Mental Health

Developing and evaluating a model program for supporting the mental health of student athletes

Many student athletes experience mental health problems such as depression, but they are often reluctant to seek help. This project developed and evaluated a multi-faceted program to increase awareness of mental health issues, reduce the stigma of help-seeking, and promote positive coping skills among student-athletes. Brief and engaging videos featuring former Michigan student-athletes who successfully overcame mental health struggles were developed. Support groups were also developed, which used the videos to attract participants and stimulate discussion. The videos and support group protocol were rigorously evaluated to determine their effectiveness.

The Female Athlete Body Project

Female Athletes are a special population of college women, and special attention is required to inform them of the proper nutritional needs of their athletic bodies.

The psychology of sports injuries

The magnitude of the injuries within NCAA athletics is significant. Injuries can hinder performance and negatively impact collegiate athletes’ mental health and well-being, including: threats to self-esteem, social isolation and motivational demands associated with rehabilitation.

Ask the expert: Anxiety and athletes – what can we do?

Anxiety disorders can affect a student athlete’s ability function effectively – academically, athletically or socially. Symptoms of anxiety disorders often worsen under stress.  A student-athlete may be experiencing stress because of the transition of being away from home and adjusting to a new living situation, or worrying about achieving academically, or meeting performance expectations in his or her sport.

Mind, Body and Sport: Mental health checklists

By Scott Goldman

Clinical and sub-clinical changes in mood and mental states can affect the ability of student-athletes to function effectively – on the field of play, in the classroom and during their lifecourse. Many mental health disorders are at least partially rooted in biology. However, environmental stressors – including stressors associated with being a student-athlete – can play a critical role in whether these vulnerabilities turn into burdensome health conditions. One of the best ways to limit the negative consequences of most mental health conditions is early detection and treatment. This is where athletics departments and sports medicine departments can play a critical role: establishing prevention programming and reducing stigma around care-seeking, setting a plan to encourage effective early detection, and communicating to all stakeholders about how to manage emergency and nonemergency mental health issues.  

The following four checklists can help athletics departments and sports medicine departments assess and plan for managing mental health issues among student-athletes.

Checklist No. 1 Prevention And Preparation

1.  Conduct a needs assessment                                       

  • Get input from all relevant stakeholder groups. Learn about perceptions of student-athlete mental health/performance needs, ideas for enhancing mental health performance services for student-athletes and barriers to change. These stakeholders groups will vary by campus but should include:
    • Athletes (talking to your Student-Athlete Advisory Committee is a good place to start).
    • Sports medicine and athletic training staff members.
    • Athletics administrators.
    • Coaches and other staff who have direct contact with student-athletes.
    • Faculty athletics representatives.
  • If you are concerned about getting honest feedback from these stakeholder groups, consider using an anonymous needs assessment form (an example is available at www.NCAA.org/health-and-safety/sport-science-institute).
  • Be sure to talk with your compliance director about concerns she/he may have about pursuing enhanced mental health/performance services for your student-athletes, or to review rules associated with these types of services.

2.  Build relationships

  • •    Contact your state psychology licensing board (http://www.ceunit.com/psychologistsstateboards.htm) to help identify individuals who could serve as competent referral sources for your student-athletes on your campus and in your community.
  • •    If your campus has a counseling center or other mental health service for students, arrange to meet with the director. Consider asking some of the following questions to get the conversation started:
    • How often do student-athletes use the campus counseling center?
    • Given identified student-athlete needs related to mental health, what do you recommend to better meet these needs?
    • What is the average wait for a student to get services?
    • Have you had specific counselors identified as liaisons to certain areas of campus?
    • Is there anyone in the center who has a background in athletics, or who would be interested to learn about the unique culture of athletics?
    • If a particularly high-profile student-athlete needed to receive counseling services, is there any provision you could offer to protect his/her privacy?
    • Would someone on your staff be willing to provide outreach programs to our student-athletes, or at least come and introduce yourselves to our student-athletes each year?
    • How do you handle psychotropic medication referrals?
    • What kind of psycho-educational assessment services do you offer?
  • Whether working with an on-campus resource (such as the counseling center or psychology department) or an off-campus provider (such as a private practitioner), make sure the provider has the following traits:
    • They are a licensed mental health professional.
    • They have expertise and/or credentialing in clinical AND performance services.
    • They understand and appreciate the unique needs of student-athletes.
  • Initiate interactions with the mental health provider and your student-athletes when there is not a need for service. These non-clinical interactions will establish a rapport between the provider and your student-athletes, which will make it easier when the provider’s services are needed. Some non-clinical interactions include:
    • Presentations about sport psychology to teams.
    • Attending staff meetings with coaches, academic counselors and sports medicine personnel.

3.  Make a plan

  • Before an incident, develop a general plan to address mental health issues and make sure your staff is aware of it. Your plan should be written into your policy and procedures. The plan should include:
    • Flexibility.
    • How to refer and triage.
    • How to educate staff.
    • What to do after hours.
  • Know your school’s policies and procedures for on-campus mental health issues. Ensure that your plan and program are consistent with the campus’ general student population.
    • Know your school’s “duty-to-report” policy on mental health issues.
    • Know how your school manages “conflict of laws.”  For example, do licensed mental health providers on your campus follow HIPAA or FERPA?
  • Establish a liaison between the mental health care provider and the athletics department.

Checklist No. 2

Managing a Nonemergency Mental Health Issue

When student-athletes come to you in emotional distress and they do not present an immediate threat to the safety of themselves or others:

1. Demonstrate compassion

Some helpful tips for calming the student-athlete and demonstrating compassion are:

  • Remaining calm yourself — maintain calm body language and tone of voice.
  • Listen to the student-athlete. Allow him/her to express his/her thoughts. Provide him/her a forum in which he/she can be heard. It’s OK to have a moment of silence between you and the student-athlete.
  • Avoid judging the student-athlete.
  • Provide unconditional support. You do not have to solve his/her problem.
  • Normalize the student-athlete’s experience and offer hope.

