Jan 29, 2015Cry For Help
An athlete’s mental well-being is just as important as their physical health. Athletic trainers are in a great position to recognize the signs of anxiety and depression, and to step in if need be.
By Dr. Nicki Moore
Nicki Moore, PhD, is a licensed psychologist, AASP-certified sports psychology consultant, and Senior Associate Athletic Director at the University of Oklahoma, where she serves as in-house psychologist for the athletic department. She can be reached at: [email protected].
Many people work with student-athletes on a daily basis: coaches, tutors, academic advisors, compliance personnel, strength coaches, and plenty of others. I feel fortunate to have been among them as an in-house psychologist for the University of Oklahoma athletic department for the past six years. The student-athletes I’ve treated and the range of issues they’ve presented has made for a rich and interesting career–one that’s rewarding in many of the same ways I imagine athletic training is rewarding.
While the typical athletic trainer is concerned mainly with athletes’ physical health, you are also well positioned to recognize when student-athletes are struggling with anxiety, depression, or a host of other mental health problems. At early morning workouts, you’re there. On long bus rides, you’re there. In the depths of despair following a career-altering injury, you’re there.
It’s not always easy knowing how to proceed when you observe the signs of a mental health issue in an athlete under your care. But the costs of doing nothing can be great, and the benefits of intervening can mean as much as–or even more than–any other form of treatment or service you provide. This article will familiarize you with anxiety disorders and clinical depression in athletes, and give you a blueprint for helping them through some of the most challenging health problems life has to offer.
Several myths about anxiety disorders and depression persist, and one of the most prevalent is that these illnesses are rare. The truth is that over the course of one year, about 16 percent of the U.S. population develops an anxiety disorder, and about seven percent of men and 12 percent of women develop some degree of clinical depression.
Athletes, of course, are a special population, with factors that can both increase and decrease their predisposition to these forms of illness. On the positive side, the sense of self-worth, inclusion, and accomplishment provided by training for and competing in sports provides a measure of protection for some. But on the other hand, the stressors associated with competitive athletics can easily negate the protective factors. For that reason, anyone who works with athletes on a regular basis is very likely to encounter individuals who are facing anxiety or depression in some form.
Another common myth is that anxiety disorders and depression are transient things that an athlete just needs to “snap out of.” No doubt, every athletic trainer with more than a day under their belt has dealt with grumpy, irritated, stressed out, or dejected student-athletes–it comes with the territory. In most cases, a few encouraging words and a sympathetic ear are enough to help them through a bad day. But when the symptoms are especially pronounced and don’t go away with time, they may indicate an underlying disorder and not just a situational mood or reaction to specific events.
When anxiety or depression reach the disorder level, it means daily overall functioning has become impaired for an extended period, usually lasting at least two weeks without relief. With anxiety disorders, the main symptom is abnormally high anxiety with no apparent reason or anxiety that’s out of proportion with the circumstances at hand. Besides those self-reported feelings, anxiety-related symptoms may include an increased heart rate, muscle tension, upset stomach, sleep disturbances such as insomnia, and difficulty focusing on or engaging in normal life activities.
There are at least seven specific types of anxiety disorders, including obsessive-compulsive disorder, phobias, and post-traumatic stress disorder, but all of them share at least some of the above symptoms. If you observe them in an athlete to a degree or duration that seems abnormal, they will most likely benefit from referral to a mental health professional.
Depression, which falls under the clinical category of mood disorders, is typically characterized by excessive, unexpected, prolonged feelings of sadness, emptiness, or hopelessness, often accompanied by diminished interest in or ability to carry out normal activities, lack of energy or motivation, difficulty concentrating, sleep disturbances, and possibly even suicidal thoughts. Physically, it can lead to significant weight loss or gain in a relatively short period.
Having a few symptoms of depression is quite normal. For student-athletes, it can be triggered by the doldrums or struggles of rehabilitation from injury, pressure surrounding a big game, disappointment after a loss, or something not related to sports at all–a break-up, a family death, or academic problems.
But like with anxiety, the key factors that determine whether these feelings reach the disorder level are depth and duration. If the withdrawn, sad behavior lasts longer than seems reasonable given the circumstances, or if it’s so paralyzing that it interferes with daily life, the athlete should be steered toward seeking help. (To better understand the line between the subclinical and clinical range for depression-like symptoms, see “Sad or Depressed?” below.)
BARRIERS TO OVERCOME
If an athlete has a sprained ankle or torn ligament, there’s not much argument over the fact that they’re not healthy and need treatment. Mental illnesses are different because they’re more subjective and carry a stigma that makes acknowledging the problem and seeking help more difficult.
In addition, the perceived consequences of a mental illness diagnosis are especially great for athletes. Besides the usual pressures of student life, an athlete whose performance is hampered by anxiety or depression may worry about things like reduced playing time and loss of a scholarship.
