Keywords

Introduction

Although mental health is being increasingly recognized as an important issue in the sport setting (e.g., [1, 2]), it is still infrequently addressed at an organizational level [3]. One reason may be because the prevalence of mental illness is under-recognized [4], potentially due to the overlap between some symptoms of mental illness and “good athlete” traits, or conflation of physical functioning with the absence of mental illness. Estimates of the prevalence of mental illness among athletes vary by sport (e.g., team, individual), age group and level of competition (e.g., pre-college, college, professional/elite), illness or disorder (e.g., depression, anxiety, eating disorder), and the means of measurement (e.g., clinically relevant symptoms, clinically diagnosed disorder) [5]. However, estimates tend to be relatively similar to same-age nonathlete peers [6, 7], meaning that at least one-quarter of athletes will likely experience challenges related to mental illness [8, 9].

While reducing the health burden of mental illness is important, so too is increasing positive psychological functioning, including subjective well-being [10]. Mental health is increasingly being conceptualized using a dual-factor model, in which subjective well-being and mental illness are viewed as on separate but related continuums rather than opposite ends of the same continuum [11, 12]. Thus, in addition to reducing the burden of mental illness, some sports organizations are also focusing on the importance of fostering positive psychological functioning [1]. Despite relatively similar prevalence of mental illness among athletes and nonathletes, athletes experience a unique set of risk and potentially protective factors for the onset of mental illness and different factors that may facilitate or constrain early detection and appropriate management [7, 13, 14]. Similarly, sport settings can present both unique challenges and opportunities for the promotion of positive psychological functioning and subjective well-being.

Strategies for reducing the health burden of mental illness can be broadly grouped into categories of primary prevention (e.g., reduce risk factors for onset of mental illness), secondary prevention (e.g., early detection), and tertiary prevention (e.g., ensure appropriate management of mental illness). When discussing primary prevention of mental illness in the sport environment, it is important to emphasize the range of factors that may influence whether an individual will experience mental illness. These include immutable factors like their underlying biological vulnerability to mental illness [15, 16], which may interact with early life experiences to produce a unique risk profile [17]. However, even after the early life period, and while recognizing individual variability, environmental stressors and learned coping behaviors can influence the manifestation of mental illness [18]. Athletes experience unique stressors (e.g., related to athletic performance, time demands of sport, coaching and parental pressures, injury, transition from sport) but also have the potential to learn positive coping skills within the context of the repeated challenges of sport [19].

Secondary and tertiary prevention are also critical for reducing the health burden of mental illness as untreated mental illness can progress to worsened symptomology [20]. Many mental illnesses are never identified or treated, and when individuals do seek care, adherence to treatment is low [21]. Adolescence and emerging adulthood are the time of onset for many types of mental illness [22], making contexts within which these individuals live, learn, work, and play, which is of critical importance for early detection and facilitation of care seeking.

There are unique barriers to care seeking among athletes [23]. These include perceived stigma by others in the sport environment (e.g., coaches, teammates) and a perception that mental health help seeking will negatively impact athletic performance [7, 13, 14]. However, athletes also can theoretically benefit from the engagement of others in the sport environment in mental health promotion efforts. Stakeholders within sport environments, including coaches, sports medicine personnel, and organizational administrators, can help create sport environments that destigmatize/support mental health care seeking [19, 24]. They also can help facilitate the identification of potentially symptomatic athletes who could benefit from care seeking, either directly [19, 24, 25] or through screening initiatives [26, 27]. Tertiary prevention or care provision to athletes who are struggling with mental health problems is a critical final step in reducing the health burden of mental illness. To be optimally efficacious, this care should be from licensed mental health providers with cultural competence engaging with athletes [1]. Stakeholders in sport settings (e.g., coaches, primary medical providers, athletic trainers, administrators) can help provide access to these individuals, either directly or through information provision to athletes. Communication with sport settings can help facilitate care seeking to appropriate individuals. This can include ensuring that all sport stakeholders have access to the organization’s mental health management plan. It could also include encouraging integration between mental healthcare providers and sport stakeholders to increase familiarity, for example, through an annual meeting.

