Mental Health Conversations
Overview | Supporting Athletes | Reducing Stigma | Verbal De-Escalation | Resources | Training Opportunities
Research suggests that student-athletes may be internalizing prejudices against mental illness, influencing their ability to seek help and/or engage in optimal health behaviors.6 This stigma is perhaps the most important barrier to seeking mental health care that athletes experience.7 Athletes experience less privacy and live in the public eye, in addition to a celebrity status on campus which may influence their fear of the mental illness stigma.6 Coaches play a key role in addressing stigma, through facilitating education about mental health, encouraging athletes to seek help, and opening the conversation about mental health. One way coaches can reduce negative stigmas is by keeping an eye on the language they use.
Sports can be a high-emotion experience. Athletes may experience joy, panic attacks, anger, frustration, anxiety, and other high-level emotions. As a coach or staff member, you may be the first person responding to high-level emotions that are disruptive, distressing, or dangerous. It is therefore a good idea to have some de-escalation strategies ready in your toolbox. Agitation is not a diagnosis, it is a symptom, and can happen for a number of reasons. Agitation can be triggered by stress or traumatic events, such as athletic injury, perceived failure in competition, or conflict in the team. Agitation can also be triggered among people with mood disorders such as depression, anxiety, or bipolar mood if their treatment is not working properly. Agitation exists on a spectrum, with mild, moderate, and severe symptoms.4 It looks different depending on the person and situation, but you'll know it when you see it. Verbal de-escalation is used a potentially verbally and/or physically explosive situation happens.5
References
1. Mental Health First Aid International. (2015). Mental health first aid USA (1st edition). Washington DC: National Council for Behavioral Health.
2. Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Jr, Zeller, S. L., Wilson, M. P., Rifai, M. A., & Ng, A. T. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. The western journal of emergency medicine, 13(1), 17–25. https://doi.org/10.5811/westjem.2011.9.6864
3. Sarkar, M., & Fletcher, D. (2014). Psychological resilience in sport performers: A review of stressors and protective factors. Journal of Sports Sciences, 32(15), 1419–1434. Doi: 10.1080/02640414.2014.901551
4. Depression and Bipolar Support Alliance (2021). Understanding agitation. Retrieved from: https://www.dbsalliance.org/education/educational-webinars/understanding-agitation/
5. Skolnik-Acker, E. (n.d.) Verbal de-escalation techniques for defusing or talking down an explosive situation. Committee for the Study and Prevention of Violence Against Social Workers, National Association of Social Workers, Massachusetts Chapter. Retrieved from: https://network9.esrd.ipro.org/wp-content/uploads/sites/5/2015/12/verbal_de-escalation.pdf
6. Kaier, E., Strunk, K., Cromer, L. D., Davis, J. L., & Johnson, M. D. (2015). Perceptions of mental illness stigma: Comparisons of athletes to nonathlete peers. Journal of College Student Development, 56(7), 735-739. Retrieved from: http://libproxy.uwyo.edu/login/?url=https://search-proquest-com.libproxy.uwyo.edu/docview/1731521968?accountid=14793
7. Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine, 50(3), 145–148. doi: 10.1136/bjsports-2015-095586
Developed 2021 by Quinn DeStefano, OTD Student
Reviewed 2021 by Aaron Grusonik, MA, Psy.D
Overview
Coaches and trainers spend a lot of time with athletes and are on the front lines of their mental health care. Often, wellness concerns reveal themselves in the form of decreases in function. For example, an athlete may seem withdrawn during practice, stop taking care of their hygiene, begin lashing out at their teammates, or show other signs of distress. At this time, it is especially important to show your support and get them the help they need in order to improve their overall wellness and athletic and academic performance. Social support plays a crucial role in helping people to cope with adversity and stress.1 It is a protective factor against mental illness. In fact, perceived social support is a core element of resilience found among Olympic champions, that helped them withstand the many stressors involved with elite athletics.3 On the flip side, elite athletes identified coach behaviors, interactions, personality, and attitudes as key organizational stressors.3 In short, interactions with athletes can be another stressor the athlete copes with, or a protective factor against mental illness, depending on what these interactions entail. Here are some helpful and unhelpful things you can do to support athletes.Supporting Athletes
*Inspired by the Mental Health First Aid USA Adult Training1Helpful Actions
- Listen to your intuition
- If you think an athlete seems "off," trust yourself - you know what to look for. Ask them how they are doing and let them know you care
- Candidly point out any changes that you've noticed or concerns you have for the athlete.
