Experiences of Current National Collegiate Athletic Association Division I Collegiate Student-Athletes With Mental Health Resources

Research Design

Our investigation was guided by the consensual qualitative research tradition. The research team comprised 5 ATs with various levels of experience (1–18 years certified) and mental health teaching or research. Three members of the research team (R.D.Y., E.R.N., T.A.A.) had previous suicide-prevention training certificates. All 5 members of the coding team had experience managing patients with mental health challenges and providing health care to collegiate SAs. The experiences of these ATs may have informed the data analysis and coding process of this research study.

Participants and Sampling

Before recruitment, we obtained ethics approval from the University of South Carolina Institutional Review Board. We used social media, specifically Twitter and Instagram, combined with snowball sampling to identify potential participants who were current NCAA Division I SAs. We excluded collegiate SAs from all other sport associations and NCAA divisions. To recruit participants on social media, we posted messages on our professional and personal social media pages (Twitter and Instagram) explaining the purpose of the study with a link to a Qualtrics survey. In addition to the public messages, the primary investigator (R.D.Y.) directly invited participants from Instagram who self-identified as an NCAA Division I SA in their public biography on social media. Each message contained the same link to the Qualtrics survey, where the potential participants provided their preferred email address and pseudonym that they wished to use for scheduling and the interview process. Fifty-one individuals expressed interest in the study via the link, and none were excluded for not meeting inclusion criteria. In total, 23 participants (women = 18, men = 5; average age = 20 ± 2 years) engaged in the interviews. The pseudonyms and demographics of the participants are provided in Table 1.

Table 1 Participant Information

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Data Collection

Interview Protocol

To explore the experiences of SAs, 2 members of the research team (R.D.Y., Z.K.W.) developed an interview protocol that consisted of 7 demographic questions and 6 mental health questions, with follow-up questions about their specific experiences. These authors conducted multiple revisions of the interview protocol (Table 2). The interview protocol was then sent to the other 3 members of the research team to obtain feedback. This process occurred multiple times, with feedback provided on each revision until all 5 members of the research team came to consensus. The interview questions were modified for wording, phrasing, and elaborating.

Table 2 Interview Protocol^a

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Data Analysis and Trustworthiness

Consensual qualitative research was the research design of this study to capture the lived experiences of SAs with mental health and the resources available to them.¹⁸ This method of data collection allowed us to document the personal experiences of SAs, analyze the data, and agree on a common interpretation of findings. The 3 members of the data analysis team (R.D.Y., E.R.N., T.A.A.) received the same 4 transcripts to review and identify preliminary domains. Core ideas were constructed from each domain and accumulated to establish a codebook for data analysis. Next, 2 of the initial transcripts and 2 new transcripts were analyzed. The data analysis team met to come to a consensus, and peer discussion preceded any changes to the codebook. Six transcripts were analyzed by each member and then rotated among the data analysis team for triangulation, and a two-thirds vote resolved any disagreement. For cross-analysis, the quotes were grouped based on categories, and then the frequency of each category was classified into general, typical, variant, and rare.¹⁹ The general frequency count applied when the category appeared for all or all but 1 of the cases.¹⁹ The typical frequency count applied when the category appeared for more than half of the cases and up to the cutoff for the general category.¹⁹ The variant frequency count applied when the category appeared for more than 2 cases and up to the cutoff for the typical category.¹⁹ The rare frequency count applied when the category appeared for only 1 or 2 cases.¹⁹

The final codebook, frequency table, and transcripts were sent to the external auditor (Z.K.W.) for review. The external auditor proposed changes in the terminology of domains and categories, which were implemented. To ensure trustworthiness and reduce bias, we conducted member checking, triangulation, and peer discussion in the data analysis.²⁰

Domain 1: Expectations of the SA

This domain represented the challenge of balancing sport and life as a college student, academic stressors, performance expectations, and a sport-first mindset the SAs perceived coaches and teammates as embodying.

Domain 2: Resources and Management

The SAs described their support from internal and external networks, their perceptions of mental health resources, accessibility of resources, and self-regulation strategies that had helped them cope with mental health conditions.

