Considering the Mental Health of Athletes

It is almost 7:00 AM and the workout is about to begin. The last athlete comes into the facility and the strength and conditioning coach greets the athlete with, “Hi, how are you today?” The athlete responds with a lower tone and says, “I wish my alarm didn’t go off today.”

That is a scenario from real life. What should the strength and conditioning coach do next in responding to the athlete’s statement? Is this a situation where it is early in the morning and the athlete is simply tired? Was the athlete up late? Is, or should, this scenario be of significance to the strength and conditioning coach at all? Does it change if the 7:00 AM group includes 49 other athletes waiting for the strength and conditioning coach to start the session? Those are all important questions, and questions that are largely yet to be addressed specific to the strength and conditioning context. However, it seems clear these types of questions should be important to strength and conditioning coaches even if their daily job tasks and responsibilities on this topic are further along than the specific research on the topics targeting strength and conditioning coaches.

The importance, and impact, of words has never been more apparent in society. The Black Lives Matter movement is impacting culture across the globe, as well as within sport with at least three prominent Power 5 universities: Clemson, University of Iowa, and Oklahoma State (8,11,20). Severe Acute Respiratory Syndrome Coronavirus Disease of 2019 (SARS-COVID-19) is having dramatic effects across the world and within sport, too. The combination of the Black Lives Matter movement and the SARS-COVID-19 pandemic has undoubtedly left many athletes and coaches with feelings and thoughts that are unique, and manifest in some behavior changes and comments that can be witnessed by others. Some research is emerging on these unique circumstances, though the majority of effects to and from social justice efforts and SARS-COVID-19 will remain unknown for some time (1). While that research continues to emerge, it seems logical that the more generalized cycle of anxiety, coping, and performance that is well known in the sport psychology literature will apply (4). The purpose of this article is to explore some phrases that strength and conditioning coaches may hear or behaviors they may witness, and provide some direction to identify which allied healthcare and performance professionals may need to get involved to best help the strength and conditioning coach and athlete elevate their performance.

Athlete Mental Health Considerations

The mental health of athletes is an area of emerging concern, or at least it seems to be getting more media attention than in the past. In the United States, suicide is the second leading cause of death for 10 – 34 year olds (3). A recent study on suicide at the collegiate level was a retrospective examination of the rate of suicide among National Collegiate Athletic Association (NCAA) athletes (22). Over the nine-year study period, 35 cases of suicide were identified from a review of 477 student-athlete deaths during that time (22). Suicide represented 7.3% of all-cause mortality among NCAA student athletes (22). Additional noteworthy results from the study were that NCAA male athletes have a significantly higher rate of suicide compared with female athletes, and football athletes appear to be the greatest risk (22).

Suicide would be considered the most serious concern for an athlete’s mental health due to the high potential for mortality, but it is not the only behavioral health concern that is seen in student-athletes. Many athletes believe that disclosing a mental health concern could be construed by coaches or teammates as a sign of weakness or failure (9). College athletes, coaches, and staff, out of their own lack of understanding of the seriousness of some behavioral health conditions may tend to ignore or discount symptoms, due to stigma, as it is antithetical to traditional sport culture values of mental toughness and resilience. An additional factor that might influence an athlete’s decision to seek mental health attention is their own lack of education about the continuum of mental health concerns compared with normal mood adjustments as part of customary stress responses. A third factor is the student-athlete’s personal biases and views regarding mental health professionals and ideas about how a mental health professional will view their problem, which includes a lack of understanding of how services will be kept confidential and whether or not coaches or other school officials will be privy to such services (18). Finally, athletes may believe that disclosing a mental health concern could result in loss of playing time, scholarship, changed relationships with teammates, and disapproval from coaches (5).

Athletes present unique risk factors when it comes to early identification of mental health symptoms and their willingness to access resources (15). The NCAA has put forward specific recommendations for best practices providing consistently updated data and education modules (17). One of the NCAA’s key recommendations is ensuring athletes are referred to qualified mental health providers in the case that services are needed. This early identification and assisting with referrals to professionals is a main point of this article.