Some of the main obstacles that stand in the way of prompt intervention for athletes with anxiety disorders and/or depression are:
Recognition barriers. When immersed in an athletic culture, it’s easy to attribute symptoms to known and assumed stressors rather than to a diagnosable psychological issue. Student-athletes tend to have a “suck it up” mentality, so symptoms can be ignored, masked, or misinterpreted for long periods of time.
Furthermore, team strength is frequently built on a “no excuses” mantra, so there is a tendency to attribute deficiencies in attitude, motivation, or desire to character problems. An athlete might find him- or herself accused of not being a team player or not giving 100 percent out of selfishness or laziness, when in fact they may be suffering from a disorder that’s addressable through treatment.
The machismo associated with both men’s and women’s sports is another barrier, as it encourages athletes to display an exaggerated sense of toughness. Even if an athlete knows something is wrong, they may go to great lengths to avoid admitting the problem to anyone, even–and sometimes especially–their teammates and coaches. Some choose to suffer in silence rather than acknowledge something that others may perceive as weakness or fragility.
Furthermore, some symptoms of anxiety and depression can be mistaken for a normal response to sports-related stressors. For example, significant or rapid weight loss is one of the most objectively observable warning signs of depression, but in a competitive athlete, it may be attributed to the pursuit of a performance goal. Likewise, ongoing “moodiness” might be dismissed as frustration with a slow rehab or lack of on-field success, when it may in fact be caused by mental illness.
Sometimes, sports is among the last places that compromised mental functioning manifests itself. For many student-athletes, it is their escape–a refuge where they can leave behind everything that’s bothering them. Thus, it’s not unusual for a student-athlete’s school work, social life, and relationships to be “falling apart” while their athletic life appears fairly normal.
Referral barriers. Compared to the extensive and trusted referral network of medical doctors athletic departments use to address physical problems, the network of mental health professionals is usually much less developed. It’s also often less accessible to someone on the front lines, such as an athletic trainer, who may observe an athlete struggling with mental health.
While athletic trainers are generally quite aware of what it’s like to work with a physician and comfortable talking to student-athletes about what to expect in treatment, they often have little to no personal experience with mental healthcare. Add in the aforementioned stigma associated with anxiety disorders and depression, and you may find it’s difficult to take an athlete aside and tell them you think you’ve observed a problem and would like to refer them to a counselor or psychiatrist.
Student-athletes are accustomed to many people knowing about and keeping tabs on their medical conditions, but they’re frequently hesitant to discuss anything related to their mental health. They worry about coaches and teammates finding out, and fear repercussions that can make their condition even worse, such as diminished responsibilities on the team, further isolation, or a loss of trust in their ability to perform or lead others.
Treatment barriers. Competitive athletics has a subculture all its own, with unique languages, sets of rules, costumes, and rituals. For participants, it’s often a source of personal identity. If a mental healthcare provider isn’t familiar with this culture, providing counseling to student-athletes can be akin to working with someone from a foreign country. If they overlook, devalue, or simply don’t understand the cultural differences, they can create an unintentional barrier in the therapeutic relationship that’s difficult to overcome. That’s why it’s important to connect athletes with a professional who understands the culture and pressures of sport–if your athletic department and campus don’t have a counselor or psychologist on staff, an off-campus referral may be the best option.
Another potential issue is that student-athletes may have heightened concerns about confidentiality that make them less forthcoming than typical counseling clients. Some, particularly higher-profile athletes, understand their personal value as a “sports property” and feel they must carefully guard their public image. Other times, they worry about their parents’ insurance being billed for therapy sessions and their families finding out that they are in counseling. Additional reassurances and the explanation of strict privacy rules counselors must abide by can help athletes to openly engage in the process.
Time is another concern. Student-athlete schedules are generally rigid, overbooked, and both physically and emotionally draining. The idea of adding therapy appointments as another commitment may seem like a burden. There’s no easy answer to scheduling issues, but if a need arises, remember that an athlete may need assistance in this area–you might be able to tailor their athletic training room appointment times, get your campus counseling center to make special arrangements, or set up quick and easy transportation to off-campus appointments.
Once they do start counseling, athletes may set unrealistic expectations about how quickly they should make progress, especially if it’s during their competitive season. It’s important for them to understand that treating depression or anxiety isn’t like healing a sprained ankle–it’s an ongoing process that takes time and effort to succeed, but the results are well worth it.
What happens after you refer an athlete for mental healthcare? Decisions are always made on an individual basis, but the most common forms of intervention are counseling, also known as psychotherapy, and prescription medication. Practitioners often choose to treat a patient using both methods simultaneously.