2.  Gather information

  • Ask questions, including questions of safety (“Are you thinking of hurting yourself?” and “Are you thinking of suicide?”)
  • Asking the important questions will NOT plant the idea in his/her head.
  • By asking questions about suicide, you will receive valuable information. If he/she hesitates or confirms, you know to elevate the intervention (see “Managing an Emergency Mental Health Issue” checklist).

3.  Make a referral

  • Present the student-athlete with treatment options.
  • When you identify a student-athlete who would benefit from mental health services, but he/she doesn't appear to be aware of this need:
    • Inform the student-athlete matter-of-factly that you believe he/she would benefit from counseling. Base your recommendation on his/her behaviors, or identify specific behaviors that you have noticed and are concerned about.
    • Ask the student-athlete how he/she is feeling, how his/her actions are affecting his/her life, and if he/she has done anything about it so far.
    • Leave open the option for the student-athlete to accept or refuse the recommendation.
    • Encourage time to “think it over.” But, remember to follow up.
    • If the student-athlete refuses to attend counseling, leave the issue open for possible reconsideration.
    • Notify the student-athlete’s team athletic trainer, the director of sports medicine, and the mental health provider affiliated with your department.
    • If the recommendation is accepted, help create a plan to schedule an appointment, and follow up with the student-athlete in a timely manner. You may call the mental health provider with the student-athlete. If you call with him/her, you will know that an attempt to schedule has been made and when the student-athlete’s appointment is, which can assist you in follow-up.
    • Inform your mental health provider that a referral had been made.

4.  Respect boundaries and abilities

  • Know what you’re comfortable doing and what you’re not comfortable doing.
  • Don’t promise secrecy. If necessary, you can say to the student-athlete, “It took courage for you to disclose this information to me. And, by telling me, it says you want to do something about what is going on. The best thing we can do is to inform someone else, such as a mental health provider, who can give you the care you need.”

Checklist No. 3

Managing an Emergency Mental Health Issue

1.  Identify whether there is an immediate threat to safety

  • To identify whether the situation is an immediate threat to safety, ask the following:
    • Am I concerned the student-athlete may harm himself/herself?
    • Am I concerned the student-athlete may harm others?
    • Did the student-athlete make verbal or physical threats?
    • Do I feel threatened or uncomfortable?
    • Is the student-athlete exhibiting unusual ideation or thought disturbance that may or may not be due to substance use?
    • Does the student-athlete have access to a weapon?
    • Is there potential for danger or harm in the future?

2.  Manage immediate risks

  • •    In the case of an immediate risk to safety:
  • o Keep yourself safe — do not attempt to intervene.
  • o Keep others safe — try to keep a safe distance between the student-athlete in distress and others in the area.
  • o Get help from colleagues.
  • o If the student-athlete seems volatile or disruptive, alert a co-worker for assistance. Do not leave the student-athlete alone. However, do not put yourself in harm’s way if he/she tries to leave.
  • o Call 911 or campus security, or have the person taken directly to the emergency department at the nearest hospital.
  •      ◊ When you call, be prepared to provide the following information:
  •             ○ Student-athlete’s name and contact information.
  •             ○ Physical description of the student-athlete.
  •                 ♦ Height, weight, hair and eye color, clothing, etc.
  •             ○ Description of the situation and assistance needed.
  •             ○ Exact location of the student-athlete.
  •             ○ If the student-athlete leaves the area or refuses assistance, note the direction in which he/she leaves.
  •             ○ Follow campus and department protocols and policies.
  • •    If possible, offer a quiet and secure place to talk.
  • o Listen to the student-athlete; maintain a consistent, straightforward and helpful attitude.
  • o If the student-athlete is expressing suicidal ideation:
  •      ◊ Listen.
  •      ◊ Show your genuine concern.
  •      ◊ Emphasize risk to safety.
  •      ◊ Do NOT leave the person alone.

 

 

How to ask about suicide:

“Are you/Have you been thinking about suicide?”

“Are you/Have you been thinking about killing yourself?”

“Sometimes when people are (your observations), they are thinking about suicide. Is that what you’re thinking about?”

 

How NOT to ask about suicide:

“You’re not thinking about suicide, are you?”

 

 

3.  Contact a mental health care provider

•    Make arrangements for appropriate university intervention and aid.

•    Call the mental health provider to initiate next steps of care.

•    If medical care seems appropriate, head to the nearest hospital or call 911.

•    If the student-athlete is expressing suicidal ideation, make a referral for a suicide risk assessment.

    o On-site mental health professional.

    o Local hospital.

    o Local crisis line/mobile assessment team.

        ◊  Suicide hotline: 1-800-784-2433 or 1-800-273-Talk.

 

 

 

Checklist No. 4

After Managing a Mental Health Issue

 

1.  Initiate follow-up care

•    Identify what is needed for follow-up care.

•    Identify available resources.

•    Initiate continuity of care:

    o How is the mental health issue going to be managed within the athletics department?

    o If the issue is not to be managed within the athletics department, how do you make appropriate referrals and

    transitional steps to ensure the safety and well-being of those involved?

 

 

2.  Debrief and plan for the future

•    Schedule a meeting with athletics department staff involved with the intervention and athletics department staff who will be involved moving forward. While maintaining appropriate confidentiality:

    o Identify the strengths of the intervention approach.

    o Identify what did not work with the intervention approach.

    o Identify what improvements could be made to the departmental protocol for prevention, early detection and

    management of mental health issues.

