Mental Health

Mind, Body and Sport: The haunting legacy of abuse

By Cindy Miller Aron

As previous chapters have pointed out, student-athletes may be an at-risk population for developing psychiatric symptoms. But individuals with abuse histories can be at even higher risk, given the likelihood of greater emotional vulnerability.  

The highly functional exterior of athletes often belies psychological fragility. Individuals with histories of abuse can lack the emotional resilience to cope with the ordinary acclimation to college life, let alone the extraordinary demands made upon student-athletes.

The legacy of abuse operates on a preconscious level. There is an individual’s obvious response to an athletics experience, and then there is what lies underneath. It is the preconscious, underlying areas of loss/sadness that compounds the intensity of what occurred.

The individual experiences his or her frustrations or disappointments as greater than the reality of what transpired. The student-athlete loses his or her ability to distinguish how he or she feels from what actually happened. Battling the persistence of these feelings results in an inefficient use of psychological energy. As a result, depletion can occur rapidly. Soon the student-athlete is emotionally running on empty. This is when psychiatric symptoms present.

Individuals with a history of sexual/physical/emotional abuse can suffer from post-traumatic stress disorder, which is a psychological reaction to experiencing a highly stressful event or series of events, outside the normal range of human experience. The disorder is characterized by depression, anxiety, flashbacks, intrusive thoughts and nightmares, among others. The demands of college athletics create an area ripe with “triggers” for the affected student-athletes.

Individuals with abuse histories have an extraordinary sensitivity to boundary violations or perceived boundary violations. A seemingly benign exchange can provoke a flood of effect with debilitating results. These responses can be confusing to the individual as well as teammates and other athletics department personnel. The student-athlete can begin to be labeled as “hot-headed,” “overly emotional,” “an over-reactor,” “too sensitive” and so on. These kinds of dismissive responses trivialize what is a deeper-seated struggle for an individual that bears attention.

Less than benign exchanges, in the form of harsh coaching behavior, create a different set of challenges for those with abuse histories. The familiarity of mistreatment may allow a greater degree of tolerance than for individuals with no abuse history. However, this is not without emotional cost.  

The individual can quickly experience a shrinking sense of self and self-worth, which over time compromises the individual’s ability to manage these exchanges. The student-athlete likely begins to experience increased frustration, distortion in thinking, unrealistic performance expectations and self-deprecating statements.

Coaching feedback can intensify arousal, causing further emotional distress in the individual. The person begins to feel worthless, and helpless about having any impact on the circumstance, which then can lapse into hopelessness. Images of failure loom large, compounded by feelings of embarrassment, self-loathing and the potent affect of shame.

It is common for individuals with abuse histories to experience inappropriate guilt, meaning the assumption of greater responsibility for what transpired than is reasonable. This is the result of the masterful way in which abusers can project responsibility for their actions onto the victim. The abused individual experiences a mistake or disappointment as a crime of sorts for which they need to be punished.

Errors/mistakes are inherent in performance-based endeavors. An athlete can experience a relentless feeling of responsibility for such a metaphoric crime, triggered by a game error or dismal performance. This burden of failure, which “demands punishment,” deploys more assaults on the individual’s self-esteem and sense of his or her own character, further eroding the individual’s effective stability.

Somatic complaints, without medical explanation, are a psychiatric symptom that is split off from the origin in internal distress. These are often manifestations of depression. These can present as pregame nausea, chronic aches/pains, headache and so on.  

Depression/anxiety can come in many disguises, such as psychomotor agitation, balking, hitting a hurdle, cramping and tight muscles. Additional disguises involve psychomotor retardation, inability to pass a fitness test, missing balls/shots and fumbling, to name a few. Somatic complaints bear further exploration. The preconscious conflicts of those with abuse histories can be a primary driver of such concerns.

Student-athletes are especially vulnerable to losses in physical functioning through injury, which removes them from the athletics activity. Considerable research – described in some detail in Chapter 4 of this publication – has been done on this issue outlining predictable post-injury adjustment/depression. For student-athletes, an injury can become a significant life stressor. It not only prevents participation in their sport and with their team, it affects self-image and status on the team. The inability to participate in practice creates increased social isolation, all of which exacerbates their emotional response to injury.  

Individuals with abuse histories can suffer more acute psychiatric symptoms in response to injury as a result of an already compromised sense of self, tolerance for stress, frustration and emotional distress.

Individuals with histories of abuse are also at a higher risk for developing eating disorders. It is estimated that 30 percent of individuals who develop eating disorders have abuse histories. Once again, student-athletes are already an at-risk population for developing eating disorders (see Ron Thompson’s article in Chapter 3). Combine this with an abuse history, and the preponderance of this psychiatric condition comes as no surprise.

An injury or incident can derail a student-athlete, causing a psychological free fall. Some of the warning signs are reckless behavior, such as careless sexual encounters, smoking pot, drinking and irritability, which can translate into fighting. Reckless behaviors are efforts to manage intolerable feelings, and are but temporary solutions that inevitably exacerbate the circumstance at best and can land individuals in considerable trouble at the worst.

The free fall can result in destructive thoughts, such as suicidal ideation, suicide attempts and other forms of self-harm. Student-athletes lose their capacity to manage unacceptable and intolerable feelings, trapping themselves in a black hole of despair.

Student-athletes competing at the collegiate level are at a confluence of circumstances, with limited preparation for the magnitude of the pressures they will encounter. Student-athletes with histories of abuse are subjected to an unusual combination of internal and external pressures that place them at risk for emotional compromise and struggle.

This can be mitigated with keen recognition of the signs of psychiatric distress, combined with early intervention and treatment.

Cindy Miller Aron is a licensed clinical social worker and certified group psychotherapist providing outpatient mental health services, including the assessment, and treatment of depression, anxiety, adjustment disorders, traumatic loss, with specializations in group therapy, late adolescence, sports psychology, supervision and consultation. She is a fellow in the American Group Psychotherapy Association and is the founding president of the Oregon Group Psychotherapy Society. Aron is also a member of the Association of Applied Sports Psychology.

Mind, Body and Sport: Harassment and discrimination – LGBTQ student-athletes

By Susan Rankin and Genevieve Weber

Perhaps nowhere is the expression “the only constant is change” more evident than in higher education. The experiences of college students, including student-athletes, are ever changing, which means that faculty, staff, coaches and administrators have to recognize and act on these changes or they will quickly find themselves left behind.

Those of us who work with students who identify within the queer-spectrum (bisexual, gay, lesbian, queer, pansexual, same-gender loving, etc.) or the trans-spectrum (androgynous, gender-nonconforming, gender-queer, transfeminine, transmasculine, transgender, etc.) can attest to the extensive changes that members of these groups have experienced just in the last decade.

The settings of college campuses have improved for queer-spectrum and trans-spectrum students over the years; yet, when research examines the experiences of queer-spectrum and trans-spectrum students, one group – student-athletes – is routinely absent from studies.

One of the biggest changes has been the age at which students disclose their sexual identity. From the 1970s through 1990s, it was commonplace for queer-spectrum individuals who were planning on attending college, especially if the college was away from home, to wait until they were on campus and had developed new friends before they disclosed their identity. This disclosure is colloquially known as “coming out.”

In some cases, the students were not delaying disclosure, but simply did not recognize themselves as lesbian, gay, bisexual and queer (LGBQ) until they met others like themselves and were in a more supportive environment. Today, with a growing number of gay-straight alliances in middle and high schools, the availability of online resources and (for student-athletes) the rising number of professional athletes who are “coming out,” students more readily understand themselves to be attracted to others of the same sex/gender and often come out in high school and, increasingly, in middle school.

Although there has been an increased focus in the professional literature on the experiences and perceptions of queer-spectrum and trans-spectrum college students, there is limited research examining sexual identity and transgender identity in intercollegiate athletics.

In this section, we offer a review of the influence of campus climate on the well-being of queer-spectrum and trans-spectrum college students, including those who identify as student-athletes. We summarize a large amount of empirical and conceptual research related to the collegiate experiences and perceptions of queer-spectrum and trans-spectrum non-athletes in the absence of student- athlete-focused research. This is based on the assumption that the unique stress related to sexual and gender identity development influences both queer-spectrum and trans-spectrum student-athletes and non-athletes alike.

Campus climate within athletics

Historically, athletics programs on college or university campuses might be sources of specific concerns for queer-spectrum and trans-spectrum students. Studies have shown that despite the diversity of ethnicity, socioeconomic status, geographic background and even sexual orientation, coaches, administrators and student-athletes nonetheless often exhibit heterosexist and homophobic attitudes.

One study of five Division I campuses in fact explored how athletics teams respond to diversity, including race, gender, socioeconomic level, geographic region and sexual orientation. The authors noted that “questions about sexual orientation brought about the most highly charged responses.” Many also denied that LGBT individuals were members of their teams or expressed negative reactions to the idea of having LGBT team members. The overall message from the findings was that hostility toward gay men and lesbians exists on nearly all teams and at all the case study sites.

In one of the first studies to comprehensively explore the perceptions and experiences of student-athletes with regard to campus climate, we developed and tested the Student-Athlete Climate Conceptual Frame, which suggests that individual and institutional characteristics directly influence both how student-athletes experience climate and a variety of educational outcomes unique to student-athletes. At the same time, student-athletes’ experiences of climate can also influence these educational outcomes.

The findings offered that climate significantly affects lesbian, gay, bisexual, transgender and queer (LGBTQ) student-athletes’ academic and athletics outcomes. LGBTQ student-athletes generally experience and perceive a more negative climate than their heterosexual peers. These negative experiences with climate adversely influence their athletics identities and reports of academic success. Although sexual identity is not a direct predictor of academic success or athletics identity, the way LGBTQ student-athletes experience the climate significantly influences both.

Thirty years of research underscore the disproportionately higher rates of depressive symptoms, substance use/abuse, suicidal ideation and suicide attempts among queer-spectrum and trans-spectrum youth.

Experiences with harassment place queer-spectrum and trans-spectrum individuals at high risk for alcohol and drug use/abuse, and previous studies have noted that binge drinking is more prevalent among LGB college students than their heterosexual counterparts and that there is a relationship between psychological distress and alcohol use for LGB college students.