- Approach them privately
- Be honest and transparent
- It's okay to say something like, "I've noticed you seem withdrawn during practice lately and I'm worried about you."
- It's okay to gently press them to open up – "no, how are you really doing?"
- Listen to what the athlete has to say.
- Sometimes, the most helpful thing you can do is listen – let them get things off their chest.
- Don't interrupt. Let them finish their thought completely before you speak
- Make good eye contact
- Try to normalize/validate their experience.
- "That's really challenging," "You're not alone," or "I have felt down before too, and it's really tough."
- Sometimes, the most helpful thing you can do is listen – let them get things off their chest.
- It is okay to ask them if they have considered suicide or have thought about killing themselves – this will not give them any new ideas or "make them suicidal"
- They will likely feel relieved that someone asked because it is extremely difficult to volunteer this information.
- Asking the athlete candidly is a great way to open the door for discussion, and to refer them to the help they need.
- If they are not considering suicide, they will simply reassure you that they are not a suicide risk.
- Person-first language: avoid saying, "committing suicide," or "are you suicidal?"
- We commit crimes, not mental illnesses
- We are people experiencing mental illness, not "the mentally ill" or "the suicidal"
- Instead, say "thinking of suicide," "attempted suicide," or "killed themselves."
- They will likely feel relieved that someone asked because it is extremely difficult to volunteer this information.
- Refer them to resources (you can even offer to go with them if they need support)
- National Suicide Prevention Lifeline: 1-800-273-8255
- National Crisis Text Line: 741741
- Aaron Grusonik, MA, Psy.D: aaron.grusonik@montana.edu, 406.994.6373
- MSU Counseling & Psychological Services: 406-994-4531
- On-Campus Resources
- Off-Campus Resources
- Emergency line: 911
- Encourage self-care
- What do you do to take care of yourself?
- Going for a walk, positive self-talk, coloring, baths, dinner out with friends, poetry, music, sitting quietly in the park, etc.
- Encourage them to use information from the "Wellness " tab
- See: Stress Management for some ideas, or The Big List of Self-Care Activities (PDF)
- What do you do to take care of yourself?
- Offer Assistance
- When people are physically ill, we support them by bringing them soup or casseroles, sending them flowers, helping them with work or caregiving duties, and more. Mental health challenges are no different.
- When an athlete is struggling with a mental health challenge, you can support them like you would with a physical illness. You could get together with the team to send them flowers, have a one-on-one practice with them to help them catch up, have the team sign a card for them, or other.
Unhelpful Actions
- Becoming too involved
- Being your athlete's therapist: you aren't trained to provide therapy, so don't put that kind of pressure on yourself.
- Forcing them to get help: it is ultimately their choice whether or not to get help, and there is no need to frog-march them to CPS.
- Invalidating their distress by saying things like, "Well, at least you don't have cancer," or "Everyone gets sad sometimes," or "Just think of all the people who are worse off than you," or "You're being a little dramatic."
- Promising confidentiality
- Don't promise athletes confidentiality, because if they are a danger to themselves or to others, you will need to report it.
- Making it about yourself
- If someone shares challenging mental health concerns with you, let them share. It is not helpful to say something like, "I have experienced the same thing, and I know exactly how you feel, let me tell you all about it..."
Reducing Stigma
Research suggests that student-athletes may be internalizing prejudices against mental illness, influencing their ability to seek help and/or engage in optimal health behaviors.6 This stigma is perhaps the most important barrier to seeking mental health care that athletes experience.7 Athletes experience less privacy and live in the public eye, in addition to a celebrity status on campus which may influence their fear of the mental illness stigma.6 Coaches play a key role in addressing stigma, through facilitating education about mental health, encouraging athletes to seek help, and opening the conversation about mental health. One way coaches can reduce negative stigmas is by keeping an eye on the language they use.
