Barriers to and Facilitators of Collegiate Athletes Seeking Mental Health Services

Participants consisted of 266 student-athletes (women = 53.8%, White = 42.5%) who represented an entire NCAA Division I athletic department. Recruits were drawn from 11 sports. Detailed demographic information is provided in Table 1.

After an extensive review of the literature,^13,14,17,18  we identified 9 internal factors (ie, beliefs, knowledge, and attitudes) that have been supported as possible barriers to athletes seeking mental health care. Each of the 9 factors, written as statements, was presented to the student-athletes with the following prompt: “Which of the following would keep you from using the mental health services that are available to you as a student-athlete?” Each factor as presented to the student-athletes is listed in Table 2. For each factor, participants selected yes or no to indicate if they thought the belief or attitude would keep them from using available mental health services. The response to each belief or situation served as its own outcome.

Also extending from our literature review,^17–19  we identified the 7 key stakeholders who surround and influence college student-athletes. Each stakeholder was presented independently to the student-athletes with the following question: “For each person listed below, if they had a negative attitude about seeking help for psychological concerns, would that keep you from using the mental health services that are available to you as a student-athlete?” The 7 stakeholders are listed in Table 3. The response to each stakeholder (ie, yes or no) served as its own outcome.

Consistent with the matching hypothesis²⁰  and based on our review of the pertinent research, we categorized 10 key identities (eg, race, sex, and athlete status). Each identity was presented independently in the following prompt: “If you were going to seek mental health care from a sport psychologist, how important would it be for your sport psychologist to…” Then, for each identity, such as “…be of the same race/ethnicity” or “…share your sexual identity,” athletes responded from 1 (not at all important) to 5 (extremely important). The identities are listed in Table 4, and the response to each identity served as its own outcome.

Although the term sport psychologist may suggest a sport, performance, or mental skills focus to some, in this university’s athletic department, all the sport psychology staff were part of an American Psychological Association–accredited counseling psychology doctoral program that had an integrated specialization in sport psychology. The doctoral program had been providing the sport psychology or mental health services for this athletic department for the last 25 years; all services were overseen or supervised by licensed psychologists (who were also trained in sport or performance). Further, mental health screening and education had been ongoing in this athletic department for 10 years, and the athletes, coaches, and staff were aware that the sport psychology staff provided both mental health care and more traditional sport psychology services. Therefore, for this sample of collegiate athletes, responses reflected how important they believed each identity was in relation to seeking help from someone they understood to provide mental health care.

Our university’s institutional review board approved the study. As part of their 2020 to 2021 mandatory annual mental health screening, student-athletes completed the items in this study (a copy of the full mental health screening survey is available upon request). Review of the research items was performed by 12 doctoral-level counseling or sport psychology students and their professor. Student-athletes were sent the online survey link, which was hosted on Qualtrics, and then voluntarily consented for their data to be used in this research project (84.2% consented). The review focused on item clarity, adherence to what had been identified in past research, and ease of completion. The entire survey took approximately 10 minutes to complete; as part of the screening process, student-athletes were informed that their data would not be shared with their coaches and would be part of their confidential medical record. Although student-athletes provided their names and contact information as part of the mental health screening to facilitate treatment follow-up as needed, this identifying information was removed from the research dataset. The student-athletes received no compensation for their participation.

Statistical analyses were conducted using SPSS (version 25.0; IBM Corp). For each set of barriers, internal (eg, beliefs and attitudes) and external (eg, perceptions of stakeholders), we computed how frequently the athletes endorsed each item (ie, responded yes). To examine differences in the athletes’ endorsement of each item within the set of barriers (eg, among all 9 internal factors), we conducted a repeated-measures analysis of variance, with each set of barriers (eg, the 7 stakeholders) serving as the within-subject factor and gender (men versus women; no athlete selected any other gender identity) and race (due to the numbers of the racial identities selected by the student-athletes [see Table 1], they were grouped as White or Athletcs of Color) as the between-subjects factors. Thus, we conducted this analysis separately for the ratings of the stakeholders and for the athletes’ internally held beliefs or attitudes. We were specifically interested in the within-subject main effect as well as its possible interaction with either of the between-subjects variables. For significant within-subject effects, we conducted least significant difference pairwise comparisons to differentiate the student-athletes’ ratings across each set of items.