Domain 1: Expectations of the SA

Participants identified time management as the biggest stressor, which supports previous authors’²¹ findings that SAs dedicate a concerning amount of time to their sport. Time constraints for this population have been shown to affect SAs’ sleep, nutrition, and academic pursuits,²¹ causing mental and physical exhaustion.³ Academically, we determined that SAs struggled with meeting team grade point average requirements, increased course loads, and absences for athletic responsibilities. Time demands and rigid scheduling often left SAs tired and overwhelmed, which not only affected their academic and athletic performance but could take a significant toll on their mental health and well-being.²¹ Consistent with previous research,²¹ our participants cited injury as a stressor. When injured, SAs are psychosocially concerned about disconnectedness and anxiety caused by the unpredictable and unfamiliar recovery process.²¹ These emotions can trigger more serious mental health concerns, including depression, eating disorders, and substance use disorders.²²

Collegiate SAs comprise a unique population vulnerable to mental health conditions.¹⁷ Some participants in this study disclosed their diagnosis of a mental health condition and commented on their struggles in addition to performance anxiety and body image concerns. Drew and Matthews² found that 31% of their SA participants reported moderate to severe symptoms of depression, anxiety, or both. These experiences described by SAs and the prevalence of mental health conditions in this population are concerning because depression and anxiety are predictors of a lower grade point average and poor athletic performance and are correlated with risky behaviors and suicide.³

Interactions, programs, and cultural attitudes in athletic environments have the potential to reduce stressors and help SAs cope effectively.³ Collegiate SAs are more willing to seek help for personal concerns with support from coaches, friends, and family.¹⁵ Stigma is the most common factor influencing an SA’s entry into or follow-up with counseling and seeking resources.^3,15 Outdated coaching philosophies use exercise as punishment to increase SA motivation and team cohesion and modify behavior; other problematic coaching characteristics are untrustworthiness, disrespect, unrealistic expectations, lack of knowledge about the SA, and inability to support injured SAs.^23,24 This sport-first mindset values mental toughness and perseverance so highly that SAs may be less likely or even unwilling to seek help for mental health conditions.²⁵ The sport-first mindset perpetuates a fear of being viewed as weak, deficient, or psychologically unfit by coaches and teammates, which leads to less self-reassurance and increased self-criticism, anxiety, and depressive symptoms.^17,26

It is interesting to note that this category was classified as variant, with only 11 of the 23 participants identifying a sport-first mindset throughout their SA experience. We hypothesize that this reflects a shift in the culture of collegiate athletics and a step toward reducing mental health stigma. Based on the experiences and expectations reported by SAs in this study and previous research, we suggest that it may be helpful to strengthen athletic programs by addressing the behavioral concerns of team culture. Coaches can shape an environment in which both physical and mental injuries are taken seriously and addressed early.²⁷ Sixty-five percent of our respondents discussed positive experiences in which coaches and support staff encouraged use of mental health services and supported mental health initiatives. In contrast, 17% described coaches and teammates as embracing an outdated, sport-first mindset in which mental health concerns were disregarded.

Domain 2: Resources and Management

Our results indicated that SAs’ internal support networks included coaches, ATs, and various staff within athletic departments. Outside of the university and athletic department, their external support networks included their family, friends, organizations, and personal psychology services. Educating SAs on mental skills to cope with stressors and educating coaches and teammates about social support decreased the anxiety SAs experienced.²⁸ Our SAs described helpful self-regulation strategies that benefited them. However, a conflict exists between time management and self-care, the latter of which was reported to be beneficial to participants. We believe that SAs should be educated on time management strategies and healthy coping mechanisms and mental health discussions among teams encouraged to ensure that SAs are better equipped to handle stressors. Social support from the aforementioned networks can also be a coping mechanism, and higher levels of social support have been correlated with fewer depressive symptoms.²⁹ Respondents in our study voiced feelings of support when mental health was addressed by coaches and discussed among teammates. In a recent study of minority SAs,²¹ the authors determined that mental health was not a topic of discussion in the locker room, it was rarely addressed by coaches, and the SAs had to “wear” their mental health condition in order to receive help. Vocalizing stressors is still considered a weakness in collegiate athletics, but it can aid in reducing the debilitating stigma associated with SAs’ stress, anxiety, and mental health concerns.¹⁶ Participants in this study perceived a reduced stigma to mental health through shared experiences and the willingness of SAs to talk about mental health. We believe this to be an advancement and a positive step toward improving mental health in collegiate athletics. However, not all participants shared this experience, and the stigma against mental health remains a challenging barrier to increasing mental health service use.³⁰