 

 For more resources, see www.NCAA.org/health-and-safety/sport-science-institute

Mind, Body and Sport: Understanding and supporting student-athlete mental wellness

Introduction

Brian Hainline, NCAA Chief Medical Officer

 

Chapter 1 – First-Person Perspective

  • Game Face Is Not the Only Face (By Aaron Taylor, former football student-athlete)
  • Living the Dream – and Waking Up To Reality (By Cathy Wright-Eger, former coach)
  • Resilience, Empathy and True Toughness (By Molly McNamara, cross country and track student-athlete)
  • One Coach’s X and O: Pay Attention, Give Permission (By Mark Potter, current coach)
  • Make the Experience Positive (By Bradley Maldonado, Division II Student-Athlete Advisory Committee)
  • Solving the Mental Health Puzzle (By Rachel Sharpe, current assistant athletic trainer)

Chapter 2 – Positioning the Experts

The Psychologist Perspective (By Chris Carr and Jamie Davidson)

The Psychiatrist Perspective (By Todd Stull)

Chapter 3 – Dissecting the Disorders

Eating Disorders (By Ron Thompson)

Anxiety Disorders (By Scott Goldman)

Mood Disorders and Depression (By Chris Bader)

Depression and Anxiety Prevalence in Student-Athletes (By Ann Kearns Davoren and Seunghyun Hwang)

Substance Use and Abuse (By Brian Hainline, Lydia Bell and Mary Wilfert)

Gambling Among Student-Athletes: Cause for Concern (By Jeffrey L. Derevensky and Tom Paskus)

Sleeping Disorders (By Michael Grandner)

Suicidal Tendencies (By David Lester)

Education-Impacting Disabilities and the NCAA Waiver Process (By Marcia Ridpath)

Chapter 4 – The Big Injury (And Small Ones, Too)

How Being Injured Affects Mental Health (By Margot Putukian)

Post-Concussion Syndrome (By David Coppel)

Supporting Student-Athletes in Transition (By Penny Semaia)

Chapter 5 – Social and Environmental Risk Factors

Risk Factors in the Sport Environment (By Emily Kroshus)

Harassment and Discrimination – Ethnic Minorities (By Terrie Williams)

Harassment and Discrimination – LGBTQ Student-Athletes (By Susan Rankin and Genevieve Weber)

The Haunting Legacy of Abuse (By Cindy Miller Aron)

Interpersonal Violence and the Student-Athlete Population (By Lydia Bell and Mary Wilfert)

Potential Barriers to Accessing Mental Health Services (By Ken Chew and Ron Thompson)

Chapter 6 – What Do You Do Now?

Best Practices for Athletics Departments (By Chris Klenck)

Interassociation Recommendations (By Timothy Neal)

Mental Health Checklists (By Scott Goldman)

Mind, Body and Sport: Interassociation recommendations

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.

Background

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.

Confidentiality

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 www.nata.org.

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.

Mind, Body and Sport: Best practices for athletics departments

By Chris Klenck

While the previous chapters in this publication have expertly documented the unique challenges student-athletes face regarding mental health, individuals charged with caring for student-athletes need help recognizing and managing these concerns.

The purpose of this article is to identify “best practices” for establishing mental health services at the collegiate level. While “best practices” are defined as “methods or techniques that have consistently shown results superior to those achieved with other means,” medical “best practices” often are considered to be no more than expert opinion.

In addition, individual athletics departments (and campuses overall) vary regarding the resources they have available to allocate toward mental health services. Thus, perhaps the best approach is to suggest key components believed to be consistent with “best practices” for establishing mental health services at the collegiate level, while allowing individual institutions to formulate their own consensus as to the best way to incorporate these components into the fulfillment of their unique needs.

The following eight components are suggested for constructing mental health services on college campuses:

Identifying members of the mental health services team. While institutions will vary greatly with respect to human resources available to them, all collegiate athletics programs should have both an athletic trainer and designated team physician who will serve as core members of the mental health team. These individuals may not be mental health experts, but they can serve as a “point person” for referring student-athletes to the appropriate professional for evaluation and treatment.

Other ideal core members should include a psychiatrist, a clinical psychologist or a licensed clinical social worker with experience in mental health counseling. As these professionals may not be readily available to all athletics departments, it is critically important that the institution collaborate with on-campus services such as university counseling services or student health services, or off-campus services such as community mental health facilities or hospital clinic, private psychiatric, psychological, or other psychotherapy practices, and disordered eating clinics.

Establishing these relationships before a specific need is particularly important when timely referrals are essential. Additional team members may include sport psychologists, licensed drug and alcohol counselors, a team chaplain, academic counselors, sport dietitians, athletics directors or sport administrators, and coaches. Finally, the confidentiality of the student-athlete should always be of utmost importance and taken into consideration when involving various members of the team.  

Raising awareness of the mental health services available. The goal is to ensure that every student-athlete or athletics department member is familiar with the services available and how to access them. Potential ways to accomplish this goal include: (1) presentations at team meetings; (2) presentations at coaches or staff meetings; (3) printed handouts or pamphlets with program information and contact numbers; (4) information posted on athletics department websites; and (5) use of social media (such as Facebook). Increased awareness will enhance the likelihood of self-referrals by student-athletes or referrals from teammates, coaches or other staff, and improving the timely evaluation of those student-athletes in need.

Screening, recognition and appropriate referral. Screening student-athletes for psychological concerns such as depression and anxiety is extremely important for early recognition and intervention. Pre-participation physical examinations (PPE) afford an excellent opportunity to screen for and discuss issues such as depression, anxiety and disordered eating. Many PPE questionnaires specifically address these issues and can be a useful tool for screening. Other validated screening tools include the PHQ-9 Patient Depression Questionnaire.

It’s also important to ask about current and past prescription medications, recreational drug and alcohol use, and family history of mental health issues, as these are important indicators of possible psychological and psychiatric concerns.  

In addition to screening, it is important that both student-athletes and those working with them are able to recognize signs and symptoms of potential mental health issues. Behaviors such as missing classes, uncharacteristically poor academic or athletics performance, frequent physical complaints, disheveled appearances, and fighting with teammates or coaches can suggest an underlying mental health issue.  

Educational sessions with student-athletes and staff about the recognition of mental health concerns and the importance of timely referral will help improve outcomes for those affected. Special emphasis should be made to discourage unqualified individuals from attempting to counsel or treat student-athletes in need of professional care.  

