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Managing Student-Athletes’ Mental Health Issues MENTAL HEALTH

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Managing Student-Athletes’ Mental HealthIssues

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ManagingStudent-Athletes’ Mental HealthIssues

Developed by:Ron A. Thompson, PhD, FAEDRoberta Trattner Sherman, PhD, FAEDBloomington Center for Counselingand Human DevelopmentBloomington, Indiana

NCAA Contact: Mary Wilfertwww.ncaa.org/health-safety

1

Introduction ............................................. 2

Chapter 1 — Mood Disorders ............... 5• Depression• Suicide Intervention

Chapter 2 — Anxiety Disorders ........... 13• Panic Attacks• Stress• General Anxiety• Obsessive Compulsive Disorder

Chapter 3 — Eating Disorders and Disordered Eating... 19

Chapter 4 — Substance-Related Disorders ........................ 25

Chapter 5 — Management and Treatment Issues............ 33

Resources ............................................ 43

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Managing Student-Athletes’ MentalHealth Issues

IntroductionWhen you think of a student-athlete’s

health, you probably are inclined to think pri-marily of the person’s physical/medical con-dition and what effect the injury will have onathletic performance. A student-athlete’s“mental health” might be viewed as second-ary to physical health; however, it is every bitas important. It makes little sense to try toseparate the “mind” and “body.” One affectsthe other. Medical problems often have psy-chological or emotional consequences.Psychological problems (e.g., eating disor-ders, substance-related problems, etc.) typi-cally have medical consequences. Student-athletes who suffer from depression after aninjury illustrate the relationship between“physical” and “mental” health. At the sametime, some depressed student-athletes areat increased risk of injury. Given the inter-relationship between the physical and men-tal, it might be helpful to think of student-athletes with mental health problems as“injured” — just as you would of a student-athlete who has a physical or medical prob-lem. As with physical injuries, mental healthproblems may, by their severity, affect athlet-ic performance and limit or even precludetraining and competition until successfullymanaged and treated.

This handbook’s primary purpose is toprovide information that you can use toeffectively and quickly identify student-ath-letes who are at risk or are experiencingemotional symptoms. Like most medicalproblems, early identification of mentalhealth problems usually means less disrup-tion to a student-athlete’s life, fewer severehealth complications and a less complicat-ed, quicker recovery.

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A student-athlete’s“mental health”might be viewedas secondary tophysical health;however, it is everybit as important for healthy performance.

3

Coaches should be involved in identifyingmental health problems because you:• Are in an ideal position to identify when

your student-athletes are having difficul-ty because you spend so much qualitytime with them;

• Have considerable power and influencewith your student-athletes that canincrease the likelihood your student-ath-letes will receive timely and effectivetreatment;

• Can minimize by early detection theeffects of the disorder on your student-athletes’ health and performance; and

• Can recommend prompt treatment todecrease your student-athletes’ timeaway from training and competition.

Student-athletes may be at risk for men-tal health problems because:• Their age increases the risk for certain

disorders, such as eating disorders orsubstance-related disorders;

• College is a time of transition (significantchanges), and psychological disordersoften develop or worsen during transitionperiods (i.e., leaving home for college,changing colleges, significant lossesthrough death or the ending of importantrelationships, etc.); and

• Some mental health problems can betriggered or exacerbated by pressure.These pressures are often unrelated tosport participation, but sport participa-tion may also increase pressure for cer-tain student-athletes.

General Signs and Symptoms that MayIndicate a Possible Mental HealthProblem

Some signs and symptoms of possiblemental health problems in your student-ath-letes might surprise you. You may notice prob-

A stronger case for a referral to a

mental health professional canbe made as thenumber of signsand symptoms

increases.

lems in your student-athletes’ behavior, cogni-tive/intellectual functioning, physical/medicalstatus, and/or psychological/emotional condi-tion. On this page, there is a list of generalsigns and symptoms that are present acrossmany, if not most, psychological disorders.

The following chapters contain informationrelated to specific mental health problems andtheir specific signs and symptoms. The cate-gories of “Behavioral,” “Cognitive,”“Emotional/Psychological,” and“Physical/Medical” are not intended to repre-sent separate and exclusive groups. Becausemany signs and symptoms are related, con-siderable overlap exists among the differentcategories. These signs and symptoms do notnecessarily confirm the presence of mentalhealth problems; however, a stronger case fora referral to a mental health professional canbe made as the number of such signs andsymptoms increases.

DisclaimersThis handbook does not cover all mental

health problems. Such an undertakingwould be well beyond the scope of thehandbook. The disorders included werechosen because of their prevalence in thegeneral population and because they areprevalent in the college-age population.

The purpose of this handbook is to assistcoaches in identifying student-athletes whomay be having difficulty and to help coacheslearn to respond appropriately and effective-ly with those student-athletes. It should beconsidered as a very important part of alarger cooperative effort involving other sportand healthcare professionals. The purpose isnot to train coaches to be therapists or treat-ment providers. This handbook is a guide. Itis not meant to be a substitute for psycho-logical evaluation and treatment by qualifiedmental health practitioners.

4

Cognitive SymptomsSuicidal thoughtsPoor concentrationConfusion/difficulty making decisionsObsessive thoughtsAll-or-nothing thinkingNegative self-talk

Emotional/PsychologicalSymptomsFeeling out of controlMood SwingsExcessive worry/fearAgitation/irritabilityLow self-esteemLack of motivation

Physical/Medical SymptomsSleep difficultyChange in appetite and/or weightShaking, tremblingFatigue, tiredness, weaknessGastrointestinal complaints, headachesOveruse injuries

This is not intended to be an exhaustive list of symptoms, but rather a list of more common symptoms.No one sign or symptom is indicative of a mental healthproblem, but the need for a referral for an evaluationincreases with the number of signs and symptomsreported or observed.

Behavioral SymptomsDisruption of daily activitiesSocial withdrawalIrresponsibility, lyingLegal issues, fighting, difficulty

with authority Decrement in sport or academic

performanceSubstance use

Mood disorders sometimes are calledAffective Disorders, but more frequently aresimply called “depression.” Approximately10 percent of the American population suf-fers from a mood disorder during any one-year period, which is the same percentageof depression in college students asreported by the National Mental HealthAssociation. Certainly, most people will feeldepressed for short periods from time totime for various reasons. However, whenthe depression becomes more severe, lastslonger and occurs more frequently, evalua-tion and treatment are warranted. Althoughmost mood disorders primarily involve lowmood or depression, bipolar disorder con-sists of episodes of abnormally elevated(high) moods, in addition to the character-istic low moods.

Signs and Symptoms/IdentificationTypically, mood disorders (or depression)

are characterized by: • Low or sad moods, often with crying

episodes. • Irritability or anger.• Feeling worthless, helpless and hope-

less. • Eating and sleeping disturbance (reflect-

ed in an increase or decrease).• A decrease in energy and activity levels

with feelings of fatigue or tiredness. • Decreases in concentration, interest and

motivation.• Social withdrawal or avoidance. • Negative thinking. • Thoughts of death or suicide.• In severe cases, intent to commit suicide

with a specific plan, followed by one ormore suicide attempts.

5

Chapter 1Mood Disorders

• Depression

Effects on Health and PerformanceYou can tell from these depressive

symptom descriptions that most aspects ofa person’s life are negatively affected bythe disorder. Athletic performance is noexception. In fact, poorer performancewould be expected. If a student-athlete isnot eating or sleeping well and feels tiredor fatigued, you would expect performanceto decrease from a physiological perspec-tive. Add in emotional and cognitive com-ponents of low mood, decreased motiva-tion, poor concentration, and negativethinking, and you could not expect a stu-dent-athlete to perform well. Poor sportperformance can increase a student-ath-lete’s depression and the pressure to per-form better. Depression may also increasea student-athlete’s risk of injury.

Causes of DepressionThere are many different types of

depression and a variety of causes. Athorough discussion of the causes ofdepression is beyond the scope of thishandbook. However, you should be awareof the three most common causes ofdepression in the general population andone type that is unique to student-athletes.• Depression can occur in response to a

specific event in a person’s life (i.e.,death of a family member, break-up of asignificant relationship). When these situ-ational factors become intense or anindividual feels out of control with his orher life, depression may follow.

