Tag Archives: sports counseling

Rebuilding after brain injury

By Bethany Bray May 31, 2022

“I just want to feel useful again, like I have some purpose.”

“I just want to know is there anything I can do?”

“I just want to know I’m not going crazy.”

“I want to be happy again, have friends again and feel satisfied in relationships.”

These are among the heartbreaking responses Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist, receives from clients who have experienced a traumatic brain injury (TBI) when he asks what they want and need from counseling.

Individuals who have experienced a TBI often find themselves facing change and challenge in nearly every aspect of life. Depending on the severity of the injury and their recovery trajectory, TBI survivors can experience memory loss, personality changes and difficulty with language, comprehension, impulsivity, anger and decision-making. This is in addition to physical issues such as having challenges with balance, coordination and mobility. Individuals with a TBI may no longer be able to work in the field or job they once had. They may lose the independence to do things such as drive a car, and their friends and loved ones may struggle — or even give up on — maintaining a relationship with this new, changed person.

These clients might come to counseling after experiencing a hospitalization and lengthy rehabilitation process involving countless appointments with a variety of medical specialists. Brain injury survivors “are so steeped in the medical environment,” Lukow says, that they’re used to practitioners telling them what to do. Professional counselors can be the first to flip that narrative and ask the client what they want and need.

Lukow, who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s (VCU’s) Traumatic Brain Injury Model System program, says he has had clients break down in tears because he was the first professional to ask them about their wants and needs since their injury.

A professional counselor can be the one to “honor what they want and empathize with them and help them understand this huge shift in their life that has occurred in a blink of an eye,” Lukow says. “This work takes a lot of patience, a lot of reframing. But some of my most appreciative clients have been TBI survivors.” In counseling, “they’ve finally found someone who doesn’t make them feel like a burden or judged.”

A difficult road

The Centers for Disease Control and Prevention estimates that on any given day, roughly 176 people die and 611 people are hospitalized in the United States because of a TBI.

The Brain Injury Association of America (biausa.org) defines TBI as an “alteration in brain function, or other evidence of brain pathology, caused by an external force.” One of the most common causes is falls, but TBI can also result from motor vehicle accidents, sports/recreation or workplace injuries, child abuse or intimate partner violence, blast injuries during war or disaster, or acts of violence such as assault or gunshot wounds. Nontraumatic (or acquired) brain injury can occur from a stroke, seizure, meningitis, lack of oxygen, exposure to toxins, pressure from a tumor, drug overdose and other scenarios.

Research suggests that certain populations are more likely to be affected by TBI, including veterans and members of the military, racial and ethnic minorities, survivors of intimate partner violence, those who live in rural areas and people who have experienced incarceration or homelessness. According to a recent article published in JAMA Network Open, it’s estimated that between 9% and 28% of U.S. soldiers who served in the conflicts in Iraq and Afghanistan experienced a TBI.

Not only do the causes and severity of brain injury vary, but each survivor will also have a different recovery trajectory and array of symptoms depending on which areas of the brain were affected, the person’s age, the support and treatment they received during recovery, and numerous other factors.

TBI “is anything but cookie-cutter,” stresses Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI.

Not only will these clients’ needs and presenting concerns differ, but their therapeutic expectations, outcomes and what can be counted as “successes” will also vary, says Bradham-Cousar, who has a private counseling practice in Tampa, Florida. For one client, success may be returning to work full time; for another, it may be learning to calm down to keep from getting into fights with other residents of their group home (as was the case for one of Bradham-Cousar’s TBI clients).

“Success needs to be measured differently for each client — and it won’t look the same as your last client” with TBI, she emphasizes.

Lukow agrees, noting that benchmarks or signs that counselors may associate with improvement or growth in their other clients may not be apparent — or appropriate — with clients who have experienced a brain injury. Also, what might seem to be resistant behavior in this client population is often not intentional, he stresses. They may miss sessions or be hard to contact, but this is more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance.

Bounce forward

People who have experienced a brain injury will often hear well-meaning friends, family members, caregivers and even medical and other practitioners reference “bouncing back” when talking about their recovery. Lukow urges counselors to avoid using the phrase “bounce back” with these clients because there is no way for them to fully return to the life they had before their brain injury. Not only is such language unhelpful, but it can also give the recipient a sense of false hope.

Lukow instead uses the phrase “bounce forward” with his TBI clients. “In many cases, they can’t go back; they can only bounce forward,” says Lukow, who lives in Tennessee and works remotely as a staff counselor at a private practice in Williamsburg, Virginia.

Although these clients can’t go back to the way things were prior to their injury, they can work to move forward and make the most of their life with impairments through the support they receive and the skills they learn in counseling, Lukow says.

And these clients don’t always want or need encouragement, Lukow adds. At times, TBI clients may feel that the work they’re doing in counseling sessions only emphasizes what they have lost.

“Don’t always be a cheerleader,” Lukow urges. “Sometimes they don’t need to hear ‘that’s alright, you’ll get through it’ [from a counselor], but instead, ‘that really sucks.’”