Communication among members of the mental health services team. Communication among appropriate team members enhances appropriate follow-up and helps track progress. As confidentiality is always a chief concern, it is important early on to identify those individuals with whom the student-athlete will allow to share information, and to obtain appropriate written releases as indicated.  

The mental health services team should meet weekly to discuss the care of student-athletes. These sessions help identify those student-athletes who are not attending appointments or making progress toward their goals.

HIPAA-compliant text messaging or emailing can also help facilitate communication among providers.

Medication management. It is important to help student-athletes manage medications that may be prescribed to them. Many medications, such as antidepressants, may have undesirable side-effects or provide inadequate efficacy, which leads to poor compliance. Consideration should be given to having one provider, such as the team physician, prescribe all medications when indicated. The team physician frequently interacts with the student-athletes and athletic trainers. As such, this strategy may improve communication of adverse effects and will allow monitoring of refill requests to ensure compliance and appropriate use.  

Crisis management. A student-athlete may present in “crisis” at any time. Issues such as active suicidal or homicidal ideation, acute psychotic episodes, or death of a family member, teammate or staff often require immediate professional attention. Having an established crisis management plan prevents lapses in care and improves outcomes. Every student-athlete who is at risk of a crisis should have a “safety plan” developed with a member(s) of the mental health team. He or she should be provided with contact numbers and a written plan of how to access services at any time if a crisis should arise. In addition, collaborating in advance with local resources such as crisis stabilization units, mobile crisis evaluations, or emergency rooms at hospital facilities will streamline care when needed.

Risk management. Mental health service members and athletics department staff should be aware of their responsibilities to report specific behaviors to appropriate institution officials or law enforcement officials when indicated. Examples of such behaviors may include expressing intent to harm another person or suspected sexual involvement with a minor. Educational sessions with university officials involved in risk management are strongly encouraged so each mental health services team member is aware of his or her legal responsibilities while providing care.

Transition of care. A final component for establishing mental health services is the transition of care for student-athletes who are leaving the athletics department. As student-athletes graduate, transfer, are dismissed from teams or are removed from continued participation due to their condition, a plan should be in place for the timely and orderly transition of their care to another provider. Helping the student-athlete identify a primary care physician, mental health care professional, or other provider in his or her community will ensure appropriate follow-up and continued care. Providing written information about mental health resources available to the student-athlete in his or her community may also facilitate his or her care. Finally, providing the student-athlete with a sufficient supply of prescription medications until he or she can establish care with another provider, and arranging for delivery of medical documentation to appropriate providers, will ensure a smooth transition of care.  

*  *  *  *

While diagnosis and treatment of physical injuries and illnesses are critical to the success of student-athletes, so should management of their mental health needs.  

Mental health services should be a part of the comprehensive care provided to student-athletes at the collegiate level. In successfully integrated healthcare programs, mental health issues are treatable, and positive outcomes through timely access to care are likely.  

Even though available resources vary from one athletics department to another, all institutions should be able to establish certain basic components for establishing mental health services. Care that encompasses the entire well-being of the student-athlete is certain to translate into success both on and off the playing field.

Chris Klenck was named team physician at the University of Tennessee, Knoxville, in November 2006 after a primary care sports medicine fellowship at Indiana University Medical Center. During his fellowship training, Klenck was an assistant team physician for the Indianapolis Colts preseason training camps and at Purdue University (his alma mater), and he worked the NFL Scouting Combines in Indianapolis. He has NCAA championships experience and served as a team physician in the Indiana high school ranks. Chris earned his doctor of pharmacy degree from Purdue before completing his doctor of medicine degree at Indiana University School of Medicine. He is a member of the American Academy of Pediatrics, American College of Physicians, American Medical Society for Sports Medicine and America College of Sports Medicine.

 

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

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.

Mind, Body and Sport: Interpersonal violence and the student-athlete population

By Lydia Bell and Mary Wilfert

Sexual assault, harassment, bullying and hazing – these serious interpersonal injuries to an individual’s sense of safety and well-being find their way into athletics departments from the culture at large, tainting the experience of student-athletes.  

When an event unfolds on campus, it can cast a shadow on a university’s reputation as a safe place for emerging adults to explore who they will become and how they will contribute to society. As educators, we have an understanding of some of the underlying factors that may increase the risk of interpersonal violence for students-athletes and students at large.

The challenge before us is to examine components of the athletics culture, including issues around masculinity, encouraging aggression, group-think, bystander effect, homophobia and gender discrimination, that may contribute to violence, and to identify ways to mitigate the impacts of these factors on behavior.

As we consider education and prevention, it’s important to note that many aspects of the student-athlete experience provide opportunities to reinforce positive behaviors and outcomes, including the influence of coach as mentor, the support found in being part of a team, and leadership roles and skill development integrated in competitive play.

We do not have the data to indicate whether student-athletes experience more violence than their non-athlete peers, nor if the athletics culture by nature increases the risk of interpersonal violence. However, violence precursors, such as aggression and control, are part of the athletics culture, and “group-think,” which is embedded in team play, may allow some behaviors to go unchallenged.

Though most men on campus and on athletics teams are not involved in perpetrating violence, most interpersonal violence is perpetrated by men, and occurs more often within the context of group behaviors, and these can include fraternities and athletics teams. It is imperative that we take a critical look at these precursors and assess in what manner and to what extent they need to be tempered to reduce the potential they may exacerbate the behaviors of those with a predisposition to become violent.   

Our data sources include the 2012 NCAA Social Environments Study and the 2008-12 iterations of the National College Health Assessment*. The Social Environments Study features a representative sample of more than 20,000 male and female student-athletes across Divisions I, II and III. The survey included items assessing campus environment, entitlement and aggression, social relationships and help-seeking behaviors, and character education and intervention.

The National College Health Assessment, a comprehensive survey covering issues including substance use, sexual behavior, physical health, weight, personal

safety, violence, and mental health and well-being, is offered through the American College Health Association and administered in either the spring or fall term. Varsity student-athletes were identified upon indicating that they had participated in organized, varsity, college athletics within the last 12 months. All other participants constituted the non-athlete comparison group.

