Mental health is a significant issue in the United States, with approximately 18.5% of adults and 22% of adolescents having a diagnosable mental illness. Athletic trainers are in a prime position to recognize signs of mental health illness in their patients and to facilitate referral to a mental health professional.
To introduce interactive approaches for developing mental health first aid and referral skills in professional athletic training students.
Although the 2020 Commission on Accreditation of Athletic Training Education curricular content standards require programs to educate students about identification and referral for mental health conditions, the standards do not provide specific suggestions for instructing this content.
Three educational activities have been implemented into the curriculum: an exploratory counseling session, Mental Health First Aid certification, and a standardized patient encounter.
The exploratory counseling session improves athletic training students' empathy for individuals living with mental illness. The Mental Health First Aid curriculum has been shown to raise awareness of mental health conditions and positively influence the number of people who receive professional help. Standardized patient scenarios have been shown to increase critical thinking and confidence with mental health cases and to increase knowledge in mental health assessment.
Students' reflections support that these components have increased their competence and confidence in recognizing, intervening, and making referrals for individuals with suspected mental health concerns.
KEY POINTS
Professional athletic training program administrators and faculty should consider incorporating novel educational techniques such as standardized patients, exploratory counseling sessions, and Mental Health First Aid to increase competence and confidence in athletic training students' abilities to recognize, intervene, and refer in cases of suspected mental illness.
The use of standardized patients in mental health curriculum can provide professional athletic training students with authentic, real-time experience interacting with patients with suspected mental illness.
The use of reflective journaling after interactive education techniques enhances the value of the experience.
INTRODUCTION
Mental health problems are common, with 18.5% of the US adult population1 and 22% of US adolescents suffering from a mental health disorder in a given year.2 Seventy-five percent of mental health disorders will have their peak onset by the age of 25.3,4 Approximately 40% of individuals who meet diagnostic criteria for one mental illness also meet the criteria for a second illness.2 Only 41% of individuals with mental illnesses use mental health services each year, with younger adults being less likely to receive mental health services.1 The median delay from onset of symptoms to use of services is 8 to 10 years.1 In the United States, mental health illness is more common than heart disease, lung disease, and cancer combined.5 Mental health illness diagnosis increases the risk for developing other forms of chronic disease,6 with a median reduction in life expectancy among those with mental illness of 10.1 years (range, 1.4–32 years).7
Although many primary and secondary schools, as well as colleges and universities, offer mental health services, research indicates that barriers such as gender, perceived stigma, cultural competence, and peer norms may discourage prospective patients (both student-athletes and non–student-athletes) from getting appropriate treatment.8,9 Stigma associated with mental health illness serves as a powerful deterrent to an individual seeking help.10 The culture of athletics also tends to discourage athletes from expressing any kind of mental health issue. Although 33% of all college students experience symptoms of mental disorders, 30% of nonathletes seek help as compared with only 10% of athletes.11,12 One way to decrease the stigma associated with mental health problems is to educate the public and future health care providers about both the illnesses themselves and how they can help.13,14 This is particularly important for adolescents, as normal developmental changes are similar to prodromal signs of mental illness. Evidence supports that recognition of signs and symptoms of mental health conditions and knowledge of professional help and treatment options facilitate early help-seeking behaviors in individuals experiencing a mental health crisis.15 Evidence also supports that courses in Mental Health First Aid (MHFA; National Council for Behavioral Health) can improve participant knowledge and actual helping behaviors.15
Mental Health First Aid is the help offered to a person developing a mental health problem or experiencing a mental health crisis. The aid is given until appropriate treatment and support are received or until the crisis resolves. As with traditional first aid (initial injury and illness management), we recognize that professional help is not always readily available. The average person does not know how to respond to a mental health crisis, and less than 1% of the US population is trained in MHFA.16 Individuals who are certified in MHFA learn the MHFA action plan, including how to assess the situation for risk of suicide or harm, to listen nonjudgmentally, to provide reassurance and information, and to encourage appropriate professional help, self-help, and other support strategies.15 Athletic trainers (ATs) are in prime position to recognize potential signs and red flags of mental illness, and to intervene and make referral recommendations.8
Athletic trainers work closely with their patients, and patients may be more comfortable discussing a potential mental health concern with their AT than with other individuals. Although ATs receive education in their professional programs related to mental health, there is little existing research on the confidence or perceptions of practicing ATs.17,18 Current standards19 within the athletic training curriculum require formal education and training on patient-centered care (Standards 56–60), practicing in collaboration with other health care and wellness professionals (Standard 61), and identifying and referring mental health conditions (Standard 77 and 94). However, these standards are relatively broad, leaving the amount of education and method of mental health training ambiguous for athletic training programs. Curricular methods of developing mental health management for professional athletic training students should be explored and studied.
