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Mind, Body and Sport: Interassociation recommendations

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

By Timothy Neal

The athletic trainer holds a unique position in college sports. In addition to being charged with protecting student-athlete health and safety, the athletic trainer often is a friend and companion – sometimes even a confidant – for the hundreds of student-athletes in his or her care. In fact, it is the athletic trainer who is often alongside even during a student-athlete’s worst moments. Usually, those worst moments entail a physical injury that ends the student-athlete’s season or career, and in some cases may threaten the student-athlete’s life.

Increasingly, though, some student-athletes’ worst moments are not physical in nature, but are a result of psychological concerns that affect the student-athlete’s well-being.

As such, the following is an executive summary of the NATA-sponsored, Interassociation Consensus Statement: “Recommendations in Developing a Plan for Recognition and Referral of Student-Athletes with Psychological Concerns at the Collegiate Level.”

These recommendations should help athletic trainers create a student-athlete “psychological concerns plan” in their athletics departments, and encourage them to collaborate with university departments to better assist student-athletes and manage institutional risk.


Studies are starting to reveal the growing prevalence in the types, severity and percentage of mental illnesses in young adults ages 18 to 25, the same age group that includes most college students and student-athletes. Data indicate that approximately one in every four to five youths in America meets criteria for a mental health disorder, with severe impairment across a lifetime.

The U.S. Substance Abuse and Mental Health Services Administration reported in 2012 that 45.9 million American adults age 18 or older (20 percent of the survey population) experienced a mental illness in 2010. The rate of mental illness was more than twice as high in those in the 18- to 25-year-old range (29.9 percent) as it was in those age 50 years and older (14.3 percent).

Given that more than 460,000 student-athletes participate in NCAA intercollegiate sports, it’s likely that every athletic trainer will encounter at least one student-athlete with a mental health issue during his or her career.

Behaviors to monitor

Most student-athletes manage the stressors of being both a student and an athlete without any long-term consequence to their mental well-being. Some student-athletes, however, will not be aware of how a stressor is affecting them – or if they are aware of their potential psychological concern, they will not inform anyone but may well act out in a non-verbal way to alert others that something is bothering them.

Following are some of the behaviors athletic trainers should monitor that may indicate a psychological concern in a student-athlete:

  • Changes in eating and sleeping habits
  • Unexplained weight loss or gain
  • Drug or alcohol abuse
  • Gambling
  • Withdrawing from social contact
  • Decreased interest in activities the student-athlete previously considered enjoyable, or taking up risky behavior
  • Talking about death, dying, or “going away”
  • Loss of emotion or sudden changes of emotion within a short period
  • Problems concentrating, focusing or remembering
  • Frequent complaints of fatigue, illness or being injured that prevent participation
  • Unexplained wounds or deliberate self-harm
  • Becoming more irritable or having problems managing anger
  • Irresponsibility, lying
  • Legal problems, fighting, difficulty with authority
  • All-or-nothing thinking
  • Negative self-talk
  • Feeling out of control
  • Mood swings
  • Excessive worry or fear
  • Agitation or irritability
  • Shaking, trembling
  • Gastrointestinal complaints, headaches
  • Overuse injuries, unresolved injuries, or continually being injured

Circumstances that may affect a student-athlete’s mental health

By nature of the profession, athletic trainers are accustomed to dealing with injury. But as has been pointed out earlier in this publication (Chapter 4), the athlete’s psychological response to an injury can manifest in many ways.

Injury. Whenever a student-athlete is injured, those caring for the student-athlete should consider a possible psychological response to the injury. Any injury, especially a season-ending or career-ending injury, or a chronic injury that needs constant attention to participate, may become a source of stress to the student-athlete. Additionally, a student-athlete returning from a significant or time-loss injury may also experience a fear of re-injury.

Concussion. Our evolving awareness of the aftereffects of concussions includes the cognitive and psychological consequences on the student-athlete. After a concussion, the student-athlete should be monitored for any changes in behavior or self-reported psychological difficulties, both while recovering from the concussion and during their return to play after the injury.

ADHD. The prevalence of behavior disorders includes attention deficit hyperactivity disorder (ADHD) at 8.7 percent of the population. Some legitimate medications for this disorder contain NCAA-banned substances, namely stimulants; however, student-athletes with ADHD may need these medications to support their academic performance and general health. The NCAA has specific requirements for student-athletes with ADHD who want to compete while taking a banned stimulant.

Alcohol and substance abuse. Despite the risk of negative results, including diminished performance and the loss of scholarships, some student-athletes use illegal substances and alcohol at higher rates than do age-matched non-athletes. Student-athletes also report more binge drinking than the general student population because they view alcohol use as “normal.”