• Depression also can occur without anyspecific precipitant (trigger). Somedepressions are believed to be more bio-logical or neurobiological in nature. Thatis, there appears to be a genetic vulnera-bility or predisposition to depression thatruns in some families. Also, depression

6

Case Illustration

Sam, a member of a collegeswim team, had been missing hismorning swim practices.Although his coaches were angryand made him make up the prac-tices and perform additional workas a punishment for missingpractices, he still had difficultygetting out of bed in the morning.He could not explain to them whyhe could not get up and get topractice, other than to say that hewas tired because he kept wak-ing up between 3 and 4 a.m. andcould not get back to sleep until itwas time for him to get up. Hisacademic and athletic perform-ance dropped off, and heappeared less motivated to per-form well. Teammates hadremarked that Sam was less talk-ative and was turning down offersto join them socially. One team-mate reported that Sam told himthat he felt so bad that he wouldrather be dead than feel the wayhe was feeling.

for some people appears to involve animbalance in brain chemicals called neu-rotransmitters. These individuals mayneed or benefit from antidepressantmedication. Antidepressant medicationscan have numerous side effects (i.e.,weight changes, sedation, etc.). As aconsequence, athletic performance maybe affected.

• Another cause of depression involvesnegative thought patterns that manydepressed individuals have. Individualswith this type of depression constantlymake negative self-statements thatmaintain their depressed mood.

• Although most depressions probablyoccur from the aforementioned causes,student-athletes may get depressedfrom their sport participation. Forexample, some student-athletes becomedepressed in response to an injury. Theirself-esteem and identity may be nega-tively affected by their inability to do thething that they do best and enjoy most-play their sport. Other student-athletesmay become depressed as a result of“overtraining syndrome” or “staleness.”This syndrome sometimes follows heavytraining and can include physical (i.e.,decreased performance, fatigue, musclesoreness, weight loss, sleep disturbance,etc.) and psychological (i.e., depression,anxiety, irritability, decreased concentra-tion, etc.) symptoms. The decrease inperformance as a result of this syndromecan further depress a student-athlete.

Depression and Risk of InjuryA student-athlete may become

depressed after an injury, but the relation-ship between depression and injury mayalso occur in reverse order. Depression canprecede an injury and may increase a stu-

7

Difficulty in Identificationof Depression

Although depressive symptomsappear to be fairly straightforwardand easy to recognize, identifyingdepression can be difficult forseveral reasons:

1. Depressed people often with-draw socially. Thus, you mayhave less opportunity to noticea problem.

2. Many depressed individualsdo not believe they “deserve”your time and attention. Infact, they often do not want to“bother” others with their diffi-culties.

3. Others may hide their symp-toms by smiling and acting asthough nothing is wrong.

4. Some depressed individualsmay engage in behaviors,such as alcohol or drug use oran eating disorder, that aredesigned to help manage theirdepression. These otherbehaviors may serve to dis-tract themselves, you and oth-ers from their underlyingdepression.

dent-athlete’s risk of injury. Depression inmany student-athletes occurs for non-sports related reasons. For such student-athletes, their depression — or more specif-ically their depressive symptoms — mayincrease the likelihood of injury primarilythrough distraction (decreased concentra-tion resulting in being less alert, respondingmore slowly, or making poor decisions orjudgments). A depressed batter might beless able to avoid being hit by a fastball. Adiver might more easily lose where she is inspace before impacting the water.Additional risk to the student-athlete mayincrease because the body has been med-ically compromised from the depressivesymptoms of eating and sleep disturbance.

Suicidal RisksResearch suggests that suicide is the

second leading cause of death among col-lege students. Approximately three suicidesoccur daily among college students, andseven to 10 percent of college studentseither attempt or contemplate suicide in agiven year. The increased possibility of sui-cide attempts and suicides makes depres-sion the most critical disorder discussed inthis handbook. Although early identificationand treatment are important for all mentaldisorders, they are more important formood disorders because of the potentialfor self-harm. Coaches sometime want toassume that student-athletes are healthysimply because they are athletes. Coachesmust remember that they are not just stu-dent-athletes. They are human beings withthe same potential frailties as non-athletes.They are young people attempting to dealwith all of the complexities of life, thedemands of college life and the pressuresthat sometimes accompany athletic performance.

8

Depression canhave many

causes, and mayhave little to do

with sport. Whendepression is

related to sport, itis often in

response to injuryand/or is a result of

“overtrainingsyndrome.”

ManagementAlthough general recommendations on

how to approach and respond to a dis-tressed student-athlete are specified inChapter 5, a depressed individual whoexhibits suicidal risks requires specific rec-ommendations about what to do and not do.

Recommendations RegardingIndividuals at Risk for Suicide:• When dealing with a student-athlete who

has expressed, indicated an intent orplan, or attempted suicide, do not try todetermine the “lethality” (seriousness) ofthe thought, gesture or attempt. Suchthoughts, behaviors or threats are seri-ous and potentially dangerous.

• Do not assume the person is engaging insuicidal thoughts or actions for “attention.”

• Make an immediate referral. It is evenbetter to call a mental health profession-al to treat the student-athlete. Most col-lege campuses have a counseling centerstaff that can offer guidance or referral.Many counseling centers will offer “walk-in” or “emergency” services. For emer-gency situations after normal officehours, counseling center staff can rec-ommend other options, such as going tothe nearest hospital emergency room.

Reasons for Responding Quickly andSeriously• Your quick response lets a student-ath-

lete know that you take his or her health,difficulties and life seriously.

• It’s better to err on the side of respond-ing too quickly rather than too late.

• Depressed individuals engage in negativethinking. They often feel unworthy, or worseyet, worthless. The lack of a response onyour part may be interpreted as confirma-tion for the student-athlete that he or she is

9

Suicide Intervention

If a Student-athlete:

• Expresses a suicidal thought

• Indicates an intent or plan

• Or makes a suicide attempt

MAKE AN IMMEDIATE REFERRAL

not worth the time or trouble, which couldworsen the student-athlete’s condition.

• As a coach, you have power and influ-ence with your student-athletes. Thatpower and influence can be positive ornegative. You need to be more respon-sive and careful with a depressed stu-dent-athlete, who might interpret yourresponse negatively.

Sport ParticipationAn important part of a mood disorder

assessment and management plan iswhether the student-athlete should continuesport participation. Depending on the cause,nature and severity of the mood disorder, itmay or may not be beneficial to the student-athlete to continue with training and compe-tition. Withholding a student-athlete with amood disorder from participation mayincrease depression because sports compe-tition can provide a sense of identity, asource of self-esteem or a sense of accom-plishment. For others, sport participation thatis apt to be negatively affected by depres-sion may increase the student-athlete’ssymptoms. A healthcare team must makethis treatment decision.

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• Do not assumethe person is

engaging in suicidal thoughts

or actions for“attention.”

• Student-athletesengaging in suicidal

thought needprompt attention

and referral.

SUMMARY1. Signs and symptoms of depression

often include low moods, feelings of hope-lessness, disturbance in sleeping and eat-ing, decreases in energy, activity, concen-tration and motivation, and suicidalthoughts.

2. There are several different types ofdepression, and the causes can vary.Depression can occur in response to anevent (outside of the individual) or becauseof a biological vulnerability to depression(inside the individual). Depression in stu-dent-athletes can be related to aspects ofsport participation (i.e., injury).

3. All thoughts, behaviors and threatsof suicide should be taken seriously.

4. Decisions regarding whether adepressed student-athlete should continuetraining and competing should be made bythe healthcare treatment team.

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SUICIDE PreventionBe Prepared: Make a Plan

A 2 a.m. telephone call about asuicidal student-athlete is not thebest time to generate a plan.Coaching and sports medicine staffsshould work together to have asuicide prevention plan in place. Thefollowing steps should be clearlydescribed and available to yourcoaching and sports medicine staffs.

