Adolescence and young adulthood are the periods of onset for most mental health disorders.1 Early identification and management of such disorders in the contexts in which adolescents and young adults live, learn, work, and play is critical for reducing their health burden.2 Estimates of the prevalence of depression and anxiety among high school and college athletes are approximately the same as their non-athlete peers.3–6 However, compared to their non-athlete peers, college athletes often face additional barriers to seeking professional psychological help, such as a belief that care seeking will impede their performance or be viewed as “weak.”7–12 More than 8 million high school students13 and more than 500,000 college students14 participate in organized interscholastic sports every year and the identification and management of mental health disorders is being increasingly recognized as an important issue in these settings.15,16
Social cognitive theory17 is useful for framing our thinking about mental health help seeking broadly and among athletes in particular. It is based on the premise of the triadic reciprocal relationship between the individual, his or her environment, and his or her behavior.17 At the individual level, Eisenberg et al.18 described an appraisal process prior to seeking help in which individuals decide that they need professional help and then weigh the costs and benefits of seeking that help. At a more general level, this appraisal process can be viewed as part of an individual's stress response.19 When an individual experiences a stressor, be it related to mental illness or otherwise, that individual appraises the challenge and then employs a coping strategy.20 Coping strategies that an individual can employ range from avoidance to confrontation to problem solving.20 In general, employing positive coping skills when approaching a challenge, such as problem solving or using positive reappraisal, is associated with more satisfactory outcomes.20
A sport environment is a controlled setting where such positive coping skills may theoretically be learned because individuals encounter repeated and relatively low-stakes challenges and setbacks and can experientially learn the benefits of different approaches to coping with challenges.21–25 Data from the achievement orientation literature indicate that individuals tend to respond more proactively to setbacks when focus is placed on effort rather outcome.26 This type of process orientation is functional on the sports field because it can help keep challenges in perspective and foster continued effort and positive focus in the face of adversity.27–31 Theoretically, individuals who internalize a positive, process-orientated coping style on the sports field may be more willing to seek professional psychological help when faced with a mental health challenge. For example, in their cost–benefit appraisal of help seeking, such individuals may weight improvement and growth more strongly than someone who has a less process-oriented coping style. Such individuals may also view externally visible markers of “failure” less negatively because their focus is on improvement and growth. However, such an adaptive mindset is not the inevitable consequence of exposure to repeated challenges in the sports context. Compounding dispositional differences in coping,32 the extent to which different coping strategies are learned and employed in sport environments, depends on direct instruction, modeling, and reinforcement provided by the individuals surrounding the athlete.33
Consistent with social cognitive theory, an athlete's appraisal of mental health care seeking may also be influenced by his or her expectations of the consequences of help seeking in his/her environment. One key element of this appraisal process is perceived stigma,18,34 which is an individual's perceptions of the negative stereotypes and prejudice regarding mental illness held by others.18,35,36 For example, others may be perceived as viewing individuals with mental illnesses as untrust-worthy or less likely to perform well athletically. Prior research has indicated that college athletes perceive greater stigma related to mental illness as compared to their non-athlete peers.37 Social cognitive theory guides us to think about how context, when broadly framed,38 may shape the stigma that athletes perceive. At the macro level, this may include cultural narratives about what it means to be an athlete. One frequently described challenge for the identification and management of mental health issues among athletes is the legacy of traditional masculinity as a defining aspect of sport, in which self-reliance and playing through pain are often normative and highly valued. Athletes who conform more strongly to these traditional gender norms are less likely to seek psychological help.39,40 Performance of these normative behaviors is often reinforced within the sport microsystem. Through direct instruction, modeling, and reinforcement, coaches communicate to team members the extent to which certain behaviors are valued41–45 and, in doing so, play a large role in shaping team norms. Thus, perceived coach stigma related to mental health may theoretically influence athletes seeking help through the appraisal process of the costs and benefits of seeking help. However, no research to date has examined how these beliefs are associated with the athlete's own mental health help seeking.
