May 18, 2016United Stance
With its new Athletes Connected program, the University of Michigan has come together campus-wide to raise awareness and offer support for student-athlete mental health.
This article first appeared in the May/June 2016 issue of Training & Conditioning.
Those of us who work closely with student-athletes see them differently than the public does. Outsiders see excitement, entertainment, the satisfaction of victory, and the disappointment of defeat. We see those things, too, but we also see the pressures athletes are under and the challenges they face as they navigate new academic, athletic, and social environments. In some cases, we see these stressors take a toll and impact their mental health.
Student-athletes experience mental health issues at about the same rate as the general student body-30 percent. However, while 30 percent of those struggling students will get help, only 10 percent of their athlete counterparts will. Put more dramatically: 90 percent of student-athletes who could benefit from mental health services do not seek them out.
There are a variety of reasons for this. Some are concrete-athletes might not know about the resources available to them or may have trouble fitting a counseling appointment into their already busy schedules. More frequently, though, they are hindered by the stigma surrounding mental health troubles. The culture of athletics values toughness, and student-athletes often fear they will be viewed as weak if they acknowledge a mental health challenge. Others believe they should be able to handle their problems on their own.
Fortunately, several organizations are taking steps to eliminate this stigma. Both the NCAA and NATA have recently released guidelines on best practices for addressing mental health concerns in student-athletes, and the topic has gained a foothold in academic research.
Similarly, some schools are making strides on their own. At the University of Michigan, we took action by starting a program called Athletes Connected in early 2014. Uniting several groups on campus, its goal is to create a comprehensive program that increases awareness of mental health issues facing student-athletes and promotes help-seeking and positive coping skills.
OFF THE GROUND
Athletes Connected began as a collaboration between Michigan’s Depression Center, School of Public Health, and athletic department. I am the key participant from athletics. In addition, former Michigan football player Will Heininger is involved via a joint appointment in athletics and at the Depression Center, and Emily Brunemann, a former Michigan swimmer and current student in the School of Social Work Master’s Program, is a liaison from the athletic department.
In March of 2014, we submitted a proposal for an Innovations in Research and Practice grant from the NCAA to finance our project. We were awarded funding in April, and Athletes Connected kicked off soon after.
To have any success generating a discussion on mental health with Michigan student-athletes, we knew we had to first get buy-in from several groups. We started with senior athletic administration because we knew their support would allow us to access coaches and athletes. We informed them about the connection between mental well-being and sport performance. Once administrators understood that mental health could impact academic and athletic performance, they quickly jumped on board.
With their backing, we moved forward by holding a series of focus groups with student-athletes over the summer. Consisting of five to nine people, these 90-minute sessions covered participants’ perceived barriers to accessing mental health services as well as issues they thought would resonate with their peers.
These meetings produced lots of ideas and feedback that helped guide Athletes Connected. One of the most interesting revelations was that athletes wanted to talk about mental health. This came up repeatedly and encouraged our efforts moving ahead.
Next, we held focus groups with our athletic training and academic support staffs. Because of their close relationships with players, athletic trainers and academic counselors are crucial in recognizing signs of distress. They are often the first ones to notice when something is off with student-athletes and usually have the skills to start a dialogue and facilitate a referral to a mental health provider.
This second round of focus groups consisted of seven to 12 staff members per session. They discussed their level of comfort in talking about mental health, as well as best ways to promote services to athletes. In return, we provided them with talking points to use when working with athletes who had mental health concerns.
UP AND RUNNING
After concluding our focus groups, we started the official rollout of Athletes Connected in September 2014 with a presentation to all sport coaches. Because coaches spend a large chunk of time with athletes, they should know how to help when a player on their team is struggling. Responding in a supportive, nonjudgmental way is an important start. In addition, they can establish a program-wide culture to reinforce that dealing with mental health issues is nothing to be ashamed of. The meeting covered the signs and symptoms of depression and anxiety and outlined the mental health resources available on campus to student-athletes.