• Have the names and phonenumbers of referral sourcesavailable. Include daytimesources such as the studenthealth center, campus counselingcenters and other local services.After-hours options also need tobe included. Universities in largercommunities may have severalpsychiatric emergency options.In smaller communities, the bestoption may be the nearesthospital emergency room.Determine your options nowbefore you need them.

• Make sure a suicidal student-athlete is not left alone. This isespecially true for a student-athlete who actually hasattempted suicide (i.e.,overdosing on pills, cutting wrists,etc.). The student-athlete shouldhave someone with him or heruntil a psychiatric evaluation iscompleted. In the meantime,follow the recommendationslisted above.

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An important partof a mood disorder

assessment andmanagement plan

is whether the student-athlete

should continuesport participation.

Everyone from time to time experiencessymptoms of anxiety. For individuals withan anxiety disorder, however, these symp-toms tend to be bothersome daily andworsen when pressure or stress occur.According to the National Institute ofMental Health, anxiety disorders are themost common type of mental illness in theU.S. Approximately 40 million people overthe age of 18 are affected each year. Thecause of anxiety can vary with the disorderand the individual. Most anxiety disordersare probably due to genetic factors, per-sonality factors or life experiences.

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Chapter 2Anxiety Disorders

Signs and Symptoms/IdentificationAnxiety symptoms can be general or

specific to a particular stressful situation orset of circumstances. They may or may nothave an apparent cause. Symptoms caninclude any of the following:• Excessive worry, fear or dread;• Sleep disturbances, especially difficulty

falling asleep;• Changes in appetite, including either an

increased need to eat when anxious ordifficulty eating due to anxiety;

• Feelings ranging from a general uneasi-ness to complete immobilization;

• Pounding heart, sweating, shaking ortrembling;

• Impaired concentration;• A feeling of being out of control;• Fear that one is dying or going crazy; or• A disruption of everyday life.

Types of Anxiety DisordersThere are several types of anxiety disor-

ders. The most common ones include:“Generalized” anxiety disorder. This

type of anxiety has sometimes been called“free-floating” anxiety because it seems tooccur without a particular precipitant.Individuals with a generalized anxiety dis-order often find it difficult to sit still, donothing or relax. They also may beplagued with constant worries that interferewith concentration or daily functioning.

Panic Attacks or Panic Disorder. Thistype of anxiety can occur without warning,often with a sense of impending doom.These feelings usually are accompanied byconsequent or complicating physicalsymptoms (i.e., racing/pounding heart,shortness of breath, etc.).

Obsessive Compulsive Disorders. Otheranxiety symptoms manifest themselves as“obsessions” (recurring, redundant, rumi-

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Case Illustration

Allison’s softball coach wasconcerned about her lack of con-centration. She had errors in theoutfield and was making mentalerrors. She seemed distracted. Inthe dugout, at team meetingsand traveling to away games, shehad difficulty sitting still and wasoften — as her parents called it— “fidgeting.” When her coachasked if she was worried aboutsomething, Allison said she hadalways been a “worrier” andsometimes had difficulty fallingasleep because her mind was“racing.” Allison also admittedthat she specifically worried thatshe sometimes felt as thoughsomething “awful” was going tohappen. When that feelingoccurred, she worried that shemight die from a heart attackbecause of her racing heart andshortness of breath. Allisonadmitted that she was worriedthat this “thing” would happenagain, and she felt powerless tostop it. She said that she hadmentioned it to her mother, whoadmitted that she had experi-enced the same problem.

native or irrational thoughts), while othersinvolve “compulsions” (behaviors an indi-vidual feels compelled to perform). If theaffected individual is unable to practiceobsessive thinking or perform compulsivebehaviors, anxiety can worsen. Obsessionsand compulsions are initially practiced inan effort to reduce anxiety. However, theycan take on a life of their own at somepoint and have to be practiced in order forthe individual to avoid the increase in anxi-ety that will occur if they are not practiced.

Phobias: A phobia involves an exagger-ated fear of a specific object or situation.One such phobia is a social phobia (some-times called social anxiety disorder). In thiscase, the individual has a significant fear ofbeing judged negatively by others in asocial or performance situation.

Although many of the fears or anxietiesassociated with anxiety disorders are “irra-tional” (not logical, reasonable, or based onexperience), others have developed as aresult of an actual experience or trauma(i.e., sexual assault) and are sometimescalled “post-traumatic stress disorders.”

Effects on PerformanceNot all anxiety is necessarily bad. In fact,

a little anxious excitement can facilitateperformance if managed properly. Somestudent-athletes without anxiety disordersmay experience anxiety or nervousnesswhen under pressure in an important com-petition. Often these student-athletes canovercome these problems with instructionin mental skills training that can help themfocus, concentrate and perform. However,student-athletes with an anxiety disorderare less apt to be able to manage theiranxiety properly and positively. Dependingon the nature of the anxiety disorder,effects can vary. An anxiety disorder can

15

Effects on Performance

• Student-athletes with an anxi-ety disorder are less able tomanage their anxiety in sportand non-sport activities prop-erly and positively.

• Anxiety disorders can nega-tively affect concentration, pri-marily through distraction byphysical and psychologicalsymptoms.

• These student-athletes willoften have difficulty focusing.In addition, they will attend tothe negative rather than thepositive.

• Negative emotion can occurbefore, during and after competitions.

negatively affect concentration, primarilythrough the student-athlete being distract-ed by his or her symptoms, which couldinclude physical and psychological symp-toms. These difficulties can affect the stu-dent-athlete before, during and after com-petition. During competition, many of thesestudent-athletes will have difficulty focus-ing; or they will focus on the negativerather than the positive. Before competi-tion, they are inclined to worry that theywill not perform well, perhaps setting uptheir worst fears. After a competition, espe-cially one in which they perceive that theirperformance was inadequate, they worrythat they are “not good enough” and thatsignificant others (i.e., coaches, team-mates, family, friends, etc.) will be disap-pointed in them.

StressSymptoms of stress are similar to anxi-

ety disorder characteristics. Symptoms ofanxiety disorders often worsen understress. Stress refers to the tension, pres-sure and anxiety that are common to oursociety. We all feel stress to some degree.Some feel it more than others and areaffected more. Its symptoms can be bothphysiological and psychological. Stresscan affect sleep, eating and relationships,and academic and athletic performance. Astudent-athlete may be experiencing stressbecause of the transition of being awayfrom home, living in a dorm, or from aca-demic performance in terms of “makinggrades” and becoming or staying “eligible.”They may feel stress related to their ownexpectations and from those of significantothers regarding their sport performance.Their stress also may be related to familyproblems or issues related to significantpeople in their lives, either at home or

16

A student-athletemay be

experiencingstress because of

the transition ofbeing away fromhome, living in a

dorm, or from academic

performance interms of “making

grades” andbecoming or

staying “eligible.”

school or both. Many college campuscounseling centers offer “stress manage-ment” assistance. Your student-athletesmay benefit from such programs.

Sport ParticipationShould a student-athlete with an anxiety

disorder train and compete? From a physi-cal/medical health standpoint, there is noobvious reason why a student-athleteshould not continue sport competition,unless it in some way renders the student-athlete more at risk for injury. From a psy-chological/emotional health standpoint, proand con arguments could be made to per-mit the student-athlete to train and com-pete. It might be helpful for a student-ath-lete to have sport as a healthy distractionfrom his or her symptoms. Not havingsport participation might create more“spare” time in which to worry and obsess.Additionally, the physical nature of sportmight provide the student-athlete with aphysical means to release some of thetroublesome anxiety. Less anxiety in turnmight create less of a need for sympto-matic behavior used to manage the anxi-ety. On the other hand, sport participationmight be perceived as another stressor orworry and increase the need for symptoms.The decisions regarding training and com-petition should be made by the healthcareprofessional(s) treating the student-athlete,in consultation with sport personnel andthe student-athlete. The decision should besolely based on what is in the student-ath-lete’s best interest.