Lukow specializes in counseling clients who have experienced TBI. He estimates that 10% to 20% of his current client caseload is recovering from a brain injury. During his time as a researcher at VCU, he developed resilience-based interventions for mental health practitioners to use with couples and individuals after a TBI.

It’s not uncommon for individuals recovering from a brain injury to be told by medical personnel, rehabilitation specialists and others that recovery ceases after a few years. An often-repeated message is that the only gains a person will make after a TBI are those made in the first two years, he says.

Although that may be true for some of the physical aspects of TBI recovery, growth and progress in other arenas — especially the emotional and psychological aspects — can continue for years and even decades, Lukow says. He has seen TBI clients make strides many years after their injury, especially in coming to accept that they may never get some of their abilities back and will need to rely on aids, such as memory reminders, for the rest of their life. Learning and growth can also happen years later for clients related to their social skills and in responding to awkward questions and assumptions made by others. (Lukow explains that these situations occur because TBI is often an “invisible” injury and people misjudge or misunderstand the actions or challenges of survivors because they don’t look disabled.)

Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis, agrees that recovery can occur long after the period of intensive treatment TBI survivors receive immediately after their injury. Goldstein once counseled a client who developed aphasia (language difficulty) after a TBI. This client, with the help of a speech therapist, was still relearning and mastering new words 10 years after his injury, Goldstein recalls.

“The good news is that brain plasticity is much better than we once thought it was,” Goldstein says. “But people are still told that they have a year to improve or a limited time.”

Asking the right questions

Individuals can experience an array of symptoms and difficulties after a brain injury that dovetail with mental health or the client’s presenting concern in a wide variety of ways. Because brain injury varies from person to person and there is no one concise set of symptoms, professional counselors must know some of the more common symptoms (e.g., memory loss) and — perhaps, more importantly — how to ascertain whether a client may have experienced a brain injury in the past.

Brain injury is nuanced and complicated, and there is a good deal of misunderstanding about it among the general population, Lukow asserts. Clients may come into counseling without realizing that their presenting concern (such as trouble maintaining relationships) could be tied to an unacknowledged brain injury or one that happened in the past.

Lukow points out that a person wouldn’t necessarily have needed to be hospitalized or even received a blow to the head for a brain injury to have serious consequences. A car accident, for example, can cause a person’s head to move so forcefully that the brain impacts against the skull without the head touching any part of the car.

Or clients may not realize that brain injury can be cumulative (e.g., “I had a few concussions back when I played lacrosse …”) and affect them later in life, Lukow says. He advises counselors to ask clients not only if they have had any brain injuries but also whether they have experienced any related issues such as a loss of consciousness, cognitive difficulty, a head or sports injury, or a fall.

Bradham-Cousar, a clinical assistant professor in the Department of Counseling, Recreation and School Psychology at Florida International University, urges counselors to listen for client language that may indicate they have had head trauma, including phrases such as “concussion,” “woke up a little while later,” “unconscious,” “got stitches,” “car accident” and “slipped and fell.”

Past brain injury can cause behavior and other deficiencies that are hard to pinpoint or connect to a diagnosis or for which psychiatric medicine doesn’t seem to help. Bradham-Cousar provides examples such as a person who has trouble understanding social cues but does not have autism spectrum disorder, someone who has reading difficulties but does not have a learning disorder, and someone who struggles with attention span and focus but does not have attention-deficit/hyperactivity disorder. In other examples, an individual may struggle with anger, self-control, problem-solving, object recognition or articulating what they’re trying to say and not realize that a past brain injury could be the root cause, she adds.

Goldstein advises counselors not to overlook issues that the client feels are “minor,” such as a concussion, because these could be contributing to their mental health challenges. Counselors should also be aware that in some cases, TBI can cause violent behavior or the urge to self-medicate with alcohol or other substances. So, Goldstein says, practitioners need to be comfortable screening for substance use and be familiar with the reporting protocol for their state in case a client discloses violent behavior (including when the client is a spouse or a family member of a TBI survivor).

TBI survivors sometimes turn to alcohol or other substances to temporarily escape or “slow down” from impulsivity and other challenges, Goldstein notes. However, “one drink for someone with TBI is not the same as it is for someone without [a brain injury]. Their symptoms will be amplified by any substance use, including alcohol,” he explains. “Brain injury and substance use don’t mix. It’s one of the worst things they can do to themselves, but it’s commonly seen among those with TBI.”

Complicating factors

The counselors interviewed for this article note that TBI can co-occur with common challenges that bring clients into counseling, most notably depression, anxiety and issues that correspond with loss and relationship problems. And sometimes there can be a chicken-and-egg debate about which of these issues came first, which adds a layer of complication for practitioners trying to assess and plan treatment for a TBI survivor in counseling.

For example, isolation, loneliness, and a loss of meaning and purpose — the classic markers for depression — are common after TBI and the related challenges that come with it, Lukow says.

In these situations, Bradham-Cousar notes that depression is often a secondary diagnosis to a client’s TBI that becomes co-occurring.