Other studies found that sexual-minority college students were more likely to experience and witness incivility (disrespectful behaviors) and hostility (overt violence), and personal incivility and witnessing hostility were associated with greater odds of problematic drinking. These studies and others generally conclude that experiences with minority stress place LGB individuals at high risk for adverse mental health outcomes, including alcohol and drug use/abuse.

The social stigma and discrimination associated with LGBTQ identities are contributing factors to the elevated rates of depression and suicide as well. Discrimination at the individual level (hostility, harassment, bullying and physical violence) and institutional level (laws and public policies) have been identified as risk factors for depression, social isolation and hopelessness, which in turn place LGBTQ people at risk for contemplating suicide.

Among college students, extant studies also indicate that sexual minorities are at increased risk for poorer mental health, including suicide attempts. LGB students have been found to be more depressed, lonely, and had fewer reasons for living compared with heterosexual students.

How athletics departments can help

While many of the experiences of LGBTQ student- athletes are similar to the general population, there are several ways in which their lives are very different from their heterosexual peers. Overall, “in-house” harassment, or harassment experienced at practice or similar athletics-related events, whether intentional or not, is the most prevalent kind experienced by our respondents. It follows, therefore, that athletics departments have the power to improve the collegiate experiences of all student-athletes through cooperation with athletics personnel, student- athletes and faculty members at their institutions.

However, to effectively address the experiences of LGBTQ student-athletes in particular, it behooves athletics personnel to look beyond the obvious and attend to the myriad ways in which LGBTQ student-athletes encounter discrimination and harassment as they strive to achieve both academic and athletics success as well as overall well-being in college.

We propose the following best practices for creating positive campus climates for queer-spectrum and trans-spectrum student-athletes.

The power of language. First, we encourage the use of language that extends beyond the binaries in all of the following recommended potential best practices. Many individuals do not fit the socially constructed definitions of gender identity, sexual identity and gender expression. Language instills and reinforces cultural values, thereby helping to maintain social hierarchies. While definitions facilitate discussion and the sharing of information, terminology remains subject to both cultural contexts and individual interpretation. As a result, the terminology that people use to describe themselves and their communities is often not universally accepted by everyone within these communities.

Therefore, it is recommended that we value the voices of those within our campus communities and use language that reflects their unique experiences. It is important for athletics personnel to familiarize themselves with the language offered in the beginning of this article with respect to LGBTQ communities. Using inclusive language provides a sense of safety for LGBTQ student-athletes.

Finally, the frequent use of derogatory language such as “faggot,” “that’s so gay,” or “dyke” are common sources of harassment experienced by LGBTQ student- athletes. Language is powerful and has a significant impact on LGBTQ student-athlete success. To create a more inclusive environment, we encourage athletics personnel to respond quickly to end the use of derogatory language aimed at LQBTQ student-athletes.

Offer a visible and supportive presence. There are multiple venues where intercollegiate athletics can offer a visible and supportive presence. This serves two goals: (1) It lets the LGBTQ community know that intercollegiate athletics at your institution is knowledgeable of the issues/concerns facing the LGBTQ community and stands as an ally in the fight against anti-LGBTQ bias, and (2) It provides an environment for LGBTQ student-athletes and athletics personnel to feel safe and supported in acknowledging their sexual and/or gender identities.

  • Create an athletics department or individual team videos (PSAs) that show your support of LGBTQ people and student-athletes. New York University ( and the University of North Carolina, Chapel Hill, ( have developed videos to give you an example.
  • Support LGBTQ events on your campus (for example, National Coming Out Day; Day of Silence, LGBTQ Pride Week) by encouraging student-athletes and athletics personnel to attend the events. Just standing in solidarity alongside LGBTQ students and allies will speak volumes with regard to your support and may encourage them to attend more athletics events. If your institution has an LGBT Resource Center, they can provide a calendar of events. For a list of LGBTQ Resource Centers or other support services available on your campus, go to the Consortium of Higher Education Lesbian Gay Bisexual Transgender Resource Professionals home page at

Develop inclusive policies. Policies that explicitly welcome LGBTQ student-athletes, coaches and athletics personnel powerfully express the commitment of an athletics department and, based on the results of this project, will add to team success (winning!). Individuals will be more likely to be open about their sexual identity or gender identity when they know that the institution is supportive. When individuals do not have to expend energy hiding aspects of their identity, they are able to focus on team and individual goals.

Our recommendations include:

  • Develop/enforce inclusive policies. If your institution does not have a nondiscrimination policy inclusive of actual or perceived sexual identity, gender identity, and gender expression, you can work with senior administrators to adopt one.
  • Develop fair and consistent enforcement (consequences) for incidents related to the inclusive nondiscrimination policies.
  • Prohibit homophobic, transphobic, and heterosexist behavior and language by fans at athletics events.
  • Include sexual identity and gender identity in the athletics department’s student-athlete handbook.
  • Include sexual identity and gender identity in the Student-Athlete Advisory Committee (SAAC) publications.
  • Extend health insurance coverage to athletics personnel’s same-gender partners/spouses.
    • If the institution does offer health insurance coverage, “gross up” wages for employees who enroll for these benefits to cover the added tax burden from the imputed value of the benefit that appears as income for the employee.
    • If the institution cannot offer health insurance coverage to employees’ same-gender partners/spouses, offer cash compensation to employees to purchase their own health insurance for same-gender partners/spouses.
  • Include sexual identity and gender identity issues and concerns or representations of people with various sexual identities and gender identities in the following:
    • Application for student-athlete financial aid/athletics grants-in-aid
    • Student-athlete health intake forms
    • Alumni materials/publications
  • Offer students who identify outside the gender binary the ability to self-identify their gender identity/gender expression, if they choose, on standard forms. For example:
    • Application for admission
    • Application for housing
    • Student health intake form
  • Provide appropriate health care for transgender student-athletes.

Increase awareness of LGBTQ issues and concerns. Since LGBTQ and non-LGBTQ individuals are socialized into a homophobic and heterosexist society, athletics community members need the space to question and examine unfounded attitudes and beliefs.

Acknowledging the contributions of LGBTQ former athletes/coaches in the sports arena is important to fully integrate LGBTQ concerns and experiences into the athletics community. The omission of such topics from athletics “de-historicizes” LGBTQ experiences and paints a false picture of the world in which we live. We offer the following potential best practices for consideration:

  • Provide the 2013 Champions of Respect: Inclusion of LGBTQ Student-Athletes and Staff in NCAA Programs to all athletics personnel. A copy of the publication is available at
  • Integrate LGBTQ issues and concerns into the Challenging Athletes’ Minds for Personal Success (CHAMPS)/Life Skills Program for student-athletes.
  • Integrate LGBTQ issues into existing courses for student-athletes. For example:
    • First-year student-athlete class (first-year seminar)
    • Student-athlete leadership development courses
    • Athletic Directors Leadership Institutes
  • Integrate LGBTQ issues and concerns into existing professional development programs. For example:
    • National Association of Collegiate Directors of Athletics (NACDA) Management/Leadership Institute
    • NACDA Sports Management Institute
    • NCAA Women Coaches Academy (WCA)
    • NCAA Achieving Coaches Excellence Program (ACE)
    • NCAA Career in Sports Forum (Forum)
    • NCAA Diversity Education Workshops
    • NCAA Emerging Leaders Seminar
  • Include programs that incorporate topics regarding sexual identity and gender identity in all new athletics personnel orientations.
  • Promote the use of inclusive language in all athletics venues (playing fields, locker rooms, training rooms, etc.).
  • Create a pamphlet with examples of heterosexist assumptions and language with suggested alternatives.
  • Provide course credit to LGBTQ student-athletes for participating in peer education initiatives (Straight Talks, Speakers Bureaus, etc.).
  • Offer programming to discuss multiple identities of LGBTQ people (LGBTQ Latinos/Latinas, international LGBTQ people, LGBTQ people with disabilities, LGBTQ Muslims, etc.).
  • Offer resources about LGBTQ people and the intersections of their sexual identity and gender identity with their religious and/or spiritual needs (Unity Fellowship for Students, Gays for Christ, etc.).
  • Acknowledge the different ways that LGBTQ student-athletes experience harassment. Take steps to improve their perceptions of climate (for example, athletics department responses to acts of anti-LGBTQ bias incidents).

Respond appropriately to anti-LGBTQ incidents/bias. As long as anti-LGBTQ bias persists in athletics, LGBTQ student-athletes and athletics personnel will need to feel safe and supported by their departments when acts of anti-LGBTQ intolerance occur. LGBTQ student-athletes and athletics personnel should be able to speak and act without fear of homophobic reprisal.

  • Offer a clear and visible procedure for reporting LGBTQ-related bias incidents.
  • Develop a bias incident and hate crime reporting system for LGBTQ concerns that includes the following:
    • Bias incident team
    • Methods for supporting the victim
    • Outreach for prevention of future incidents
    • Protocol for reporting hate crimes and bias incidents

Offer comprehensive counseling and health care. The literature suggests that LGBTQ people who experienced both ambient and personal heterosexist harassment had the lowest overall well-being as compared with respondents who experienced only ambient heterosexist harassment and those who did not experience any heterosexist harassment.

Given that our results indicate many LGBTQ student- athletes experience heterosexist climates, the need for counseling support is evident. Further, more students are “coming out” as transgender in intercollegiate athletics. Although this growing population has unique needs related to physical and mental health care, most colleges and universities offer little or no support for this population.