In order for an athlete to be referred to a mental health counselor, someone needs to notice the athlete is in need, and actually take action to help that athlete. The National Strength and Conditioning Association’s (NSCA) most recent standards and policies document specifically charges the strength and conditioning coach with participating on an allied team of professionals to enhance athlete performance (18). That allied team of professionals may, and probably should, include clinical and applied sport psychology consultants. Strength and conditioning coaches are often the athletic department staff members that come into contact with athletes most frequently. Yet, the typical academic training paths of a strength and conditioning coach leaves gaps where psychosocial skills are concerned, highlighting the need for that type of professional development (23). A recent article promotes these psychosocial skills being added into academic training programs for strength and conditioning coach (7). Moreover, the most recent International Sport Coaching Framework parallels the NSCA’s continuing education requirements and highlights the need for all coaches to make lifelong improvement to their craft (14).

There is no possible way to create an exhaustive list of all the things athletes may say or do that warrant a follow-up question or specific action from a strength and conditioning coach. However, similar phrases, both in their actual content and likely responses to them, can be collated and are possible to establish. The phrases included in Table 1 were received from a full-time strength and conditioning coach. In order to improve the applicability of this paper, strength and conditioning coaches at multiple NCAA Division I and II schools, as well as a private high school-aged training facility, provided examples of athletes’ words and behaviors they have personally experienced. The aggregate of those responses populates Table 1.

One way to categorize these phrases was to group them on immediacy of need. The most immediate being “emergent threats.” The two middle categories were “mental health” and “applied performance” concerns; with the final category being simple “banter” between athlete and coach or even simply among the athletes in a group. The point to be stressed is clarifying the athlete’s statements, and then assisting with the most appropriate referral based on the severity of threat of the athlete’s statements. Several evidenced-based trainings do exist to develop individuals who work with athletes in this including “Mental Health First Aid” and “Question, Persuade, Refer” (16,21). The physical safety of athletes training with a strength and conditioning coach is always a key consideration (18). That level of safety should extend to the mental health of athletes too.

Table 1. Example Athlete Statements

Emergent Threats

This is certainly the most serious of the categories and includes concerns that must be dealt with immediately, as in when they immediately occur. These are so serious they cannot wait until after the workout or when a strength and conditioning coach has a break from training groups. Emergent threats may well be life and death situations and simply must be treated as such. Suicidal or homicidal thoughts and expression of those thoughts must garner the strength and conditioning coach’s maximum attention immediately. Sexual assault victimization is also a tremendously serious and time-sensitive concern. A final type of emergent threat is if the athlete seems to have lost contact with objective reality. This may be due to onset of some psychosis, substance usage, or even a medical illness. These individuals typically require extra steps to connect them to professional help as they are unable to do so on their own due to the severity of their symptoms.

The commonality of these emergent threats is they all require a strength and conditioning coach to be mindful that they exist and to be aware of what emergency protocols have been established for the organization employing the strength and conditioning coach or hosting the training session. Additional beneficial resources include reaching out to the mental health staff on-site at the training location or calling the National Suicide Prevention Hotline at 1-800-273-TALK (19). This helpful resource can be called 24/7 to speak with a trained mental health professional who can help as a guide and a resource for both the athlete and the strength and conditioning coach. The real-life alarm clock example at the beginning of this article could have indicated a suicide risk, if the athlete truly meant he never wanted to hear his alarm clock sound again. The only way for a strength and conditioning coach to gauge that risk is to fully engage with the athlete making the comment right then and there and ask follow-up questions.

Mental Health

Within the context of strength and conditioning, the dividing line between the emergent threats and the mental health categories listed on Table 1 is a temporal aspect. While the emergent threats are literal, right-now concerns, the mental health examples are ones that warrant follow-up questions from the strength and conditioning coach, and possibly a referral out to a counselor or clinically-trained sport psychology consultant; yet, they are concerns that are likely able to wait until after the training session concludes or even later in the day. This area of risk also contains concerns with eating disorders and flawed perceptions of body size.

A significant concern with the mental health category is to whom the strength and conditioning coach refers the athlete. Ideally, and consistent with NSCA recommendations, the strength and conditioning coach will have already established a professional relationship with someone trained in sport psychology and mental health (6). Nearly all higher education campuses have a counseling center with trained staff on hand. However, as organizations adjust to the SARS-COVID-19 world, those counseling centers may be more difficult to access due to staffing or scheduling changes. It may be that an athlete is not even physically on campus and the strength and conditioning coach is working with the athlete remotely, which further complicates referring the athlete to a qualified allied professional. Many communities have mobile crisis programs that are only a phone call away. Strength and conditioning coaches should check with the local counseling office to gain familiarity with these numbers or utilize the National Suicide Prevention Hotline when no local mobile crisis program is available.

