Game Face

National debate has swelled around the term student-athlete — a college student who also plays a varsity sport. So much is expected of this subset of the student body, which brings in millions for universities, that some would prefer they not be called students at all.

For the student-athlete, long hours, grueling physical work and the pressure to constantly perform hang in a delicate balance with the desire for a fulfilling education, social life and a “normal” college experience.

Striving for success in both aspects of the student-athlete identity can lead to the loss of a larger sense of self — the individual outside of school and outside of sport. In the constant battle to achieve, mental health and wellness can be overlooked.

“If you’re doing well academically and you’re doing well in your sport, it’s easy to stay happy and positive and motivated. The stress is there, but you can handle it,” said Abby Fisher, a UNC sophomore and member of the varsity swim team. “But when I was struggling with swimming it was a lot harder to focus on school and all of a sudden that seemed to get a lot harder, too.”

Last summer, during a rare two-week break from swim practice, Fisher tried running to stay in shape. She tore a ligament in her ankle, leaving her in a boot and out of the pool. The injury, combined with persistent illness throughout the fall, left her swimming below the standard she expected.

Disappointed with her performance in the pool, Fisher felt increased pressure to succeed academically. Worried she let down her team and coach, she would not fail as a student, too. She is a student-athlete, and that name demands excellence in both fields.

“We’re competitive people. If we’re not doing well in one aspect, we tend to put more pressure on other aspects,” Fisher said.

Healing physically and the support of teammates and coaches helped Fisher move forward. She learned she is not defined solely by achievements in sports and academics. She is not only a student-athlete.

“You need to realize you’re someone outside of your performance,” she said. “That’s a very big lesson that needs to be learned, but I think it can be challenging coming from such a competitive background and personality that says ‘I need to perform.’”

Will Heininger, a former football player at the University of Michigan who graduated in 2011, struggled with depression in silence.

“How could I keep living if every day, every hour, every minute, was so damn difficult?” Heininger asks in a video for Athletes Connected, a program at the University of Michigan, which is shown to student-athletes.

Fear of losing playing time, his scholarship and place on the team kept the four-year defensive end from seeking help. Eventually, the pressure to bulk up, get faster and keep good grades, combined with problems at home, broke him. An athletic trainer noticed Heininger in distress and referred him to a therapist.

“I was lucky to be put in an environment where it was good to work on yourself,” Heininger said in an interview. “I think everyone deserves that opportunity. But instead we get these messages that we have to be perfect, be flawless.”

Student-athletes should feel comfortable seeking help for mental health just as they would physical, he said. Heininger hopes to create an environment at Michigan where addressing mental health concerns is normalized.

“People are not aware that people have emotional and mental health issues that are quite normal and quite common,” he said. “You have to learn what to do, just like you learn what to do if you’re sore and go to the trainer.”

Today, Heininger works jointly with the Athletics Department and Depression Center on Athletes Connected to encourage awareness and help-seeking through educational presentations for all teams and coaches, videos featuring former student-athletes and informal support groups. The program, a collaboration between Athletics, the Depression Center, and the School of Public Health, began in 2014 with a $50,000 grant from the NCAA.

“If I can be as low as I was, not thinking I could get better and not knowing how to, then overcome the hardest thing of my life by opening up, then that message needs to be shared,” he said.

Heininger said student-athletes must separate overall wellness from how they perform on the field.

“I think there’s this perception of what toughness is, and not showing weakness,” Heininger said. “But if you’re well, not only are you going to perform better, but you’re going to enjoy life more.”

The mental health of student-athletes is weighing on the minds of the NCAA. In 2013, the organization hired neurologist Brian Hainline as its first chief medical officer amid national concern for student-athlete safety, particularly with concussions.

Hainline deemed mental health a priority and convened a task force to discuss mental health issues facing student-athletes, which led to the publication of Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. Available online, the booklet offers essays from athletes, mental health professionals, coaches and others on how to identify and treat mental health concerns among players.

The NCAA plans to release a report of best practices for universities to handle student-athlete mental health, said Dr. Jeni Shannon, one of two sports psychologist who works part-time with student-athletes at UNC in the Department of Sports Medicine.

Nationally, the number of sports psychologists working with universities is increasing as awareness grows, Shannon said. However, universities struggle to find professionals trained to work with both performance issues and clinical mental health concerns.

Depression and anxiety are the most common concerns the UNC sports psychologists see. Shannon also works frequently with students diagnosed with eating disorders and body image issues.

Having a sports psychologist on campus is key because student-athletes are more likely to see him or her than another mental health professional, Shannon said. Because they are specifically trained to work with athletes, sports psychologists can build trust and make athletes feel safe in a way others might not.

“For student-athletes, they live in a really unique world,” she said. “It can be really frustrating at times when they talk to someone who isn’t familiar with that culture and doesn’t understand the demands. They might say you shouldn’t go to practice today. But that isn’t usually an option.”

A variety of factors, both biological and environmental, can make college a hotbed for mental health issues for all students. The typical age of onset for mental health issues is 15 to 22.

“You get to college and there are other factors at play — you’re away from your support network, there are extra stressors, and not enough sleep,” said Stephanie Salazar, a project coordinator at the University of Michigan’s Depression Center.

Shannon said there has been much debate on whether student-athletes are at higher or lower risk for mental health concerns than other young people.