Following our session with coaches, we held similar presentations with sports teams in October and November. During these meetings, we shared two videos of former Michigan student-athletes who dealt with mental health issues while in college. The videos were funded by our NCAA grant, and we brought in Will Del Rosario, an established film and commercial producer, to provide direction and generate ideas.
One video featured Will Heininger discussing his battle with depression and how he had trouble understanding his emotions. At the time, he felt there was a stigma that made it hard to seek help, but an athletic trainer was key in convincing him to access mental health services.
In the second video, Kally Fayhee described her personal struggle with anxiety and an eating disorder while she served as captain of the swim team. She too mentioned a fear of disclosing her struggle to others and worried she would not be considered “captain material” by her teammates or coaches if she opened up. Thankfully, she found the opposite to be true. Because Will and Kally remained local after graduation, they were able to attend each session and answer questions from athletes after the videos.
Along with the videos, we offered information about mental health to the athletes. We explained symptoms of depression and anxiety, how to help a friend, and the resources available to them.
A big part of our message was getting athletes to view a mental health diagnosis like a physical injury. We explained that when someone tears an ACL, they don’t ignore it or “tough it out,” and no one questions that the injury requires treatment. Mental health concerns should be viewed the same way. They may not be as obvious as a torn ACL, but treatment methods can get athletes performing at their peak again.
We also made it clear athletes didn’t have to be experiencing a diagnosable, clinical disorder to benefit from mental health services. In fact, we pointed out that being proactive when an issue first arises could keep it from becoming something more serious down the road.
After each presentation, we passed out surveys to gauge the athletes’ responses. We were pleased to find that 99 percent of attendees said the videos of Will and Kally were engaging and relevant. In addition, 96 percent indicated they were likely to use the information they learned in their daily lives.
One of the more surprising survey results was that 63 percent of athletes reported a mental health struggle had affected their performance in the previous four weeks. This does not mean they all experienced problems at the level of a clinical diagnosis, but they recognized some degree of psychological distress that had a negative impact on them.
Further post-presentation feedback revealed that, overall, athletes felt:
• More confident in their ability to identify a teammate who may be struggling with mental health issues
• More confident in their ability to help a teammate access mental health care or other support services on campus
• More likely to consider seeking help if they were having a personal problem that was bothering them
• More willing to accept someone who has received mental health treatment as a close friend
• More knowledgeable about depression.
After team presentations, we advanced the Athletes Connected programming by hosting group meetings biweekly, which we continue to do. These informal, drop-in sessions are open to all Michigan student-athletes and run for 75 minutes every other week. The meetings are facilitated by a clinical social worker who specializes in working with college students but is not an employee of the athletic department.
The structure of the sessions is flexible. However, we always make time for a “check-in” period so participants can share how things are going for them. We also typically present and discuss one or two topics that attendees may benefit from learning about. Examples include relaxation breathing, reframing thoughts, helping a friend who is struggling, and managing test or performance anxiety.
Attendance at the group meetings has ranged from one to 10 participants. We have experimented with different days and times in an effort to increase this number, but participation continues to be a challenge due to the time demands on student-athletes.
Like the presentations, we conducted surveys after every biweekly meeting. Overall, the feedback has been positive:
• Attendees reported improved mood
• Attendees said they were more likely to speak with a professional clinician or teammate or share at an Athletes Connected group meeting if they experienced serious emotional distress
• Participation in the group increased attendees’ readiness to seek further information about mental health support services
• 92 percent of attendees expect to apply lessons or skills learned in the group in their daily lives
• 67 percent of respondents reported implementing one or more strategies from the group in their daily lives
• Attendees realized their sport didn’t define them, and it was important to create a balance of healthy and fun activities outside of school and athletics
• Attendees learned how to share and talk about things that were upsetting them.
To supplement the Athletes Connected programming, we also created a website (athletesconnected.umich.edu). It provides personal stories from student-athletes, articles about mental health, and coping strategy videos. We hope these resources are beneficial for those who can’t attend our group meetings or are struggling to ask for help.