Conceptual Framework

This chapter is framed using a social ecological model, in which the individual is viewed as nested within the context of interpersonal, organizational, policy, and societal levels of influence [28]. For this chapter, “individual” will be operationalized as the individual athlete among whom mental health optimization is the focus. However, this same framework could be used to think about influences on the behaviors of coaches, bystander teammates, or other stakeholders involved in mental health promotion efforts. The specific individual behaviors of focus will be care seeking and care adherence. At the interpersonal level, we will focus on coaches, as they play a central role in shaping team environments and influencing other stakeholders with the sport setting. However, we will also briefly discuss the role of other important interpersonal relationships that can influence individual care seeking and care adherence behaviors. At the organizational level, we will focus on school-level policies and initiatives, as well as school-level implementation of policies and initiatives mandated legislatively. At a policy level, we will focus on legislation and best practice guidelines of large sport governing bodies (e.g., NCAA, other college sports organizations, large single-sport governing bodies, and high school sport governing bodies). For each level of the social ecological model, our discussion will consider a continuum of prevention inclusive of primary, secondary, and tertiary prevention.

Coaching and Mental Health

Attend to Unhealthy Mental and Physical Stressors

While recognizing the centrality of risk factors outside of the sport context on an individual athlete mental health, coaches can nonetheless play an important role in primary prevention through their coaching practices. One key way is by attending to stressors associated with risk of symptomatology of mental illness. This includes chronic stressors (e.g., monitoring training loads and recovery that may contribute to overtraining and eliminating abusive coaching practices) [6, 29, 30] and acute stressors (e.g., injury) [6, 16, 31, 32]. Coaches can also attend to factors predictive of burnout (physical and emotional exhaustion and sport devaluation) by providing opportunities for connection with others, autonomous decision-making, and a sense of competence [33]. Such coaching practices must be developmentally appropriate, recognizing that what qualifies as healthy sport-related physical and psychosocial demands will vary between athletes and be patterned by age [10, 34]. For example, among younger (e.g., pre-secondary school) athletes, there is a growing focus on the developmental appropriateness of keeping sport fun, reducing achievement-related pressure, and limiting physical demands by reducing early specialization and promoting multisport participation [35].

Coaches also need to communicate about developmentally appropriate training to parents to assure parent buy-in. Parents help select the sport environment for this child and then can either amplify or counteract coaching practices designed to support sport participation that is physically and emotionally appropriate from a developmental perspective [36]. This means that in addition to themselves implementing healthy coaching practices, coaches should communicate with parents to enlist their support in reinforcing (or at least not undermining) these practices. Drawing on integrated theories for behavior change that emphasize the importance of expected outcomes, norms, and skills on behavior [37], such communication could involve sharing with parents the expected benefits of such practices, the approval of such practices by leading sports professionals and organizations, and specific and actionable strategies for their own behavior (e.g., tips for a positive discussion with their child on the way home from a loss).

Help Athletes Learn Positive Coping Skills

Sport can be used as a context within which coaches can help foster positive psychosocial development among athletes [38], in part by helping athletes learn how to respond to stressors in healthy and functional ways [19, 39]. This includes helping athletes learn skills predictive of resilience [40], such as psychological flexibility [41] and self-compassion [42]. This means adapting to situational demands (e.g., recognizing that everything might not always go as planned and being willing to change course), shifting perspectives, and making decisions about how to act while balancing competing desires and staying consistent with one’s values [41].

Coaches can also help foster a process-oriented mindset, in which effort and improvement are emphasized and achievement or outcomes are de-emphasized [43]. Such mindset has been associated with improved ability to manage stressors and increased likelihood of post-traumatic growth [44]. The repeated challenges and almost inevitable losses inherent with sport participation provide a laboratory in which coaches can model, instigate, and reinforce healthy coping practices consistent with psychological flexibility, self-compassion, and a process-oriented mindset. For example, this could mean modeling responding flexibly to unexpected challenges in the sport setting (e.g., a travel delay to a game). This could also mean providing positive reinforcement when observing athletes who are performing desired coping behaviors (e.g., focusing on effort and planning steps to learn from a loss). It is also useful for minimizing performance-related anxiety [45], reducing attrition from sport [46], and optimizing the positive psychological experiences of sport participants [47].