Aggression in athletics

In his 2010 book “Anger Management in Sport,” sport psychologist Mitch Abrams identified two forms of aggression, which he termed as instrumental and reactive. Instrumental aggression is behavior defined by actively, forcefully pursuing one’s goal, where harm to others may be a potential result of the action, but would never be a primary goal.

Reactive aggression or hostile aggression is related to anger, and is behavior that has harming another as a primary goal. Abrams also notes that anger, in and of itself, if not necessarily negative, is an emotion like any other, and does not have to lead to violence.  

In some cases, anger may enhance athletics performance as it prompts a physiological response of increased muscle strength. However, slower cognitive processing, and decreased fine motor skills are also part of that physiological response, which could hamper athletes, depending on the sport.

It is important to keep these differences in mind when viewing the data regarding aggression both on and off the field for student-athletes, as not all aggressive behavior is linked to interpersonal violence.

The 2012 NCAA Social Environments Study examined both athletics aggression and general aggression. Responses indicated that more than a third of males and a quarter of females have been trained to be aggressive in competition and believe that aggression is key to being a good athlete (see the table at the top of the following page).

Additionally, 45 percent of men and 29 percent of women are willing to do whatever it takes to win, and more than a fifth of men indicate that winning is more important than good sportsmanship. It is important to note that these numbers are nearly identical across divisions, with the exception that Division I males agree that they would do whatever it takes to win at slightly higher rates than those in Divisions II and III.

Athletics aggression among NCAA student-athletes

% Agree/Strongly Agree that… Men Women
I’ve been trained to compete with aggression. 42% 25%
Being fiercely aggressive during competition is a key to being a good athlete. 40% 23%
During a competition I would do whatever it takes to win. 45% 29%
Winning is more important to me than good sportsmanship. 21% 5%
I perform better in competition if angry. 26% 14%
If an athlete is fouled hard, he/she is justified in retaliating physically. 15% 5%

The data also reveal that being athletically aggressive may be entwined with unethical decision-making. In determining whether an athlete is justified in retaliating physically when fouled hard, we find that when a student-athlete indicates that he or she has been trained to compete with aggression, he or she is three to four times more likely to agree that the retaliation is justified.

For example, only 2 percent of women not trained to be athletically aggressive agreed that retaliation was acceptable, as compared with 11 percent of the women who were trained to be aggressive. Among men, 7 percent of those not trained to be athletically aggressive agreed that retaliation was acceptable, as compared with a quarter of the men trained to be aggressive.

In examining aggressive behavior off the field, males indicated higher levels of physical aggression than females, which is consistent with existing research on aggression. In most cases, men agreed to these items at twice the rate of women, with the exception of the question asking if they exhibited irritation when frustrated, with nearly one in five men and women agreeing to the item. Additionally, some of these items specifically ask about violent behavior resulting from anger, indicative of reactive aggression.

Aggrssion measures for NCAA student-athletes

% Agree/Strongly Agree that… Men Women
I have trouble controlling my temper. 13% 7%
Some of my friends think I get angry easily. 13% 7%
When frustrated, I let my irritation show. 17% 18%
Given enough provocation, I may hit another person. 19% 6%
I have become so mad that I have broken things. 19% 8%

While these data do not allow us to determine whether general aggression predicts aggression on the field, a relationship between the two scales is clear. Males prone to general aggressive behavior were far more likely to agree that winning was more important than good sportsmanship (64 percent vs. 20 percent), and aggressive females were six times more likely to agree (30 percent vs. 5 percent) that winning was more important than good sportsmanship.

Additionally, as we do not have a nationally representative sample of non-athletes responding to these questions, we do not know if the rates of off-field aggression for student-athletes is any higher or lower than their non-athlete peers.

The influence of alcohol

The role alcohol plays as a factor in violence and sexual assault has been well documented. At least 50 percent of college student sexual assaults are associated with alcohol use.

The NCHA survey data provided insight on negative behaviors attributed to alcohol consumption, which include engaging in regrettable actions, memory loss, police encounters, unprotected sex, physical injury to self or others, and suicidal thoughts.

Behaviors as a consequence of alcohol consumption (Figure 5A)

  Males Females
As a consequence of drinking, have you… Athlete Non-athlete Athlete Non-athlete
Done something you later regretted 33% 27% 33% 28%
Forgot where you were/what you did 32% 27% 30% 24%
Got in trouble with the police 6% 5% 3% 3%
Had sex without giving consent 2% 1% 2% 2%
Had sex without getting consent 1% 1% 0% 0%
Had unprotected sex 19% 13% 14% 12%
Physically injured self 16% 15% 14% 13%
Physically injured another person 5% 3% 2% 1%
Seriously considered suicide 1% 2% 1% 1%

Percentages represent the percent of respondents in each group that answered “yes” to each survey item. The other choices were “No” and “N/A, I don’t drink.” Approximately 20 percent of male and female student-athletes reported not drinking, so if one was to compare only the behaviors of those who drink, the respondents who say “yes” to experiencing these consequences are higher in number. For example, of the nearly 5,500 male student-athletes who reported that they consume alcohol, 24 percent reported that they had had unprotected sex as a consequence of drinking.

As the table indicates, male and female student-athletes report higher rates of alcohol-related regrettable actions and memory loss than their non-athlete peers. The high-profile nature of the student-athlete role, coupled with the pressure to serve as role models, may in part explain this higher rate of regrettable actions.

However, the higher rates of memory loss may indicate higher rates of excessive drinking among the student-athlete population.

The other statistic that bears further consideration is that more than one in 10 students overall reported engaging in unprotected sex related to alcohol consumption, and that this number jumped to nearly one in five among male student-athletes.

Additionally, student-athletes and non-athletes attributed alcohol consumption to incidences of physical violence and sex without consent, reinforcing the role alcohol can play in interpersonal violence.  