At the same time, it’s not uncommon for TBI survivors to be misdiagnosed with a mental illness because some post-injury symptoms can mimic those associated with other disorders, Goldstein adds. Brain injury can cause people to experience hallucinations, hear voices or have severe personality changes, impulse control problems and erratic moods that can resemble mania. This can lead to diagnoses such as personality disorders, psychosis, bipolar disorder or even antisocial personality disorder, Goldstein says.

“I call it [TBI] the great imposter,” Goldstein says. “Mental health [symptoms] are only part of the story. Sometimes it’s the tip of the iceberg, and sometimes it’s not at all what’s going on.”

Because of this, Goldstein recommends that counselors begin work with each client by first ruling out brain injury as the root cause of their mental health challenges. He stresses not to automatically assume that a client’s symptoms are psychiatric in origin. When it comes to mental health diagnoses and TBI clients, false negatives and false positives are very common, he says.

This challenge can be compounded when a client doesn’t recognize or disclose that they’ve had a brain injury (e.g., a concussion that they weren’t hospitalized for), Goldstein says. It’s also likely that the practitioner who referred a client to counseling — whether a medical or mental health professional — hasn’t ruled out TBI as the root of the individual’s symptoms because the connection between brain injury and mental health is simply not on the radar of most professionals.

“Even if a client has a big fat DSM diagnosis, don’t assume, and keep an open mind,” Goldstein says. “I implore [counselors] to rule out brain injury, and even if you think you’ve ruled it out, revisit it. Don’t assume the person that you’re seeing, no matter how they were referred, has a mental health diagnosis.”

Goldstein recommends that in addition to conducting a thorough intake process, counselors screen clients for brain injury by asking for access to their medical records and the ability to confer with the other professionals they are being treated by, such as a neurologist.

“Keep your mind open, and consult, consult, consult with people who are experts in areas that can help you tease apart where these symptoms are coming from,” Goldstein says. “Don’t assume that what you’re seeing is due to a mental health disorder. Your default should be that their brain has been injured.”

Helping clients adjust to loss and change

The crux of what many clients who have experienced a brain injury need in counseling is help adjusting to change and processing loss. Most professional counselors already have an array of tools that can help in this realm, from coping mechanisms and goal setting to the therapeutic relationship itself.

“Often, they need [empathic] listening from a counselor and a large amount of time just to talk about their situation, what they need and what they’re struggling with,” Lukow says.

Any counseling technique or method that builds coping skills or helps clients deal with life changes and loss would be appropriate and helpful to use with clients who have experienced TBI, Lukow notes. This population may also need grief counseling and help with managing emotions and improving communication and social skills. Seemingly small skills, such as being able to politely ask someone to slow down or repeat themselves when they are outpacing the client’s cognition abilities in a conversation, can go a long way to boost the person’s self-esteem, rebuild their relationships and, in turn, reduce isolation, Lukow says.

Stress recognition and management are also important skills for brain injury clients to learn, Lukow adds. Techniques such as diaphragmatic breathing, muscle relaxation, guided imagery and mindfulness, as well as activities such as walking or exercising, painting, coloring, and listening to white noise or ambient sounds, can help these clients learn to calm themselves.

“[Brain injury] survivors are ‘allergic’ to stress,” Lukow says. “When their stress gets worse, their impairments get worse.”

Occasionally involving a client’s spouse, partner or loved ones in individual counseling sessions can also be beneficial for both parties. They provide comfort and moral support to the client in session, Bradham-Cousar explains, and in turn are better able to understand the client’s needs and therapeutic goals. For TBI clients who struggle with memory challenges, having another person in session can also serve to provide them with reminders of what was said and what was assigned as homework.

TBI clients’ loved ones can also benefit from group counseling. The counselors interviewed for this article agree that the supportive environment that group counseling provides can be extremely helpful for this client population and their family/caregivers. (For more on this topic, read the article “Life after traumatic brain injury: Lessons from a support group.”)

Bradham-Cousar specializes in counseling clients who live with disabilities, including cognitive difficulties from a brain injury, stroke or dementia. A large part of what these clients need, she says, is therapeutic work to move them toward acceptance of the change in their lives, including the things they can no longer do. She often uses cognitive behavior therapy and a working

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alliance approach to foster trust with clients who are brain injury survivors and adjust their thought patterns and perspective. Counselors can also help the client see the opportunity to gain new skills; they’re not just losing things but gaining them as well, she says.

Grief counseling and psychoeducation about grief can also help this client population process the many losses they have experienced, including the loss of a part of themselves, Bradham-Cousar adds.

“Counselors can help these [clients] to grow and understand their regenerated self and look at it [through] the eyes of a new opportunity, a new chance. They still have a life to live,” says Bradham-Cousar, a past president of the Florida Counseling Association and the American Rehabilitation Counseling Association. “It’s a transformational process. … They need to move forward to accept that they’re not as they used to be.”

Similarly, Lukow finds that using a solution-focused approach, as well as equipping clients with coping mechanisms and skills that can boost their self-esteem and resiliency, is helpful for clients who have experienced brain injury. For instance, a counselor might suggest that a client who struggles with memory issues set up a “launch pad” — a spot in a visible area of the home, such as a kitchen counter, to keep their keys, wallet and other essential items they need when going out so that they’re less likely to forget or lose them.