GROWING FROM HERE
Over the past two years of implementing Athletes Connected, numerous colleges and universities have contacted us to see how they could start a similar program on their campuses. We have lots of lessons to pass on from our experience.
For starters, the key to a successful mental health initiative for student-athletes is the proper approach. There must be an ease and comfort in talking about mental health that does not shame or stigmatize. Many student-athletes judge themselves negatively for how they feel, so addressing the issue in a reassuring, matter-of-fact tone will go a long way in getting them to open up. Additionally, giving student-athletes opportunities to connect with peers will show them that they are not alone in their struggle, which can decrease the isolation and shame of secrecy.
That being said, athletes need to have a reason to participate in your program, so make your content engaging and relevant. We did this by relying on videos. When we first started, we asked athletes whether they’d prefer reading an article about a coping strategy or watching a video on it. They overwhelmingly preferred the video format. Featuring their peers in our programming helped keep athletes connected, as well.
When it comes to actually providing mental health care, remember that not everyone seeking help will do so because they have a clinically diagnosable condition. You should be able to offer services on a spectrum. Some student-athletes may simply want to improve upon what they are already doing or learn additional coping strategies. Athletes Connected is designed to benefit student-athletes no matter where they are on the health and wellness continuum.
Finally, if you’re going to talk about mental health on a college campus, be prepared for an increase in help-seeking and respond in an effective, timely way. It can be very difficult for student-athletes to get up the courage to ask for help, so if they have to wait two or three weeks to speak to someone, they may lose the motivation that led them to reach out in the first place-an unfortunate missed opportunity.
We experienced an increased demand for services firsthand in the early stages of Athletes Connected. Following the rollout of team meetings in fall 2014, our athletics counselors received 40 requests for appointments. Fortunately, we were able to accommodate all these athletes within a reasonable time frame, but it did put additional strain on our resources.
Going forward, Athletes Connected will continue to educate teams and coaches on mental health. We will look to increase the utilization of the biweekly groups and find other ways for athletes to connect around mental health and well-being.
One additional element under consideration is expanding Athletes Connected to include club sports. These activities draw a large number of participants at Michigan, and many of these students are likely affected by the stigma around help-seeking for mental health.
A challenge we’ll have to overcome in the future is funding. Our grant from the NCAA has expired, so our budget for staffing and creating new content is now totally dependent on fundraising. In January, Michigan’s Interim Athletic Director Jim Hackett donated half his salary to our cause, which will certainly help. Meeting any additional budgetary needs will require collaboration between Michigan athletics, the campus Depression Center, and the School of Public Health.
Efforts to raise awareness about student-athlete mental health cannot be limited to an occasional seminar or press release. To effectively eliminate the stigma attached to mental health issues, everyone working with student-athletes must take a role in keeping the conversation going and normalizing help-seeking. Only when mental health aligns with physical health can athletes perform at their best.
A version of this article appears in Training & Conditioning’s sister publication, Athletic Management.
GROUP EFFORT
By Kellie Peiper and Brian Bratta
As the issue of student-athlete mental health gains attention, many schools are implementing programs to address it. We took action at the State University of New York at Buffalo by creating the Student-Athlete of Concern Committee, which monitors athletes who may need assistance managing daily stressors.
The multidisciplinary group is composed of the directors of our athlete academics, sports medicine, and strength and conditioning departments. By utilizing these different disciplines, we are able to assist student-athletes from multiple angles.
When we identify a student-athlete who may need help, he or she first meets with Kellie Peiper, MEd, the Assistant Athletic Director of Student-Athlete Excellence. Kellie counsels the student-athlete and then discusses the case with other members of the committee to determine the appropriate course of action. Depending on the scenario, we might refer the athlete to an in-house counselor, utilize the campus counseling center, or recommend placement into an inpatient mental health facility. Making the proper referral requires open lines of communication within the committee and a strong support network on campus.