Training for coaches can help with developing the ability to implement such positive coaching practices [48]; however, such educational practices are rarely if ever required for coaches. Helping athletes develop such positive coping skills cannot be considered sufficient in isolation to prevent mental illness among individuals with underlying vulnerability. However, it can nonetheless help reduce the impact of potential environmental triggers. More broadly, among all athletes regardless of their vulnerability to mental illness, developing positive coping skills can help optimize their subjective well-being in response to the inevitable challenges of sport. These skills also have the potential to be generalized off the sports field to help with coping in other domains [19] and after athletes have transitioned away from competitive sport [49].

Encourage Appropriate Care Seeking

The frequent and repeated contact that coaches have with athletes means they are often in a position to notice athletes who are struggling. Not all coaches feel confident in responding appropriately if they believe an athlete is experiencing a mental illness [50], meaning that there is scope to improve knowledge translation to coaches about symptom identification. Because of the possibility of athlete-specific presentation of symptoms (e.g., as manifested in athletic performance) and confounding between “good athlete” traits and symptoms of mental illness (e.g., perfectionism), sport-specific education about identification of mental illness is important. This can include information about sport-specific potentially triggering events, such as injury [6, 16, 31, 32] or retirement [7], and chronic stressors such as high training loads [6, 29].

Such education should emphasize that the coach’s role is not to make a diagnosis but rather to ensure that potentially symptomatic athletes seek further evaluation from a licensed mental health care provider [1]. Theoretic models that explain whether coaches intervene to support care seeking among athletes suspected of experiencing a mental disorder point to the importance of mental health literacy, perceived stigma, and self-efficacy as key factors in explaining behavior [50,51,52]. A small but growing number of educational interventions have found efficacy in shifting one or more of these cognitions among coaches [53,54,55].

A key reason why athletes do not seek mental health care is the perception of stigma associated with such health-seeking behavior [14]. Coaches have the potential to help shape team cultures supportive of care seeking, and coach education can help support coaches in this process. Coaches can engage in direct verbal communication to their team about the importance of care seeking, starting long before there is a specific concern about mental illness. Coaches can also attend to the indirect or informal messages they are sending about mental health/mental health care seeking, for example, through their choice of language, which may unintentionally stigmatize mental health concerns. To help support desired coach behaviors, specific guidance should be provided to coaches within the context of education programming about how to communicate effectively about mental health, such as utilizing analogies to physical health (e.g., mental health concerns should be as easily addressed as a sprained ankle) and emphasizing the interplay of physical and mental health – both for well-being and for performance.

Once a coach has identified that an athlete may benefit from further evaluation or care, a trusting coach-athlete relationship can be leveraged to encourage care seeking from a licensed mental health provider. To do so, coaches need to know that care should be provided by a licensed mental health professional and be aware of appropriate individuals within a given organizational setting or community from whom care could be sought. Although athletes may choose to seek care elsewhere after consultation with their family and in consideration of financial considerations (e.g., insurance), it is important that all initial recommendations are appropriate. Additionally, coaches can help encourage adherence to the ongoing care-seeking process. This can include continuing to normalize and destigmatize care seeking and providing emotional support as appropriate within the context of the coach-athlete relationship. The response of collegiate track and field coaches to student-athletes suffering with depression suggests that coaches may require additional support to engage in optimal secondary and tertiary preventive behaviors. One-third (33%) of coaches provided student-athletes with information about campus resources, one-quarter (24%) encouraged the student-athlete to seek health care, and one-fifth (21%) alerted a member of the team’s medical staff [51]. Fewer engaged in emotionally supportive communication, such as showing support (15%), sharing from personal experience (3%), attempting to remove stigma or normalize (3%), or asking if they want to talk (3%) [51]. Such coaching behaviors should be addressed by coaching education related to mental health.