Sexual violence

The NCHA survey also gathered data about experiences of sexual violence within the past year. The accompanying table contrasts rates of sexual violence by sex and compares student-athletes with non-athlete populations.

Experiences with sexual violence (Figure 5B)

  Males Females
Within the past 12 months… Athlete Non-athlete Athlete Non-athlete
Sexually touched without consent 4.6%* 3.5% 9.1% 8.5%
Sexual penetration attempted without consent 1.2%* 0.9% 4.0% 3.6%
Sexually penetrated without consent 0.9%* 0.6% 2.1% 2.1%
Sexually abusive relationship 1.0% 0.9% 2.0% 2.1%

As indicated in the table, the percent of student-athletes and non-athletes in self-reported sexually abusive relationships was not significantly different. However, male student-athletes experienced some form of sexual assault at rates significantly (p<.01) higher than their non-athlete peers, and female students overall experienced sexual violence at rates twice that of men, across all categories.   

The data also revealed that lesbian, gay, bisexual and transgender (LGBT) students, independent of sex or athlete status, experienced significantly higher rates of sexual assault within the past 12 months than those who did not identify as LGBT. Such data serve as a reminder that sexual assault prevention training is applicable to both male and female student-athletes, and bring our attention to the need for additional focus on this topic among those athletes who identify as LGBT.

Mental health implications of sexual violence

NCHA survey participants were asked a series of questions about their mental health status within the past 30 days. To understand the mental health implications of sexual assault, the mental health responses of participants who indicated experiencing any sort of sexual assault (touched, attempted penetration, penetrated without consent) within the past 12 months were compared with those who had not experienced any of these conditions.  

The data revealed that for both athletes and non-athletes, males and females who self-reported experiences of sexual assault were significantly more likely to experience hopelessness, mental exhaustion, depression or suicidal thoughts; struggle academically; find it hard to handle intimate relationships; and experience sleep issues.  

However, student-athletes – both those who have experienced sexual assault and those who have not – appear to experience each of these conditions, with the exception of academic struggles, at lower rates than non-athletes. It is important to note that among both male and female student-athletes, those who indicated experiences of sexual assault within the past 12 months were three times more likely to have had recent suicidal thoughts than those who did not (13 percent vs. 4 percent for women, and 12 percent vs. 4 percent for men). (See Figures 5C and 5D)

Hazing and bullying

Hazing has been a topic of discussion for many years, and research has shown that the student-athlete population may be particularly vulnerable when first joining their teams.

The 1999 Alfred University hazing study of college athletics shed light on this topic when it revealed that upon joining their team, more than two-thirds of college student-athletes had experienced humiliating hazing, and half were required to participate in alcohol-related hazing.  

Male responses to mental health items (Figure 5C)

  Male Non-athletes Male Athletes
  No sexual abuse Sex abuse in past 12 mo. No sexual abuse Sex abuse in past 12 mo.
Felt hopeless within last 30 days 22% 33%* 17% 32%*
Felt exhausted (not from activity) within last 30 days 57% 66%* 47% 61%*
Felt so depressed it was hard to function within last 30 days 13% 24%* 10% 23%*
Seriously considered suicide within last 12 months 6% 14%* 4% 12%*
Diagnosed with depression within last 12 months 12% 20%* 8% 12%*
Difficult to handle academics within last 12 months 19% 32%* 35% 51%*
Hard to handle intimate relationships within last 12 months 28% 48%* 27% 48%*
Sleep issues within last 12 months 22% 35%* 18% 32%*

Female responses to mental health items (Figure 5D)

  Female Non-athletes Female Athletes
  No sexual abuse Sex abuse in past 12 mo. No sexual abuse Sex abuse in past 12 mo.
Felt hopeless within last 30 days 27% 40%* 23% 36%*
Felt exhausted (not from activity) within last 30 days 71% 81%* 65% 74%*
Felt so depressed it was hard to function within last 30 days 16% 29%* 12% 22%*
Seriously considered suicide within last 12 months 6% 16%* 4% 13%*
Diagnosed with depression within last 12 months 18% 29%* 13% 19%*
Difficult to handle academics within last 12 months 48% 62%* 43% 59%*
Hard to handle intimate relationships within last 12 months 33% 59%* 31% 55%*
Sleep issues within last 12 months 25% 41%* 20% 34%*

The prevalence of hazing in sport – despite harsher penalties and intensive prevention efforts – has been attributed in part to group-think and masculinity in sport. Athletics teams are like a family and become extremely close, allowing for forgiveness or ignorance of negative situations.

Student-athletes are especially vulnerable to group-think when they are isolated from outside opinions, when they are in homogenous groups, when they are expected to be obedient to “superiors,” and when there are no clear rules for decision-making.

Masculinity can also play a role in hazing, as the definition of being a “real man” can encourage hazing as a practice to prove that one can be physically and emotionally tough.  

Despite increased attention on this topic and stricter enforcement of anti-bullying codes of conduct, the University of Maine’s National Hazing Study (2008) found that more than 55 percent of college students involved in clubs, teams or Greek organizations have been subject to hazing, and more than 25 percent of club advisers or coaches were aware that this behavior was occurring.

Such discouraging data reinforce the need for continued anti-hazing programming for student-athletes, in addition to programming tailored specifically for coaches who may be able to prevent such actions at the outset.

The Maine Collaborative is currently conducting pilot programs on a number of NCAA campuses, engaging multi-departmental cross campus working groups, to test effective comprehensive prevention programs. As a supporter of this effort, the NCAA will receive and share findings to the membership on how best to decrease the risk of hazing.

Cyberbullying

An Indiana State University study in 2011 defined cyberbullying as using technology, such as social networking, text messaging or instant messaging, to harass others with harmful text or images or intentionally isolate another from a social group. The study found that almost 22 percent of college students reported being cyberbullied, 38 percent of students knew someone who had been cyberbullied, and almost 9 percent reported cyberbullying someone else.