We recommend the following best practices for addressing the counseling and health care needs of LGBTQ student-athletes:

  • Offer support for student-athletes in the process of acknowledging and disclosing their sexual identity and for other concerns with one’s sexual identity.
  • Offer counseling services that support LGBTQ people, with a staff that knows and understands LGBTQ student-athletes’ needs and experiences.
  • Provide training for team physicians, athletic trainers and other medical staff to increase their awareness of and sensitivity to LGBTQ people’s health care needs.
  • Actively distribute condoms and LGBTQ-inclusive information on HIV/STD services and resources.
  • Offer a student health insurance policy that covers ongoing counseling services for transgender students who need such counseling, as consistent with the World Professional Association for Transgender Health’s (WPATH) Standards of Care.
  • Offer a student health insurance policy that covers the initiation and maintenance of hormone replacement therapy for transgender students who need such therapy, as consistent with the World Professional Association for Transgender Health’s (WPATH) Standards of Care.
  • Offer a student health insurance policy that covers gender confirmation (“sex reassignment”) surgeries, including mastectomy and chest reconstruction, breast augmentation, complete hysterectomy, genital reconstruction and related procedures, for transgender students who need such surgeries, as consistent with the World Professional Association for Transgender Health’s (WPATH) Standards of Care.

Increase awareness of transgender issues and concerns. In 2010, the NCAA reported that its national office received 30 inquiries in the previous two years about how colleges should “deal with transgender athletes.” Those numbers, NCAA officials offered, could increase, given that more people than in the past are identifying themselves as transgender, more are doing so at younger ages than in the past, and a growing number of colleges have anti-bias policies that cover gender identity.

A report titled, “On the Team: Equal Opportunity for Transgender Student-Athletes,” argued that in this environment, the lack of a national standard is unfair both to transgender students and to all student-athletes. The report divides its recommendations for colleges into two categories of transgender students: those who are undergoing hormone treatments and those who are not, and the report notes that many people who identify as transgender do not take medical steps.

For those undergoing hormone treatments, the report recommends that a male-to-female transgender student-athlete should be able to participate on a men’s team but should complete one year of hormone treatments before competing on a women’s team.

The report recommends that a female-to-male transgender student-athlete who is taking prescribed testosterone should be allowed to compete on a men’s team but must seek an exemption to NCAA rules barring the use of testosterone.

For those not undergoing hormone treatments, the report recommends that transgender students should have the option of competing on the teams consistent with sex assigned at birth, female-to-male students be allowed to participate on either the men’s or women’s team, but that male-to-female transgender students not be permitted to compete on women’s teams.

In 2011, the NCAA clarified its policies on transgender student-athletes. The new policy, which embraced the suggestions in the 2010 report from the National Center on Lesbian Rights and the Women’s Sports Foundation, ensures that student-athletes are allowed to participate on male or female teams, so long as they adhere to two key rules. The policy required no new legislation but rather clarified two pieces of existing legislation regarding banned substances – namely, testosterone – and a team’s official “status,” determined by the gender of its players.

  • Provide the publication “On the Team: Equal Opportunity for Transgender Student-Athletes” for all athletics personnel. A copy of the publication is available at 2013/07/TransgenderStudentAthleteReport.pdf
  • Provide the 2011 NCAA Policy on Transgender Inclusion to all athletics personnel. The policy is aimed at allowing student-athletes to participate in competition in accordance with their gender identity while maintaining the relative balance of competitive equity among sports teams. The policy will allow transgender student-athletes to participate in sex-separated sports activities so long as the student-athletes’ use of hormone therapy is consistent with the NCAA policies and current medical standards, which state:
    • A trans-male (female to male) student-athlete who has received a medical exception for treatment with testosterone for gender transition may compete on a men’s team but is no longer eligible to compete on a women’s team without changing the team status to a mixed team. A mixed team is eligible only for men’s championships.
    • A trans-female (male to female) student-athlete being treated with testosterone suppression medication for gender transition may continue to compete on a men’s team but may not compete on a women’s team without changing it to a mixed-team status until completing one calendar year of documented testosterone-suppression treatment.
  • Provide the resources offered by the NCAA to all athletics personnel that includes:
    • Inclusion of Transgender Student-Athletes resource book.
    • A CD that contains the resource book and a slide presentation to educate administrators and student-athletes.
    • A 30-minute video that discusses transgender issues.
  • Increase the awareness of student-athletes regarding transgender student-athletes and policies in the NCAA.

Further recommendations for future research and promising best practices are offered in recent studies by Beemyn and Rankin (2011), Marine (2011) and Rankin et al. (2010).

Other recommended resources include the Campus Pride Friendly Campus Index (http://www.campuspride, Promising Practices for Inclusion of Gender Identity/Gender Expression in Higher Education (, and the Consortium for LGBT Professionals in Higher Education Architect (

Susan Rankin is a research associate in the Center for the Study of Higher Education and associate professor of education in the College Student Affairs Program at Pennsylvania State University. Rankin earned her B.S. from Montclair State University in 1978, an M.S. in exercise physiology from Penn State in 1981, and a Ph.D. in higher education administration in 1994, also from Penn State. Before moving into her current position, Rankin served for 17 years as the head softball coach and a lecturer in kinesiology at Penn State. She has presented and published widely on the impact of sexism, racism and heterosexism in the academy and in intercollegiate athletics.

Genevieve Weber is an associate professor in the School of Health and Human Services at Hofstra. She is also a licensed mental health counselor in the state of New York with a specialization in substance abuse counseling. Weber teaches a variety of courses related to the training of professional counselors, includes group counseling, multicultural counseling, psychopathology, and psychopharmacology and treatment planning. In her research and professional presentations, she focuses on the impact of homophobia and heterosexism on the lives of lesbian, gay, bisexual and transgender (LGBT) individuals, with particular attention to the relationship between homophobia, internalized homophobia, and substance abuse among LGBT people.

Mind, Body and Sport: Harassment and discrimination – ethnic minorities

By Terrie Williams

While previous sections of this publication talked at length about common stressors on student-athlete mental health because of the unique position these students are in as athletes, cultural factors exist that complicate those stressors even further for under-represented student- athlete populations.

As a woman of color and someone who has experienced her own clinical depression, I am acutely aware of the challenges and stigma facing blacks when trying to address mental health issues. And as a trained licensed clinical social worker, I’ve had the great opportunity to engage with the National Alliance on Mental Illness, the Substance Abuse and Mental Health Services Administration, and other mental health organizations that have allowed me to create mental health advocacy campaigns for the black community. 

The following comments focus on the work my colleague, Yolanda Brooks, and I have done over the past decade with black male athletes. To be sure, there are some commonalities in the experiences of black male athletes and the experiences of men and women from other racial and ethnic minority groups – and in the experiences of student-athletes from socioeconomically disadvantaged backgrounds, across all races and ethnicities. In my work with black male athletes, I have seen many struggle with socioeconomic barriers and remnants of a racist system that continues to plague many in this community. It is critical that athletics administrators and others working with minority and socioeconomically disadvantaged

student-athletes gain an appreciation for their unique experiences and backgrounds. 

To be a black man in our society often means to experience overt violence and subtle forms of racism. It may mean being stopped and frisked, racially profiled and made to feel insecure about the complexion of one’s skin. It may mean feeling pressure to not appear threatening to others for fear of being further harassed by police. Even in the absence of overt discrimination and racial violence, black men are too often aware that discrimination and violence are possible. Having to be constantly on guard has real physiologic consequences.

The young, developing black male may have experienced family violence and an absentee father. In some families, as a coping mechanism, black men are taught to cut off their feelings and normalize horrific events that happen to them personally or to people they know. What happens to the child and/or adult who watches a relative – or anyone – be killed in front of him and then has to go about his normal routine?

Another cultural factor that can negatively affect a young, developing black male is an adherence to hip-hop culture, which is heavily influenced by street culture and may define “ownership” of women and money as a means to feel valuable in place of authentic self-esteem. Within these settings, a maturing black male may learn or interpret that in order to be considered a man, one never discusses his feelings. It becomes safer to lash out in anger than to let on to the hurt within. The bruised ego, pride and self-loathing eventually manifest into a stoic demeanor that sabotages any chance of meaningful and intimate relationships.

In a number of instances, as young black student-

athletes were developing, parents altered the family lifestyle (changed/left jobs, moved to another city, etc.) so that the most talented child would have the best opportunity to succeed in his/her sport. This could mean playing for the best elite team (which is expensive) or getting the coveted college athletics scholarship.

But if the student-athlete is underperforming, loses passion for the sport or wants to develop a more balanced lifestyle (engaging in social behaviors of a typical adolescent athlete versus the insulated, isolated, intense, laser-focused, all-consuming lifestyle of elite sports), there may be strong pushback from the support network – especially those who’ve sacrificed or have made a strong investment in the student-athlete. They aren’t allowed to quit even if they wanted to, as there has been too much invested in that student-athlete – too much is at stake.

When they arrive at college, many black student-athletes experience an additional set of stressors. These can include a feeling of isolation from the majority and from dominant social-cultural aspects of college life, the absence of supportive social networks outside of sports, academic struggles (and in some instances, barriers) created by socioeconomic challenges. 

In environments where there are sociocultural differences, some black student-athletes may struggle to transition and fit in. This may overwhelm an already stressed individual. Student-athletes – particularly those in high-profile sports – are not new to high-pressure situations. However, if stretched beyond their capacity to manage, they may find themselves struggling to adjust to the demands of their life situation regardless of talent, potential or sport.

These stressors can leave the student-athlete overwhelmed and vulnerable to developing stress-related symptoms, mental disorders such as clinical depression and anxiety, or even at higher risk to incur a career-threatening injury. As a group, blacks tend not to seek help for psychological problems – and student-athletes are even less likely to do so in fear of appearing weak and vulnerable.

Managing all of these stressors and pressures can challenge the strongest adult; however, for a college student- athlete (who is still growing and developing mentally and physically), such demands can quickly overwhelm and lead to serious mental and behavioral problems. Reactionary high-risk behaviors (substance abuse, sexual promiscuity, illegal activity, etc.) may emerge along with avoidance and detachment from support networks.

To effectively address this issue, there need to be outreach strategies embedded systemically in collaborative athletics and health programs in order to identify, enhance and encourage these student-athletes to access support – and if warranted, intervention – before sliding down the slippery slope of stressed to distressed to depressed.


Mind, Body and Sport: Risk factors in the sport environment

By Emily Kroshus

Many mental health disorders are at least partially rooted in genetic biological predispositions (genetic vulnerability). However, genetic vulnerability is not destiny – environmental stressors and resources play a critical role in whether individual vulnerabilities turn into burdensome health conditions. By environment, we mean all of the factors outside the individual, ranging from their interactions with people close to them, to institutional policies and programs, to the broader culture within which they live, learn and play.