The purpose of this article is to introduce interactive approaches for developing MHFA and referral skills in athletic training students. This article will describe how the course was developed and will present a brief synopsis of each main activity presented in the course. Use of student response data in this manuscript was approved by the institutional review board.
COURSE DEVELOPMENT
Students in the Master of Science in athletic training (MSAT) program take a 2-credit course on psychosocial issues during their second year in the program. A primary focus of this course is to develop athletic training students' competence and confidence in identifying mental illness, approaching an individual with their concerns, and making mental health referrals. To this extent, 3 activities were developed to provide education and experience and to aid in the development of empathy related to mental illness. These activities included an exploratory counseling session, MHFA certification, and a standardized patient (SP) encounter (see Figure).
Exploratory Counseling Session
At the beginning of the course, the concept of stigma related to mental illness was discussed. The instructor asked the class, “How would you feel if someone told you that you had to see a counselor?” After several minutes of open discussion, the instructor informed the students that they were each going to be required to meet with a faculty member or graduate student from the counseling program to engage in an exploratory counseling session. Students were told they would be required to complete intake paperwork and attend a 1-hour individual counseling session in which they would be the patient. The purpose of this assignment was to develop empathy for an individual for whom counseling has been recommended and to gain firsthand experience with attending an on-campus counseling session. Students were told they did not have to talk about personal issues; they could use this hour to talk with the counselor about their experiences in making and receiving referrals, or strategies for initiating conversations about mental health with new patients. They were asked only to keep an open mind about the experience. Following the counseling session, students were required to submit a reflective journaling assignment (see Table 1 for a list of guided reflection questions). Once all students had attended their exploratory counseling session and submitted the reflective journal, the clinical counseling faculty member was invited to attend a class session to debrief and answer questions. Discussion topics typically centered around how to approach individuals about observations and concerns, how to develop rapport with patients coming to see one for mental health concerns, and general questions about referral and reporting, especially related to minors and mental health concerns.
One of the concerns in developing this assignment was the additional strain on an already busy college counseling center. For this assignment the athletic training program (ATP) partners with our college's master of arts in clinical counseling program. Faculty who are licensed counselors, or graduate student-interns in the counseling program supervised by licensed counselors, see the athletic training students for 1-hour appointments, and we have found this to be a mutually beneficial experience. Despite national data indicating that university students' attitudes toward seeking mental health services have actually become more negative over the past 40 years,9,20 over the 6 years of implementing this assignment, across 2 different institutions, there has been a positive change in perception of students engaging with this assignment. Six years ago, the majority of students had a very negative attitude about going to see a counselor, and few (if any) admitted to having seen a counselor in the past. In the last 1 to 2 years, students' attitudes about this assignment have been overwhelmingly positive, with many students looking forward to the opportunity to try out a counseling session, and with others openly discussing their previous experience with counselors and their own mental health concerns and illnesses. Sample student reflections (via reflective journaling) from years 1 and 2 versus years 5 and 6 are provided in Table 2.
This positive shift in professional graduate athletic training students may be a function of the increase in positive messaging about mental health coming from the National Collegiate Athletic Association, the National Athletic Trainers' Association, and various other youth, intercollegiate, and professional sport organizations and athletes. Student reflections of this experience have been extremely valuable, with students recognizing how this experience will benefit their ability to talk with patients about referral and what to expect as part of a counseling session when these situations arise during their professional career. Examples of student reflection comments are included in Table 3.
MHFA Certification (National Council for Behavioral Health)
As part of the course, all students participated in the copyrighted MHFA adult curriculum (there is also a youth course, designed for adults helping young people ages 13–17). The MHFA course involves 8 hours of instructor-led content, including small and large group discussions, role-playing activities, mental health scenarios, and educational videos. Students learned the MHFA action plan (outlined previously) and became certified in MHFA through the course; this certification is valid for 3 years.