Everyone on the committee is a volunteer. We meet once a month, communicating regularly at all other times through phone calls, emails, and in-person conversations. Our meetings and discussions are scheduled around our normal daily requirements. If further action is ever needed for a student-athlete, we adjust our schedules to ensure appropriate care. This can include follow-up conversations with the athlete, the counseling department, or a whole sport team.
What sets the Student-Athlete of Concern Committee apart from similar programs is that we not only work with athletes who are struggling with clinical mental health issues, but we also assist them with daily stressors. To date, the committee has helped student-athletes navigate challenges such as behavioral issues, body image concerns, disordered eating, and performance anxiety. Our coaches, administrators, and other campus officials have identified that the committee is a worthwhile investment in the bettering of student-athletes, and we will continue to utilize it for the foreseeable future.
Kellie Peiper, MEd, is Assistant Athletic Director of Student-Athlete Excellence at the State University of New York at Buffalo. She can be reached at: [email protected].
Brian Bratta, PhD, ATC, CSCS, is Assistant Athletic Director of Sports Medicine at the State University of New York at Buffalo.
BEING PROACTIVE
By Dr. Shayla Sullivant
The impact of teen suicide-the second leading cause of death in teens-hit close to home for those of us at Children’s Mercy Kansas City in November 2014 when two local high school athletes died by suicide. In the aftermath, we wanted to find a way to identify at-risk athletes, so our Sports Medicine Department started administering suicide screenings for all of our teen patients.
This initiative began with Kevin Latz, MD, Chief of Sports Medicine, and Angie Vanderpool, APRN, MSN, RN, ONC, CPNP, Nurse Practitioner, along with other members of the Sports Medicine Department’s leadership team. We have been working toward universal screening in other parts of the hospital, trying to find the most efficient and effective way to identify those at risk, so Sports Medicine seemed like a logical and necessary expansion.
We started out using the Columbia Suicide Severity Rating Scale (C-SSRS). It asks three basic questions about thoughts, plans, and actions regarding suicide to identify a patient’s lifetime history of suicidal thoughts. We are now working on a validation study using the Ask Suicide Screening Questionnaire. The ASQ focuses on the patient’s thoughts over the past couple of weeks, as well as his or her history of suicide attempts. We chose these tools because they are evidence-based and easy to use.
To ensure the screenings went as smoothly as possible, we had to make some changes to our standard procedures. For example, we knew the teens weren’t likely to open up to us in front of their parents, so we would need to screen them in private. To accomplish this, our staff nurses and athletic trainers changed their flow and saw patients alone at the beginning of their visit to complete the screen.
We also had to educate our staff on how to ask about suicide and address questions from parents. The C-SSRS has an online training component that our staff completed to help them prepare. In addition, we presented them with data on why we were doing the screenings and that asking patients about suicide was safe. Role playing got them more comfortable with what to say and how to handle awkward situations, as well.
Finally, we assigned a “champion” to the sports medicine clinic, Jen Farrell, MSN, MBA, RN, Orthopaedic Clinic Charge Nurse, who fielded any questions that arose in the screening process. She helps link the sports medicine staff to the suicide prevention group at Children’s Mercy.
Since we started the screenings, roughly two percent of teens surveyed have expressed suicidal thoughts. When a patient is identified as at-risk, we have a social worker evaluate him or her further to determine what kind of action is needed.
The care after the visit is critically important. We know that most patients we identify are not acutely suicidal, and most do not require inpatient admission for suicidal thoughts. They do, however, benefit from follow-up, which can include referral to a mental health care provider or family physician. Our social workers contact the patient’s family weekly to ensure he or she gets what they need.
Overall, our suicide screening process has been well-accepted by patients, families, and staff. While we initially worried that parents would be uncomfortable with the questionnaires, we have had few families express concern-most thank us for raising awareness about this important issue.
Shayla Sullivant, MD, is a Child and Adolescent Psychiatrist at Children’s Mercy Kansas City. She can be reached via Children’s Mercy’s Division of Developmental and Behavioral Sciences at: 816-234-3674.