Approach and referral

The stigma that is still stubbornly attached to mental health issues can inhibit a student-athlete from seeking an evaluation and care. Approaching a student-athlete with a concern about his or her mental well-being can be an uncomfortable experience for anyone, including an athletic trainer. It is important that you have the facts correct, with context, relative to the behavior of concern before arranging for a private meeting with the student-athlete. The conversation should focus on the student-athlete not as an athlete, but as a person. Empathetic listening is vital. Encouraging the student-athlete to seek a mental health evaluation can be put in perspective, reminding the student-athlete that his or her psychological health is just as important as physical health. As Newman University men’s basketball coach Mark Potter said in Chapter 1 of this publication, permission to seek help is sometimes the best tonic for the problem.

Once a student-athlete self-reports wanting an evaluation, or agrees to go for a mental health evaluation, the student-athlete should be referred expeditiously to a mental health care professional. If possible, help set up the initial appointment. Having an established relationship with counseling services or community mental health professionals is highly recommended to expedite referrals.

If student-athletes demonstrate or voice an imminent threat to themselves, others or property (which, in many cases, rises to a code-of-conduct violation), or they report feeling out of control or unable to make sound decisions, then an emergent mental health referral is recommended. A university’s psychological concerns plan should include the protocol for emergent referral.


The issue of informing the student-athlete’s coach or parents invariably comes up. In a routine referral, inform student-athletes that while their referral is confidential, it may be helpful if they informed their coach and parents of their appointments. The student-athlete is not compelled to do so, but the athletic trainer should emphasize that coaches and parents are concerned about each student-athlete’s well-being, and keeping health care providers and coaches informed of their mental health care (without disclosing confidential information) is no different than any other forms of physical care. Encourage the student-athlete to inform his or her coach or parents, but do not insist on it.

When referring to community-based mental health care professionals where the student-athlete’s medical insurance may be used, it is important to inform student-athletes that their parents or guardians will receive notification of their mental health care treatment from their insurance company in the form of an explanation of benefits notification.

Campus counseling services and satastrophic incidents

It is important that the campus counseling center has a relationship with the athletics department, and that its mental health professionals understand the unique variables of student-athletes. It helps to identify an individual within the athletics department who is the primary contact. Because health and wellness falls under the purview of the athletic trainer, it is acceptable that the athletic trainer serve as the point person for referrals.

Stress reactions after a catastrophic incident are typical human reactions to the event. Many, if not most, of these reactions are self-limiting and will resolve with support, time and natural resilience. However, whenever a reaction persists, referral for mental health support is indicated. After a catastrophic incident (for example, death of a student-athlete or coach, or a disabling injury), offering early psychological intervention for those potentially affected has shown to be more effective in resolving traumatic stress than waiting before mental health care is implemented.

Risk management and legal counsel

University administrators face the challenge of managing the risks associated with mental health within the student-athlete population. To prepare for and respond to mental health incidents, administrators should be aware of risk management implications and be involved in developing the psychological concerns plan.

Legal considerations promote the idea that an interdisciplinary approach, including individuals in various departments within the institution of higher education, should be a goal in confronting the complex issues of mental health and the student-athlete. Two good resources for a university general counsel on the issues involved are “Managing the Student-Athletes’ Mental Health Issues” from the NCAA, and “Student Mental Health and the Law: A Resource for Institutions of Higher Education” from the Jed Foundation.

For in-depth information on how to develop your own institutional plan and develop an educational component on psychological health for your student-athletes, download the full NATA Consensus Statement on Developing a Plan for Recognition and Referral of Student-Athletes with Psychological Concerns at the Collegiate Level at

Timothy Neal is the assistant director of athletics for sports medicine at Syracuse University, where he provides leadership and supervision of seven full-time athletic trainers and 10 graduate assistant athletic trainers. He’s also a member of the New York State Board of Athletic Training and received the National Athletic Trainers’ Association’s Most Distinguished Athletic Trainer Award in 2010. Neal authored the “Catastrophic Incident in Athletics” guideline, and authored revisions in the “Mental Health: Interventions for Intercollegiate Athletics” guideline, in the NCAA Sports Medicine Handbook. He also served on the panel for the NCAA Concussion in Sport Medical Management Summit. In addition, Neal served as the NATA liaison to the NCAA Football Rules Committee from 2004-09, writing language for the helmet contact penalty, defenseless opponent penalty, and the horse-collar tackle penalty in college football.

Suggestions for approaching student-athletes with possible mental health concerns

  • Practice empathetic listening.
  • Focus on the individual as a person and not as an athlete.
  • De-stigmatize care seeking for mental health concerns.
  • If you think the student-athlete might be a threat to him/herself or others, enlist emergency mental health services.

Suggestions for institutional protocol and policy

  • Develop a written plan for identifying and referring student-athletes with possible mental health concerns to appropriate resources for evaluation and care.
  • Establish a collaborative relationship with counseling services and/or community mental health professionals before they are needed for referrals.
  • Identify an individual within the athletics department, such as the athletic trainer, who will be the primary point of contact with campus counseling services.

Questions for reflection

  • Do you have a strategy for how you would approach a student-athlete with potential mental health concerns?
  • Are you aware of your institution’s policy related to student-athlete mental health?