Organizational Practices and Mental Health

Provide Evidence-Based Education to Coaches

One key way that organizations can influence athlete mental health is through the education that they provide to coaches. As discussed above, coaches can engage in behaviors related to primary, secondary, and tertiary prevention, but they require support in delivering these behaviors. Critically, such education should be evidence-based and efficacious [56]. At present, there are several programs that meet such threshold, largely developed and evaluated in Australia. The most commonly used educational intervention is Mental Health First Aid [57]. This two-day program teaches strategies for responding to emergent and non-emergent mental health issues, increasing mental health literacy, self-efficacy, and helping behaviors [58]. Adapted versions have been used in Australian sport settings, with similarly positive results [54, 55].

A less time-consuming intervention is the mental health in sport (MHS) workshop for coaches and support staff in elite sport settings, which is focused on increasing knowledge of mental illness signs and symptoms and confidence in helping an athlete who is experiencing a mental health problem [53]. Additional interventions, typically focused on increasing mental health literacy, have been targeted at coaches [53, 54, 56, 59]; however, there is a need for additional work evaluating these interventions, with a focus on unbiased approaches to measurement and determining clinical impact [56]. Other sports organizations, such as the NCAA, provide education for coaches based on established theoretic models (e.g., addressing mental health literacy, stigma, and self-efficacy) [60]; however, evaluation work is ongoing. There is an ongoing need for health education professionals to work collaboratively with stakeholders in the sport setting and for mental health providers and epidemiologists/biostatisticians to develop and evaluate needed educational materials for coaches. This can include evaluating whether intervention used in other countries or levels of sport translates to different sporting contexts.

Attend to Organizational Incentives

Target behaviors can be viewed within the scope of expectancies and function for coaches, thereby increasing the incentive of delivering appropriate coach education [37]. Organizational resource allocation, priorities, and the outcomes or behaviors that are rewarded can communicate to coaches whether mental health is viewed as an organizational priority. For example, if coaches are going to engage in coaching practices that are developmentally appropriate but less focused on short-term athletic achievement, they need to be confident that their organization values more than just wins and losses. Sports organizations should also attend to structural decisions made at the organizational level that can impact the extent to which coaches can engage in coaching practices supportive of athlete mental health. There may also be scope for sports organizations to provide guidance to coaches about how coaching time is allocated and whether some practice time is allocated to intentionally teaching positive psychosocial skills. Such intentional structuring of time allocation in sport settings has been associated with better youth developmental outcomes [61].

Consider Universal Screening

Some sports organizations may also be able to help screen athletes for symptoms of mental illness. However, consistent with guidance from the US Preventive Services Task Force, screening should occur only if accompanied with systems that subsequently allow for accurate diagnosis, effective treatment, and appropriate follow-up [62]. In implementing screening, organizations must also attend to the need for confidentiality in the data collection process. Screening practices may not be appropriate for all sports organizations, but should be considered by sports organizations that have integration of medical care and athletics, such as collegiate sports programs [26, 27]. One strategy for screening is for it to be conducted universally, for example, as part of the pre-participation exam [26, 27]. However, temporal changes in depression symptoms across season in collegiate athletes [63] suggest potential utility of screening at multiple time points, not just on entry. Although screening for mental illness using questionnaire-based tools has benefits in terms of relative ease of implementation and potential for each, there are nonetheless challenges. Existing questionnaire-based screening tools have been developed for a general population and not athletes [26]. Consequently, their sensitivity and specificity may be limited due to factors such as potentially confounding between mental health symptoms and symptoms of other athlete-specific health issues such as overtraining syndrome [5, 64]. The possibility that screeners are inaccurate or temporally unstable raises concern that screening could have unintended negative consequences as a result of complacency (e.g., ignoring behavioral factors that could modify risk or continued monitoring), as has been observed related to screening for other health issues such as cardiovascular disease [65].