Much of this work, Lukow says, is supporting clients as they navigate the learning curve of trying new skills, abandoning things that aren’t working for them and finding solutions and workarounds to live life.

For example, a TBI survivor who is unable to drive may struggle with this loss of independence and feel like a burden for having to ask for rides from others. A counselor can help the client process these feelings so that it’s easier for them to ask for help and find solutions that boost their self-worth.

One such solution could be supporting the client as they learn how to take the bus, Lukow suggests. “Help them find a [bus] schedule and look together, asking, ‘Which stop is closest to your house?’ ‘How much does it cost?’ etc. Something as little as looking up a bus schedule can be a success. And with it, a shift in thinking: ‘Yeah, I can’t drive anymore, but it doesn’t mean I can’t get around.’”

Goldstein notes that motivational interviewing can be useful in helping TBI clients to focus on adjusting to change. Influenced by Irvin Yalom and Viktor Frankl, Goldstein also uses an existential approach to guide clients to make meaning of their new circumstances.

This client population “is searching for new meaning in a hugely altered life. They need to construct new meaning, and it’s sometimes not the meaning that they were hoping to construct,” Goldstein says. “These folks need to adjust to ‘the new me.’ They’re forever changed. As with big changes in our lives that are negative, there’s grief, and if we don’t work through the grief, it metastasizes.”

Language workarounds

Brain injury often affects a person’s ability to speak. Counselors who work with this population must be knowledgeable of and comfortable using adaptive technology or creative workarounds to communicate with clients who may not be able to respond verbally.

Bradham-Cousar sometimes uses a speech-generating app such as UbiDuo 3 with clients because it allows them to type responses to counseling prompts on a smartphone or other device. She also has an extra keyboard linked to a computer monitor in her counseling office for clients to use to type and display their thoughts during sessions.

Bradham-Cousar suggests that counselors use a collaborative approach by asking clients (during the intake process) to identify adaptive tools or supports they are comfortable using. Counselors can also find information on meeting these clients’ adaptive needs by searching for “brain injury” on the Job Accommodation Network’s website at askjan.org.

In addition to specializing in psychotherapy for brain injury, Goldstein’s subspecialty is helping clients with aphasia. He says that counselors need to be comfortable not only with using different modalities and tools to communicate with TBI clients who struggle with speech but also with long periods of silence in counseling sessions. This can be hard for some practitioners.

Goldstein urges counselors to become sensitive to the wealth of information communicated through a client’s body language and leverage what skills a client does possess. Remember, he says, that these clients have the same range of needs and emotions that verbal clients have; they know what they want to say, but it just won’t come out.

Goldstein sometimes uses a method he calls “facilitated therapy.” He invites another professional who is working with the client (such as a speech and language pathologist) to consult or co-treat with him or come to counseling sessions to serve as a mediator/facilitator until he has forged a bond with the client and learned to “speak their language,” even if it’s nonverbal.

This was the case for one client whose speech was severely limited after his brain injury. However, the client was a gifted artist and would draw pictures during sessions to communicate. When Goldstein began working with this client, he involved the client’s vocational rehabilitation counselor in sessions because she had been working with him for a while and understood the nuances in the way he expressed himself.

“He had his own language,” Goldstein recalls. “He communicated wonderfully; it was just not via speech.”

Once Goldstein established a relationship with this client, they were able to communicate and do one-on-one sessions without the other professional. In addition to drawing and art, the client would play songs he had saved in an extensive library on his phone to express how he was feeling.

“Counselors may have to get creative because these clients [can] have speech limitations and cannot do traditional talk therapy,” Goldstein says. “Look for the gifts they have and use it, use it, use it.”

Team approach

Counselors working with clients who have experienced TBI also need to be comfortable reaching out to, consulting with and co-treating with a number of professionals in different fields. Depending on the severity of their injury, TBI survivors may be treated by surgeons, neurologists, speech and language pathologists, occupational and physical therapists, social workers and vocational/career professionals, among others.

Goldstein recommends counselors build connections with a base of these types of professionals in their local area so they can consult and ask questions when facing a challenge or sticking point with a TBI client. When treating clients who have experienced TBI, “don’t fly solo,” Goldstein urges. “In this work, it’s not a two-way street [with other practitioners]; it’s a superhighway.”

The counselors interviewed for this article emphasize that counselors should resist the urge to refer TBI clients to a specialist right away. Counseling this client population can be complicated and challenging and it requires lots of patience, but the empathic listening and supportive relationship that a counselor provides can make a world of difference for these individuals and their families.

Goldstein encourages those counselors who are interested in this client population or who thrive working in multidisciplinary teams to think about specializing in counseling TBI clients. “Brain injury is scary, and it puts a lot of therapists off,” he says. “If you see someone with a brain injury and you’re baffled, pat yourself on the back, because you should be. And if you’re intrigued and interested [in this topic], consider it as a specialty.”