Collegiate student-athletes face many of the same mental health risk factors as their non-athlete peers, but their roles as student-athletes both expose them to additional environmental risk factors and offer protective resources to help mitigate those factors.

The environmental risks can take the form of direct stressors (for example, time demands, performance pressures, coaching style); interactions with others in their environment that encourage risk behaviors and discourage individuals from seeking help; harassment and discrimination related to personal characteristics such as race/ethnicity or sexual orientation; and exposure to interpersonal or sexual violence.  

The protective factors can include prevention and screening programs, and interactions with others that encourage individuals to seek help.  

These risk and protective factors are introduced briefly below, and then discussed in greater detail later in the chapter in essays from leading clinicians.   

Sport-related stressors

Stress is not inherently bad. In fact, in many cases it is a healthy part of growth. However, if it is chronic or inadequately managed, it can result in negative health outcomes either directly or through unhealthy coping behaviors (such as substance abuse).  

Interactions, resources, policies, programs and cultural attitudes in the sport environment have the potential to reduce the presence of stressors and to help student-athletes deal effectively with them.  

Time demands are a frequent source of stress for student-athletes. Many student-athletes spend more than 30 hours per week on their sport, with extensive in-season travel and early morning practices that limit sleep. Managing both sport and academic demands often results in elevated stress, inadequate sleep, and an inability to participate in other extracurricular or leisure activities that help promote overall well-being. Because of the physical demands on their sport, many student-athletes need more sleep than the average college student. Individuals with adequate sleep also respond more effectively to stressors as they arise. Research has indicated that sleep is critical for mental acuity, sport performance and injury prevention.

Another frequent source of stress is pressure to perform athletically. Some of this pressure is self-imposed. When sport is central to identity, so is sport performance. Pressure often comes from outside sources, most critically from coaches. Coaching style plays a role. When coaches use an ego/performance-centered motivational climate (as compared with a skills-mastery motivational climate), student-athletes tend to experience greater anxiety and distress, and are at elevated risk of negative outcomes, including burnout and disordered eating.

Institutional policies matter, too. Athletics scholarships put a dollar value on athletics performance, and policies related to scholarship reductions heighten performance-related pressure for student-athletes, particularly those with financial need. Interactions with parents, peers and fans can put a premium on athletics performance and a microscope on failure to perform athletically. The growing use of social media allows alumni and other fans to interact with student-athletes directly, and can have the result of exacerbating this pressure.

Normative behaviors

Interactions with teammates can be a source of risk – or protection. Adolescents and young adults often place a high value on peer approval and in looking and acting like their peers. For student-athletes, this often means teammates. The stronger the group’s identity and cohesion, the more important individuals tend to find conforming to the group’s norms.  

Sports teams often have extremely high group identity and cohesion. When some teammates model unhealthy behaviors, such as disordered eating or substance use, other teammates are at elevated risk of adopting those behaviors. Whether exposure to or experimentation with these types of unhealthy behaviors results in an individual progressing to a clinically diagnosable mental health disorder depends in part on his or her underlying genetic vulnerability. However, environment matters a great deal.  

Another way in which teammates and others in the sport environment can influence mental well-being is in the extent to which mental health issues and help-seeking are stigmatized or encouraged. If teammates and coaches stigmatize mental health conditions or encourage a culture of toughness and not admitting weakness, symptomatic or at-risk individuals will be less likely to disclose their mental health conditions or seek help. Conversely, teammates who don’t stigmatize disclosure of mental health conditions and who encourage help-seeking can be powerful positive forces. Coaches can play a critical role in serving as a resource for student-athletes who want to discuss mental health issues, and in encouraging or discouraging help-seeking for these issues.  

Harassment and discrimination

Minority populations, including racial/ethnic minorities and sexual minorities, often experience negative mental health outcomes connected to their experiences with harassment and discrimination. While some sport environments may be fully inclusive of all minority groups, others are not. Additionally, while the sport environment is a critical one for student-athletes, it is not the only environment in which they function. Even when a sport environment is fully inclusive, student-athletes from minority populations who are stigmatized or who experience more overt forms of harm such as verbal harassment and violence in nonsport environments can experience negative health consequences. For example, sexual minority college students tend to experience more anxiety and mood disorders, engage in more frequent suicidal ideation, and make more suicide attempts than their heterosexual peers.

The Minority Stress Model has helped explain this difference. Acute and chronic stressors – including violence and harassment and the fear of violence and harassment occurring – as well as internalized stigma lead to physiologic responses, such as elevated cortisol levels. These physiologic processes can have direct bodily harm. They can also increase the risk of maladaptive coping behaviors such as substance abuse.

In addition to ensuring that sport environments are free of harassment and discrimination of minority populations, coaches, clinicians and others who interact with student-athletes need to be aware that individuals of minority status may be shouldering a heavy load from their experience functioning outside the sport environment. In some cases, it may be appropriate to engage resources to help athletes cope with these external sources of stress, or at the very least to function in a supportive and understanding role.

Interpersonal violence

Experiencing interpersonal violence, particularly sexual violence, can have lasting mental health consequences. Recent evidence from the National Collegiate Health Association indicates that nearly 10 percent of female college students have been sexually touched without their consent during the past 12 months, with no significant differences between athletes and non-athletes.  

Sexual minority students – both male and female, athlete and non-athlete – experienced significantly higher rates of sexual assault within the past 12 months than those who did not identify as lesbian, gay, bisexual or transgender. Individuals who self-reported experiences of sexual assault were significantly more likely to struggle academically, find it hard to handle intimate relationships, and experience hopelessness, mental exhaustion, sleep issues, depression and suicidal thoughts.

Interpersonal violence, including hazing and bullying, may be elevated in certain sport environments. While being a student-athlete does not increase risk of experiencing sexual violence, student-athletes who experience sexual violence or other forms of interpersonal violence in any settings bring these experiences and the resultant mental health consequences back with them to the sport environment. Consequently, individuals in the sport environment need to be aware of the resources available to student-athletes so that they can manage the mental health consequences that often result from experiencing these forms of violence. Individuals in the sport environment can also play an important role in encouraging victims of violence to report their experience and in supporting them emotionally in this process.

*  *  *  *

The sport environment matters for both risk and prevention of mental health disorders. Unique stressors often accompany the experience of being a student-athlete. Resources in the sport environment can potentially mitigate stressors and encourage help-seeking for individuals who are experiencing mental health disorders or who are at risk of these disorders.

Student-athletes benefit from being part of the sport family – with teammates and coaches who see them on a daily basis. Whereas many students transitioning to college run the risk of being isolated and not finding a supportive community, college student-athletes often have a built-in community from the moment they step foot on campus.

Student-athletes are often used to working with a team of multidisciplinary health care professionals to facilitate optimal health and sport performance. Coaches, athletic trainers and teammates can reinforce to symptomatic individuals that mental health professionals are just one more piece of this equation.  

Student-athletes are also used to adhering to routines and dealing with aversive conditions rehabilitating injuries – and receiving support from teammates and coaches during this process. The process of recovery from mental health disorders can in some cases be similarly onerous – and social support matters a great deal here, too.

Drawing on the experience of recovering from other health- and performance-impacting injuries in the sport environment can help more positively frame mental health-related treatment-seeking and adherence for the symptomatic individual.   

While the sport environment presents numerous risk factors for student-athlete mental health, it can also play an important role in prevention and wellness. Reducing unnecessary sources of stress and stigma in the sport environment, increasing access to resources to help mitigate stress, and encouraging help-seeking for mental health disorders are all critical ways in which the sport environment can function to improve mental well-being among student-athletes.

Emily Kroshus is a Postdoctoral Research Fellow at the Harvard School of Public Health and the NCAA Sport Science Institute. She received her doctoral degree from Harvard School of Public Health in the department of social and behavioral sciences, with a concentration in health communication. As an undergraduate at Princeton, Kroshus was a three-time NCAA Division I All-American in cross country and track and field.

Mind, Body and Sport: Student-athletes in transition

By Penny Semaia

It’s been 10 years since I last strapped on a helmet and played the game that has done so much for me. Yet, I still have this bond with football that seems to never go away. It’s almost like a sixth sense that pops up when someone mentions the game. When I’m watching a Pitt game at Heinz Field, it’s as if each play is in slow motion. I see every block. I can predict certain movements. Sometimes, I catch myself lifting my arm up as if I was the one shedding a block. I laugh when I think about it. I laugh even harder when I see my old teammates do the same thing. It’s a reflection of our past and what we were – student-athletes.

Today, I work in student-athlete development at the University of Pittsburgh, where I earned my degree and played football. Although it’s been a long time since I played, I’ve transitioned out of my sport in my own way, yet am still connected to it through work and play.

However, not everyone is as fortunate as I am, in the sense that I’m still connected to my sport and alma mater on a daily basis. For much of the 10 years that I’ve been out of uniform, I’ve witnessed many of my student-athletes go through their own transition of taking off their jersey for the last time. For some, it was seamless; they were able to move on to the next phase of their life and not look back. For others, it was the day they wanted to avoid the most; the day they realized they are no longer athletes. Their commitment to their sport had been their identity for as long as they remembered. Now, their identity is a question mark.

As professionals working in student-athlete development, it is our duty to help our student-athletes gain the knowledge and skills to prepare for life after sport. In the area of identity and life transitions, this is one of the most difficult and time-sensitive topics. There is a fine balance to helping student-athletes understand the importance of focusing on their current situation while also preparing them for the next stage. I believe that one of the most important steps in helping student-athletes successfully navigate this transition starts with establishing a strong baseline relationship with them. Programs and resources are important, but in my experience, they are most effective when delivered with what I like to call a human touch.

For example, a student-athlete walked into my office, sat down and stared at me. She said, “Penny, I can’t believe this is it. It’s over. I’m done with track.”

Knowing this student-athlete, I knew she had a great job lined up and was prepared. Yet, she was so caught up in her athletics career ending. My immediate response was, “How do you feel?” She answered, “Well, I don’t know. I’m just … I don’t know.”