Establish and Rehearse a Mental Health Protocol

Another key way that sports organizations can help facilitate secondary and tertiary prevention of mental illness is by having a mental health protocol for emergency and nonemergency situations [26]. This protocol should clearly outline the responsibilities of different stakeholders and describe pathways for referral in both emergency and nonemergency situations. For mental health protocols to be useful to coaches and other stakeholders in the sport environment, it needs to be communicated to and rehearsed by all relevant stakeholders. Among high school coaches, those who were aware of their school’s mental health protocol had greater confidence in their ability to respond appropriately to support an athlete believed to be struggling with mental illness [50]. This protocol can also help with tertiary prevention, ensuring that referrals are made to licensed mental health providers and including guidance for stakeholders in the sport environment on the importance of supporting care-seeking adherence.

Attend to Staffing

Other ways that some sports organizations can foster secondary and tertiary prevention are through staffing decisions and the types of behaviors they encourage among existing healthcare professionals who work with their athletes. Additional research is needed to understand the conditions under which coaches are able to implement positive coaching practices. In sports organizations that employ or consult with sports medicine physicians who provide care for a range of health issues, efforts can be made to encourage a more holistic focus on athlete well-being. Injury can function as a trigger for worsening symptomatology of mental illness [31]; however, physicians providing injury care in sports medicine settings infrequently screen for or discuss psychological issues potentially related to or emergent at the time of injury [26]. Communication with sports medicine physicians about increasing the integration of mental health care with injury care, even if just for purpose of screening, may be useful in sport settings that work with dedicated sports medicine professionals [23].

Individuals providing screening and initial consultations should be appropriately trained and licensed. Some sports organizations (e.g., large collegiate athletics programs or elite/professional sports teams) may have the budget to employ dedicated mental health professionals. Having sufficient professional staffing to meet athlete demand for mental health care helps ensure that symptomatic athletes receive attention as needed. Hiring dedicated staff to work with athletes (as opposed to making referrals for athletes to community or general campus mental health care providers) means that care providers can be selected in part based on their expertise working with athletes. Cultural competence of mental health care providers is an important factor in treatment adherence in general [66]; within the context of athletics, cultural competence working with athletes is a unique consideration that intersects with the need for the healthcare provider to be culturally competent in other regards (e.g., attending to the athlete’s additional identities related to race/ethnicity, gender, and sexual orientation).

Policy and Mental Health

Although sports organizations may choose to independently implement practices related to supporting athlete mental health, guidance from sport governing bodies can help with the reach of such practices. In this section, we will discuss both legislation (e.g., policy that is voted upon and approved as mandatory by a governing body such as state high school athletics associations or the NCAA) and best practice guidance provided by such governing bodies. Given the challenges related to passing legislation and then assuring compliance at the organizational level, governing bodies may choose to provide instructions to sports organizations in the form of best practice guidance. Legislation, if passed, may be broad (e.g., “provide education”), while best practice guidance can be more flexibly responsive to an evolving evidence base, recommending specific programs, practices, and protocols to sports organizations. This is the approach the NCAA has taken, working to pass legislation where possible while using inter-association documents to recommend consensus best practices to member institutions. In the United States, of the ten sports with the highest participation rates, we were unable to find formal policies of the respective national governing bodies (NGBs) related to the prevention, identification, or management of mental health concerns. However, USA Track & Field has a psychological services subcommittee with responsibilities that include mental health education for members [67]. This lack of policy-level guidance related to mental health may reflect a missed opportunity for agenda setting by leading sports organizations. The NCAA provides a model related to policy-level approaches to mental health promotion that other sports organizations may seek to adapt.

Provide Guidance Related to Coach Training

Sport governing bodies can require or recommend that coaches complete specific trainings. Such directives could theoretically be extended to include completing evidence-based training related to how they can support athlete mental health. Nearly all NGBs in the United States require that national coaches complete the SafeSport training (https://safesport.org/), an online training from the US Center for SafeSport that is focused on ending abuse in sport (e.g., bullying, harassment, hazing, physical abuse, emotional abuse, and sexual misconduct and abuse). At present, we are not aware of policies requiring coach training explicitly focused on mental illness prevention, identification, and management at any level of sport. Critically, prior evidence suggests that even when coach education is required in sport settings, there will often be variable implementation [50]. Thus, any required training related to athlete welfare, whether SafeSport or otherwise, will be exceedingly difficult to mandate or enforce at the local, grassroots level because of the minimal requirements for coach certification in the United States. While not required of coaches, the NCAA does include annual coach education about mental health as part of its best practice guidance to member institutions. Groups involved in developing educational materials about mental health for coaches should attend to dissemination and implementation throughout the program development and evaluation process. This can include working with sport governing bodies to determine how to make materials fit the needs of member organizations and how they are most easily disseminated and implemented within existing communication channels. One key strategy to facilitate implementation may be making evidence-based programming easily available to organizations, rather than making broad mandates without specific actionable support. Requiring or suggesting education without providing guidance about what is appropriate is a strategy for variable choice to materials and lack of effectiveness [68].