Psychotherapy. While psychotherapists vary in their training, credentials, and models for treatment, the first session for most types of counseling or “talk therapy” will have some common components. The student-athlete will likely complete some paperwork in advance, and from the outset, most counselors will explain that confidentiality will be strictly followed except in a few specific circumstances, such as when a patient appears to be homicidal or suicidal.
From there, most therapists will ask the client to describe what brought them to counseling and encourage discussion of short- and long-term symptoms and concerns. The first session usually includes direct questioning by the therapist to ascertain individual and family history and various factors that may impact diagnosis and treatment planning. A trusting and caring relationship is usually established rather quickly, and more often than not, patients leave the first session already feeling a bit better, as if a weight has been lifted.
In subsequent sessions, the therapist will help the patient explore the underlying causes for their anxiety and/or depression. Together, they will seek new ways to gain perspective on troubling issues and process negative and stressful thoughts and feelings. Over time, the patient develops a set of internal tools for mental health and coping mechanisms they can use for the rest of their lives.
Prescription medication. As with talk therapy, approaches to psychoactive medication vary from one practitioner to the next. There are many types of drugs on the market to address psychological disorders, each with its own potential benefits and side effects. There’s sometimes an element of trial and error before a patient finds the drug that works best with their biochemistry to address a mental health issue.
With most medications, side effects are mild and last for only the first couple of weeks. There is usually no negative impact on athletic performance, and patients often find medication to be of great help, especially at first as they work to develop better coping skills and healthier supportive behaviors. In some cases, long-term medication use provides the best outcome.
Common problems in the student-athlete population related to prescription medication use include lack of strict compliance, consuming alcohol or other drugs while on the medication, and lack of sleep, which may exacerbate side effects. If an athlete has been prescribed medication to deal with anxiety or depression, it’s a good idea to talk with them about avoiding these potential hazards.
Besides those two mainstays of mental healthcare, alternative methods are sometimes used if the athlete or practitioner feels they may be helpful. Options such as herbal remedies, meditation, yoga, and acupuncture have varying levels of scientific and anecdotal support, but if they bring an athlete comfort and relief, they may be worth exploring as a complement to traditional therapy.
There’s no specific formula for how you should act if you suspect a student-athlete may be experiencing depression or have an anxiety disorder. The best course depends on your relationship and comfort level with them, the resources available in your department and at your school, and many other factors. Here are some tips that may be helpful if you’re ready to step in:
• To broach the subject, tell the athlete about your concerns in a private setting using objective, non-judgmental language. Use specific examples of what you have observed, and emphasize that if they are willing to consider treatment, you will help them find the best possible arrangement for mental healthcare while respecting their privacy.
• Research the mental health resources available on your campus and in your community in advance, so you are already familiar with the available options when an athlete needs services. If your athletic department doesn’t already have a standing relationship with a mental healthcare provider or at least a referral list, work toward creating one.
• Before using any mental health professional for the first time, meet with them to assess their ability to provide care for student-athletes. Someone with experience in sports psychology is better prepared to understand the unique culture and its role in an athlete’s mental health.
• If the best available mental healthcare professional is not familiar with the culture of sports, take some time to educate them. Enhancing their sensitivity to the student-athlete worldview can go a long way in fostering a positive therapeutic relationship. It may be helpful to remember the Four A’s, a set of concepts developed by Dr. Don O’Donaghue for team physicians that’s also applicable to other professionals who interact with student-athletes. A professional should be Affordable, Available, Amiable, and Accepting of the value of athletics to the athlete.
• This may sound like common sense, but it’s worth a reminder: If a student-athlete makes comments that lead you to believe they are considering suicide, your top priority is making an appropriate referral and taking whatever steps necessary to ensure their immediate safety, even at the expense of your relationship with them.
As an athletic trainer, you have an excellent opportunity to help athletes not just with physical maladies, but mental ones as well. If you take on this responsibility, you can positively impact the lives of your athletes in ways you might never have imagined when you chose this profession. It’s just one more avenue for achieving the goal of helping student-athletes be at their best.
Sidebar: SAD OR DEPRESSED?
Everyone goes through periods of sadness brought on by life circumstances. But when those feelings persist for a long time or are severe enough to affect the ability to function, they may indicate clinically diagnosable depression.
The line between “normal” sadness and clinical depression is sometimes difficult to discern. Applying adjectives to the moods and behaviors of others is an inexact science, but the comparisons below can help you determine whether an athlete might be struggling with depression. If you suspect they are, or even if you’re unsure, consider referring them to a counselor or other mental health professional, who can use tools to evaluate whether the individual is clinically depressed.
Subclinical Range Temporarily sad Nervous Somewhat isolated Irritated Unmotivated Frustrated Angry Raging Minor sleep disturbance
Clinical Range Consistently sad Persistently anxious Truly withdrawn Explosive Apathetic Having emotional outbursts Insomnia