I’m sure this sounds familiar. It’s the end of the academic year. We get the trickling-in of seniors who just want to chat, and the conversation somehow always flows into the end of their athletics career. I always anticipate going into this topic with seniors. We’ve been talking about it since day one.

This is where the human touch is most important. The key is taking all of the programs and services that we deliver and narrowing them down to the individual level. It’s also about understanding our student-athletes as individuals and knowing that they are all unique.

For example, just because two student-athletes may compete in the same sport and are from the same region, or even the same family, we cannot assume that we will serve them in a similar way as individuals. The groundwork to all of our programs and services relies on the human touch approach.

The initial phase of this happens by developing:

Positive and trusting relationships. When student-athletes trust us, they will approach us for anything – especially when they need help facing the end of their athletics careers. One thing that has helped me gain trust is taking the time to really listen – that has allowed me to get to know student-athletes as individuals. The information gained through listening, no matter the topic, is often vital for future conversations. I always take notes after my meetings with student-athletes, no matter how insignificant it seems at the time (such as noting a pet’s name). I know that this information can be useful when I need to communicate with them in the future. The more our student-athletes know that we are interested in them, the more they will begin to trust us.

Once this is established, we can have real conversations about their future long before the end of their athletics career is imminent. To quote Theodore Roosevelt, “People don’t care how much you know until they know how much you care.” It’s when our student-athletes know that we care enough about them that they will open up.

Instances in which our student-athletes will need support are career-ending injuries, end of eligibility, and stressors in play (not playing at the same level or up to their or their coaches’ expectations). The relationships we build when our student-athletes are under the least amount of stress can help us identify the times when their behaviors are out of character. This is where our gauge of our student-athletes is both a benefit and vital to helping provide the necessary care for them.

Exercise patience. We need to know and understand that athletics is a big deal for our student-athletes. They wouldn’t be participating if it wasn’t! This came up for me early in my career while I was trying to help a young football player.

This young man did not play at all before his senior year. Following his senior season, during which he got in a few times, he still wanted to focus on working out and postpone finding a career. I was trying to help him focus on moving on. In my mind, he was a long shot and he didn’t even see that. I wanted him to know and understand this, so I took the “keeping it real” approach of providing statistics of student-athletes who play professionally, horror stories and anything else that revealed the odds that this was not a viable path for him. The more I tried to talk to him, the more he didn’t want to hear me.

This was very frustrating for me. Everything led to a standstill in our progression. It wasn’t until I heard someone say, “Who are we to shatter a kid’s dream?” that I reevaluated my train of thought. They were right. Who was I to tell this young man he shouldn’t pursue his dreams? That really stuck with me.

Since that experience, I’ve shifted my approach and have focused on the idea of Life Beyond Sport. Instead of saying, “move on,” my approach is “prepare for when the day comes.” Helping our student-athletes learn how to balance their preparation is tough, especially when they’ve been told to focus on their athletics for so long. We have to help them realign their objectives and dig deeper into understanding what they want most out of life and how they will get there.  

Maintain the educator role. One last bit of advice I’d have for anyone working in our field is to maintain the educator role. Being in a position where we are on the front lines – working directly with student-athletes daily, I’ve learned that I can’t be the answer for everything. Instead, when student-athletes approach me, I want to engage them in the learning process as much as possible instead of just spoon-feeding them the answers. Our focus should be on helping them learn how to figure things out, helping them identify the necessary resources, or just simply pointing them in the right direction.

Far too often we are looked at as the “go-to office” that solves all of the issues. As nice as that is, it can stir up misinterpretations of what our mission is and what we do. For example, if a sophomore gymnast enters our office and is looking for a summer job and then we provide the individual with a person’s name and phone number to call for a job, are we truly helping that gymnast? By the time their senior year comes around, they will have the same expectations of our services and think that we will just hand them a career. For that office staff, the pressure is often to help serve this student-athlete as quickly as possible.

Instead, our approach should be focused on the process. We should help point them to the resources (such as career services) that can help them develop skills to search for a job and learn about the types of careers that they may want to pursue after graduation. We can support them in this process, but they must be active participants for it to be effective. We cannot be the answer to everything, but we can be a great resource to help point our student-athletes in the right direction. For some student-athletes, this will include referral to a mental health professional.   

Foster trust. For us to effectively help our student-athletes transition to life beyond sports, a foundation of trust must be laid. We cannot simply rely on programs and lectures to have the type of impact necessary. The stronger the relationship, the more likely our student-athletes will understand and accept the services we are providing and the recommendations we are making.

This is where our role becomes a key factor for our athletics departments. I understand that not everyone has one role. Many of us share coaching, academic, or athletic training responsibilities – some have all three roles. No matter what hat we wear, when it comes to the health and well-being of our student-athletes, this should always be the top priority.

By implementing services with a human touch and keeping a focus on life beyond sport – no matter what the student-athlete’s athletics goals – our student-athletes will have the right type of support in their journey.

Penny Semaia is the senior associate athletics director of student life at the University of Pittsburgh. He oversees the Cathy and John Pelusi Family Life Skills Program, which prepares student-athletes for success for life after college by using academic, athletics and community resources. Semaia also serves as the president of Get Involved! Pittsburgh, a nonprofit organization focused on young professionals being active in their communities. Semaia was a four-year letter-winner for the Pitt football team from 2000 to 2003. He graduated with a degree in anthropology with related areas in sociology and theater. Semaia joined Pitt’s athletics department in 2005 as the career and life skills coordinator.

Mind, Body and Sport: Post-concussion syndrome

By David Coppel

Over the last decade, sport-related concussions have become an important focus within the general sports injury and sports medicine field. Clinical and research studies regarding this form/context of mild traumatic brain injury have increased geometrically as its position as a public health concern elevated and the Centers for Disease Control and Prevention (CDC) became involved.  

The CDC has compiled guidelines and resources for health care providers, coaches, parents and athletes regarding concussions. Great progress has been made in understanding and managing sport-related concussions, especially in terms of:

  • Incidence and prevalence of sport-related concussion at all levels of sports participation,
  • Delineating acute symptoms and sideline management,
  • Describing the general course of recovery for most athletes, and
  • Identifying risk factors or modifiers associated with prolonged recovery and/or persistent symptoms.  

Expert reviews of available scientific evidence have resulted in a series of consensus or position statements that have guided concussion definitions, evaluation, management and return-to-play guidelines.

The current definition of concussion is a brain injury involving a “complex pathophysiological process affecting the brain, induced by mechanical forces.” Concussion has a number of described features:

  • Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with impulsive force transmitted to the head.
  • Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously or may evolve over  minutes or hours.
  • Concussion may result in neuropathological changes, but the acute clinical changes largely reflect a functional disturbance rather than structural injury.
  • Concussion results in a graded set of clinical symptoms that may or may not involve a loss of consciousness, and resolution of clinical and cognitive symptoms typically follows a sequential course, with some cases having prolonged symptoms.

Diagnosing concussion may be complicated in some instances, as most do not involve a loss of consciousness or overt neurological signs, and impact on functioning can be quite mild and temporary. No consistent biomarkers or neuroradiological findings have been delineated, although the research continues in these areas.

The neuro-pathophysiology of sport-related concussion has been described in terms of changes in brain metabolism and evidence of temporary metabolic-based vulnerability to secondary injury. Typically, concussion events produce physical, cognitive and emotional/neurobehavioral symptoms that are generally most severe in the acute post-injury time frame (one to two days) and then reduce/resolve over subsequent days and weeks.  

Recent consensus guidelines indicate that 80-90 percent of concussions resolve in seven to 10 days, sometimes longer for children and adolescents. The diagnostic complexity emerges when symptoms are delayed or prolonged, or when symptoms are not specific to concussion, but instead are temporally related to the concussive event or experienced/perceived as having been brain-injury related. Due to the range of symptoms (physical, cognitive, emotional) and the individual factors influencing recovery, a multidisciplinary management approach is often indicated. Physicians, athletic trainers, neuropsychologists, academic advisers, physical therapists and clinical/sport psychologists all play roles in clarifying symptoms and providing support.

The strong desire and motivation of some athletes to return to play provides the opportunity for these motivational factors to be manifest in symptom reporting. Since tracking self-reported post-concussion symptoms over time (typically with checklists) is the main aspect of management, some athletes will minimize or report resolved symptoms in order to be seen as “symptom-free” and begin the return-to-play protocol or be cleared. Knowing the athlete and his or her baseline or pre-injury functioning can be crucial in evaluating post-injury symptom reports and presentations.

Acute sport-related concussion signs may include loss of consciousness, headache, dizziness and alteration of mental status (confusion or fogginess). Headache, nausea, fatigue, irritability, sleep disturbance and sensitivity to light and noise may continue over the next few days. Other symptoms seen on post-concussion symptom checklists include attention and concentration difficulties, slowed processing, distractibility, memory problems, slowed visual tracking or vision problems, balance disturbance, and anxiety or depressed mood. Typically, depressed mood or anxiety levels improve as the physical symptoms resolve, but it is important to assess and intervene if these emotional issues persist.

While most sport-related concussions (concussion symptoms) resolve over days and weeks (most within three weeks), a subset of sport-related concussion patients may not resolve in this expected time frame and have persistent post-concussion symptoms, or be seen as developing post-concussion syndrome/disorder. Diagnostically, according to the International Classification of Diseases, post-concussion syndrome occurs after a head trauma (which may include a loss of consciousness), and includes at least three of the following symptoms:

  • Headache
  • Dizziness
  • Fatigue
  • Irritability
  • Difficulty in concentration and performing mental tasks
  • Memory impairment
  • Insomnia
  • Reduced tolerance to stress, emotional excitement and alcohol.  

Symptoms of depression or anxiety resulting from loss of self-esteem or fear of permanent brain damage are seen as adding to the original symptoms.