Avoid Words with Negative Connotations
When describing mental illness or related impact on function, avoid using words with negative connotations. The words/phrases you use can influence the athlete's attitude about mental health and mental illness. As a coach, it is important to be a leader by avoiding phrases like these so as to foster a positive mental health culture at MSU.- Crazy
- Psycho
- Nuts
- Lunatic
Use Person-First Language
Person-first language or identity-first language emphasizes the individual in the sentence, rather than the diagnosis. We are people experiencing mental illnesses, not "the mentally ill". When talking about mental illness, try to say things like, "he had depression," and "she is experiencing alcohol use disorder," rather than "he was depressed," or "she is a drunk." In doing this, we avoid labeling people with their diagnosis or mental health challenges. We avoid "putting them in a box," or defining them by their diagnosis.| NOT Person-First | Person-First Language |
| Homeless man | A man without a home |
| She is anxious | She is experiencing anxiety |
| He is a victim of rape | He survived sexual assault |
| The schizophrenics | People with schizophrenia |
Verbal De-Escalation
Sports can be a high-emotion experience. Athletes may experience joy, panic attacks, anger, frustration, anxiety, and other high-level emotions. As a coach or staff member, you may be the first person responding to high-level emotions that are disruptive, distressing, or dangerous. It is therefore a good idea to have some de-escalation strategies ready in your toolbox. Agitation is not a diagnosis, it is a symptom, and can happen for a number of reasons. Agitation can be triggered by stress or traumatic events, such as athletic injury, perceived failure in competition, or conflict in the team. Agitation can also be triggered among people with mood disorders such as depression, anxiety, or bipolar mood if their treatment is not working properly. Agitation exists on a spectrum, with mild, moderate, and severe symptoms.4 It looks different depending on the person and situation, but you'll know it when you see it. Verbal de-escalation is used a potentially verbally and/or physically explosive situation happens.5
Symptoms of Agitation
Mild-Moderate4- pulling/picking at hair, skin, or clothing
- unconscious movement (fidgeting, pacing, hand wringing)
- outbursts
- shuffling feet
- clenching fists
- excitement
- hostility
- poor impulse control (such as throwing things)
- tension
- uncooperative
- violent/disruptive behavior
De-Escalation Techniques5
- It is not possible to reason or use a logical argument with a person experiencing agitation. The point of de-escalation is bringing them down to an arousal level where they can be reasoned with.
- When we are confronted with a panicked or angry person, fight/flight/freeze responses are natural. Remaining calm and using verbal de-escalation is very difficult in these situations. Therefore, it is important to practice and review these strategies so that you are ready to use them when the time comes.
- Every situation is different - and response to a panic attack versus an angry outburst will look differently. As you read this list, think of a time an athlete was agitated, what you did, and what you might do differently next time.
- The Coach in Control of Him/Herself
- Appear calm, centered, and self-assured even though you feel a fight/flight/freeze response. Take a deep breath. Relax facial muscles and pretend you are confident. Just like your emotions changed in response to the athlete's agitation, showing anxiety can make them feel anxious and unsafe which can escalate aggression.
- Use a modulated, low monotonous tone of voice (our normal tendency is to have a high-pitched, tight voice when scared).
- If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you confront the person (not in front of him/her)
- Do NOT be defensive: even if the comments or insults are directed at you, they are not about you - remember, there are other things going through their head that led them to this state. Do not defend yourself or anyone else from insults, curses, or misconceptions about their roles.
- Be aware of any resources available for backup and crisis response procedures. This may be other coaches and staff, or 911 depending on the situation.
- Be very respectful even when setting limits or calling for help. Avoid danger by treating them with dignity and respect. If the athlete is agitated, they will likely be sensitive to feeling shamed and disrespected. We do not want them to feel like they need to show us that they must be respected - this can be a dangerous situation, and they may do something regrettable.5
- Physical Stance
- Never turn your back for any reason
- Always be at the same eye level. This is not possible if they are taller than you, but the main thing is to not stand "towering" over the athlete. This can be scary to them because it demonstrates dominance.
- Encourage the person to be seated, but if they need to stand, you stand up also to stay at the same eye level.
- Make extra physical space between you, about four times greater than usual.
- DO NOT stand full front to person. Stand at an angle so you are able to sidestep away if they become violent.
- DO NOT maintain constant eye contact. Let the person look away from time to time because constant eye contact can come across as invasive or dominant.
- DO NOT point or shake your finger. This will only escalate the situation because it seems accusatory.
- DO NOT smile. The athlete may think you are mocking them.
- DO NOT touch. Even if some touching is normally appropriate on your team and in the setting. People experiencing agitation (especially anger) may misinterpret physical touch as hostile or threatening. Plus, you wouldn't be maintaining your distance if you physically touched them.
- Keep hands out of your pockets. This non-verbally shows them you are an ally. You may also need your hands for protection if things get violent.
- DO NOT be defensive or judgmental.5
- De-Escalation Discussion
- Remember that there is no content except trying to calmly bring the level of anger down to a safer place.
- DO NOT get loud or try to yell over a screaming person. This will only make matters worse. Keep your low, monotonous voice. Wait until they take a breath; then talk.