Provide Guidance Related to Screening

Sport governing bodies can also play a role in secondary prevention through the requirements or guidance that they provide to member organizations related to screening. In their best practice guidance, the NCAA recommends that institutions screen athletes as part of the PPE. As new screening tools are developed and validated, such best practice guidance should evolve to communicate updated recommendations and actionable strategies to member organizations. Similar guidance about screening may be more challenging, or in some cases inappropriate, for other sport governing bodies with less direct coordination with healthcare providers for athletes. However, there may be opportunity for interdisciplinary collaboration, for example, sport governing bodies working with medical and mental health organizations to make recommendations about the inclusion of mental health screening as part of standardized PPEs.

Provide Guidance Related to Mental Health Protocols

Sport governing bodies can require or provide guidance to member organizations related to having and rehearsing mental health action plan. This is of critical importance for appropriate response to emergency mental health situations and can also help facilitate appropriate response to nonemergency mental health concerns. This is one element of the NCAA’s best practice guidance [1] but to our knowledge is not common practice among other sport governing bodies. Efforts to support implementation of such protocols may include providing concrete examples of policies that have been useful in different types of sports organizations.

Provide Guidance Related to Staffing

Finally, sport governing bodies can play an important role in tertiary prevention by providing guidance and resources related to staffing. One element of the NCAA’s best practice guidance is the recommendation that all mental health care be provided by a licensed mental health professional. Depending on the size and nature of the sports organizations under the governing body’s purview, recommendations could potentially also be made about the importance of adequate staffing to meet athlete referral needs and about the benefits of culturally competent mental health care providers.

Conclusion

While there are many factors that impact athlete mental health, most centrally their underlying biological propensity to mental illness and early life exposures, environmental factors, and learned behaviors in the sport environment has the potential to make a difference. Framed by a social ecological model, the present chapter focused on ways in which coaches, sports organizations, and sport governing bodies can positively impact athlete mental health. This includes working to help prevent, identify, and help facilitate care seeking for mental illness and by helping to promote positive psychological functioning. Although individual coaches, organizations, and sport governing bodies may be engaging in practices supportive of athlete mental health, there is a need for improvement to ensure the reach of evidence-based practices. There are several key areas of need for research and programming to support such efforts.

One key need is to evaluate educational programming related to mental health promotion in a diversity of sport settings, building on the important program development and evaluation work being conducted in Australia. Such programming may be effective in other cultural contexts, or it may require adaptation. Recommendations that coaches and other sport stakeholders complete education are limited in their scope for impact if effective programming is not available. There is also a critical need to validate existing screening tools for symptoms of mental illness to ensure appropriateness for athletes. Such work may point to the need to develop and validate athlete-appropriate measures, or it may provide confidence in the utility of existing measures.

Finally, where policy and sport governing body guidance for organizations related to mental health exist, there is a need for implementation studies to understand (1) reach and fidelity of implementation and (2) barriers and facilitators to successful implementation. Such efforts can be used to develop strategies for implementation of support for organizations and/or coaches. Given the prevalence of mental illness among athletes, the potential harms associated with untreated mental illness, and the potential benefits of positive psychological functioning, supporting athlete mental health should be a priority of sports organizations and sport governing bodies. As research, program development, and program evaluation work related to mental health continue to evolve, such efforts should be framed by a social ecological model. This means recognizing that a range of stakeholder individuals and organizations play a key role in supporting athlete well-being and that all need to be engaged in shaping sport cultures supportive of mental health.