Ensuring that all athletes who are experiencing mental health challenges receive appropriate care is important for reducing the health burden of mental illness. Grounded in social cognitive theory, the current study sought to test the hypothesis that athletes who perceived less coach stigma and had more positive coping skills would have attitudes more supportive of seeking psychological help. On average, it was expected that females would have attitudes more supportive of help seeking than males given the gendered differences outside of the sport environment in the reinforcement provided for help seeking.46,47 The current study is a step toward developing a comprehensive and contextualized model of why athletes seek care for mental health concerns, with the goal of helping to shape sport environments to positively influence this process.
Sample and Procedure
Participants were student-athletes competing at one of four colleges located in the United States. Participating colleges were a convenience sample included on the basis of their pre-existing agreement to participate in an educational program related to mental health. Data were collected prior to delivery of this educational programming. Within the participating colleges, team participation was voluntary on the basis of coach interest or athletic department recommendation. Within the participating athletic teams, survey completion was voluntary. A total of 644 student-athletes chose to complete at least some of the survey questions relevant to the current study (college 1, n = 200; college 2, n = 160; college 3, n = 64; college 4, n = 220). Surveys were completed online and accessed through an e-mailed link hosted on the Qualtrics survey platform (Qualtrics, Provo, UT). The study was approved by the Seattle Children's Hospital Institutional Review Board.
Positive Coping. Positive coping skills were measured using the coping with adversity subscale of the Athletic Coping Skills Inventory.48 This 4-item scale measured the athlete's mindset and behaviors when facing challenges. An example item is “I remain positive and enthusiastic during competition no matter how badly things are going.” Items were scored on a 4-point scale ranging from (0) almost never to (3) almost always and summed to create a scale with a possible range of 0 to 12. Internal consistency reliability was adequate in the current sample (Cronbach's alpha = 0.74).
Coach Stigma. Perceived coach-endorsed stigma related to seeking mental health treatment was assessed using an adapted version of Eisenberg et al.'s18 approach to measuring perceived public stigma. Three items were provided to determine what athletes believed their coaches thought about an individual who sought mental health care. A sample item was “My coach would think less of someone who has received mental health treatment.” Each item was scored on a 6-point scale, with response options ranging from (1) strongly disagree to (6) strongly agree and a possible summed range of 3 to 18. Internal consistency reliability was adequate in the current sample (Cronbach's alpha = 0.83).
Attitudes Toward Psychological Help Seeking. Athlete attitudes toward seeking help from a mental health professional were measured using the Attitudes Towards Seeking Professional Psychological Help scale.49 Response options were (0) disagree, (1) partly disagree, (2) partly agree, and (3) agree. This 10-item scale had a possible summed range of 0 to 30, with attitudes that were more supportive of seeking professional psychological help indicated by higher scores. Internal consistency reliability was adequate in the current sample (Cronbach's alpha = 0.80).
Depression. Athlete depression was measured by the Patient Health Questionnaire-9.50 This 9-item scale measured depression severity by asking how frequently the respondent had been bothered by a series of issues during the 2 weeks prior to the survey. Items were scored on a 4-point scale, with response options of (0) not at all, (1) several days, (2) more than half the days, and (3) early every day. Responses were summed to create a scale with a possible range of 0 to 27. Cut-off scores for mild, moderate, moderately severe, and severe depression were 5, 10, 15, and 20, respectively, which are the recommended cut-off scores for clinical referral but are not in and of themselves diagnostic thresholds.50
Demographic Characteristics. Athletes indicated their gender and year in school.
Pearson pairwise correlations were calculated for the association between all continuous model variables (attitudes toward help seeking, positive coping, coach stigma, and depressive symptom scores), with Bonferonni correction for multiple comparisons. Spearman correlations were conducted between gender and the other model variables. Normality of the dependent variable (attitudes toward help seeking) was assessed using the Shapiro–Wilk normality test and normality of residuals was visually inspected. As assumptions of linear regression were met, a series of linear regression models were subsequently tested, beginning with a model including individual and contextual covariates (depressive symptomatology, gender, and school). To test the primary study hypothesis, coping skills and perceived coach stigma were then added to the final multivariate model. A P value of less than .05 was considered statistically significant. Analyses were completed using STATA Data Analysis and Statistical software (version 14.2; STATA, College Station, TX).
