Unique barriers to psychosocial treatment in high-level athletes

Despite progress in the awareness of and action toward the treatment of psychosocial health concerns in athletes, many challenges remain. Chief among these challenges is the stigma around emotional health concerns and help-seeking that continues to exist in the high-level sport environment (Moreland, Coxe, & Yang, 2018). Wahto, Swift, and Whipple (2016) conducted an important study on the role of stigma in predicting college student-athletes’ attitudes toward psychosocial help-seeking. The researchers considered the influence of both selfstigma, or negative attitudes toward oneself for engaging in a given behavior, and public-stigma, or the perceptions of negative attitudes that others may have about one’s behavior, on 43 collegiate student-athletes’ attitudes toward seeking mental health services (Wahto et al., 2016). After controlling for gender and treatment history, the two stigma variables accounted for a robust 66% of the variance in help-seeking attitudes. Athletes reported being more willing to seek help when referred by a family member as compared to a coach, teammate, or when considering seeking help on their own.

So, although the public disclosure of psychosocial health concerns by high-profile athletes has likely resulted in some help-seeking de-stigmatization, the findings of Wahto et al. (2016) suggest that stigma is still a powerful barrier preventing athletes from acting on psychosocial health concerns. And despite the finding of no significant gender difference in help-seeking by Wahto et al., several researchers have found that male athletes, and especially those who have internalized a hyper-masculine identity, are significantly less likely to seek treatment for psychosocial health issues (e.g., M. Steinfeldt & J. A. Steinfeldt, 2012). The reticence of male athletes to seek treatment is not surprising, as men in the general population are more deterred by stigma than women (Clement et al., 2015), and the hyper-masculine nature of certain sports likely heightens male athletes’ sense that psychosocial health concerns are a sign of mental weakness (M. Steinfeldt & J. A. Steinfeldt, 2012).

Although stigma may represent the most powerful barrier to psychosocial health treatment in athletes, sport psychiatrists have identified several other factors that make treatment of this population uniquely challenging (Stillman, Brown, Ritvo, & Glick, 2016). First, the training demands of high-level sport can result in symptoms which mimic those of clinical disorders (e.g., burnout vs. clinical depression). Second, Stillman et al. (2016) noted how some athletes engage in rigid and ritualistic behaviors that can be confused with obsessive compulsive disorder. Third, when athletes perceive that a certain behavior, such as disordered eating or performance enhancing substance use, confers a performance advantage, they may be reluctant to engage in a process aimed at changing these practices. Finally, the social stature afforded to some high-level athletes may result in a sense of entitlement, in which athletes expect special accommodations related to the timing and location of sessions (Stillman et al., 2016). Thus, clinicians who provide psychosocial treatment to high-level athletes need to be especially mindful of balancing the unique needs of these individuals with the delivery of ethical and quality care.

The current state of psychosocial health treatment services for high-level athletes

The last decade has seen a growing concern for athlete psychosocial health by high-level sport organizations (Kliegman, 2017). In the U.S., the NCAA has been at the forefront in promoting research and practice related to optimizing studentathletes’ emotional health. Since the inception of the Sport Science Institute in 2013, the NCAA has awarded research grants for psychosocial-based intervention projects and published a variety of resources for athletes and those with a vested interest in student-athlete psychosocial health (NCAA, n.d.). Although the total number of professionals dealing with psychosocial health at NCAA member institutions remains elusive, it has likely grown from the fewer than 25 full-time professionals employed in 2014 (Noren, 2014). Of course, it is also likely that many of the over 1,200 NCAA institutions, and particularly those at the Division II and III levels, lack a full-time mental health professional. Although many collegiate athletics departments partner with the on-campus university counseling center to support student-athletes treatment needs, the presence of a dedicated psychologist or other mental health practitioner enhances the probability that athletes and coaches will seek help (Kliegman, 2017). Even at those institutions with a full-time position, it is doubtful that one person can adequately address the psychosocial health needs of several hundred student-athletes. Some athletics departments have begun using post-doctoral clinical or counseling psychology student interns to enhance quality of care (e.g., USC Student Health, n.d.). However, given that there are almost 500,000 student-athletes across North America, the NCAA must remain committed to supporting member institutions in improving the staff-to-athlete ratio for psychosocial healthcare.

Similar to the NCAA, other high-level sport organizations have displayed support for psychosocial health services for athletes. Although decisions regarding psychosocial health services are at the professional level are at the discretion of individual clubs/teams, organization administrators and players’ unions have a large role in advocating for the psychosocial health needs of athletes. Several major professional sport leagues have done just that in recent years. In 2012, the Professional Footballers’ Association, which is the labor union for professional footballers in England and Wales, began assisting current and former players in obtaining treatment for emotional health concerns (Keble, 2016). As of 2014, all 20 clubs in the English Premier League had a full-time mental health professional on staff (Hughes, 2014). In the National Basketball Association, the league and players’ association have partnered to provide players with emotional health resources (Reynolds, 2018). Of all professional sport organizations, however, the National Football League (NFL) appears to offer the most comprehensive psychosocial treatment services to its athletes. All NFL players participate in the league’s Total Wellness program, which includes mandatory psychoeducation for rookies on a variety of psychosocial health topics (e.g., stress management, relationships, decision-making), as well as a service called Life Line, which is a confidential 24/7 phone line for current and former NFL players, coaches, or staff dealing with an emotional health crisis (Rapaport, 2012). Further, all NFL players receive eight free counseling sessions for themselves or any member of their household. An additional strength of Total Wellness is its train-the-trainer approach, in which former NFL players are used as transition coaches for retiring players, and team staff are trained to recognize and appropriately handle emotional health crises (Clay, 2017). Although no data are publicly available on the number of players who have taken advantage of these services, or the effect of the program on relevant long-term health outcomes, the NFL’s multifaceted approach appears to have promise for both the treatment and prevention of psychosocial health concerns in its players.

Conclusion

Although primary prevention should remain a priority for high-level sport organizations, the strong demands on athletes require that organizations are ready to support those who do need psychosocial treatment. CBT-oriented psychotherapy and psychoeducation are common modalities of treatment for high-level athletes. However, a lack of rigorous evaluation, particularly regarding psychoeducation, precludes a complete understanding of what works best for athletes. Further, despite calls for the use of psychoeducation with injured athletes (e.g., Naylor, Clement, Shannon, & Connole, 2011; Granito, Hogan, & Varnum, 1995), no researchers have undertaken an evaluation of such a program. Even if certain treatments are found to be effective, challenges remain in the provision of psychosocial health services to athletes. Such challenges include self and public stigma around help-seeking (particularly for male athletes), the overlap of certain clinical disorders with typical athlete behaviors, and issues of entitlement for certain high-profile athletes. Public disclosure of psychosocial health struggles by several high-profile athletes has prompted sport governing bodies such as the NCAA, English Premier League, NBA, and NFL to invest in treatment-based initiatives. As discussed regarding prevention in Chapters 9 and 10, organization-sponsored psychosocial treatment efforts await proper evaluation of both the process and the impact of these services.

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