For the identity items, we first computed the mean and SD for each; all items were normally distributed based on skewness, kurtosis, and outliers. Similar to the barrier analyses, we used a repeated-measures analysis of variance, with the identity items as the within-subject variable and gender and race as the between-subjects variables. Among the sample of 266, some athletes did not provide data for each set of barriers and identities. Because of the nature of the data (ie, each question serving as its own outcome), we could not use traditional procedures to replace the missing values. Therefore, the number of participants in each analysis differed slightly and is stated in each section of the results. We set α at .01 for all analyses to control the family-wise error rate.

The interactions of the student-athletes’ perceptions of their beliefs or attitudes by their gender and race (F_6.91,1719.99 = 19.942, P = .096, η²_p = .007), their perceptions by gender (F_6.91,1719.99 = 2.179, P = .034, η²_p = .009), and their perceptions by race (F_6.91,1719.99 = 1.930, P = .052, η²_p = .008) were not significant. However, the main effect for the student-athletes’ perceptions of the internal barriers was significant (F_6.91,1719.99 = 2.72, P < .001, η²_p = .074), suggesting that they viewed the items differently as potential barriers to seeking help.

From the post hoc least significant difference analysis, we found that, regardless of the athletes’ gender or race, a lack of knowledge about mental health disorders and symptoms (mean ± SE = 0.420 ± 0.032), having a negative attitude toward seeking help (0.383 ± 0.031), a lack of confidence that mental health treatment will be effective (0.391 ± 0.031), a belief in your own self-reliance (0.490 ± 0.031), and not enough time in your schedule (0.487 ± 0.031) were the most frequently endorsed internal barriers. Although their ratings of these 5 barriers did not differ from one another, all were perceived as barriers by more athletes than was having had a previous negative experience with a sport psychology provider (0.255 ± 0.028) and lacking support from family members for seeking mental health care (0.198 ± 0.026; Table 2).

The interactions of athletes’ perceptions of each stakeholder by their gender and race (F_4.65,1177.45 = 0.620, P = .673, η²_p = .002), stakeholder perceptions by gender (F_4.65,1177.45 = 1.005, P = .410, η²_p = .004), and stakeholder perceptions by race (F_4.65,1177.45 = 0.443, P = .806, η²_p = .002) were not significant. However, a significant main effect was evident in the student-athletes’ perceptions of the stakeholders as barriers to mental health help-seeking (F_4.65,1177.45 = 9.461, P < .001, η²_p = .036). The post hoc analysis indicated that the student-athletes, regardless of gender and race, were more likely to endorse their head coaches (0.323 ± 0.030) as a barrier to their help-seeking than any other stakeholder; the next closest stakeholder was assistant coaches (0.267 ± 0.028; Table 3).

The interaction of the importance of sharing identities or characteristics by athlete gender and race (F_6.69,1646.07 = 1.857, P = .037, η²_p = .009) and the importance of sharing identities or characteristics by race (F_6.69,1646.07 = 2.339, P = .024, η²_p = .009) were not significant. However, the importance of sharing identities or characteristics by gender interaction (F_6.69,1646.07 = 3.354, P = .002, η²_p = .013) and the importance of sharing identities or characteristics main effect (F_6.69,1646.07 = 30.792, P < .001, η²_p = .111) were significant.