Prevalence of cyberbullying

% Agree/Strongly Agree with the following Men Women
White Black Latino Other White Black Latina Other
I sometimes receive negative or threatening messages from fans via social networking sites. 9 17 12 11 3 6 3 4

 

The rise in cyberbullying is not limited to college students, and has received increased attention and in some cases local and state-level law adoption designed to mitigate this behavior among the K-12 population.

Among the student-athlete population, concerns about cyberbullying are not limited to peer-to-peer interactions. The 2012 NCAA Social Environments Study revealed that coaches have begun to encourage student-athletes to interact with fans via social media. While many reported positive interactions, some also noted receiving negative or threatening messages. (See Figure 5E)  

Of particular concern is black student-athletes who reported receiving negative or threatening messages at twice the rate of white student-athletes. Although approximately 80 percent of student-athletes noted that their coaches or others in athletics talk to them about responsible use of social media, departments may also want to consider how to help student-athletes address negative or threatening messages from fans.

Hazing and bullying, both in traditional forms and online, exist in the absence of strong leadership and direction, when groups are allowed to operate in secrecy and without supervision. These groups are more likely to deviate from social norms of conduct when coaches and administrators take a “hands-off” position, and when there are not clear policies or they are not consistently enforced.  

The NCAA Hazing Prevention Handbook recommends actions that administrators, coaches, team captains and athletes can take to ensure an athletics environment that speaks clearly to discourage hazing and that provides positive opportunities to enhance team building and bonding.

The NCAA Social Environments Study revealed that when faced with concerns over hazing and bullying, nearly 30 percent of student-athletes turn first to their parents for advice, support or assistance. While many would turn to teammates or coaches, parents were the most consistent first choice across the sample.

This was particularly true for freshmen, as nearly 40 percent indicated a desire to turn to parents first. As such, athletics departments may consider sharing information about hazing and bullying prevention and campus resources with parents so they can assist their children if approached about this topic.

Various efforts have recognized that effective hazing prevention requires collaboration across campus to assure clear and consistent hazing policies, and targeted educational programming to address the unique cultural elements for various student groups. The NCAA published the Hazing Prevention Handbook (www.NCAA.org/ssi), which provides examples of hazing prevention policy and education, and specific guidance for athletics administrators, coaches and student-athletes.  

Athletics departments can join the broader campus effort to address hazing through www.HazingPrevention.org, which sponsors the annual Hazing Prevention Week (http://www.hazingprevention.org/programs/national-hazing-prevention-week) the third week of September, providing resources that support hazing prevention at the campus level.  

Participation with campus colleagues working to decrease hazing in student groups will facilitate the athletics effort to assure team environments are free of hazing activities.  

Additionally, best-practice models in effective hazing prevention are under development through the National Collaborative for Hazing Research and Prevention (http://umaine.edu/hazingresearch), a multiyear pilot project to build an evidence base to better understand how to change the campus culture in order to reduce the risk of hazing for any one student.  

Intervention and character education

The 2012 NCAA Social Environments Study included items regarding participants’ willingness to intervene in a range of situations that could lead to aggressive or violent behavior. As the accompanying table reveals, the rates of intervention vary widely depending on the situation, and men and women appear willing to intervene at significantly different rates depending on context.

Likelihood of intervention

% Likely/Extremely Likely to do the following Men Women
Step in to stop a fight if someone threatens a teammate 82% 74%
Walk away from a confrontation 58% 74%
Get in a fight if the situation calls for it 50% 19%
Confront a teammate if he/she is treating a partner inappropriately 59% 47%
Intervene in a situation if it could lead to inappropriate sexual behavior 63% 71%

Understanding the considerations students weigh when deciding whether to intervene is useful when designing future training or having relevant discussions about intervention behavior.  

Participants’ responses reveal that there is a range of incentives and drawbacks to intervention that come into play when deciding whether to act. Overall, a large majority of student-athletes felt that they had a duty, at least in some cases, to act in a way that kept others safe. Additionally, many, especially females, agreed that they liked to think of themselves as helpers.

When considering drawbacks, fears of physical harm, angering teammates, and being perceived as over-reacting, often play a role in deciding whether to step in. Perhaps most concerning is that for 37 percent of males and 29 percent of females, intervening is at times perceived as just too much trouble.

Considerations regarding intervention

% who Agree/Strongly Agree with the following statement about deciding whether to help someone in trouble.
Incentives Men Women
All community members play a role in keeping people safe 78% 85%
I like thinking of myself as a helper 58% 89%
Teammates will look up to me if I intervene 59% 47%
Drawbacks    
I could get physically hurt by intervening 45% 40%
Intervening might make my teammates angry with me 43% 41%
People might think I’m overreacting to the situation 40% 37%
Sometimes it’s just too much trouble to intervene 37% 29%
I could get in trouble if I intervene 37% 32%

Character education

The Social Environments Study also included items that asked both about the types of training and character education student-athletes were receiving from their coaches, and also in what areas they would like more discussion or information.

Character education provided to and sought by student-athletes

Coach/athletics department education topic: Men Women
Discussed Want more Discussed Want more
Conducting self appropriately on campus and in community 90% 29%  (#2) 94% 31%  (#3)
Drinking/substance use 87% 25%  (#3) 93% 32%  (#2)
Diffusing/avoiding confrontations 83% 22% 79% 26%
Speaking up when you see things around you that aren’t right 80% 35%  (#1) 77% 47%  (#1)
Appropriate treatment of members of the opposite sex 80% 16% 66% 19%
Hazing/bullying 78% 16% 74% 20%
Relationship violence 67% 13% 54% 18%

More than any other topic, student-athletes want their coach or athletics department to talk about what to do when they see something around them that is not right. This is the No. 1 request across divisions, for both men and women. Student-athletes are seeking empowerment and want to build their skills in bystander intervention.

The second- and third-most requested topics were conducting one’s self appropriately on campus and in the community, and drinking and substance use. Approximately one in three men and women request more information about personal conduct, while women seek information about drinking and substance use at higher rates (32 percent) than men (25 percent). (See Figure 5H)

Coach implications for intervention

In examining character education and intervention, it is important to note some very interesting analyses a colleague at the Harvard School of Public Health has been doing with these data.