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Contact the counselors interviewed in this article:

Michelle Bradham-Cousar: info@adhamwellness.com
Hillel Goldstein: goldstein.psyd@bifstl.org
Herman Lukow: hermanlukow@williamsburgcounseling.com

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Related reading, from Counseling Today:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Considerations for athletes in counseling

By Jessie Huebner April 11, 2022

“I have to do what’s right for me and focus on my mental health and not jeopardize my health and well-being.”

Hearing those words from Simone Biles, the epitome of talent in the world of gymnastics, and witnessing her personal battle in deciding to remove herself from competition at the Summer Olympics in Tokyo was eye-opening, to say the least.

As the world prepared to observe the talents of the athletes in the 2022 Winter Olympics this past February, it made me reflect on all of the groundbreaking disclosures by elite athletes concerning their personal challenges with mental health leading up to, during and after the conclusion of the prior year’s Summer Games. These challenges had never previously been disclosed and discussed to such magnitude.

For example, following the U.S. Olympic team trials, swimmer Simone Manuel disclosed that she was experiencing depression, anxiety and insomnia resulting from overtraining syndrome. Liz Cambage, a Women’s National Basketball Association player who was scheduled to compete for Australia in Tokyo, identified anxiety symptoms as the reason that she pulled out of the Olympics a week before the opening ceremony. She has since described how daily medication helps her manage her anxiety symptoms so that she can continue competing.

Throughout the broadcast of the Summer Games and following the conclusion of competition in Tokyo, numerous brave, elite-level athletes shared their prior or current difficulties with mental health symptoms. U.S. shot-putter Raven Saunders shared her experience with depression and prior suicidal ideation and her need to continually monitor and focus on her mental health. Cross-country mountain biker Jenny Rissveds of Sweden disclosed that a year after winning gold in the 2016 Summer Olympics in Rio de Janeiro, two deaths in her family triggered depression symptoms that she has been addressing since that time. U.S. sprinter Sha’Carri Richardson qualified to run the 100 meters in the Summer Olympics in Tokyo, but a positive test for marijuana resulted in a temporary suspension, causing her to be ineligible to compete in the race. Richardson acknowledged using marijuana to cope with and avoid negative emotions following the death of her birth mother and the stress connected with elite performance expectations. American gymnast Sam Mikulak revealed that swimmer Michael Phelps’ openness about his mental health journey encouraged Mikulak to seek treatment and experience the benefits of therapy. Phelps’ disclosures about his own struggles with mental health continue to be highlighted through his endorsement of an online therapy service provider.

Not just Olympic athletes

Olympic athletes’ willingness to openly discuss their mental health seemed to spark discussions in the Olympic community about the need for increased support and mental health interventions for athletes. Because of concerns regarding the impact of stigma on discussions about mental health, the U.S. Olympic & Paralympic Committee in 2020 suggested administration of the Sport Mental Health Assessment Tool during routine physicals for athletes. The tool was first administered with a group of 165 USA Swimming and U.S. Soccer athletes; 58% of participants tested positive for a mental health issue, and four athletes were found to be potentially at risk for self-harming behaviors or having suicidal ideation.

Difficulties with mental health are not limited to athletes at the Olympic level. This suggests the need for counselors working with elite athletes at any level to be prepared to offer services that take into consideration this unique client population.

A 2019 meta-analysis by Vincent Gouttebarge and colleagues identified that mental health symptoms and disorders for current elite athletes ranged from 19% for alcohol misuse to 34% for anxiety/depression. Symptoms for former elite athletes ranged from 16% for distress to 26% for anxiety/depression. Some studies noted that while athletes in general may be at comparable risk for these mental disorders in distinction against the general population, some subgroups of athletes (e.g., those in retirement, those experiencing performance failure) may be at elevated risk.

Common sources of tension identified by elite athletes include stress, injury, errors on the sporting field, fatigue, and their club’s or organization’s climate. Athletes experience increased stress related to factors including restricted social and occupational opportunities, pressure to maintain superior fitness and performance, scheduling and time constraints, social isolation, demands of multiple relationships, lack of energy and motivation due to physical fatigue, limited funds due to restricted financial opportunities, public criticism, injuries, and fear of career-ending injuries. While some elite athletes endorsed employing active coping strategies in their everyday lives, athletes were more likely to use less adaptive (avoidance) strategies when faced with unexpected stressors.

Seeking to learn more about the mental health of student-athletes, in 2015, Andrew T. Wolanin and colleagues implemented multiple measures with 465 college athletes during yearly physicals across three consecutive years of their athletic careers. Clinically relevant levels of depression symptoms were exhibited by 23.7% of the sample, with 6.3% exhibiting moderate to severe levels of depression symptoms. Significant gender differences were found, with females exhibiting 1,844 times higher risk of clinically relevant symptoms than males. Prior studies have also identified gender differences, with female student-athletes scoring significantly lower than males on sense of self-worth, stress management and leisure.