Although the athletes’ mean ratings of the importance of each identity were below the midpoint of the scale (ie, 3), suggesting that they did not believe it was important that a sport psychology consultant hold any of the stated identities, significant differences were present even among their lower ratings. Through the post hoc analyses, we found that the most important identities or characteristics were being able to discuss similarities and differences in identities (2.25 ± 0.09) and having been at least a collegiate-level athlete (1.92 ± 0.07). Student-athletes also rated having played the same sport (1.77 ± 0.07) as more important than many of the other identities or characteristics. Of the demographic identities (eg, gender, race, age, socioeconomic status), gender was rated as the most important identity (1.63 ± 0.07; Table 4).

Regarding the gender-by-importance interaction, only 1 effect was significant. Male and female athletes differed when rating the importance of a sport psychology consultant matching their gender identity. Specifically, women (1.816 ± 0.09) indicated that sharing the same gender identity was more important than it was for men (1.454 ± 0.11).

We investigated student-athletes’ perceptions of potential barriers (internal and external) and facilitators of seeking mental health care. Regarding internal barriers (ie, the athletes’ own beliefs or attitudes), regardless of the student-athletes’ gender or race, they most frequently endorsed a belief in their own self-reliance and a perceived lack of time to seek care as barriers, which is consistent with previous research assessing the realities of athletes’ personalities and the demands they are under.²⁴  For example, collegiate sports environments may contribute to self-reliance by rewarding athletes who push through adversity and demonstrate mental toughness.²⁴  Other significant internal barriers were a lack of knowledge about mental health disorders, a negative attitude toward seeking help, such as feeling ashamed or embarrassed, and being concerned that mental health information would not be kept confidential. These findings suggest that, despite efforts athletic departments may already be making, there is a continuing need to provide mental health education to help student-athletes feel less stigma (eg, shame) about mental health, understand how the process of counseling works and how it can help them alleviate their concerns, and assure them that mental health information is kept confidential in their medical records; such efforts would be consistent with best practices for supporting student-athlete mental health.¹² 

Regarding the 7 stakeholders we identified in the literature,¹⁸  student-athletes generally perceived them as not being strong barriers to seeking help, although they did identify their head coaches as being most important or influential as a barrier. No other differences in how the athletes perceived the remaining stakeholders were seen. Head coaches possess high levels of control over their athletes (eg, schedules, scholarships, and playing time), especially in collegiate sports.²⁵  Thus, if student-athletes believe that their coaches have a negative attitude about mental health and seeking help, they may defer needed care out of fear of their coaches seeing them as weak or thinking less of them and losing playing time.²⁵  Similar to student-athletes, and again consistent with best practices,¹²  head coaches should undergo mental health education that reduces their own stigma and increases their mental health literacy and knowledge, which can increase their comfort in talking about mental health with athletes and making sensitive and supportive referrals for psychological care.²⁶  Unfortunately, a recent study²⁷  indicated that coaches’ mental health literacy remained only moderate.

As for athletes sharing identities with a sport psychologist, their lower ratings suggested that they did not view any identity or characteristic as being particularly important in relation to their seeking mental health care from that person. However, 3 identities or characteristics were rated as more important than all the others, including being able to openly discuss similarities and differences in identities, having played sports at an elite level (eg, college or higher), and having played the same sport as the athlete. Individuals who believe their clinicians are not sensitive to cultural factors may feel mistrust, leading to potential premature termination of services.²⁸  Thus, it is important for sport psychologists to broach the subject of identities in sessions, especially as discussions of gender, race, sex, and sexuality have become more frequent and salient in sport and among athletes. Consistent with this perspective, Lubker et al²¹  determined that unchangeable attributes of sport psychologists, such as gender and race, were less important to athlete clients than changeable ones, such as the level of training and interpersonal skills. Similarly, Horst et al demonstrated that counselors with cultural awareness and understanding of differences were more important to clients than sharing an identity, such as gender or race.²⁹  Sport-related identities may serve as a proxy for how well sport psychologists understand and are comfortable in sport environments. Knowing that their sport psychologists had their own high-level sport experiences would likely make it easier for athletes to feel comfortable in the counseling relationship and trust the sport psychologist and for the provider to be able to appropriately understand and contextualize the athlete’s concerns and not make recommendations that are misaligned with the athlete’s goals and realities, such as dropping out of the sport. Finally, female student-athletes rated having a sport psychologist of the same gender as more important than male athletes. This result coincides with previous results in which women expressed a preference for a hypothetical “less effective, same gender” therapist over a “more effective, different gender” therapist.^30(pp707)