Our program elected to have 1 faculty member become instructor certified in MHFA; however, there are other options to bring MHFA into your program. The MHFA Web site (https://www.mentalhealthfirstaid.org) allows you to search for available courses in your area, or you can contact a local instructor to see if the instructor will come to your institution to offer the course to your group. Mental Health First Aid also offers a hybrid course, which involves 2 hours of self-paced online learning followed by 5 hours of instructor-led content. This hybrid option may be a better fit for programs with limited class time to devote to MHFA. Research has shown that the MHFA training increases participant knowledge and confidence in providing help to someone in need.21 It has also been shown that MHFA has the ability to raise awareness of mental health conditions and positively influence the number of people who receive professional help.21
Students from our program who completed the MHFA course have responded very positively. One student commented,
It made me more confident in the correct approach and management process with mental health conditions. Prior to this course, I was nervous and awkward about whether I was being too forward to a patient or not pushy enough in steering them in the proper direction.
Other student feedback collectively agreed that the course increased students' knowledge and made them more open to discussing mental health conditions with patients and others in their lives. Students also appreciated the additional certification that they received after participating in the MHFA course.
SP Encounter
The SP encounter was the culmination of the unit on mental health and referral. Students worked in pairs to interact with an individual in a live simulated clinical encounter involving nonsuicidal self-injury; this encounter was video recorded to allow for student review. In accordance with recommendations by Armstrong and Walker,22 faculty developed educational goals for the encounter, then collaborated with ATs employed by a local health network to develop a case to be used both in our professional MSAT program and by certified ATs employed by the health network. The network has access to a simulation center that incorporates high- and low-fidelity simulators and SPs. We worked with the director of the simulation center to refine the case, and she then worked with several of the network's SPs to train them on the specific case. Each SP attended three 1-hour training sessions with the simulation center director. During the first session, the director reviewed the script and case materials with each SP; in the second and third sessions, the director and patient role-played the scenario to ensure the SP's confidence and comfort with the role.
On the day of the SP encounter, students participated in a 10-minute orientation (outlined below), followed by the 20-minute SP encounter, a 5- to 10-minute individual debrief with the SP, and a 20-minute large group debrief with the course instructor. Students interacted with the SP in pairs, and we had 5 SP rooms going simultaneously. The entire student time for this exercise was 1 hour, and this was repeated twice to allow all students to participate in the encounter.
As part of the orientation, students were given the following information:
The purpose of this SP encounter is to give you authentic practice interacting with an individual with a mental health concern or experiencing a mental health crisis.
Often ATs feel unprepared to deal with mental health concerns, so it is important to role-play these types of scenarios to help ATs become more comfortable approaching patients about both mental and physical health concerns.
Remember your MHFA training and the 5-step action plan. Remember that it is OK to allow for silence and to tell yourself to WAIT (why am I talking?).
Students were given “doorway information” about the SP (a brief paragraph about the scenario, including the patient's name, age, and relevant background information; see Table 4), then entered the room. They then practiced applying the MHFA action plan to access the individual, try to understand what the individual was experiencing, and determine whether a mental health referral was needed. Following the SP encounter, both the SP and each student completed a survey related to the students' attitudes and behaviors in the encounter. The SP then debriefed with the pair of students and shared how he or she felt during various parts of the encounter, and then the whole class debriefed with the instructor. After the experience, students were required to view their recorded encounter and submit a reflection paper regarding the experience (please see Table 5 for a list of debriefing and reflection questions).
Previous research has explored SP encounters in athletic training education, including encounters specific to psychosocial intervention and referral skills. These studies have found that small-group SP encounters can improve athletic training students' psychosocial intervention and referral skills (based on objective measurement)23 and students' confidence in their ability to perform psychosocial intervention and referral.24 Although not specific to psychosocial topics, previous research has found SP encounters to be useful instructional techniques for ATs to promote self-reflection and to translate newly learned skills to their clinical practice,25 and that students' confidence in their clinical evaluation techniques improved after each encounter.26
The SP encounter has been one of the most well-received aspects of any course in our program. Students value the opportunity to interact with a “real patient,” without a preceptor involved, in a safe space and increase their confidence in their ability to do this as part of their clinical practice. Standardized patient encounters have long been used within medical and nursing education, and, although more research is needed to show the long-term outcomes of using SPs, research27–30 supports that students have improved critical thinking and confidence with mental health cases and increased knowledge in mental health assessment as a result of these SP encounters. The real-life scenarios help the students not only to enhance patient care and communication, but also to gain a realistic perception of the role health care clinicians have in the management of these important conditions. Examples of student reflection comments (provided via reflective journaling) are included in Table 6.