Most participants were male (57.36%) and first year students (53.34%). Eighteen different sports were represented in the sample, with most participants from track and field (17.75%), lacrosse (17.59%), and football (12.68%). The average Patient Health Questionnaire-9 score was 3.28 ± 4.43, with 7.04% of participants exceeding the cut-off score for moderately severe depression. One in five (20.34%) athletes had a perceived coach stigma score of 10 or more, indicating that they slightly agreed, agreed, or strongly agreed with the statements about coach stigma. Additional descriptive characteristics of the sample are provided in Table 1.
Descriptive Characteristics of a Sample of United States Collegiate Athletes
Pairwise correlations indicated that there were statistically significant associations between greater perceived stigma and lower coping skills and depressive symptom-atology. The mean resilient coping score for the sample was 6.98 ± 2.39. Pairwise correlations indicated that higher coping scores were statistically significantly associated with attitudes more supportive of seeking professional psychological help, lower coach stigma, and lower depressive symptom scores. Females had lower coping scores than males. All pairwise correlations are reported in Table 2.
Correlations Between Measured Variables in a Sample of United States Collegiate Athletes
Next, a series of linear regression models were tested (Table 3). In a model including depressive symptomatology, gender, and school, all variables were significantly associated with attitudes toward seeking professional psychological help and 5% of the variability in the athletes' attitudes toward seeking psychological help was explained. Males had attitudes that were more supportive of seeking psychological help than females. In a bivariate model, postive coping skills were associated with athlete attitudes that were more supportive of seeking psychological help, explaining 4% of the variability in this measure. Perceived coach stigma was not statistically significantly associated with athlete attitudes. When coping skills and perceived coach stigma were both included in a multivariate model controlling for depressive symptomatology, gender, and school, both lower perceived coach stigma and greater coping skills were associated with attitudes that were more supportive of seeking psychological help. This model explained 8% of the variability in athlete attitudes.
Linear Regression Models Predicting Attitudes Toward Seeking Professional Psychological Help in a Sample of United States Collegiate Athletes
Given concerns regarding the consequences of untreated mental health disorders and low rates of help seeking among adolescent and young adult athletes, removing barriers to care seeking for mental health concerns is an area of growing focus for sports organizations.15,16 The prevalence of depressive symptomatology in the current study supports the relevance of this issue. Although few participants met the criteria for major depression, approximately 25% of the participants reported depressive symptomatology that exceeded the threshold for mild depression in the 2 weeks prior to taking the survey. Given the importance of early initiation care, many of these individuals may benefit from additional evaluation and potential professional support before symptomatology and psychosocial comorbidities worsen.
The primary hypothesis tested in this study was supported: athletes who had more positive coping skills and perceived less coach stigma had attitudes that were more supportive of seeking professional psychological help. Interestingly and counter to what was hypothesized, females had attitudes that were less supportive of seeking professional psychological help than males and had lower levels of positive coping skills. Whereas females in the broader population are viewed as having better coping skills and a greater willingness to seek help on average,46,47 the sport environment may theoretically select for female athletes who strongly subscribe to the traditionally masculine ethos that is viewed as characteristic of sports. Consistent with social cognitive theory's triadic reciprocal relationship between individual cognitions, environment, and behavior,17 it is also possible that some female athletes excessively conform to this ethos when in the sports environment to “prove” that they belong. Thus, when appraising the challenge and their possible response, they may be considering external perceptions about the gendered framework through which their care seeking might be perceived. When thinking about care seeking for a mental health issue, they may consider whether others would view such behavior as traditionally feminine and not characteristic of a “good” athlete. Additional research is needed to explore this unexpected finding. In the meantime, it is a reminder that we should hold beliefs about the universality of gender differences in mental health help seeking lightly and subject them to empirical scrutiny.
Given prior evidence of the strong role of coaches in shaping team cultures regarding help seeking for other injuries,41–45 it was hypothesized that athletes who perceived greater coach stigma would have attitudes that were less supportive of seeking professional psychological help. This hypothesis was supported in the multivariate regression model, and one-fifth of the participating athletes indicated that they perceived at least some coach stigma. However, coach stigma explained only a small amount of the variability in the athletes' own attitudes toward help seeking.
