a dedicated specialty to work with their student-athletes on an identified issue or set of issues.  

These arrangements can range from a set amount of contracted time within athletics to see multiple athletes and teams or be limited to seeing a select number of student-athletes for specialized treatment in a private practice setting. For many institutions, having an outside consultant can save on cost and allows for a greater control over access to services.  

Nevertheless, these positions continue to pose as a barrier because access to services is only as available as what athletics contracts; services may be limited based on the specialty of the provider; there may be confusion as to whom the client is; these positions may be less stable over time; and there may be pressures for the consultant to focus more on higher-profile or revenue-producing sports.

With regard to historical and cultural barriers, these are generally more long-standing and persist because of a shared resistance by all involved entities to change. Further, these variables generally overlap with some of the previously mentioned barriers. These may include the prior history between athletics and mental health services, uncertainty about what the other does, general misperceptions from the mental health side about athletics and student-athletes, appropriateness of referral, and issues related to the control and exchange of information, which may include confidentiality and privacy.  

When combined with the previously mentioned barriers associated with stigma, ease and speed of access, limited availability of qualified professional, and confusion about who the client is, it’s not hard to see why working relationships between counseling and athletics may have a history of challenges.  

Future directions

As noted earlier, access to psychological services has positive benefits for the individual as well as the institution. This holds true for athletics as well. Reducing barriers that may prevent student-athletes from receiving mental health services can actually strengthen athletics programs by:

  • Reducing behavioral concerns that may impact team dynamics.
  • Helping prevent or moderate significant drops in academic or athletics performance.
  • Reducing risk and liability associated with mental health concerns.
  • Serving as an additional support for students in need.
  • Improving overall student wellness.
  • Taking pressure off coaches, athletic trainers and other administrators in working with student-athletes who may be in distress.
  • Helping students to enhance functioning in multiple areas of their lives, including athletics performance.

To reduce these barriers and to receive the previously mentioned benefits, we encourage the following best-practice guidelines for athletics departments and university counseling services that can make a difference going forward.

  1. Have a discussion between athletics and counseling services as to the source and structure of mental health services on campus. This should ideally include sports medicine or athletic training, as these individuals have regular contact with student-athletes and are more aware of their personal and mental health needs. The purpose of this meeting should not be to create a specialized service for student-athletes but rather to identify what is available and ways to make referral easier and more user-friendly on both sides.  
  2. Recognize that student-athletes are a specific population with an emphasis on bringing in licensed psychologists with competence in sport or counseling of athletes. Having clinicians aware of the sport culture could ease the referral process, reduce stigma, and start the process of healing any cultural rifts between athletics and counseling.  
  3. Present mental health services to student-athletes as part of the overall sports medicine package and included in any resource guides directed to student-athletes. Being made aware of psychological services, increasing their visibility, and having them normalized early on will serve to reduce stigma and ease referral.  
  4. Make sure coaches and athletics administrators learn the difference between mental health counseling versus mental performance referral to cut down on any confusion with referral.  
  5. Identify a person within athletics or sports medicine whose role includes overseeing the emotional well-being of student-athletes. This individual would help facilitate referral, establish a collaborative relationship with campus and community resources, help create opportunities for counseling and athletics to cross-educate the other as to services and structure, and work with counseling to reduce any barriers that may arise.

Ken Chew has been the director of the Indiana State University Student Counseling Center since 2007. He also serves as director of training for the Counseling Center. Chew received his doctorate from the Virginia Consortium Program in Clinical Psychology in 2001 and completed his undergraduate work at Jamestown College, where he majored in psychology with a minor in fine art. His professional interests include the counseling of athletes, performance enhancement, drug and alcohol issues, multicultural counseling, facilitation of professional and personal development training, and outreach programming. 

Ron Thompson is a consulting psychologist for the Indiana University, Bloomington, Department of Athletics and co-director of the Victory Program at McCallum Place, which offers a specialized eating disorder treatment staff to meet the unique needs of athletes. Thompson has served as a consultant on eating disorders to the NCAA and on the female athlete triad with the International Olympic Committee Medical Commission. He can be reached at rthomps2@sbcglobal.net.