Special Management IssuesStudent-athletes with an anxiety disorder

are likely to welcome an offer of assis-tance. Individuals with such disorders areoften tired or even exhausted by their

17

The decisionsregarding trainingand competitionshould be madeby the healthcareprofessional(s)treating the student-athlete, inconsultation withsport personneland the student-athlete. The decision should besolely based onwhat is in the student-athlete’sbest interest.

symptoms and are looking for some relief.The discomfort of an anxiety disorder canbe quite motivating in this regard. Althoughthey may respond positively to yourattempts to help, they might worry aboutwhat you might think of them. Such is thenature of these disorders. Given theirdoubts, worry and obsessiveness (repeti-tive thinking that is usually unwelcome),they will probably need considerable sup-port and reassurance.

SUMMARY1. Signs and symptoms of anxiety disor-

ders often include fear, worry, changes insleep and eating, shaking/trembling, and afeeling of being out of control.

2. Causes of anxiety disorders caninclude genetic and personality factors,and life experiences.

3. An individual may have more thanone anxiety disorder and other disorderssuch as depression.

4. Anxiety disorders can decrease sportperformance because they negativelyaffect concentration and focus.

18

An individual mayhave more than

one anxiety disorder as well as

other disorderssuch as

depression.

Eating disorders are somewhat of a mis-nomer. They are not only disorders of eat-ing. They are mental disorders that mani-fest themselves in a variety of eating andweight-related symptoms. Focus shouldnot only be on eating disorders such asanorexia nervosa, bulimia nervosa or aneating disorder not otherwise specified; italso should include “disordered eating.”

Prevalence, Risk Factors and CausesEating disorders are common among col-

lege-age females. They are much less com-mon among males, but it should be remem-bered that 10 to 25 percent of individuals witheating disorders are male. Eating disordersresult from a combination of factors thatinclude genetics, personality, socio-culturalpressures regarding thinness, social learningand family issues. Although sport participationfor most individuals is a healthy experience,aspects of the sport environment can increasethe individual’s risk for an eating disorder.

Eating disorders often begin or worsenduring transition periods, such as when anindividual leaves home to attend college.Because eating disorders usually are trig-gered by dietary restraint (dieting) forweight loss, they tend to be more prevalentin sports that emphasize a thin body sizeor a low weight, such as cross country,diving, gymnastics, lightweight rowing andwrestling. However, eating disorders formany student-athletes are not directlyrelated to their sport. They likely wouldhave the disorder even if they were not stu-dent-athletes. For these student-athletes,athletics may simply be another stressorthat increases the need for the disorder.

Purposes and FunctionsEating disorders can serve a variety of pur-

poses or functions for the individual. Most eat-

19

Chapter 3Eating Disordersand Disordered Eating

Good Nutrition Promotes Health,Enhances Performance

ing disorders begin as an attempt to loseweight. The disorder can generalize to manyother aspects of a person’s life and maybecome the primary means of coping with life.Usually the longer a person has the disorder,the more purposes and functions it serves.

Disordered EatingAll eating disorders are included in disor-

dered eating, but not all disordered eatingmeets diagnostic criteria for an eating disor-der. Disordered eating consists of the spec-trum of unhealthy eating from dietaryrestraint to clinical eating disorders. Dietaryrestraint or “dieting” is included as disor-dered eating because dieting is the primaryprecursor or trigger for the development ofan eating disorder. Although some disor-dered eating does not meet the criteria foran eating disorder, it can create significantproblems for a student-athlete, most notablycomplications related to what has beentermed the Female Athlete Triad — disor-dered eating, amenorrhea (loss of menstrua-tion) and loss of bone mass(osteopenia/osteoporosis). In this case, dis-ordered eating usually begins the triad bycausing insufficient energy to fuel the stu-dent-athlete’s exercise and training and tomaintain normal bodily processes related tohealth, growth and development. When thisoccurs, the reproductive system is shutdown to conserve energy. As a conse-quence, the body stops producing estrogen.Without estrogen, the body cannot buildbone mass, resulting in a loss of bone miner-al density. Extensive information about theseproblems is contained in the “NCAACoaches Handbook: Managing theFemale Athlete Triad.”

Types of Eating Disorders/Identification• Anorexia nervosa, often referred to as

20

Although sportparticipation for

most individuals isa healthy

experience,aspects of the

sport environmentcan increase the

individual’s risk foran eating disorder.

Female Athlete Triad

Disordered Eating

Amenorrhea Osteoporosis

simply “anorexia,” can be described as aself-starvation syndrome. Most anorexicindividuals also engage in excessiveexercise, which increases their risk andcan be difficult to determine or identify instudent-athletes.

• Bulimia nervosa, usually referred to as“bulimia,” can be described as abinge/purge syndrome in which individu-als ingest food and then “purge” it, usu-ally through self-induced vomiting, laxa-tive/diuretic abuse or excessive exercise.

• Eating disorder not otherwise specified(EDNOS) includes eating problems withsome of the diagnostic criteria of anorexiaor bulimia but not all.

• Binge eating disorder (eating large quanti-ties of food without purging) is included inEDNOS.

• Disordered eating includes the full spec-trum of unhealthy eating from simpledieting to clinical eating disorders.

Effects on PerformanceOf all the disorders discussed in this

handbook, performance is probably mostaffected by eating disorders and disorderedeating. In general, healthier student-athletesperform better, and health is greatly affectedby nutrition. Because of inadequate nutrition,student-athletes with eating difficulties tendto be malnourished, dehydrated, depressed,anxious and obsessed (with eating, food andweight). In addition to their negative effectson a student-athlete’s physiology, theseproblems decrease concentration and thecapacity to play with emotion.

Regarding the physical effects of disor-dered eating, research suggests that intensedieting can negatively affect VO2max andrunning speed for some student-athletes.Because most individuals with eating prob-lems are restricting their caloric intake, they

21

Case Illustration

Mary's athletic trainer mentionedto her coach that she often gaveexcuses about why she could noteat while on road trips. She wouldsay that she could not eat before acompetition because she wouldfeel ill or too heavy to run well.Mary's teammates noticed thatwhen she did eat, she often wentto the restroom shortly afterward.Mary was not overweight, but sheoften referred to herself as being“fat.” Her performance haddecreased during the past year.She maintained that in order toperform well, she needed to be“leaner.” Mary's last medical evalu-ation indicated that her menstrualcycle was irregular and that shehad lost eight pounds in the pastyear. Her medical history includedtwo stress fractures.

are likely to ingest inadequate amounts ofcarbohydrate in part because they oftenview carbohydrates as being “fattening.”Restricting carbohydrates — the best energysource — leads to glycogen depletion soon-er. Without adequate carbohydrate ingestion,the body tends to convert protein into a lessefficient form of energy. The risk of muscle-related injury and weakness increases withinadequate protein. For a variety of reasons(i.e., restriction of carbohydrates, inducedvomiting, excessive exercise, etc.), student-athletes with disordered eating are apt to bedehydrated, which negatively affects athleticperformance.

Sport ParticipationOne of the most difficult decisions that

arises with a student-athlete with a mentalhealth problem is whether he or she shouldbe training and competing while sympto-matic. This decision may be most difficultwith a student-athlete with an eating disorderbecause the disorder affects the student-ath-lete emotionally and also can significantlycompromise the student-athlete’s physicalhealth. On the surface, the simple solutionwould appear to be to prohibit sport partici-pation until recovery from the disorder. Whyeven consider allowing a student-athlete withan eating disorder to train and compete?

There are actually several rationales forallowing a student-athlete with an eatingdisorder to train and compete. Reasons forallowing student-athletes to train and com-pete include:• It allows the student-athlete to remain

part of a team and maintain a sense ofattachment.

• It can make it easier to monitor the stu-dent-athlete’s eating and condition.

• It allows the student-athlete to participate inthe primary or only activity through which

22

Effects on Performance

• Generally, healthier student-athletes perform better longer, inlarge part due to good nutrition.

• Eating disorders affect the student-athlete both physically and psychologically.

• Physical effects can includedecreased VO2max and runningspeed, low energy, weakness,dehydration, and increased risk ofenergy.