Treatment/management of sport-related concussion is often based on self-reported symptoms, and these symptoms may reflect other conditions and/or factors not related to concussion, but more with post-traumatic stress disorder. Thus, based on the nonspecificity of symptoms, there is some controversy about the validity of a “post-concussion syndrome.” In general, when athletes continue to be significantly symptomatic (or worsen) beyond the three- to four-week recovery period, the symptoms could be more influenced by psychological factors than the original physiological factors associated with the acute injury.

Following a sport-related concussion, athletes are told initially to observe relative physical and cognitive rest. Reducing physical activity for an active student-athlete can be a difficult and stressful adjustment. A prescribed reduction in cognitive demands often involves reduced class time or assignments and is described by some as “cognitive or brain rest.” These restrictions and reductions appear appropriate in the initial week of recovery, but may become harmful later in recovery, as other stressors may emerge with falling behind in school (making up and keeping up demands upon return) and concern over training/conditioning effects.

As student-athletes recover and are cleared, they begin a return-to-play protocol that incrementally increases the physical exertion level, and ultimately the risk of re-injury over days, leading to a return to full practice and participation. Student-athletes must complete each stage without emergence of symptoms. Similar “return to learn” approaches have been proposed for academic re-entry.  

Strong somatic focus, hyper-vigilance to symptoms, sleep disturbance (often due to mental activation or worry), general stress/rumination behaviors, or a pattern of maladaptive coping styles may also be factors associated with prolonged or persistent symptoms. Family or social network/support problems, which include negative/nonsupportive responses or reactions from teammates, coaches or other primary relationships can result in more emotionally based symptoms.

During sport-related concussion recovery, if significant mood swings, depressed mood, or increasing anxiety or panic symptoms arise, they are indicators for referral to clinical or counseling psychologist/sport psychologist or other health care providers with expertise in these management areas.

Most concussed student-athletes recover symptomatically relatively quickly and return to their sport and academic activities. However, some have persistent symptoms, or delayed symptom resolution, which often impacts their athletics, academic, social and emotional functioning.

In addition to the basic approach of monitoring symptoms over time, interventions aimed at sport-related concussion education, management of recovery expectancies, symptom attributions and addressing emotional issues have been positive factors in recovery from sport-related concussions.

Ideally, management and treatment of sport-related concussions should include opportunities to evaluate and address the psychological impact and emotional responses that can be activated in student-athletes in varying degrees. When student-athletes are unable to practice or train, or when they feel significant physical, cognitive or emotional vulnerability, they often perceive/feel challenges to their identity – particularly their athletics identity, self-esteem, and in some cases, their future plans or goals.

Discussion of sport-related concussion as an injury with varying degrees of concurrent neurophysiological and psychological components appears to be the most effective approach with student-athletes. It helps avoid concussion being seen with the false dichotomy of the athlete having physical or mental issues. Referrals to licensed health care providers or counseling centers can help the student-athlete deal with those challenges, as well as the fear of re-injury, and address potential concerns over long-term consequences of concussions.

David Coppel is a professor in the department of neurological surgery and the director of neuropsychological services and research at the University of Washington Sports Concussion Program. He is a clinical professor in both the department of psychiatry and behavioral sciences and the department of psychology at Washington, where he has provided clinical supervision to graduate students, psychology residents and postdoctoral fellows for more than two decades.  Since 1996, Coppel has been the consulting neuropsychologist and clinical/sport psychologist for the Seattle Seahawks. His work at the Sports Concussion Program continues his strong involvement in the evaluation of the cognitive and emotional aspects of sport concussion, research regarding the sports concussion recovery factors, and the role of neurocognitive factors such as attention, concentration and focus in sports performance.

Mind, Body and Sport: How being injured affects mental health

By Margot Putukian

Injuries, while hopefully infrequent, are often an unavoidable part of sport participation. While most injuries can be managed with little to no disruption in sport participation and other activities of daily living, some impose a substantial physical and mental burden. For some student-athletes, the psychological response to injury can trigger or unmask serious mental health issues such as depression, anxiety, disordered eating, and substance use or abuse.

When a student-athlete is injured, there is a normal emotional reaction that includes processing the medical information about the injury provided by the medical team, as well as coping emotionally with the injury.  

Those emotional responses include:

  • Sadness
  • Isolation
  • Irritation
  • Lack of motivation
  • Anger
  • Frustration
  • Changes in appetite
  • Sleep disturbance
  • Disengagement

How student-athletes respond to injury may differ, and there is no predictable sequence or reaction. The response to injury extends from the time immediately after injury through to the post-injury phase and then rehabilitation and ultimately with return to activity. For most injuries, the student-athlete is able to return to pre-injury levels of activity. In more serious cases, however, a student-athlete’s playing career may be at stake, and the health care provider should be prepared to address these issues. The team physician is ultimately responsible for the return-to-play decision, and addressing psychological issues is a significant component of this decision.

It’s important for athletic trainers and team physicians, as well as student-athletes, coaches and administrators, to understand that emotional reactions to injury are normal. However, problematic reactions are those that either do not resolve or worsen over time, or where the severity of symptoms seem excessive. Examples of problematic emotional reactions are in the accompanying table.

One problematic reaction is when injured student-athletes restrict their caloric intake because they feel that since they are injured, they “don’t deserve” to eat. Such a reaction can be a trigger for disordered eating. When a student-athlete is already at risk for disordered eating, this problematic reaction only heightens the likelihood these unhealthy behaviors will worsen.   

Another problematic response to injury is depression, which magnifies other responses and can also impact recovery. Depression in some student-athletes may also be related to performance failure. When student-athletes sustain significant injuries, such as knee injuries associated with time loss from sport, they can suffer both physically as well as emotionally with a decrease in their quality of life. When Olympic skier Picabo Street sustained significant leg and knee injuries in March 1998, she battled significant depression during her recovery. She stated: “I went all the way to rock bottom. I never thought I would ever experience anything like that in my life. It was a combination of the atrophying of my legs, the new scars, and feeling like a caged animal.” Street ultimately received treatment and returned to skiing before retiring.  

Kenny McKinley, a wide receiver for the Denver Broncos, was found dead of a self-inflicted gunshot wound in September 2010 after growing despondent following a knee injury. He had undergone surgery and was expected to be sidelined for the entire season. He had apparently made statements about being unsure what he’d do without football and began sharing thoughts of suicide.

These case examples demonstrate how injury can trigger significant depression and suicidal ideation.

Concussion is another injury that can be very challenging for student-athletes to handle emotionally. An injury like an ACL – while it poses a serious setback to the student-athlete – at least comes with a somewhat predictable timeline for rehabilitation and recovery. What makes concussion particularly difficult is that unlike most injuries, the timeline for recovery and return to play is unknown. With concussion, the initial period of treatment includes both cognitive and physical rest, which counters the rigorous exercise routine many student-athletes often depend on to handle stressors. Given the emotional and cognitive symptoms associated with concussion, student-athletes often struggle with their academic demands. In addition, compared with some injuries where a student-athlete is on crutches, in a sling, or obviously disabled in some way, with the concussed student-athlete, he or she “looks normal,” making it even more challenging to feel validated in being out of practice or play.

For the student-athlete with concussion, it is especially important – and difficult – to watch for problematic psychological responses to the injury. Some student-athletes experience emotional symptoms as a direct result of the brain trauma that can include feeling sad or irritable. If these symptoms don’t seem to be going away it is important to explore whether they might be related to a mental health issue such as depression and not directly to the injury itself. In some cases, the psychological reaction to the concussion – rather than the concussion itself – can be the trigger for the depression. When this is the case, simply waiting for the brain to recover isn’t enough: the depression also needs to be treated.

It is also important to be aware that with increasing media attention being paid to neurodegenerative diseases such as chronic traumatic encephalopathy (CTE) among professional athletes, some student-athletes might fear that even the mildest concussive injury will make them susceptible to these highly distressing outcomes. Though there is very little known about what causes CTE or what the true incidence of CTE is, the concern for possibly developing permanent neurodegenerative disease can be paralyzing. Athletic trainers and team physicians can help educate injured student-athletes about the known risks associated with concussions and can help them focus on managing the injury in the present. They should also be aware that student-athletes who are expressing a high level of anxiety could be experiencing a mental health condition that requires treatment by a mental health professional.

Seeking treatment

Injured student-athletes who are having a problematic psychological response to injury may be reticent to seek treatment. They may be afraid to reveal their symptoms, may see seeking counseling as a sign of weakness, may be accustomed to working through pain, may have a sense of entitlement and never had to struggle, and may not have developed healthy coping mechanisms to deal with failure. In addition, many student-athletes have not developed their identity outside of that as an athlete. Thus, if this role is threatened by injury or illness, they may experience a significant “loss.” Getting a student-athlete to consider treatment can be challenging (and it is complicated by privacy issues), so coaches, athletic trainers and team physicians as the support network for the student-athlete should work together to provide quality care.

As an athletic trainer or team physician, it’s important to be aware of common signs and symptoms for various mental health issues and understand the resources available to treat them. Those personnel also must do everything possible to “demystify” mental health issues and allow student-athletes to understand that symptoms of mental health issues are as important to recognize and treat as symptoms for other medical issues and musculoskeletal issues. Underscoring the availability of sports medicine staffs to provide for early referral and management of mental health issues is essential.

It’s also important for coaches, athletic trainers and team physicians to support injured student-athletes and do what they can to keep athletes involved and part of the team. This might include keeping student-athletes engaged, and at the same time encouraging them to seek help and not try to “tough their way through” situations that include mental health factors.

For coaches, one of the most powerful actions is to “give the student-athlete permission“ to seek treatment (see Mark Potter’s article in Chapter 1 emphasizing this notion). This is often incredibly helpful in encouraging student-athletes to seek care. Having programs available to educate student-athletes as well as sports medicine and administrative staffs regarding the resources available and the importance of collaborative programming helps provide appropriate care.

It is important to understand the mental health resources available on each campus and consider both early referral as well as establishing multidisciplinary teams that include athletic trainers, team physicians, psychologists, psychiatrists and other health care providers to provide care for mental health issues in student-athletes. If this can be incorporated into the overall goal of optimizing performance, along with nutrition and strength and conditioning, it may be better received by student-athletes and coaches, thereby increasing the compliance with management and treatment.