- Respond selectively; answer all informational questions no matter how rudely they ask them. "Why do I have to do this g-d practice?" (This is a real information-seeking question). DO NOT answer abusive questions. "Why are all coaches (an insult?)" No response should be given to questions like this. They are not informative questions. Ignore abusive questions.
- Explain boundaries in an authoritative, firm, but respectful tone. Give choices where possible in which both are safe options. "Would you like to continue our discussion calmly or would you prefer to stop now and talk tomorrow before practice when things can be more relaxed?"
- Empathize with feelings but not with the behavior. "I understand that you have every right to feel angry, but it is not okay for you to treat myself or your teammates this way."
- DO NOT ask how a person is feeling or interpret feelings in an analytic way.
- DO NOT argue or try to convince. Remember: it is not possible to reason with an agitated person - that will come later.
- When you can, tap into the person's "thinking" mode: DO NOT ask "Tell me how you feel." Obviously, they feel upset. Instead: "Help me to understand what you are saying to me" People are not attacking you while they are teaching you what they want you to know.
- Suggest alternative behaviors where appropriate. "Would you like to take a break and have a cup of water?" "Would you like to take a deep breath together?"
- Give the consequences of inappropriate behavior in a non-threatening way. "Choosing to hit a teammate may result in legal implications."
- Trust your instincts. You will know if your technique is working within 2-3 minutes. If you assess or feel that de-escalation is not working, STOP! Get help, and follow a crisis response plan.5
- Verbal De-escalation (PDF)
- Conflict De-Escalation tutorial
- Psychiatry/Medical: Verbal De-escalation tutorial
- Panic Attack Response tutorial
More Resources
- Big Sky Conference Mental Health Subcommittee: "The Big Sky Mental Health Subcommittees seeks to promote the resources and best practices for outreach and communication to student-athletes, coaches, staff and teams regarding mental health and wellness, at all times and especially during periods of crisis, ongoing racial injustice, systematic oppression, and prolonged uncertainty. The work of the subcommittee will focus on mental health promotion and programming to reduce stigmas and other barriers for student-athletes, coaches and staff to access mental health resources."
- NCAA Mental Health: Data & research, educational resources, best practices, and summits and task forces
- NCAA Sport Science Institute, "Supporting Athlete Mental Wellness (Coaches)": Training module
Training opportunities
- Mental Health First Aid: MHFA is an 8-hour training on mental health literacy, developed in Australia and adapted for American culture. MHFA prepares participants to respond with greater knowledge, confidence, and compassion when an adult is experiencing a mental health problem or is having a mental health crisis.
- Custom Staff Training: Contact Aaron Grusonik, MA, PsyD., aaron.grusonik@msubobcats.com, (408) 482-0323 to arrange a custom training for your staff
- Required and Other Mental Health Training: Kognito, QPR, and wellness presentations
References
1. Mental Health First Aid International. (2015). Mental health first aid USA (1st edition). Washington DC: National Council for Behavioral Health.
2. Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Jr, Zeller, S. L., Wilson, M. P., Rifai, M. A., & Ng, A. T. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. The western journal of emergency medicine, 13(1), 17–25. https://doi.org/10.5811/westjem.2011.9.6864
3. Sarkar, M., & Fletcher, D. (2014). Psychological resilience in sport performers: A review of stressors and protective factors. Journal of Sports Sciences, 32(15), 1419–1434. Doi: 10.1080/02640414.2014.901551
4. Depression and Bipolar Support Alliance (2021). Understanding agitation. Retrieved from: https://www.dbsalliance.org/education/educational-webinars/understanding-agitation/
5. Skolnik-Acker, E. (n.d.) Verbal de-escalation techniques for defusing or talking down an explosive situation. Committee for the Study and Prevention of Violence Against Social Workers, National Association of Social Workers, Massachusetts Chapter. Retrieved from: https://network9.esrd.ipro.org/wp-content/uploads/sites/5/2015/12/verbal_de-escalation.pdf
6. Kaier, E., Strunk, K., Cromer, L. D., Davis, J. L., & Johnson, M. D. (2015). Perceptions of mental illness stigma: Comparisons of athletes to nonathlete peers. Journal of College Student Development, 56(7), 735-739. Retrieved from: http://libproxy.uwyo.edu/login/?url=https://search-proquest-com.libproxy.uwyo.edu/docview/1731521968?accountid=14793
7. Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine, 50(3), 145–148. doi: 10.1136/bjsports-2015-095586
Developed 2021 by Quinn DeStefano, OTD Student
Reviewed 2021 by Aaron Grusonik, MA, Psy.D