• Psychological effects caninclude decreased concentrationdue to malnutrition, anxiety,depression and obsessive thinking.

he or she receives self-esteem. • It allows the student-athlete to maintain

the important identity of “student-athlete.” • It may facilitate the eating changes that

will be necessary. • Sport participation can be used to moti-

vate the student-athlete in treatment bywithdrawing or reinstating participationbased on the student-athlete’s treatmentcompliance and progress.

• It is a way to determine if the student-ath-lete really “wants” to participate in sport.

Despite these rationales for training andcompetition, there are conditions underwhich the student-athlete should not beallowed to train and compete. These con-ditions and others under which training andcompeting might be permitted are identi-fied in the “NCAA Coaches Handbook:Managing the Female Athlete Triad.” Thehealth and safety of the student-athlete arealways the primary consideration, and therecommendations listed in the female triadhandbook are proposed on that basis.

Management of Eating Disorders andDisordered Eating

Because this topic is covered in consid-erable detail in the “NCAA CoachesHandbook: Managing the Female AthleteTriad,” refer to the handbook for specificrecommendations on how best to managethese student-athletes (seewww.ncaa.org/health-safety). Rememberthat individuals with eating disorders areinclined to deny having a problem.Typically, they are concerned that their dis-order will displease significant others (i.e.,coaches). For this reason, they may resistyour advice and assistance. Being student-athletes, they have another reason to resist— they fear admitting the problem may

23

The health andsafety of the student-athlete arealways the primaryconsideration.

result in being withdrawn from their sport.Usually it is better to approach them withgeneral concerns for their health ratherthan directly confronting them with evi-dence of eating symptoms. For more infor-mation about this special issue and moregeneral management concerns and ques-tions, refer to the coaches handbook.

SUMMARY1. Eating disorders usually are triggered

by dietary restraint.2. Eating disorders can serve several

purposes and functions for the individual,and they usually increase with the durationof the disorder.

3. Eating disorders can negatively affecthealth and sport performance from a phys-ical and psychological standpoint.

4. Decisions regarding sport participa-tion of the student-athlete with an eatingdisorder should be made by the healthcaretreatment team and can be a way tomotivate the student-athlete in treatment.

24

Usually it is betterto approach them

with general concerns for theirhealth rather than

directly confrontingthem with

evidence of eatingsymptoms.

In this handbook, the term “substance”refers to a variety of drugs or chemicals,including those that are legal, illegal, pre-scribed, over-the-counter (OTC) and per-formance-enhancing. Primary focus is onsubstances that appear to be used fre-quently by college-age individuals, andthose that for various reasons may be stu-dent-athletes’ substance of choice.Although substance use often is associat-ed with terms like “abuse,” “dependence”or “addiction” to indicate the severity ofuse, that part of the identification processis well beyond the scope of this handbook.The focus of this handbook is to helpcoaches identify a student-athlete with apossible problem, refer the student-athleteto the appropriate professional who canassess the extent of the problem andarrange necessary treatment. Much of theinformation in this chapter was drawn fromthe six NCAA studies investigating sub-stance use by student-athletes. Based onthe self-reporting of drug use, these dataare probably conservative. Actual use isapt to be higher than reported use.

SubstancesAlcohol

Current Usage. Although alcohol con-sumption decreased among student-ath-letes from 1989 to 2005, more than three-fourths of the student-athletes surveyed ina 2005 NCAA study reported using alcoholduring the previous 12 months. More dis-turbing was the increase in the number ofstudent-athletes who reported drinking 6 ormore or 10 or more drinks in a sitting.

Effects on Performance. Alcohol is acentral nervous system (CNS) depressant. Itcan decrease concentration, coordination,reaction time, strength, power andendurance. Alcohol also can inhibit the

25

Chapter 4Substance-Related Disorders

body’s absorption of nutrients. For thesereasons, alcohol will negatively affect per-formance. The extent of the effect dependson the amount and type of alcohol ingested,the weight and health of the individual, andthe timing of the alcohol consumption. For“heavy drinkers,” the effect can last for days.See “For the Athlete: Alcohol and AthleticPerformance” for additional effects on per-formance (www.ncaa.org/health-safety).Findings in a recent NCAA survey suggestedthat many student-athletes do not see alco-hol consumption as a problem. Almost 60percent of student-athletes reported thatthey did not believe that alcohol affectedtheir athletic performance. However, almost30 percent admitted that they had performedpoorly in practice or a competition becauseof drinking or drug use.

Reasons for Use. Most individuals con-sume alcohol recreationally to “feel good”or “have a good time.” Some, however, useit as a means to calm themselves to avoidor manage anxiety. Some will even suggestthat alcohol acts as an “ergogenic” thatallows them to perform better by helpingthem to “relax.” Some may use alcohol tohelp them sleep. Others will use alcohol inresponse to being depressed; however,because it is a CNS depressant, alcoholonly serves to further (biochemically)depress them.

Signs and Symptoms. The signs andsymptoms of alcohol (ab)use can vary withthe type and amount of alcohol consumedand the individual’s personality. In general,student-athletes with this problem mightbe expected to be more irresponsibleregarding commitments or responsibilitiesto school, sport, and relationships. Theymight be more likely to drink in situationsthat could be dangerous to themselves orothers. They might show a propensity for

26

2005 NCAA StudySocial Drug Use — Historic Trends

90

80

70

60

50

40

30

20

10

01989 1993 1997 2001 2005

alcohol marijuana spit tobaco cigarettes

Perc

ent

2005 NCAA StudyAmong Drinkers, Those Having 6 or More Drinks per Sitting

70

60

50

40

30

20

10

01997 2001 2005

Male Female

Perc

ent

2005 NCAA StudyAmong Drinkers, Those Having 10 or More Drinks per Sitting

30

25

20

15

10

5

01997 2001 2005

55.5

20.7

56.5

22.6

61.9

26.9

Male Female

Perc

ent

20.5

2.3

20.7

2.4

27.8

3.4

getting into trouble when drinking (i.e.,fighting, legal problems, etc.). These exam-ples are observable signs, but it should beremembered that drinking alone often is asign of an alcohol problem. Thus, a stu-dent-athlete who abuses alcohol may dohis or her drinking alone and avoid drawingattention to observable signs.

Stimulant-Type Substances-Amphetamines, Cocaine, Ephedrine, andMedications for Attention Deficit andHyperactivity Disorder (ADHD).

In contrast to a CNS depressant likealcohol, substances in this class are CNSstimulants. Whereas CNS depressantsslow the nervous system, CNS stimulantsspeed up the nervous system. Userssometime refer to these drugs as “speed.”

Current Usage. The percentage of stu-dent-athletes reporting using ampheta-mines, cocaine and ephedrine is small(four percent or less). However, ampheta-mine and cocaine use by student-athleteshas been increasing in recent years.Ephedrine use has not increased. Thistype of drug use often begins before col-lege.

The abuse of medications for ADHD is arelatively new phenomenon, but one that isincreasing in prevalence — especially inthe college population. These medications,when used by individuals who need themfor treatment of their hyperactivity symp-toms (i.e., distractibility) have a paradoxicaleffect. Although ADHD medications arestimulants, they decrease the individual’sdistractibility and facilitate concentrationand focus. Some individuals are illegally orillicitly obtaining the medications for theirown use or for sale. These medicationsusually are amphetamines such as Adderalland Dexedrine.

27

Case Illustration

Jim was told by his coach to seehis academic counselor when hehad been placed on academic pro-bation. He explained to the coun-selor that he had been missingclasses, especially morning classes,because he often didn't feel well inthe morning. Jim reported that heseldom felt like getting up to go toclass because he often woke upwith physical symptoms that includ-ed nausea and headaches. Hiscounselor asked if he had beenexamined medically regarding thesesymptoms. Jim indicated that hehad, but that the doctors could notfind anything wrong with him. Whenhis counselor asked about his drink-ing, Jim angrily said that he was notan “alcoholic” and that he knew analcoholic when he saw onebecause his father was an alcoholic.The counselor asked about an inci-dent that had occurred the previousyear when he had been arrested forfighting outside of a bar. Jim deniedthat he had had too much to drinkat that time and said that the otherguy started the fight. When askedby his counselor if he had had anyother arrests, Jim reported that hehad been arrested as a high schooljunior for underage drinking, but hedismissed the incident by sayingthat he wasn’t drunk and was just inthe wrong place at the wrong time.