With athletes being channeled into specific sports at younger ages and with the associated changes in sport and life demands, mental health symptoms for athletes may begin even earlier. This is especially concerning because young athletes possess even fewer psychological coping skills. Among the identified stressors connected with mental health symptoms for youth athletes are pressure to perform and perfectionism, maintenance of academic and social balance, interpersonal conflict or abuse, injury and concussion, body image and weight pressures, and disrupted sleep. These stressors have been correlated with burnout and overscheduling, bullying and hazing, and risk-taking behaviors (e.g., early use of tobacco, misuse of prescription drugs, the restriction of calories, weight-dropping behaviors, use of performance-enhancing drugs).

Student-athletes, in particular, have to endure the constant demands of intense practices, competition schedules, and the need to maintain or improve upon their strength and physical skills, all while maintaining passing grades to remain eligible for athletic competition. Additionally, student-athletes often have difficulty making time for leisure activities and may be less satisfied with such activities.

Areas of focus for athlete clients

Counselors who work with athletes can assist these clients by focusing on personal and social issues that athletes commonly experience. Counselors can also help these clients in their development as individuals separate from their identity as athletes. Specific approaches might include relaxation training, solution-focused techniques, time management, cognitive behavior techniques, decision-making techniques, life management and career planning, coping skills strategies, and crisis intervention.

Perfectionism

Athletes experience both personal and external expectations of perfection. Professional skateboarder Nyjah Huston has shared about the pressure of being an elite athlete and how he is often “really hard” on himself when he does not win. Counselors can support these clients by communicating understanding and empathy regarding the exceptional standards for athletes.

Counselors can use psychoeducation to explain that extreme self-criticism can affect clients’ well-being and athletic performance and to encourage clients to identify the positive and negative aspects of perfectionism. Additionally, counselors can assist clients in setting their own realistic expectations of performance.

Incorporating the topic of perfectionism is especially important because of the potential for athletes to turn to risk-taking behaviors to achieve perceived perfection in their sport.

Burnout

Athletics is an environment in which psychological symptoms are often downplayed by the individual, likely exacerbating risk for continued symptoms, overtraining and burnout. In addition to mental health symptoms, overtraining is often connected to poor eating and sleeping patterns and increased risk of injury. Counselors should ask athlete clients about their current sleep habits or sleep disruptions. Counselors might consider offering sleep hygiene, psychoeducation and cognitive behavior approaches to promote healthy sleep behaviors.

Student-athletes may experience burnout due to the constant need to balance sport, academic and emotional demands. Counselors should communicate understanding of the totality of clients’ commitments and assess for symptoms of burnout, including physical and emotional exhaustion, sport devaluation and reduced sense of accomplishment.

Counselors can assist athletes experiencing burnout by opening discussion of what the client enjoys or previously enjoyed about involvement in their sport and what may have changed. Counselors can also encourage the reframing of clients’ (and, possibly, caregivers’) expectations of sport participation, foster fun and enjoyment both inside and outside of athletics, and explore clients’ overall values and nonathletic interests to expand their identity and promote balance between athletic and nonathletic identity.

Interpersonal needs

Athletes may be perceived to have frequent peer interactions due to constant interactions with other athletes in sport, but many athletes have been found to lack interpersonal skills in everyday social interactions. Often, athletes are isolated from peer interactions and social opportunities outside of their athletic community.

Counselors can guide these clients in assessing their schedules and time management techniques to identify nonathletic social opportunities and offer psychoeducation on the importance of interactions and connections that are not connected to their athletic world. Additionally, counselors should assess for signs of bullying or harassment (e.g., hazing; body shaming; encouragement to dope, cheat or play when injured) occurring for clients, especially for those identifying as being in a minority group at higher risk for negative interpersonal experiences in sport.

Injury

Athletes’ mental health can be affected by the fear of, and actual experience of, injuries that could affect their future athletic careers and, potentially, their overall life plans. Injured athletes have been found to exhibit greater depression and anxiety symptoms and lower self-esteem than controls, both immediately and in the months following their injury.

To best guide treatment interventions, counselors should assist clients in identifying specific sources of distress related to the injury (e.g., physical pain, trauma of injury incident, isolation, irritation with rehabilitation, fear of reinjury, fear of not returning to sport). Counselors can support their injured clients by being mindful of the significant distress that often accompanies injury for elite athletes, offering compassion-based and acceptance-based approaches, and reframing the injury as an opportunity for growth and development.

If the client’s injury involves a concussion, counselors should be knowledgeable about the psychological symptoms (e.g., irritability, anger, depression, anxiety, impulsivity) commonly associated with concussion injuries and the risk that clients may minimize symptoms or not present with awareness of the connected symptoms.

Vulnerabilities

Athletes have been identified as vulnerable to disordered eating and risk-taking behaviors such as hazardous drinking, unprotected sex, driving while intoxicated and doping.

Counselors can potentially assist in early detection of eating disorders in this at-risk population. Techniques identified to address disordered eating among youth athletes include interventions targeting motivation to change, dialectical behavior therapy skills training to develop ability to tolerate subjective distress and improve emotion regulation, and interpersonal skills development. Preventive measures to target disordered eating may include cognitive distortion psychoeducation, groups targeting improved self-esteem, and techniques to target negative coping strategies and encourage positive coping mechanisms.