Given all that is known about mental health issues in athletes – and the role of injury and the barriers to treatment – the bar is raised in terms of what athletic trainers and team physicians can do in the future. Having a comprehensive plan in place to screen for, detect and manage student-athletes with problematic response to injury is an important first step.

Margot Putukian is the director of athletic medicine and head team physician at Princeton University, where she is also an assistant director of medical services at University Health Services. She has an academic appointment as an associate clinical professor at Rutgers Robert Wood Johnson Medical School. Putukian has a B.S. in biology from Yale University, where she participated in soccer and lacrosse, and an M.D. from Boston University. She completed her internship and residency in primary care internal medicine at Strong Memorial Hospital in Rochester, New York, and her fellowship in sports medicine at Michigan State University. Putukian is a past president of the American Medical Society for Sports Medicine. She currently works with US Soccer and US Lacrosse as a team physician, and several organizations advocating for health and safety issues, including the NCAA, the NFL, USA Football, the American College of Sports Medicine, US Soccer and US Lacrosse. She can be reached at

Mind, Body and Sport: Education-impacting disabilities and the NCAA waiver process

By Marcia Ridpath

The population of students with disabilities is growing in the postsecondary setting. One of the reports provided by the U.S. Government Accountability Office (GAO) indicates that students with disabilities represented nearly 11 percent of all postsecondary students in 2008. This upward trend is reflected in the world of athletics as well.

In the NCAA waiver process, we have seen a steady increase in the number of student-athletes with disabilities, particularly those with diagnosed or suspected mental health disorders.

Athletic trainers often have a unique perspective because they work closely with student-athletes and can be one of the first to identify signs of a potential mental health impairment. When a student-athlete arrives on campus, he or she may not have a formally identified mental health concern; however, we often see difficulties develop as the student-athlete transitions to the collegiate environment.

Many student-athletes struggle both in and out of the classroom and find themselves in need of an academic waiver to establish or repair their athletics eligibility. Athletic trainers and other athletics department staff can often provide insightful documentation when an institution chooses to file a waiver on behalf of a student-athlete.

It is important that colleges and universities are aware of the NCAA’s definition of disability. We use the term “education-impacting disability” (EID) in Divisions I, II and III, in all types of waivers, and in related policy/procedures tied to disability. The definition is as follows:

“For academic eligibility purposes, the NCAA defines a disability as a current impairment that has a substantial educational impact on a student’s academic performance and requires accommodation.”

Following is a list of the various types of disabilities that typically surface in the waiver process. Learning disabilities/disorders, attention-deficit hyperactivity disorders and mental health disorders are the most prevalent impairments. Documentation often indicates that students present with more than one identified disorder.

  • Learning disabilities/disorders (LD)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Mental health disorders
  • Medical conditions
  • Hearing impairment
  • Autism spectrum disorders (ASD)

Athletics department personnel are in a key position to observe the challenges and behaviors present in the lives of student-athletes, often on a daily basis. This is particularly true for those student-athletes with suspected or formally diagnosed mental health disorders. Because “mental health disorder” is such a broad category, it helps to see a list of the most frequent impairments cited under this umbrella in the waiver process. Common disorders include:

  • Major depressive disorder
  • Generalized anxiety disorder
  • Social anxiety disorder/social phobia
  • Adjustment disorder
  • Obsessive/compulsive disorder
  • Oppositional defiant disorder
  • Addictions
  • Post-traumatic stress disorder
  • Panic disorder
  • Bipolar disorder

It is also important to note that not every individual with a diagnosed condition (including mental health disorders) is considered “disabled” under the Americans with Disabilities Act (as amended). The ADAAA is a civil rights law with the goal “to provide a clear and comprehensive national mandate for the elimination of discrimination of individuals with disabilities.”

The ADAAA provides the following definition to help identify individuals who are protected by this law:

“The term ‘disability’ means, with respect to an individual, a physical or mental impairment that substantially limits one or more major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. Major life activities include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating and working. Major life activities also include the operation of a major bodily function, including functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.”

When an NCAA member institution submits a waiver under the EID category, we review the documentation to see if the individual has self-identified as someone with an impairment under the ADAAA. This usually occurs when the student voluntarily chooses to disclose his or her documentation to the disability office on campus.

The disability office verifies the impairment and determines reasonable accommodations or academic adjustments specific to that student in order to “level the playing field and remove barriers.”

It is important to note that a diagnosis does not automatically result in certain accommodations and services. It is the role of the disability office on campus to work individually with each student to “identify the limits caused by the disability and determine … which accommodation(s) will be appropriate and reasonable.”

The EID waiver process also includes an in-depth review of the documentation to note the date of initial onset of the disorder(s), the duration and severity of the disorder(s) and the potential educational impact (including identifying the major life activities that are substantially limited). In addition, most waivers require a written statement from the student-athlete that addresses the disability(s) and the impact he or she has encountered in the academic setting.

Whether the student chooses to disclose his or her impairment is often a key component to examine in the EID waiver process. The decision and responsibility to disclose belongs to the individual with a disability. Because concern about discrimination is so prevalent, some students decide not to disclose, even though they often forfeit needed services and accommodations.  

The October 2009 GAO report makes the following comment about students and disclosure in the postsecondary environment:

“A related challenge for schools is providing services to students with disabilities who did not initially disclose their need for accommodations. Some students choose not to disclose their disability, even when they are aware of available services, according to school officials and disability experts. While a student is not obligated to inform a school that he or she has a disability, in order for the school to provide an academic adjustment or another disability-related service, the student must identify himself or herself as having a disability. Any initial nondisclosure may become problematic for schools when students disclose and request accommodations after they fall behind academically. For example, a school may find it difficult to provide timely accommodations to a student who disclosed a visual or learning disability in the middle of a semester because of the time required to convert textbooks into electronic format. School and disability group officials told us that some students choose not to register with the disability services office and request accommodations for a variety of reasons. For example, they said some students, especially those with ‘hidden’ disabilities, such as learning disabilities, are reluctant to disclose because they want a fresh start in higher education without the label of having a disability.”

Disclosure is a critical but voluntary component in the EID waiver process. Many student-athletes find themselves in need of a waiver because they haven’t accessed the services available through the disability office. This scenario can be true for many types of waivers, such as student-athlete reinstatement, progress-toward-degree, legislative relief, and 2-4 transfers.  

For students with mental health disorders, fear of disclosure can be especially inhibiting and it is often an assertion in the waiver process. There are stigmas and perceptions related to mental illness that affect both the individual with the impairment and those around that individual. This is certainly true if the student has a first-time experience with a mental health issue after enrolling in a postsecondary institution.

The combination of unsettling symptoms and transition to the collegiate environment can result in isolating behaviors and diminished participation; student-athletes pull away from people who can provide much-needed support. In these circumstances, the athletic trainers or other athletics department staff who have regular contact with the student may have firsthand knowledge with important insight into the student-athlete’s difficulties and how his or her collegiate journey has been impacted.

Looking ahead poses a unique opportunity for athletics department staff. Departments have the important responsibility of educating their staff and developing best practices to address the specific needs of student-athletes with education-impacting disabilities. This is timely and critical because the complexity and combinations of disabilities (and specifically mental health disorders) has increased over the past several years. Many EID waivers provide documentation for students with significant personal, emotional and medical issues that impact academic progress.

Athletics department personnel are in a unique position to encourage their student-athletes with disabilities to seek all of the support and services available at the institution. Self-advocacy is a crucial skill for all students but it is especially important for student-athletes with EIDs.  

Many student-athletes need assistance in developing the ability to explain their disability and its educational impact and access their approved services and accommodations to maximize academic success. Athletic trainers and department staff can play an important role in the lives of student-athletes as they learn how to navigate the intersection between their disability and the world of college and athletics.

Marcia Ridpath is the president and founder of MAR Educational Consulting. For the past 15 years, she has served as a disability consultant to the NCAA. Before starting her consulting role in 1999, she taught high school classes as a special education teacher and served as the learning specialist for Oregon State University athletics. Rid path has more than 25 years of experience in education, working as a junior/senior high school principal, academic adviser, adjunct professor and accreditation coordinator. She is a national speaker, published author and a member of the Learning Disabilities Association of America and the Association on Higher Education and Disability. She is also affiliated with the National Association of Academic Advisors for Athletics.

Mind, Body and Sport: Suicidal tendencies

By David Lester

While there’s no “good” news when it comes to suicide, the silver lining at least is that it is not especially common in undergraduate college and university students. Some studies report suicide rates that are lower than young people of the same age who are not in college, and some studies report similar suicide rates for the two groups.

As a result, when we turn to college student-athletes, there are very few cases of completed suicide. However, we do know what kinds of factors and stressors might lead to an attempted suicide, and we do know that participation in sports can actually protect against some of those stressors.

At the present time, student-athletes appear to be less likely to have suicidal ideation and to make suicide attempts than other college students, but the protective impact of sports varies with the type of sport, sex and ethnicity. The protective effect is most evident in white male student-athletes playing in traditionally “male” sports.

For amateur athletes, researchers have focused on suicidal ideation and attempted suicide, and most of the research has been conducted on high school athletes. The Centers for Disease Control and Prevention have conducted a Youth Risk Behavior Surveillance of high school students every two years from 1991 to 2011.

Of those studies, eight showed a protective effect for boys while three showed no effect. For girls, six studies showed a protective effect, one a detrimental effect, and four no effect. The protective impact of sports on suicidal ideation and attempts was, therefore, more evident for boys than for girls.

There also seemed to be an impact of ethnicity, with the protective effects more evident for white boys than for boys of other ethnicities.

We can only speculate about the reason why participation in sports generally finds a protective impact for suicidal behavior in most studies. First, participation in sports involves physical activity, and exercise may reduce depression. Second, participation in sports has many positive side effects, including the social bonding from being in a team and the increase in self-esteem from achieving success in the sport.

On the other hand, participation in some sports may increase the likelihood of hazing (especially of rookies), alcohol abuse, risky sexual behavior and violence. Since the limited research indicates a protective impact from sports participation, it would appear that the positive effects outweigh the negative ones.