Effects on Performance. Because thedrug makes a student-athlete feel more ener-getic and alert, it is assumed that it will posi-tively affect performance. The drug can makemany individuals nervous or jittery, whichwould negatively affect any skill requiring finemotor coordination and concentration.Performance also can be negatively affectedbecause this type of drug increases heartrate and blood pressure. In addition to thesepotential problems, drugs like ephedrine canincrease body heat production and bodytemperature. Because these drugs can leadthe student-athlete to feel overly energetic,they may lead to overexertion, which couldresult in injury or even death in extremecases. It is ironic that many student-athletesmay be taking these drugs as an “ergogenic”aid to help them perform better, when in factthese drugs may have more of an “ergolytic”(negative performance) effect.

Reasons for Use. This type of drug usu-ally is used for “energy” or to raise mood.It also may be used for weight control/loss.Amphetamines also may be used toimprove performance.

Signs and Symptoms. Common signsand symptoms include shakiness, rapidspeech or movements, difficulty sitting still,difficulty concentrating, lack of appetite,sleep disturbance, and irritability.

Marijuana: Current Use. Marijuana is the most

widely used illegal drug by the generalpopulation. Marijuana appears to be adrug of choice for college students, and itappears to be a popular drug used by stu-dent-athletes. Although marijuana use bystudent-athletes has declined in recentyears, a 2005 NCAA study found almost 20percent of student-athletes reported havingused the drug in the past year.

28

The abuse of medications for

ADHD is a relativelynew phenomenon,

but one that is increasing in

prevalence — especially in the

college population.

Effects on Performance. The effects ofmarijuana on sport performance are muchlike those of alcohol. It can slow reactiontime, impair both motor and eye-handcoordination, and affect time perception.Research related to the duration of theeffect of this drug is inconclusive, butsome researchers believe it can last anentire day or longer.

Reasons for Use. Student-athletesreported that they used marijuana forrecreational and social purposes in order to“feel good.”

Signs and Symptoms. Signs and symp-toms vary depending on the frequency ofuse. There may be no signs associatedwith infrequent use. Possible signs couldinclude red eyes, paraphernalia related tomarijuana use (i.e., papers, pipes, etc.),and scales for weighing the drug. Physicalsymptoms could include lethargy andincreased appetite, especially immediatelyafter smoking the drug.

Anabolic Steroids: Current Usage. Steroid use by student-

athletes has been decreasing. Now, lessthan two percent report using steroids. Themajority of users are male. Of those whouse steroids, more than half say they usethem to enhance performance and thattheir use began before college.

Effects on Performance. Steroid usetypically is associated with an increase inathletic performance. Steroids canincrease muscle mass, and as a result mayincrease strength, power, speed andendurance.

Reasons for Use. The primary reasonreported for steroid use is performanceenhancement from an increase in size andstrength, and to recover more quickly froman injury.

29

Marijuana is themost widely usedillegal drug by thegeneral population.

Signs and Symptoms. Signs and symp-toms can include a variety of changes inthe student-athlete. Some changes mayoccur in the size and musculature of thebody. There may be personality changes,often with a variety of psychiatric symp-toms, including increased anger andaggression, or what has sometimes beenreferred to as “roid rage.” Physical/medicalsigns can range from acne to reproductivesystem dysfunction to liver and cardiovas-cular system problems.

Sport ParticipationUsually, the primary issue regarding

whether a student-athlete with a mentalhealth problem should be training or com-peting concerns the physical and psycho-logical risk to the student-athlete. A deci-sion to allow the student-athlete to contin-ue with sport participation is usually madeif the healthcare team agrees that trainingand competition do not increase the risk tothe student-athlete. However, the issues fora student-athlete with a substance-relateddisorder will likely be different. Due to theuse of substances that are illegal, sub-stances on the NCAA banned substancelist or substances that are prohibited bythe coach or athletics department’s sub-stance abuse policy, the question ofwhether the student-athlete should partici-pate in his or her sport may be a mootpoint because of legal issues or animposed suspension related to the sub-stance abuse. Most athletics departmentswill have substance-abuse policies that willprovide guidance regarding recommendedprocedures. Even if the NCAA or the insti-tution’s policy does not prohibit the stu-dent-athlete from practice and competition,it may be in the best interest of the stu-dent-athlete for you to require substance-

30

Of those who usesteroids, more

than half say theyuse them to

enhance performance and

that their usebegan before

college.

abuse treatment as a condition of partici-pation. That is, sport participation can beused as a way to motivate the student-ath-lete in treatment.

Approaching a Student-AthleteApproaching a student-athlete with a

suspected substance-abuse problem issomewhat different from approaching astudent-athlete regarding symptoms ofdepression or anxiety. Student-athleteswith depression and/or anxiety may bemore receptive because they feel bad andmay be motivated for assistance, hoping tofeel better. Student-athletes with sub-stance-related difficulties may be lessreceptive to assistance for the followingreasons. • They may not actually feel bad because

they may be using the substance inorder not to feel bad or at least not beaware of feeling bad.

• They may be “dependent” on their sub-stance, whereas the depressed or anx-ious student-athlete is not apt to bedependent on their symptoms.

• Denial of the problem is common withsubstance abuse.

• The substance abuser may fear punish-ment (i.e., suspension) for his of her usebecause the substance being used maybe illegal, on the NCAA banned sub-stance list, or prohibited by the coach orathletics department.

• Although there may still be a stigmaattached to problems like depression oranxiety, there is apt to be a more nega-tive attitude associated with substanceabuse. As a result, a student-athlete withsubstance use may more actively resistadmitting to the problem.

31

Sport participationcan be used as away to motivatethe student-athletein treatment.

Given these issues, approaching student-athletes with a substance-use problemcould prove to be difficult. They will likelydeny the problem and resist your efforts toassist them. It is probably best not to arguewith them or try to convince them. Simplytell them that you are concerned and thatthe only way to know for sure if there is aproblem is for them to be evaluated by aprofessional with experience and expertisein this area. Make the referral and follow-up to make sure the referral was acceptedand completed.

SUMMARY1. Substance abuse by student-athletes

includes drugs that can be classified aslegal, illegal, prescription, over-the-counterand performance-enhancing.

2. Substance abuse by student-athletesusually begins before coming to college.

3. Many of the drugs classified as CNSstimulants may be viewed by student-ath-letes as performance-enhancing.

4. Student-athletes who have sub-stance-related disorders may be more diffi-cult to assist because of the denial that isoften characteristic of such disorders andbecause the drug use often carries sanc-tions or punishments that may have legalor eligibility consequences.

32

Denial of the problem is

common with substance abuse.

This chapter will primarily focus onresponding to the student-athlete with asuspected mental health problem. Becauseapproaching the individual is necessary foreffective management and is critical inobtaining the student-athlete’s compliance,this first step is perhaps the most impor-tant part of the process.

An important disclaimer in this chapterinvolves the limits of responsibilities of theperson responding to the student-athlete.Your job is not to evaluate, counsel ortreat. Rather, it is to assist the individual ingetting to the right treatment professional.

Talking with the Student-AthleteWho should talk with the student-ath-

lete? The person approaching the student-athlete should be a person of some author-ity. More important, however, is that thisinitial step should be taken by someonewho has a good relationship with the stu-dent-athlete or who is comfortable in dis-cussing important and sensitive issues.This might be a coach, an athletic trainer, ateam physician or some other individualinvolved in the student-athlete’s life.