Reflective journaling has been used as an educational strategy in nursing and psychology31 education programs to support the development of critical thinking and to enhance decision-making. Reflective journaling has been touted as an effective way for teachers to gather important information about the clinical application and decision-making process for frontline providers.31 Purposefully engaging in critical thinking dispositions may help prevent negative patient outcomes.32 Specific to mental health clinical education, students have reported that reflective journaling provided them opportunities for self-reflection, leading to increased understanding of patients' perspectives and mental health competency.33 This type of reflective journaling meets Commission on Accreditation of Athletic Training Education Curricular Standard 67 related to self-assessment of professional competence.19 Although this course is designed as a stand-alone course in our ATP, the various activities related to mental health could easily be incorporated into various courses spread across the curriculum. Future research efforts should examine the objective impact on student competence and confidence related to mental health educational standards.
Clinical Advantages
There are several clinical advantages of incorporating these activities, in isolation or together, into a professional athletic training program. We have found that the exploratory counseling session improves athletic training students' empathy for individuals living with mental illness. Despite national increases in negative attitudes toward seeking mental health services, we have seen a positive change in perceptions of students after engaging with this assignment. The assignment also offers the athletic training program the opportunity to partner with a clinical counseling program. This is a mutually beneficial experience, as not only do our students learn referral strategies and conversation openers, but counseling students understand the role of ATs within the broader health care network.
Related to MHFA, students' reflections support that this curriculum increased their competence and confidence in recognizing, intervening, and making referrals for individuals with suspected mental health concerns. Students' feedback was that the MHFA curriculum increased their knowledge and made them more open to discussing mental health conditions with patients and others in their lives. Athletic trainers are in prime position to recognize potential signs and red flags of mental illness and to intervene and make referral recommendations, so this increased knowledge and confidence is important in early intervention for mental health concerns. Students also appreciated the additional certification that they received after participating in the MHFA course. Finally, the SP encounter provided students with an authentic opportunity to interact with a simulated patient. This real-life scenario improved students' patient communication strategies and has been shown to increase critical thinking and confidence with mental health cases.
Future Considerations
Although these 3 activities have worked well in our professional MSAT program, there are some limitations to be noted, one of which is the reliance on some external parties to make these activities successful. The exploratory counseling session requires partnership with your institution's counseling department or counseling education program. The MHFA curriculum requires access to an individual who is a certified instructor and can deliver this training to students in your program. The SP encounter requires, at a minimum, the time to develop a SP case and space for the encounter and debriefing. There are also external costs associated with some of these activities. The MHFA course requires each participant in the 8-hour session to purchase the manual ($18.95 each), or each participant in the hybrid course to purchase a seat to access the online coursework ($29.95 each). There may also be instructor costs for the face-to-face content, depending on what is available in your area. Finally, depending on who you use as SPs and to train the SPs there may be a cost associated with their time; at our institution we paid SPs $20 per hour.
Related to quality improvement, we have some suggestions. The 3 techniques introduced in this paper can each be used independently or can be threaded together as we do in our program. We have found that incorporation of the MHFA training and engagement in the exploratory counseling session before the SP scenario has resulted in increases in students' confidence, both in their ability to interact with the SP in the encounter and in their ability to apply MHFA actions (including mental health referral) with real patients in their clinical practice. Also related to the SP encounter, we have found that groups of 2 are ideal for this type of scenario. In years in which we had students interact with the SP alone, they reported feeling extremely anxious entering the scenario and retained less of the experience because of their high stress level. In years in which we had students interact with the SP in groups of 3, there was a tendency for one student to take over the encounter, and at least one student in each group felt like he or she didn't have the opportunity to contribute. With groups of 2, when one student felt that he or she drew a blank the other student could jump in, and the students communicated well with each other and with the SP.
CONCLUSION
The program's goal was to construct a set of experiences designed to increase students' competence and confidence in identifying, discussing, and referral of mental health concerns. Through a scaffolded approach, including patient scenarios and role-plays in the MHFA curriculum and the SP scenario, students had the opportunity to practice having conversations with individuals displaying signs and symptoms of mental illness. The andragogic methods used in this 2-credit course were strategically chosen to actively engage students in multiple experiences designed to build competence, confidence, and empathy. Student reflections attached to techniques indicated that students gained the desired outcomes and appreciated the experiences.