A recent study reported that the protective impact of sports was found for some team sports, but that participation in a sports activity not generally engaged in by those of one’s own sex is detrimental. For example, boys who were cheerleaders and girls who were wrestlers more often reported suicidal ideation. The study also found that the protective effects of sports participation were not as clear in African-American, Hispanic-American and Asian-American students.

Some studies have been conducted recently that explore suicide in professional athletes and the risk factors that predict these suicides. Many of these factors may apply to the student-athlete population as well.

Anabolic-Androgenic steroids. Professional athletes’ anabolic-androgenic steroid use has been clearly documented in recent years, and research has found that it increases the risk of both suicide and outwardly directed violence such as assault and murder. One study of power lifters in Finland found that 38 percent of the deaths of power lifters who used steroids were from suicide as compared with only 3 percent of the deaths of Finnish men in general.

Concussions. Concern about the role that concussions (mild traumatic brain injury) in sports play in athletes has increased, especially with the revelation that some former professional football players have developed chronic traumatic encephalopathy (CTE). Although depression is more common in professional football players who have suffered with multiple concussions, there is no clear relationship that has been described in collegiate football players. Suicide has occurred in professional football players who developed CTE, but the causal relationship between CTE and concussion is unknown, and the relationship – if any – of suicide and CTE is also unknown.

Drug abuse and alcoholism. Both are common in professional athletes, and college student-athletes, as noted in the prior article “Substance Use and Abuse,” are also at risk for these issues. Substance abuse of any kind is a risk factor for suicide.

Psychiatric problems. Many professional and collegiate athletes have psychiatric symptoms, some of which predate their involvement in athletics and some of which are exacerbated by their sports careers. Psychiatric problems are another major risk factor for suicide.

Bullying and sexual abuse. Some studies indicate that up to 10 percent of Olympic athletes endured bullying and sexual abuse as children and adolescents, often as part of their sports involvement. In recent years, several coaches have been found guilty of sexually abusing players, and hazing and bullying, especially of rookies, are part of the culture of sports. Again, these experiences are important risk factors for suicide.

Retirement. Retirement is perhaps the most important risk factor for suicide in professional athletes. Studies of baseball players and cricket players who died by suicide found that very few professional athletes died by suicide during their careers. Most killed themselves after their careers were ended either by injury, being fired or retiring. Many professional athletes have made no plans for their lives after their careers are over and when they are no longer in the spotlight. They may have pain and physical impairment from the injuries that they received during their careers, and they may face serious financial problems once their income ends, especially if they have incurred expensive long-term costs (such as alimony and child support) and if they spent their wealth unwisely during their professional careers.

Given all of these risk factors, how common is suicide in professional athletes? A 2013 study found that, after controlling for age and sex, those currently listing their occupation as athletes did not have a higher risk of suicide, although they did have a higher risk of death from all violent causes (suicide, accidents and murder). In baseball, 1 percent of deceased players are documented to have died from suicide, less than expected for men in the United States. And for cricket in Great Britain, a 2001 study found that 1.5 percent of deaths were from suicide, again not especially high. Most of these suicides occurred in players no longer active in the sport.

Clearly, much more research is needed on this important topic to identify the reliable associations regarding suicide and suicidal ideation, and the causal mechanisms underlying these associations.

David Lester is a distinguished professor of psychology at the Richard Stockton College of New Jersey. He is a former president of the International Association for Suicide Prevention. Lester has published extensively on suicide, including “Understanding and Preventing College Student Suicide” (Charles C. Thomas, 2011) and “Suicide in Professional and Amateur Athletes” (Charles C. Thomas 2012).

Mind, Body and Sport: Sleeping disorders

By Michael Grandner

There’s a reason most people spend about one-third of their lives asleep. Sleep is not a passive state of rest, but an active state of rebuilding, repair, reorganization and regeneration.

During waking hours, we engage with the environment, taking in information, interacting with others and forming new memories and experiences. During sleep, the body performs many other vital functions for which it needs to be disconnected from the environment. For example, sleep plays an important role in memory consolidation, emotional regulation, growth and cell repair.

Despite the importance of sleep, difficulties are common. Most adults need seven to eight hours of sleep to maintain optimum functioning, and younger adults need more (eight to 10 hours). However, many people – including student-athletes – do not get the amount of sleep they need, often due to insomnia, sleep apnea or another sleep disorder.

Lack or loss of sleep can also be due to the many competing demands for time, which is a prominent concern in the student-athlete population. Either way, understanding and dealing with sleep problems may have a profound effect on mental clarity and health.

Inside the sleep process

Sleep is made up of two distinct states – REM (rapid eye movement) sleep, and non-REM (NREM) sleep. Most of the night is spent in NREM sleep, which is made up of:

  • Stage 1 (very light, transitional sleep)
  • Stage 2 (moderate sleep)
  • Stage 3 (deep sleep)
  • Stage 4 (very deep sleep)

REM sleep makes up about 20 percent of the night and is associated with (as the name implies) rapid eye movements. It is also characterized by a high degree of brain activity (similar to light sleep or waking). Dreams are common in REM sleep, and people would act out their dreams if it were not for signals from the midbrain that actively prevent skeletal muscle activity. Therefore, REM sleep is accompanied by lack of muscle tone (similar to paralysis).

Stages 3 and 4 of NREM sleep are crucial for growth, and cell rebuilding and repair. Stage 2, which accounts for more than 50 percent of the night, is important for many cognitive and bodily functions. For example, sleep is critically important for regulating many hormones that control stress, hunger and appetite, growth and healing, and biological rhythms. As such, sleep disruption is likely to disrupt any combination of these systems.

Almost 40 percent of American adults (about 80 million people) get six hours of sleep or less. The average American adult reports about two nights of insufficient sleep per week.

Insomnia, defined as a persistent difficulty falling or staying asleep, accompanied by daytime impairment, is common. Approximately one in three U.S. adults suffer from symptoms of insomnia, and about one in three of those meet criteria for an insomnia disorder (which is associated with increased risk of depression, substance use and medical problems).

Sleep apnea is also common. It is a condition in which an individual has difficulty breathing during sleep, usually because of a blocked airway, in which case it is referred to as “obstructive sleep apnea.”

It is estimated that among adults age 30 and older, rates for sleep apnea are 10-15 percent and 3-9 percent among men and women, respectively. This is significant, since sleep apnea is associated with obesity, cardiovascular disease, diabetes and neurological problems. Diagnosing and treating sleep apnea is a critical issue, since most people with the disorder do not know they have it, and untreated sleep apnea is a major health risk factor.

Since body type (such as obesity and thick neck) can play a role in developing sleep apnea, certain student-athletes may be at high risk for the disorder, especially football linemen.

How student-athletes are affected

There hasn’t been much research on student-athlete sleep patterns and problems, but given the timing of practices, travel and competition, student-athletes are likely at high risk of sleep difficulties. In addition, extra time demands, including balancing athletics with academics, can reduce sleep opportunity.

An American College Health Association survey found that on average, most student-athletes report four nights of insufficient sleep per week. However, insomnia diagnosis was very low, at 3 percent in athletes versus 2 percent in non-athletes.

An NCAA study showed that one-third of student-athletes get fewer than seven hours of sleep per night, with greater values among women.

Other studies have shown that improving sleep can lead to better performance. As such, it would benefit athletics departments to monitor their student-athletes’ sleeping patterns to ensure proper behaviors.

As to the causes for sleep deprivation in the student- athlete population, the balancing act they must perform in being both a student and an athlete (and having a well-rounded college experience) can frequently impinge on sleep time. Making sleep an important priority and a part of more general work-life balance may help student-athletes better manage their time, their stress – and their sleep.

Athletics departments also should pay closer attention to student-athletes who travel frequently for competition. Travel across time zones can result in jet lag, which can take a physiologic toll on the body and also impair physical and cognitive performance. In addition, travel (even within a time zone) can involve uncomfortable sleeping arrangements, disrupted schedules, and other changes that can impair physical and mental health in the short and long term.

What athletics departments can do

It would behoove athletics departments to have a comprehensive sleep disorders screening and treatment program available for their student-athletes. And before you say your school doesn’t have the resources to create or maintain such a program, assessing sleep problems doesn’t have to be costly or cumbersome.

Polysomnography (“sleep study” in the laboratory) is the most intensive approach to sleep assessment. It measures brain activity, muscle activity on the chin and legs, heart rhythm, and breathing effort in the chest and abdomen, among other things. Polysomnography is usually performed at a sleep center accredited by the American Academy of Sleep Medicine.

These types of studies are most useful for the detection of sleep apnea and sleep-related movement disorders, especially complex cases. For the detection of routine sleep apnea, home-based sleep recording, using portable devices that measure respiratory flow and effort and oxygen saturation, have been shown to be a useful, lower-cost option.

Insomnia and other problems with habitual sleep schedules are usually assessed with a daily sleep diary or wrist actigraphy (a device that records movement, providing an objective estimate of sleep and wake time).

Several brief screening questionnaires that can detect problem sleep are also available, including the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, the STOP questionnaire and the Berlin Questionnaire.

In assessing general problems, getting information about weekday and weekend time into bed, the time it takes to fall asleep (sleep latency), the number of awakenings, the duration of awakenings (wake after sleep onset), the final awakening time and final time out of bed can discern sleep timing, duration and overall quality of sleep, thus revealing the nature of many sleep problems.

Athletics departments can develop partnerships with local or regional sleep centers (accredited by the American Academy of Sleep Medicine: to develop and implement long-term solutions for the problems that sleep disorders pose.

Taken together, raising awareness about sleep, getting students (and staff) appropriately screened, monitoring patterns and delivering helpful treatments are critical for maintaining student-athletes’ long-term mental health.

Michael Grandner is an instructor in the department of psychiatry and a member of the Center for Sleep and Circadian Neurobiology at the University of Pennsylvania’s Perelman School of Medicine. He completed his graduate training in clinical psychology at San Diego State University and the University of California, San Diego, including an APA internship with the behavioral medicine service at the San Diego VA Healthcare System and Outpatient Psychiatric Services at UCSD. Read more about Grandner’s work at and


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