Looking specifically at predicting male student-athletes’ willingness to intervene in situations of partner mistreatment or inappropriate sexual behavior, it has been found that having a coach who talks to student-athletes about treating members of the opposite sex appropriately, relationship violence, and speaking up when things are not right, is both directly and indirectly significantly related to their willingness to intervene in both situations.

It is clear that a coach’s messages matter and can play a role in these behaviors. These analyses will be published soon and made available to NCAA members through the NCAA.org/research website.

Future directions

Interpersonal violence in the forms of sexual assault, harassment, hazing and bullying are under intense scrutiny as higher education is held accountable to provide safe environments for student life and learning. Included in this federal oversight are recommendations for education, prevention and response, identifying environmental strategies and bystander intervention training as best practices.  

A critical best practice for athletics administrators is to partner with higher education associations and experts in the field to advance our understanding of the causes and impact of interpersonal violence, and even more importantly to engage in effective prevention practices.

NASPA, the organization for Student Affairs Professionals in Higher Education, is working to identify campus practices that support healthy interpersonal relationships and that deter interpersonal violence. Athletics administrators and educators are encouraged to join in campus efforts, to meet their duties as members of the higher education community, and to address these issues in a true team effort. The NCAA is currently compiling a best-practice handbook on interpersonal violence prevention and response, to be published in the spring of 2014.

Athletics administrators and student-athletes alike are called upon to exert leadership and to model appropriate behavior, as they wear the mantle of high-profile representatives of the university community. Recent federal actions – namely the Dear Colleague Letter of Title IX, and the Campus Sexual Violence Elimination Act or SaVE Act administered under the Clery Act – have increased the duty to achieve compliance in prevention, education, and response to any violent incident. Athletics departments are equally responsible to ensure staff and students are provided resources to intervene and respond to acts of interpersonal violence.  

Current data tell us that a large number of student-athletes have been trained to compete with aggression, and that some, particularly males, exhibit aggressive behaviors off the field as well. Additionally, both male and female student-athletes are victims of sexual assault or relationship violence while on campus. Sexual assault can pose serious threats to an individual’s mental health. Those who have experienced sexual assault are significantly more likely to experience hopelessness, mental exhaustion, depression or suicidal thoughts; to struggle academically; to find it hard to handle intimate relationships; and to experience sleep issues.  

While these data shed light on some of the mental health outcomes related to sexual assault, we also want to bring attention to sexual assault and relationship violence prevention and bystander intervention.

The promise of bystander intervention training is an exciting and welcome strategy, engaging and empowering students to intervene safely and effectively when they see a friend or teammate in distress or at risk for experiencing interpersonal violence in the form of sexual assault/harassment and hazing/bullying.  

The 2012 NCAA Social Environments Study revealed that a surprising number of student-athletes appear to be reluctant to intervene in instances of relationship violence or inappropriate sexual behavior. However, more than a third of male student-athletes and half of female

student-athletes note that they would like to talk more about speaking up when they see things that aren’t right.

Many student-athletes are seeking the means to be empowered to act, and understanding their rationale for deciding when to intervene may assist us in developing programming that can directly address the perceived drawbacks to intervention.   

Sexual assault education of student-athletes and coaches is required in the U.S. Department of Education’s Title IX Dear Colleague Letter (http://www2.ed.gov/about/offices/list/ocr/letters/colleague-201104.pdf). Bystander intervention training is a defined strategy and expectation offered in the 2013 Campus Sexual Violence Education or SaVE Act (http://clerycenter.org/campus-sexual-violence-elimination-save-act) administered through the Clery Act and enforced by the Department of Education, requiring campus compliance in education, prevention and response.  

The Step UP! Bystander Intervention Program (www.stepupprogram.org), which the NCAA supports, provides facilitator-friendly training materials to conduct training with student-athletes and other student groups to help overcome the bystander effect, addressing attitudinal impediments to timely intervention and providing real skill building to safely and effectively intervene when a friend or teammate is at risk.

Athletics departments can expect to be scrutinized and expected to step up and join the campus effort to create safe and healthy learning environments for all students. Athletics administrators are in position to influence the lives of so many, and through this guidance provide a unique opportunity to assist student-athletes to experience what it truly means to be a teammate on and off the field.

Note: The NCAA issued to member schools a new handbook that illustrates the responsibility athletics departments have in collaborating with other campus leaders to fight sexual assault and interpersonal violence. Titled “Addressing Sexual Assault and Interpersonal Violence: Athletics’ Role in Support of Healthy and Safe Campuses,” the handbook was created to help athletics departments partner to change the culture surrounding this issue. The NCAA Executive Committee also issued a statement on sexual violence. To read the statement and to view more information on the issue, visit www.NCAA.org/ssi.

Lydia Bell is the associate director of research for academic performance at the NCAA. Bell assists in all aspects of development and analysis of research on current and former student-athlete academic performance and well-being. Prior to joining the NCAA, she was an assistant professor of practice and director of Project SOAR in the Center for the Study of Higher Education at the University of Arizona. She received her Ph.D. in language, reading and culture and M.A. in higher education from Arizona, and an A.B. in government and legal studies and sociology from Bowdoin College.

Mary Wilfert is an associate director in the NCAA Sport Science Institute. Since 1999, she has administered the NCAA drug-education and drug-testing programs and worked to promote policies and develop resources for student-athlete healthy life choices. She serves as primary liaison to the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, the governing body charged with providing leadership on health and safety recommendations to the NCAA membership. Wilfert has worked in the health education field for more than 30 years to empower individuals to make informed choices for lifelong health and success.

*American College Health Association. American College Health Association-National College Health Assessment, Fall 2008, Spring 2009, Fall 2009, Spring 2010, Fall 2010, Spring 2011, Fall 2011, Fall 2012 ACHA-NCHA II, ACHA-NCHA llb]. Hanover, MD: American College Health Association; (2013-10-31).

 

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