A 2020 study by Stephen P. Bird and Benjamin D. Rushton found that elite youth athletes generally lack fundamental nutritional knowledge, specifically information related to dietary reference intakes and supplementation. Therefore, nutrition education with this population is crucial; however, counselors should be aware of any specific requirements of the sport to support trust building and credibility with the athlete and to align treatment goals accordingly.

Doping is also a prevalent problem among elite athletes (across all ages). Counselors should educate themselves on signs of doping and ask clients if they are currently using performance-enhancing drugs or have been pressured to use such drugs by coaches, parents or peers. Counselors are encouraged to address doping by implementing interventions that match the specific needs and readiness of the client. Counselors may begin by helping the client identify and discuss their desire to change their behavior and offer support and alternative views or behavior options for the client. If the client presents with resistance to changing their behaviors, counselors should avoid arguing and instead work with the client on improving their self-efficacy.

Fostering the whole self

Elite athletes tend to identify themselves as athletes early in life. Individuals who exhibit this strong athletic identity can be at greater risk of emotional and social challenges, physical injury caused by overcommitment, and difficulties with transitions and future career identity development.

In 2007, Clint Galloway separated athletic identity into three separate factors: social identity, exclusivity and negative affectivity. An athlete’s social identity involves the degree to which the individual identifies as an athlete from a social perspective. In some instances, an athlete’s success in sport and their connection to this identity, status and preferential treatment may result in a sense of entitlement, permissiveness and dependence. When this is shattered by the athlete’s injury or retirement, deficits in tasks such as independent decision-making, planning, organization and time management are evident and potentially detrimental.

According to Galloway, exclusivity involves the degree to which an individual’s self-worth is determined based solely on their success in the athletic role. Elevated exclusivity can be especially detrimental when an athlete is injured or ages out of their athletic career because they may not have explored other career, educational and lifestyle options outside of their sport.

Galloway’s final identified factor, negative affectivity, relates to how the individual experiences negative emotional reactions to poor outcomes in sport. Dutch professional cyclist Tom Dumoulin highlighted the impact of an athlete’s identity conflicts when he commented about needing to leave a training camp to clear his head, noting that he was finding it “very difficult … to know how to find my way as Tom Dumoulin the cyclist.”

Counselors can support their athlete clients in developing and fostering their whole selves, expanding perspectives about their entire identity, and visualizing aspects of the self beyond their role as an athlete. Available measures to assess a client’s athletic identity include Britton W. Brewer and colleagues’ Athletic Identity Measurement Scale and Suzanne A. Nasco and William M. Webb’s Public-Private Athletic Identity Scale. Separately or in conjunction with formal measures, counselors can encourage clients to process past important experiences in their life and identify values, skills and roles that they used in these moments. Clients can then be asked to envision important experiences for their future, using their past experiences and skills as the foundation and starting point for their future life plan that may or may not be related to sports.

Counselors can play an important part in highlighting and supporting other roles in the client’s life. Counselors can assist the client in seeking balance by incorporating friend and family life, education, and activities outside of their sport. In 2011, Natalia Stambulova suggested that counselors encourage clients to sort information and life experiences into separate categories (e.g., client as person, client as athlete, client’s social roles and environment, client’s near past, client’s present situation, client’s perceived future) to visualize the role or impact of their athletic identity. Additional interventions include assisting clients with time management, fostering motivation to establish other aspects of their self and life, and reviewing their schedule to offer opportunities for experiences and social interactions unrelated
to sport.

Incorporating athletic skills

wavebreakmedia/Shutterstock.com

Elite athletes are unique. For athletes to reach their level of performance and skill, they depend on mental qualities (e.g., responsibility for self, adaptability, self-aware learning, determination, confidence, optimal performance state, game sense, attentional focus, mental toughness) and strategies/skills (e.g., physical preparation, process orientation, routines, self-talk, visualization, commitment, flexibility, creativity, problem-solving, decision-making) that can be applied in other areas of life to foster success.

Counselors might consider using solution-focused techniques to assist athletes in identifying what resources they have developed in the past that can be used in their future life. In general, counselors should assist in preparing the athlete for success for their whole self. This includes incorporating discussions of how the interventions or techniques offered to address current athlete-specific needs can also be used for other stressors that may present for the client outside of their athletic world. This mindset will support the client in recognizing aspects of their life outside of their athletic identity and prepare the client for when they are no longer an athlete due to injury or retirement (whether planned or forced).

Planning for the future

When faced with the end of their athletic careers, athletes are at increased risk of experiencing mental health symptoms. This risk is exceedingly higher when the transition was not expected (e.g., as the result of injury). These symptoms are often connected to the athlete’s losses of their athletic identity, their sources of satisfaction, their identification as a sport hero, and their daily routines and connections associated with sport.