How should the student-athlete beapproached? The layperson’s biggest fearin responding to an individual with an emo-tional problem is often the fear of sayingthe wrong thing and worsening the situa-tion. Probably the most serious mistakethat anyone can make in (mis)managinga student-athlete with a mental healthproblem is to respond as if the problemis trivial or is a sign of weakness. Forsomeone who has never been clinicallydepressed, it may be difficult to imaginethat people could be so depressed thatthey literally cannot get out of bed. In sucha case, you might be tempted to accuse astudent-athlete of simply being “lazy” or

33

Chapter 5Management andTreatment Issues

What to Do

“irresponsible” and recommend that he orshe “get the lead out of your butt.”Similarly, for someone who has neverexperienced a panic attack, it may be hardto believe that people could be so anxiousthat they become immobilized or fear thatthey are going to die. You might be inclinedto see them as being “weak” and recom-mend that they just “toughen up.” A “nor-mal” eater, who eats whatever he or shewants, may think it is silly that a student-athlete is “afraid” to eat and might demandthat she “stop being ridiculous” and “justeat.” Someone who views substanceabuse simply as a “choice” by a student-athlete who is being “stupid” may thinkthat treatment rather than punishment isonly “coddling” the student-athlete.

Even if you cannot understand the seri-ousness or difficulty of the student-ath-lete’s problem, you must accept that it is aserious problem for that individual.Depressive disorders, anxiety disorders,eating disorders and substance-relateddisorders are mental health problems inneed of treatment. They are illnesses —not choices; that is why they are calleddisorders. Individuals with mental healthproblems are not weak. Their difficultiesare not insignificant, and their recovery isnot simple or easy. If their problems weresimple or insignificant, and getting overthem were easy, they would have alreadyfound a solution and implemented it. Theyneed assistance. As their coach, you maybe the first step in the process. Admittingtheir difficulties will not be easy for them.

With the disorders we discuss in thishandbook, the student-athlete is likely toalready feel bad about his or her circum-stances. A critical, judgmental or detachedresponse on your part will likely serve toworsen those feelings. A positive, con-

34

Your job is to assistthe individual in

getting to the right treatment

professional.

cerned and involved response on your partis a good first step.

How to respond when the student-ath-lete approaches you. When an individualapproaches you, he or she is indicating aneed to talk with you. The best way torespond is to listen. Stop what you aredoing, look at the student-athlete and lis-ten. This posture communicates that youare ready and willing to listen. Listening isthe most important part of communicating.It is hard to listen when you are talking. Ifyou are listening, you will likely know whento talk and what to say. Generally, wait tospeak until the student-athlete stops talk-ing or appears to be waiting for you torespond. It is all right to ask questions forclarification, but be careful not to judge orbe critical. Accept what you are given. It isokay to repeat back what you have heardto be sure you heard it correctly. Indicatethat you are glad the person has chosen tospeak with you. Ask if there is anythingelse that needs to be said. If not, or afterhe or she finishes what needs to be said,respond by saying that you want to helpget the necessary assistance. You thenmake the referral.

Making a referral. Unfortunately, manyreferrals are not accepted or used by thestudent-athlete. There are aspects of mak-ing a referral that increase the likelihood ofit being successful. Know or at least havesome knowledge regarding the referral per-son or agency. Share that knowledge withthe student-athlete. Also, referrals are moreoften accepted when the referral is madeto a specific person. Either you make thecall or have the student-athlete make thecall at the time to make the necessaryarrangements. If you feel the individualneeds assistance at the time, take him orher to the referral person or facility.

35

How to respond when thestudent-athlete approaches you.

• The student-athlete’sapproach indicates a need totalk with you.

• Stop what you are doing,look at the person, and listen.

• Listening is the mostimportant part of communica-tion.

• It is hard to talk and listenat the same time.

• If you listen well, you willknow when to speak and whatto say.

• Accept what you are given.Ask questions for clarificationwithout judging.

• When it appears the personhas finished talking, ask if thereis anything else he/she needs tosay.

• Indicate that you are gladhe/she came to you and thatyou want to help.

• Make the necessary referraland encourage/support itsacceptance.

How to respond when the student-ath-lete is in need and has not approachedyou. Obviously, it is easier and better if thestudent-athlete with a mental health prob-lem comes to you. However, it is probablymore likely that you will need to initiate thecontact, in part because the individual maynot feel there is a problem, or because ofbeing embarrassed or uneasy aboutapproaching someone in authority regard-ing his or her difficulties. It is best toapproach the individual privately todecrease the likelihood of embarrassmentand to avoid any other activity that mightdistract you or the student-athlete.Sensitivity is a key in facilitating the discus-sion. Begin by saying that you are con-cerned about the individual’s welfare andwould like to help. Ask how he or she isfeeling, and how school, practice andgames are going. Hopefully, this approachwill allow the student-athlete the opening totalk with you about his or her difficulties. Ifso, follow the same recommendations dis-cussed above regarding when the individualcomes to you. If not, then you should tellthe student-athlete that you need to makesure he or she is okay. Relate to the personthat in order to determine this, you need tohave him or her talk with a healthcare pro-fessional and that you would like to helparrange the appointment. If the student-ath-lete resists, you should say that you simplywant to arrange an evaluation to determineif there is a problem. Tell the student-athletethat you hope that the evaluation deter-mines that he or she does not have a prob-lem, and if that is the case, then we can allbreathe a sigh of relief and go on with ourlives. The student-athlete should be toldthat if the professional’s evaluation indi-cates that a problem exists, then the pro-fessional will discuss treatment options.

36

It is best toapproach the

individual privatelyto decrease the

likelihood ofembarrassment

and to avoid anyother activity that

might distract youor the student-

athlete.

Helping the student-athlete who resiststreatment. The student-athlete may resistevaluation and treatment. In such a case,the student-athlete should be told that heor she is considered to be “injured,” andthat it’s your responsibility to take care ofyour injured student-athletes. If the stu-dent-athlete asks about being able to trainand compete as a result of the difficultyand treatment, reply that the decision willhave to be made by the healthcare profes-sionals who manage the treatment.

Knowing Your LimitsSometimes attempting to assist an indi-

vidual with an emotional problem canweigh heavily on the person trying to help.To avoid this, you need to know your lim-its. You need to be aware of what is rea-sonable to expect from yourself. It isimportant to remember that you cannotchange the person, and that you have lim-ited control with the person. Your respon-sibility is to recognize and refer. Thesemay not seem like important steps in theindividual receiving the necessary assis-tance; however, these are perhaps themost important steps in the process. If theindividual resists your attempts to be help-ful, it does not necessarily mean that youhave done anything wrong or that youneed to do more. An individual oftenresists because of the fear associated withchange or treatment, and usually greaterresistance is associated with a more sig-nificant problem. Remember that the per-son has an emotional problem. You shouldnot necessarily expect a reasonable,rational or logical response. When youbegin to feel undue stress or worry regard-ing the situation, it is time to take care ofyourself and turn the problem over tosomeone else.

37

Knowing Your Limits

• To avoid the student-athlete’sdifficulties weighing too heavily onyou, you need to know your limits.

• Be aware of what is reason-able to expect from yourself.

• You cannot change the per-son because you have limitedcontrol.

• Your responsibility is to recog-nize and refer.

• When you begin to feel unduestress or worry, it is time to takecare of yourself and turn the prob-lem over to someone else.

Understanding the Relationship Amongand Between Disorders

It is not uncommon for an individual tohave more than one mental disorder, and insome cases the disorders may be relatedto each other. These relationships can takeseveral forms. Some disorders may begenetically linked. One may be an effect orconsequence of another. One may worsenthe other. One may develop as a means tocope with another. As was mentioned inChapter 2, depressed people also oftenhave an anxiety disorder as well. Manyindividuals with an eating disorder are alsoapt to have a mood disorder (depression)and one or more anxiety disorders andabuse stimulant drugs for the purpose ofappetite suppression and weight loss.Anxious and depressed people may usesubstances to try to feel better. Many indi-viduals with alcohol problems drink in partbecause they are depressed but willbecome more depressed by consumingalcohol. The occurrence of more than onedisorder in a single individual is oftenreferred to as “comorbidity.”

Why is it important to know if an individ-ual has comorbid disorders? Sometimesone disorder is so prominent or obviousthat it can mask the existence of another.An illustrative example might be the stu-dent-athlete who is frequently “hung over.”The consequences of drinking may be soprevalent and obvious that an underlyingdepression might be overlooked.Sometimes one disorder can complicate ornegatively affect the treatment of another.For example, a significant depression couldmake the treatment of an eating disordermore difficult. Sometimes these disorderscan be treated concurrently, while at othertimes they may need to be treated sepa-rately. These are not decisions that you

38

Sometimes onedisorder is soprominent or

obvious that it canmask the

existence ofanother.

