Recently, I was filling out paperwork for my child’s school physical – better known in the sports world as the Pre-Participation Evaluation (PPE). On the back of page two was a form titled “Patient Health Questionnaire Version 4.” This page asked me to rate four questions from “not at all” (a score of zero) to “nearly every day” (a score of 3) regarding my child’s feelings about the following: anxious, on edge, losing interest or pleasure in doing things, feeling down, depressed or hopeless or an inability to stop worrying. There was a short paragraph below the questions explaining how to add up our score. If we scored three or greater, my child could have anxiety or depression.
A few years back, questions such as these weren’t on the PPE, and, so it made me think. Now that criteria for anxiety and depression are on PPE’s for pre-season (this may vary depending on what state you live in) will this help identify athletes who may need additional support or resources? Will it help or hinder their chance of playing?
For this article, I asked four athletic trainers about their experience with the PPE, their interaction with athletes who experience mental health issues such as anxiety, depression or eating disorders and found some great published research on the subject (I’ve linked them below). Their experiences vary, the state they practice varies and factors relating to demographic or socio-economic factors may play a role in how their practice responds to mental health. For reference, when I use the term “student-athlete” I am referring to a high school or collegiate athlete (in any division).
How it Works?
“Athletic trainers are often the first point of contact regarding health information for student-athletes, which may provide them with a unique perspective and insight into the individual – and community – outcomes.”
Beaupre, Meske and Buckley, Journal of Athletic Training, p. 141.
In a perfect world, an athlete tells their coach, athletic trainer or strength and conditioning coach (s/c’s get a lot of face time with athletes) they are struggling with anxiety or sadness or have a performance block. The coach will then (knowing their appropriate channel to report) have a conversation with the athlete and athletic trainer and the referral is made. In most cases, the referral will be to a sports psych, the counseling center or school counselor – in some cases athletes may have their own therapists/counselor. The athlete will then get the help they need and return to play with a plan to support their mental health and ongoing wellness.
Unfortunately, it’s not a perfect world. Some possible reasons might be:, communication can be unclear, reactive or not happening at all, relationships between athletes and coaches can be complicated or athletes may not disclose because they don’t want their playing time affected or to be removed from the field of play for mental health reasons. Some programs do this better than others, but here is quick view of the two main referral sources for high school and collegiate programs.
The Counseling Center Referral
“Communication does not happen unless we are made aware of a problem [from coaches], then we will get the counselors at the school involved as well as all needed parties. It is a very reactive environment and not proactive at all.”
Athletic Trainer (21 years)
While the counseling center referral is likely the referral most athletes need for clinical help, it is the least likely to be used. For many reasons, including funding, accessibility, timeliness of appointment and availability of the athlete due to schedule conflicts, the counseling center gets used far less than it should.
In a study conducted by Beaupre, Meske and Buckley in the Journal of Athletic Training, athletic trainers (AT’s) estimated that 32% +/- 23.5% of student athletes had expressed feelings of sadness, anxiety, depression or suicide in the past year (2022). This aligns with a study done in May, 2022 that reported that 38% of female athletes and 22% of male athletes felt “mentally exhausted constantly or every day.” This may not seem like a win, but it’s progress. In years past, the numbers athletic trainers reported were significantly higher than the numbers self-reported by athletes in similar studies. Which suggests that perhaps the stigma surrounding mental health is improving even if communication still seems to be a work in progress.
But one more thing might be contributing to why athlete’s are hesitant about using the campus or school counseling center for mental health support – athlete identity.
Most athletes are firmly planted in their identity as an athlete; it’s a place to belong and provides an identity, purpose and privilege on campus. Going to the same place for counseling that “regular” students go is recommended and often the only resource for athletes in high school or college, but athletes don’t see themselves as regular people which may create an unspoken barrier. In addition to identity and resistance, sometimes it could take a week or longer for an athlete to get an appointment, so while a referral has been made, athletes still have to make and keep an appointment.
The Sports Psych Referral
When athletes have performance blocks, sometimes – not all times, there may be a mental health issue pushing performance related anxiety or depression to the surface. Many reasons contribute to the prevalence of anxiety and depression (the most common mental health concerns along with eating disorders) in student athlete populations, but among the top reasons: perfectionistic tendencies, the need to be consistently great, family and friends who may not understand the pressure, coaches who have mental health issues of their own or have trouble relating, social media or media in general, comparison. Less frequent diagnoses include PTSD, OCD, Bipolar and personality disorders or non-suicidal self injury (NSSI) or cutting.
“Relationships are key so that medical providers get to know their student athletes. They can realize when an athlete is struggling both mentally and physically. Most coaches are focused on the game itself and may not realize when an athlete is having issues.”