Our participants expressed both positive and negative perceptions from their experiences using mental health resources. Earlier researchers³⁰ noted a lack of understanding of the SA role by practitioners as a top response for reduced use of mental health care by SAs. In a systematic review, barriers to service use were identified as the attitudes of athletic stakeholders, gender bias, and lack of mental health resources, time for SAs, mental health knowledge, and proper institutional protocols.¹⁷ We believe that these barriers can be eliminated by well-developed and updated policies and procedures as outlined by the NCAA best practices³ and the National Athletic Trainers’ Association’s recommendations for effectively referring SAs with mental health concerns.¹³

Mental health services were promoted to SAs through emails, pamphlets, posters, social media, workshops, and team meetings. Despite various mechanisms for informing SAs of resources, not all respondents were aware of the mental health resources at their universities. Use of mental health services at NCAA Division I institutions has been more widely researched compared with other divisions, and the resources available at NCAA institutions are not uniform.^17,31–33 The NCAA’s best-practice recommendations³ for understanding and supporting SA mental wellness are designed for athletic departments regardless of their size and resources, which can create health and health care disparities in a one-size-fits-all approach. The continued narrative of seeking equality in best-practice implementation must be altered to address equity in mental health care among the NCAA divisions. We hypothesize that SAs attending NCAA Division I institutions with mental health services housed in their athletic departments were more aware and informed of the mental health services available. Yet a conflict of interest may occur due to a lack of promotion of independent medical care when services are housed within the athletic department. In comparison, SAs who use the university’s mental health resources are not as informed, and the frequency of advertisement to which they are exposed is that of typical college students. This aligns with previous studies of SAs perceiving that mental health services were hidden²¹ and not knowing how or where to access mental health treatment at their university.³⁴ Accessibility to resources was improved through ATs facilitating help-seeking behaviors with referrals and access to free counseling services. Recent authors¹⁶ observed that SAs were more likely to seek help from nonteam support staff rather than coaches. Therefore, we suggest promoting mental health services through increased advertisement of and SA education about these resources through support staff.

Clinical Bottom Line

From the data collected in the interviews, we suggest that ATs and the interprofessional care team for NCAA Division I SAs create a holistic culture focused on both physical and mental health. To do so, ATs need to empower SAs to speak with them and their coaching staff regarding their mental health. This could create a climate in which a “mental health day” is seen as a positive manifestation and SAs are not punished for missing athletic activities. The words we use to describe mental health must continue to change, and ATs should be stewards of these best practices to create teams of inclusive thought relative to mental health. In addition, the health care facilities must regularly advertise resources specific to mental health and promote opportunities on campus and in the community to seek help. We believe that the narrative that “it is okay to not be okay” must stop and instead encourage a help-seeking narrative focused on “it is okay to get help.”

The stigma associated with mental health must be addressed from a top-down approach by the administration, leadership, coaching staff, health care professionals, and the athletes themselves. To do so, we recommend that annual preparticipation examinations include mental health screenings. Next, ATs need to create partnerships with mental health care professionals, even if these are not sport specific. The partnerships should be created before an emergency or crisis occurs in order for the SAs to see the clinicians as focused on risk reduction and wellness and not merely reactive in a mental health emergency. Finally, we suggest that these providers be integrated into the athletic training facility, engage in group dialogues at practice, and lead sessions on stress relief and mindfulness as avenues to promote mental well-being.

Limitations and Future Research

Our study offered insight into the lived experiences of collegiate SAs regarding mental health and the resources available to them at their universities, but a few limitations must be acknowledged. Eighty-three percent of the participants in this study were White. All were NCAA Division I SAs, and the mental health resources available are substantially higher in this division than in Division II, Division III, or National Association of Intercollegiate Athletics member schools. Five participants attended private Division I institutions; therefore, we cannot assume that the academic requirements and expectations of sport participation are standard across all university settings. In addition, some universities may provide only minimum resources, whereas others may have expansive sport psychology services housed in their athletic departments. Recall bias is another limitation to consider. The time between mental health resource interactions and this study’s interview varied for each respondent, and the experiences described may have been limited by memory. Given the recent COVID-19 pandemic, future research should reassess the prevalence of mental health conditions in NCAA SAs because of new stressors and challenging life experiences that have emerged since these factors were last identified in the literature.¹²