Although our study had many strengths and addressed questions that had not been asked regarding potential barriers and facilitators of collegiate athletes’ help-seeking, certain limitations warrant discussion. First, due to the survey being part of the student-athletes’ annual mental health screening, they supplied their names and, as such, may have been less likely to express their true perceptions about the questions asked. For example, some athletes may not have identified a stakeholder, such as their head coach, as a barrier out of fear of the coach finding out. Therefore, our findings may underestimate the extent to which collegiate athletes perceived the presented beliefs, situations, stakeholders, and identities as barriers or facilitators. Second, all student-athletes were from the same athletic department, which limits generalizability to NCAA Division I athletic departments that have similar levels of embedded sport psychology services. Additional examination is needed, with larger samples drawn from multiple athletic departments, to further delineate the presence and importance of these barriers and facilitators.

Sports medicine professionals, including athletic trainers and sport psychologists who work in collegiate athletic departments, should understand what student-athletes perceive to be barriers to seeking help. Because student-athletes reported barriers related to internal beliefs and attitudes, professionals may find it beneficial to provide both student-athletes and staff with resources and education aimed at developing mental health literacy (as recommended by the NCAA¹² ). These resources could take the form of workshops, presentations, or handouts. Also, student-athletes who have received treatment in the past could share their experiences as another way to reduce the stigma and improve attitudes about mental health and help-seeking. Through such sharing, athletes’ concerns regarding the efficacy of mental health treatment can be addressed. Though it may not be possible for sport psychologists to gain high-level experience in every sport with which they work, it is clear that their knowledge of and comfort about sport is important to student-athletes. Thus, when sport psychologists begin working with athletes from sports that they do not know well, it is incumbent on them to gain knowledge as quickly as possible. Such knowledge may be gained through viewing the sport; talking with other athletes, coaches, or sport staff (eg, athletic trainers) who have competed (or worked) in that sport; being supervised by a colleague who has worked in the sport; and, potentially, participating in the sport. Finally, educational programs must include training on how sport psychologists can broach topics related to identities with their athlete clients because in client-counselor dyads, differences will always be present.

Future researchers may focus specifically on topics that were broadly covered in our study. For instance, exploration of the effect of stakeholders’ attitudes toward mental health and help-seeking may provide valuable data for stakeholders to understand how they affect their student-athletes’ well-being. Further, investigations of team culture could inform programming to reduce the mental health stigma in athletic departments. Qualitative studies could “flesh out” the topics we evaluated. For example, applying a qualitative design similar to the one used by Horst et al²⁹  would allow authors to explore the complexities of sharing identities with a sport psychologist.

We determined that collegiate athletes perceived barriers to and facilitators of mental health care that were similar to what has been found among young adults. Student-athletes reported several internal attitudes and beliefs about mental health (eg, belief in their own self-reliance) as key barriers to mental health care. Student-athletes, regardless of gender or race, indicated that head coaches with negative attitudes about mental health would also serve as a barrier. The ability of sport psychologists to discuss differences in identities was rated as the most important characteristic enabling student-athletes to feel comfortable seeking assistance. Therefore, sport psychologists should receive adequate training to feel comfortable broaching topics related to these differences. Our data suggest a continuing need to provide adequate mental health education to student-athletes and relevant stakeholders. Doing so may improve student-athletes’ mental health literacy and help-seeking efficacy, offer realistic examples of what mental health treatment is, and assure them of confidentiality in their mental health treatment.