Athletic Trainer (24 years), MEd, SCAT, ATC
One of the first referrals for performance related issues is the sport psych referral. While Sports Psychologists help athletes work through things like performance anxiety, self-talk, breathing and visualization techniques to improve performance (and off the field habits), most Sports Psychologists are not Clinical Psychologists and cannot perform therapy or counsel an athlete with a clinical issue. Many times, the Sports Psychologist will still have to refer to a Clinical Psychologist (counseling center) for the athlete to work through the underlying issue. Note: Clinical Psychologists and Sports Psychologists have different educational and certification tracts and do their intern and trainee hours with different populations. It’s important to understand these are different practices and treat different things.
The sports psych, however, is an excellent resource for those teams and campuses who are able to fund this role. As they work through performance issues, athletes form trusting and open relationships with someone who will listen to them for who they are outside of sports and help them work through difficult things. This relationship requires vulnerability and authenticity, which is an important for healing and growth.
“In my opinion, dealing with athletes – especially at the elite competition level (youth, adolescent, college or pro) – they are not supposed to show emotions that affect their performance and are often scared to be honest with someone [a coach or trainer] when they are struggling”
Athletic Trainer (9 years), MS, AT, ATC
Because vulnerability is not usually a skill trained on the field, it is likely a big reason why in sport situations, the easiest thing to fix is the performance issue instead of a clinical issue. When the performance issue resolves, an athlete plays better and feels better. Perhaps only momentarily, athletes, coaches and family all breathe a sigh of relief because the complicated, scary thing has been taken off the table. Working through a mental block in performance may seem easier than working through an eating disorder, anxiety or depression, but just because performance improves does not mean healing or growth has happened at the root level.
Athletic Trainers -The Ones Who Know Things
“Athletic trainers are often the first point of contact regarding health information for student-athletes, which may provide them with a unique perspective and insight into the individual – and community – outcomes.”
Beaupre, Meske and Buckley, Journal of Athletic Training, p. 141.
When I was coaching Division 1 Beach Volleyball as the volunteer assistant, I had the privilege of rooming with Athletic Trainer when we were on the road. I got to learn quite a bit about what the trainers do on a daily basis for our teams. When athletes need treatment on the road, and let me tell you, if you have a good one, they are the real deal. AT’s really are the front line for all things minor, major and everything in-between to get athletes back on the court. In my sport of beach volleyball, athletic trainers do their best to keep athletes safe, get them back on the court within a reasonable timeframe (sport, admin and coaches all play a role in this too) and in general talk all kinds of life with them on a regular basis.
For the most part, athletes trust their trainers. They may not always like going to treatment or having a longer warm-up, but if an athlete knows what’s good, they will listen. Because athletes with minor or major injuries are in the training room often, trainers know things that coaches might not know. There’s just one gap … mental health education for athletic trainers is not standardized.
A recent study reported that “there are large percentages of individuals [AT’s] who self-reported not learning about many mental health disorders as part of their professional programs [and] should be of concern to the Commission on Accreditation of Athletic Training Education (CAATE),” (Ostrowski et. al., Moravian College, Sports Medicine & Rehabilitation Centers, June 2022, p. 13).
“Increased emphasis on mental health recognition and referral is needed in professional athletic training education, and should be emphasized as part of continuing education requirements.”
Ostrow et. al., Moravian College, Sports Medicine & Rehabilitation Centers, June, 2022, p.5.
So, Now What? What You Can Do.
If it seems confusing or like I’m talking in circles, imagine how it feels to an athlete who is struggling with depression, suicide ideation, panic or anxiety attacks or any other mental health issue. Confused or overwhelmed are two feeling that come to mind.
So what do we do from here? We need to understand first and foremost, in youth sports we are the adults and we can advocate for our athletes. In the past ten years, athletes have increased advocacy at all levels of sport: Michael Phelps, Naomi Osaka, Simone Biles, Ebony Nwanebu, Aly Raisman, DeMar DeRozen, Amanda Beard, Kevin Lore, Justin Duchscherer, Ricky Williams and more. What hasn’t increased is coaches certifications, education or requirements to perform coaching duties.
Here are a few ways we can do better for student-athlete mental health:
- increase education and certification for coaches from youth-collegiate sports
- increase communication between Athletic Trainers, Coaches and S/C
- More coaches advocacy for student-athlete mental care
- Know your referral sources and which on to use at what time
- Meet regularly with athletes and talk about non-sport related things
- Get curious about how you can better educate yourself as a coach and what admin staff you can ally with to make small changes. Everything helps
- Organize a coaches group/meeting to discuss challenges in this area
- Download my free resources and share them with your teams and coaching staff
Finally, the best thing we can do for our athletes is to be healthy, growing adults.
SpikeDr.com 