It is possible that the association between perceived coach stigma is largely explained by differences in a given athlete's own depressive symptomatology. Prior literature suggests that depressive symptomatology is typically associated with greater perceptions of stigma.51–53 However, in the current study, athletes with less depressive symptomatology perceived more coach stigma. It is possible that athletes who have psychological concerns have had the opportunity for positive interactions with coaches related to seeking psychological help. Those who have not had this opportunity for experiential learning may make assumptions regarding coach attitudes based on what they perceive cultural norms to be in the sport context, rather than based on direct interactions with their coach. If the directionality of this relationship is substantiated in subsequent research, it speaks to the potential need for coaches to speak more openly about mental health help seeking to dispel misperceptions about their own attitudes toward the issue. Although additional research is needed to explore the heterogeneity of how stigma is communicated to and experienced by athletes, it is important to note that the current findings suggest that perceived coach stigma is a relatively minor influence on athletes' own attitudes toward seeking professional psychological help.
The significant association between positive coping skills and attitudes that are supportive of seeking professional psychological help raises the possibility that coping skills learned on the sports field may have benefits off the field of play.54–60 Consistent with social cognitive theory,17 athletes have routine exposure to challenges (eg, close competition, loss, and injury) that provides them with the opportunity to respond to environmental demands using different coping strategies and experience the internal and external contingencies of these decisions. It is possible that athletes who have learned to implement a more positive and process-oriented approach to challenging situations through their sport experiences may theoretically view seeking psychological help as supportive of growth rather than an indication of failure.
This finding introduces a potentially promising strategy for acceptable and sustainable intervention. Positive coping skills have the well-established athletic benefit of helping to maintain focus and effort during the inevitable ups and downs of competition.27 Interventions designed for the sport environment that have a positive focus and “hook” of sport performance are often more acceptable to athletes and coaches and, therefore, more easily implemented.61 Thus, when thinking about how to intervene to promote mental health help seeking in the sport setting, one strategy may be to take a step back from a focus on mental health pathology and instead view mental health on dual continuums, not only minimizing pathology but also optimizing positive functioning.62
Developing positive coping skills would fall into the category of optimizing positive functioning and sport performance63 and the current results suggest that doing so may have the secondary benefit in terms of care seeking for mental health pathology. Additional program development and evaluation work is needed to understand how to best support coaches in shaping a positive environment that is both directly and indirectly supportive of mental health help seeking. This may include adapting existing sport- and movement-focused coping skills interventions.64,65 Efforts may also be less structured, ensuring that coaches are aware of how to instruct, model, and reinforce positive coping strategies on the sports field.
Regardless of the form that coach education takes, adult learning theory underscores the importance of connecting educational materials to the needs and priorities of learners.66 Thus, additional research is needed to determine what the needs and priorities of coaches are as related to mental health and the barriers the coaches would face in implementing strategies to foster a positive coping style among athletes. One possible priority of the coach is likely related to optimizing athletic performance. Thus, it may be useful to frame messaging for coaches around how a positive coping style can lead to benefits on the field of play. It may also be useful to engage successful coaches who already implement positive coaching practices to serve as champions for such approaches, such as sharing a narrative about their experiences within a video or online learning program.67
A core feature of the literature on positive youth development through sport is the importance of considering the many nested and overlapping contexts in which athletes live, work, learn, and play.68 Although the current study focused on two theoretically informed cognitions predictive of attitudes toward seeking psychological help, we need to situate these attitudes in a broader ecological system. These attitudes are likely a product of team and school organizational structures, priorities, and pressures. In the multivariable analysis, there were significant differences in attitudes toward help seeking between schools. This might reflect different institutional cultures about help seeking or different perceived access to psychological resources. Therefore, the current study can be viewed as a starting point for understanding how experiences in the sport context influence mental health help seeking. Caution is warranted because a minimal amount of the variability in attitudes toward help seeking was explained. Future research is recommended to take a social ecological approach that seeks to understand both individual and contextual determinants of help seeking behavior and reasons for between-school variability.