The stigma of seeing a mental health professional may also be heightened for athletes going to the counseling center on-campus due to the fear of bumping into peers in the counseling center. The “Mental Health Toolbox” does include some helpful suggestions for addressing this with your athletes, as does the NCAA’s website on mental health on college campuses (15,17). In addition, referrals to outside facilities may not be as straightforward or effective because many of those facilities could be lacking knowledge regarding the specific needs of athletes, especially if the athlete in need is high-profile in the local community. In these instances, supporting the athlete by checking in with their comfort level of accessing help and determine who might drive them to the counselor’s location or wait in the lobby for them might be a helpful option to reduce this barrier to accessing care. A challenge will be for the strength and conditioning coach to follow-up with the athlete and ensure a proper allied professional was contacted. Returning to the alarm clock example, if the athlete responded to the strength and conditioning coach’s follow-up questions indicating how homesick they are, that their parents are going through a messy divorce, or something similar, this would be an example of a possible mental health concern where the athlete may benefit from talking to a counselor.

Applied Performance

An initial dividing line between mental health concerns and applied performance concerns centers on the context of the athlete’s comments. Concerns that exist beyond sport and thus crossover into regular life as a student or non-athlete may be best-served by a mental health counselor. Concerns that are squarely focused on sport, be it competition or training, are less likely to rise to the level of needing a specific mental health counselor referral. That is an important distinction; one that leads to different types of sport psychology consultants with different training and educational backgrounds. The training of sport psychology consultants is quite varied and not well understood by sport personnel (10).

Team dynamics and interpersonal relationships between coaches and athletes, blocking out distractions during competitions, remembering offensive and defensive schemes, maintaining motivation, and improving self-confidence are all basic tenets of sport psychology that rarely require any mental health counselor collaborations. Those clearly sport-focused performance concerns, as opposed to academic or social concerns, are part of the reason the stigma with seeing a sport-based consultant may also be lower. The Association for Applied Sport Psychology has a consultant finder on their website that may be useful (2). Continuing with the alarm clock scenario, if the athlete responded about having a lack of motivation to attend early morning workouts or indicated some level of burnout with his sport or even challenges with his sport coach, those may be indications of a situation where including an applied sport psychology consultant could yield performance improvements.

Banter

The final category as described in this article is simply an acknowledgement that not every comment an athlete makes has a need for someone else to get involved. Coaches and athletes, as well as athletes to each other, say and do things as simply part of the culture of sport. When the athlete starts making jokes about how annoying his alarm ring is to the strength and conditioning coach, that is not an indication of any serious mental health or even a performance concern and it certainly is not an emergent threat. It is simple banter between the coach and the athlete and likely indicates a solid coach-athlete relationship.

Conclusion

The coach-athlete relationship is important to the athlete’s success and that is the very reason strength and conditioning coaches need to be mindful of what athletes say and do (13). The importance of establishing productive strength and conditioning coach-athlete collaborations is well-known and voiced by expert strength and conditioning coaches. Strength and conditioning coaches are in a unique position within their athletes’ lives to affect change and that position affords strength and conditioning coaches knowledge that sometimes requires additional professionals to get involved. Educational opportunities exist for strength and conditioning coaches to increase their level of understanding how to best start conversations to determine if athletes are presenting indications of mental health symptoms and then what to do if the athlete does express or exhibit a risk. The simplest takeaway message presented here is that part of being a strength and conditioning coach is to be mindful of athlete safety—physical and mental. Being mindful of athletes’ mental wellbeing will require all strength and conditioning coaches to be present and engaged with the athletes under their care and a willingness to follow-up with questions when athletes make statements that may indicate a mental health risk.

Challenges to Athletes during the Home Confinement Caused by the COVID-19 Pandemic

National Strength and Conditioning Association’s Endorsement of the National Collegiate Athletic Association Sport Science Institute’s “Mental Health Best Practices: Inter-Association Consensus Document: Best Practices for Understanding and Supporting Student-Athlete Mental Wellness”

Enriching Selves in Strength and Conditioning Society: A Multilevel Proposal to Enhance Strength and Conditioning Psychosocial Practice as Part of the Council on Accreditation of Strength and Conditioning Education

NSCA Strength and Conditioning Professional Standards and Guidelines