Disorders are often related.

need to make; they are decisions that haveto be made by the healthcare team.Usually, the risk to the individual is thedeciding factor. Consider a case of adepressed individual who has an eatingdisorder to illustrate this point. Depressioncan complicate the treatment of an eatingdisorder. If the individual’s health is greatlycompromised by the eating disorder, theprimary focus is likely to be on the eatingsymptoms rather than the depression. Onthe other hand, if the individual is sodepressed that suicidal thoughts occur, thefocus of treatment should be on thedepression.

ConfidentialityOne of the most important aspects of

psychological management and treatmentinvolves the issue of confidentiality. Health-care practitioners are legally and ethicallyrequired to maintain the privacy and confi-dentiality of their patients. They cannotdivulge any information about their patientsto anyone (even the patient’s parents) with-out the patient’s written consent. Eventhen, the information is still restricted towhat the patient agrees can be released,what is appropriate to be released, theconditions under which the information canbe released and to whom.

The only exceptions to the release ofsuch information occur in cases involvingimminent risk to the patient or others, childabuse, and a court order requesting theinformation. Confidentiality assurespatients that their information will not beshared with anyone without their consent.The purpose of confidentiality is to pro-mote a therapeutic atmosphere in whichpatients feel safe and secure enough totalk about anything related to their difficul-ties, regardless of how serious or personal.

39

Healthcare practitioners arelegally and ethicallyrequired to maintain the privacy and confidentiality oftheir patients. Theycannot divulge anyinformation abouttheir patients toanyone (even thepatient’s parents)without thepatient’s writtenconsent.

Although confidentiality is viewed as thecornerstone of psychological treatment, itcan feel like a stumbling block to peoplewho want to know about the patient’s con-dition, treatment and progress. Most of thetime, the people seeking this informationare simply concerned for the patient’s wel-fare. Regardless of their motives, however,the information cannot be released by thepractitioner without the patient’s writtenconsent. Sometimes for a variety of rea-sons, the patient may not want others toknow anything about his or her conditionor treatment. Even if the patient consents,the practitioner still makes the decisionwhether it is appropriate or in the patient’sbest interests to release the information.Obviously, this can be quite frustrating tosomeone who wants the information.

Some coaches have the benefit of hav-ing a departmental sport psychologist.Those coaches who have such a benefit,or who have an ongoing, working relation-ship with a psychologist or mental healthprofessional, will likely know what toexpect and how to proceed. Those whoare working with a mental health profes-sional for the first time are likely to havethe most success by contacting the pro-fessional, introducing yourself, explainingthat you understand and respect confiden-tiality issues, but would also like to behelpful to the student-athlete. Therefore,with everyone’s consent, you would sim-ply like to know if the student-athlete isokay, if appointments are being kept,how treatment is progressing, whetherthe student-athlete should be training orcompeting, and what you might do to behelpful. This type of dialogue will not onlybe helpful with the existing case, but canfacilitate the management of subsequentcases by laying the groundwork for a good

40

Confidentialitydoes not have to

be a problem,especially if it is

handled properlyfrom the beginning

by healthcare professionals, both

in terms ofdescribing confi-

dentiality to thepatient and to

those requestinginformation.

relationship with the professional oragency.

Confidentiality does not have to be aproblem, especially if it is handled properlyfrom the beginning by healthcare profes-sionals, both in terms of describing confi-dentiality to the patient and to thoserequesting information. In such circum-stances, most patients are usually willing toconsent to information release to signifi-cant others, especially if it pertains to gen-eral statements regarding condition andprogress rather than specific informationrelated to specific issues. Regardless, thisrelease of information must always be vol-untary by the patient. The patient shouldnever be manipulated or coerced into giv-ing permission.

Sometimes the concerned persons inthe patient’s life may not be requestinginformation. Rather, they may want to pro-vide the practitioner with information.Different practitioners handle this situationdifferently. Some may not want information.Even if they are willing to receive informa-tion, it may be difficult to do so becauseconfidentiality precludes them from evenacknowledging that they are treating thepatient.

The Role of the Coach: Final ThoughtsIn this handbook, we have discussed

why and how the coach should be involvedin managing mental health issues that arisein their student-athletes. We have stressedthat the coach’s role is not to be a thera-pist to affected student-athletes, but ratherto “identify” and “refer.” This is not to say,however, that they should be uninvolved inthe student-athlete’s treatment. Coacheshave considerable power and influencewith their student-athletes. That power andinfluence can be used by coaches to

41

Coaches haveconsiderablepower and influence with theirstudent-athletes.

encourage and support treatment, whichcan have a positive effect on treatmentoutcome.

SUMMARY1. The coach’s responsibility is to recog-

nize and refer, not treat psychologicalproblems such as depression, anxiety dis-orders, eating disorders or substanceabuse disorders.

2. Approaching a student-athlete to dis-cuss psychological issues requires goodlistening skills.

3. Referrals are most successful whenmade to a specific person.

4. Confidentiality is an essential aspectof psychological treatment.

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Depression:• Depression and bipolar support alliance:

www.dbsalliance.org DBSA is a patient-directed non-profit organization whosemission is to provide information and sup-port to anyone needing help with depres-sion. This site aims to provide scientificinformation about depression and bipolarillness written for the lay public. It alsoprovides numerous resource informationand links to further contact information.

• Suicide Prevention Hotline: www.suicidepreventionlifeline.org Thenational suicide prevention lifeline is a 24-hour, toll-free suicide prevention serviceavailable to anyone in suicidal crisis.

• Ulifeline Mental Health Service Information:www.jedfoundation.org Working to pre-vent suicide and promote mental healthamong college students.

• QPR - Question, Persuade, Refer:www.qprinstitute.com/athletics.htm QPRoffers suicide prevention training program.

Anxiety:• www.nimh.nih.gov/healthinformation/

anxietymenu.cfm Information on anxietydisorders provided by the national insti-tute of mental health.

• http://mentalhealth.samhsa.gov/publications/allpubs/ken98-0045/default.asp Information about anxietydisorders is provided along with a toll-free information line (1-888-ANXIETY).

Eating Disorders: • NCAA Coaches Handbook on Managing

the Female Athlete Triad. This handbookprovides coaches with strategies toidentify, manage and prevent the FemaleAthlete Triad, which involves the interre-lated problems of disordered eating,amenorrhea, and osteoporosis. The

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reso

urc

es

Handbook is available from the NCAA orat the following Web site:www1.ncaa.org/membership/ed_outreach/health-safety/index.html

• National Eating Disorders Association(NEDA): www.nationaleatingdisorders.orgNEDA provides a toll-free helpline to providesupport services, guidance and referrals tohealthcare professionals, to individuals withdisordered eating, and to their families.

• Academy for Eating Disorders (AED):www.aedweb.org This site provides themost current information on eating disor-ders. It also provides referral informationon healthcare providers who specialize inthe treatment of eating disorders. There isa link to the AED’s Special Interest Groupon Athletes for more information.

Substance Abuse:• http://ncadi.samhsa.gov This site is

SAMHSA’s National Clearinghouse forAlcohol and Drug Information. Withinthis site are quick facts about mostdrugs, along with prevention information.

• Substance Abuse Hotline:www.hazelden.org One of the largestdrug treatment facilities provides a hot-line, along with information about drugsand drug treatment.

General Mental Health:• Mental Health Services Locator:

http://mentalhealth.samhsa.gov/databases This site offers help findingmental help professionals throughout thecountry.

• Mental Health America: www.mentalhealthamerica.net This siteprovides general mental health information.

• Screening for Mental Health:www.mentalhealthscreening.org CollegeResponse offers programs to promoteprevention, early detection and treatment.

• www.ncaa.org/health-safety

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NCAA 57313-6/07

The NCAA salutes the more than

380,000 student-athletes

participating in 23 sports at

more than 1,000 member institutions