Participation was voluntary and it is possible that coaches who are more interested in mental health (and potentially those coaches who have fewer stigmatizing attitudes related to mental health help seeking) were more likely to encourage their team to participate in the survey. At the individual level, participation was voluntary and it is possible that athletes who had attitudes more supportive of mental health were more likely to choose to complete the survey.20 Additionally, the study was cross-sectional and the results explained only a small fraction of the variability in attitudes toward seeking mental health care. It is possible that the cross-sectional associations found to be significant in this study were explained by other unmeasured variables. There is a need to expand this work to assess the influence of other contextual and individual characteristics of these attitudes and to determine the extent to which attitudes are predictive of behavior in this population.
Implications for Clinical Practice
Decreasing barriers to mental health care seeking among athletes requires consideration of the range of ways in which the sport environment shapes attitudes toward help seeking. Although reducing perceived stigma is undoubtedly an important universal goal, the current findings suggest that we should think about creating supportive environments through a broader lens. Sports can help develop positive psychological skills that facilitate healthy coping, which may have secondary benefits in terms of attitudes toward seeking professional psychological help. Coaches can play an important role in shaping environments supportive of these behaviors. Individuals involved in developing education for coaches or providing informal instruction and support to coaches should help coaches reinforce the importance of developing positive coping skills on the sports field. Sports medicine staff are in a position to play an important role in formal and informal coach education related to psychological help seeking. Future work in this area should explore the role of the sports medicine team, through their formal educational efforts and informal interactions with athletes and coaches, in helping to shape attitudes that are supportive of psychological help seeking.
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Descriptive Characteristics of a Sample of United States Collegiate Athletes
| Female||42.64% (281)|
| Male||57.36% (378)|
|Year in school|
| First||53.42% (344)|
| Second||18.32% (118)|
| Third||13.66% (88)|
| Fourth||12.58% (81)|
| Fifth||1.71% (11)|
| Missing||0.31% (2)|
|Positive copinga,b (mean ± SD)||6.98 ± 2.39|
|Perceived coach stigmab,c (mean ± SD)||6.57 ± 3.05|
|PHQ-9b||3.29 ± 4.43|
| PHQ-9 score < 5||68.63% (442)|
| PHQ-9 score ≥ 5 and ≤ 10||15.68% (101)|
| PHQ-9 score ≥ 11 and ≤ 15||5.12% (33)|
| PHQ-9 score ≥ 16 and ≤ 20||2.17% (14)|
| PHQ-9 score > 20||1.09% (7)|
| Missing||7.30% (47)|
|Attitudes toward seeking psychological helpb,d (mean ± SD)||14.85 ± 3.31|
Correlations Between Measured Variables in a Sample of United States Collegiate Athletesa
|Variable||Attitudes Toward Help Seeking||Positive Coping||Coach Stigma||Patient Health Questionnaire-9||Gender (ref = male)b|
|Attitudes toward help seeking||–|
|Patient Health Questionnaire-9||0.03||−0.28d||−0.24d||–|
|Gender (ref = male)||−0.12c||−0.20d||−0.04||0.16d||–|
Linear Regression Models Predicting Attitudes Toward Seeking Professional Psychological Help in a Sample of United States Collegiate Athletes
|Variable||Model 1 (Beta)||Model 2 (Beta)||Model 3 (Beta)||Model 4 (Beta)||Model 5 (Beta)||Model 6 (Beta)|
|B (SE)||P||B (SE)||P||B (SE)||P||B (SE)||P||B (SE)||P||B (SE)||P|
|Positive coping||0.22 (0.06)||< .001||0.21 (0.06)||< .001|
|Coach stigma||0.08 (0.04)||.074||−0.31 (0.08)||< .001|
|Patient Health Questionnaire-9||0.02 (0.03)||.480||0.08 (0.03)||.009|
|Gender (ref = male)a||−0.80 (0.27)||.003||−0.71 (0.27)||.010|
|School (ref = college 1)b|
| College 2||1.29 (0.36)||< .001||1.37 (0.35)||< .001|
| College 3||0.69 (0.48)||.152||0.59 (0.47)||.213|
| College 4||< 0.01 (0.33)||.993||−0.03 (0.33)||.927|