“Athletics is seen as having some protective factors — regular exercise, a good support system, structure, and you might be feeling good about yourself.” she said. “But the other side of it, which just depends on the person, is there tends to be a lot of additional pressure and stress.”

Student-athletes face a unique set of stressors. Over-scheduling, high expectations and the pressure of being in the public eye can all take a mental toll. Stress, among other factors, can trigger mental health concerns.

“In general, the mental health issues athletes face are similar to those in the general population. We see anxiety, depression, alcohol and substance abuse,” said Dr. Kelly Waicus, a primary care physician at UNC Sports Medicine. “I think the difference is the pressures on the Division 1 athletes at this level are in addition to the same pressures everyone else has a college student.”

To cope, Houston Summers, a former professional baseball player, member of the men’s track and field team and UNC student body president, plans ahead. He writes everything down, highlighting assignment due dates and days that will be filled by exams, competitions or travel.

Academic advisors in the Athletic Department help athletes choose schedules that will not overburden them during their busiest seasons.

“There’s a lot of support there that tries to help balance how far we can push ourselves and how far we need to stretch,” Summers said.

Fisher, who applied to the nutrition program in the Gillings School of Public Health, takes her most difficult classes such as“Organic Chemistry” in the summer. Though coaches try to accommodate class schedules with practice times, her days offer little flexibility or free time.

“It can be overwhelming,” she said.

Depression and anxiety are not necessarily higher among student-athletes than the student body as a whole, Salazar said. However, there is a difference in the number of student-athletes utilizing mental health resources.

Among students with symptoms of anxiety or depression, 10 percent of student-athletes used mental health resources, compared with 30 percent of students overall, according to a 2014 survey of students at nine colleges and universities. This difference could relate to a perceived need to hide weakness.

In a focus group of the Athletes Connected program at Michigan, students identified lack of time, self-stigma, fear of negative repercussions and being perceived as weak as barriers to seeking help, Salazar said. For many, the greatest fear is telling coach.

“There’s also the belief the problem will get better on its own,” she said. “One of the reasons these are such great athletes is they can tough things out. They think they can do that with a mental health problem, but they can’t.”

Shannon cites the culture of toughness in sports as a barrier to asking for help.

Images of athletes wiping blood from broken bodies, playing through the pain, leaving it all on the court, permeate the consciousness of any student-athlete. There is no crying in sports.

Summers said in his experience in professional and collegiate athletics, athletes are taught to be tough, and relying on others is not a prevalent attitude.

“We’re taught as a sports culture to be strong, to persevere, to handle things on our own,” he said.
Stigma persists on college campuses and nationwide, keeping many students quiet, said Taylor Swankie, co chair of Rethink Psychiatric Illness, a student organization dedicated to changing the conversation around mental health on campus.

During the sensitivity training Rethink offers to students, students are asked to agree or disagree with various statements about mental health.

When presented with the statement, “I feel the need to be strong,” every student agreed.

Many student-athletes identify entirely with this name and the sport they have dedicated their lives to. When a majority of a personal identity is ripped away by a career-ending injury, the consequences for mental health can be dire.

Physical injury, especially when it is career ending, is one of the biggest reasons students-athletes are referred to Shannon. In the aftermath of an injury, student-athletes may fear returning to the sport, or, with a career-ending injury, may need to grieve, she said.

“It’s devastating,” Shannon said. “They have to figure out who they are and have to cope with a huge loss.”

UNC Sports Medicine physicians will suggest any athlete who suffers a season or career ending injury visit a mental health professional, Waicus said.

“That’s a huge loss of identity and what their self worth and self value is wrapped up in,” she said. “We really try to make aware the resources that are available for mental health and suggest it’s completely natural.”

Student-athletes at UNC can utilize campus mental health resources such as Counseling and Psychological Services. They also have access to two sports psychologists for concerns about performance or clinical mental health. Shannon and Dr. Bradley Hack are each on campus to work with student-athletes one day per week, though they hope to increase time on campus as budgets allow.

“A lot of our teammates use our sports psychologists regularly just to check in, talk about performance, or how to handle relationships with coaches,” Summers said. “There’s an open dialogue there — a level of trust.”

Waicus said the athletic training staff at UNC knows the athletes they work with well and can often direct them to resources. She said athletes often feel comfortable with trainers.

“The way our sports medicine is set up we have trainers on field at every practice,” she said. “They’re involved in identifying injury or illness and facilitating referral to the clinic.”

About two-thirds of the student-athletes who visit the sports psychologist are referred there, Shannon said. The rest come on their own.

Summers said he would expect the channels for help seeking to be different among student-athletes.

“We would probably talk to coaches first, then they would report that and seek out the psychological resources,” he said.

In universities across the country, there should be a system in place to deal with mental illness among student-athletes, just as there is with physical health, said Heininger.

“There would be an understanding that that coach or trainer would have a responsibility to refer [student-athletes] to the right professional either within the athletic department or to whichever administrator would get them linked up to people outside,” he said. “And there would be no penalty for admitting that you’re suffering from a health issue, because you wouldn’t have that if you were suffering from any other health issue.”

Universities have a responsibility to provide mental health resources to their student-athletes, Heininger said.

“I think it would be ignorant, unfair and harmful not to have mental health support and guidelines in place for universities because mental health issues are human health issues,” he said. “These things happen to people and we shouldn’t just treat one part of it.”

“We should treat the whole person.”