Counselors can assist clients through this transition from life as an athlete to their new path, whether academic or professional. Clients with a strong athletic identity may have experienced disempowerment and the loss of personal autonomy, which may have resulted in limited opportunities to reflect on their personality or sense of self outside of their athletic identity. Counselors who are working with athletes can play a role in reducing the risk for problems during transition times by engaging in academic advising, life management techniques and career planning with clients while they are still active in their sport.

Most athletes will not make it to the professional or Olympic level in their sport, so they would benefit from interventions that focus on skill development and life planning across the life span. Career development for athletes can incorporate discussions about the client’s knowledge, abilities and opportunities that can be transferred to areas outside of athletics. In helping clients develop coping strategies to use when dealing with unexpected and unforeseen life events in general, counselors might also be preparing these clients for future events that may occur in their athletic careers.

Be prepared for resistance

Athletes have been raised within a community and a culture that emphasizes the importance of being not only physically tough but also mentally tough. At elite performance levels, this may result in athletes being resistant to seeking or engaging in mental health services. Additional barriers to athletes seeking counseling include time limitations, a lack of problem awareness, a difficulty or unwillingness to express emotion, fear of the potential impact of help seeking, and concerns that their high degree of visibility may be a threat to their confidentiality and privacy.

Counselors should be familiar with the culture of sport and the specialized needs of athletes and how these factors may affect athletes’ service engagement. Identified preferences when athletes seek counseling have included the counselor’s familiarity with sport; the counselor’s race, ethnicity or gender; and counselors who offer expanded operating hours to accommodate athletes’ schedules.

Final thoughts

Athletes are a special client population. When counselors are working with a client involved in, or previously involved in, elite sport, consideration should be given to the client’s unique experiences, presentations and needs. As is the case with all clients, the diversity of client athletes (e.g., race, ethnicity, socioeconomic status, age, ableness, sexual orientation) must also be considered. Also be aware that there are many differences in athletes’ motivations for being involved in sport, their preparation or development for sport, their academic needs, and the perceived importance of their athletic role in life planning. When working with current or former athletes, counselors should consider their client’s athletic identity, pressures for perfectionism, time and physical commitments, and elevated vulnerabilities to problematic behaviors.

The openness of Olympic athletes has sparked new awareness of the potential mental health needs of all athletes. It is now our turn as counselors to promote the need for mental health services for athletes at all levels of sport and to adjust our assessments, techniques and treatment planning for this unique client population.

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Jessie Huebner is a licensed clinical social worker and a doctoral candidate at Northern Illinois University in counselor education and supervision. Jessie’s current professional role is as a clinical screener for children and adults involved in child welfare. Prior professional experience includes counseling, supervision and administration for children and adolescents receiving residential treatment and juveniles with sexually problematic behaviors. Contact Jessie at jhuebnerlcsw@gmail.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Life after sport

By Kris Amos November 16, 2021

I will never be the same. I have struggled with reshaping my identity after being separated from sport due to injury.

As a track and field athlete, where overuse injuries are most common, I did not consider myself to be at significant risk for a career-ending injury. However, athletes can also incur life-changing injuries outside of their sport, as I experienced firsthand when a drunken driver traveling the wrong way down the freeway crashed into my car head-on.

Personal background

For me, growing up on the west side of Detroit, success meant making it in sports or music. I moved out of Detroit at the beginning of high school and began competing as a track and field athlete. That’s when I discovered my love for the high jump. The thrill of competition was a sensation that brought me life. It provided me a sense of accomplishment, belonging, identity and passion. Competing as a high jumper became a career goal, and when I graduated from high school in 2007 and was offered a scholarship to compete as a track and field athlete at Michigan State University (MSU), I was one step closer to that goal.

My athletic career was promising. I earned a varsity letter my freshman year after finishing sixth in the high jump at the 2008 Big Ten Outdoor Championships with a jump of 2.07 meters. At the time, the competition level in the field events in the Big Ten Conference was very high, and I managed to have the top placement by a freshman at the meet. I barely missed the qualifying standard for the regional championship but was reassured by the fact that I was only a freshman.

That was until Aug. 20, 2008. At approximately 1:30 a.m., I was driving 75 mph on cruise control heading back to campus when I noticed headlights traveling toward me at very high speed. I was only able to cover my face as my perception of time slowed right before our cars collided. I woke up to a woman knocking on my window, attempting to get my attention. My head was on the steering wheel, the airbags were deployed, and the windshield was crushed in toward my face. I was pulled out of the vehicle through the window and transported to the hospital for surgery. Among the many injuries I sustained were a traumatic brain injury and an extensive injury to my right knee. This was the leg I used to launch myself in the high jump event.

I learned later that the drunken driver had entered the exit ramp and begun traveling in the wrong direction on the highway before colliding with me head-on. After I was struck, a third car hit the side of my vehicle before colliding with the drunken driver. A passenger in the drunken driver’s vehicle died, and the passenger from the third vehicle had a miscarriage. I didn’t really appreciate the extent of my injuries at the time, in part because I was eager to return to competition. Concussion/brain injury protocols were not as established in the NCAA then as they are now, and although I was offered an opportunity to redshirt (to sit out a year without losing any of my collegiate athletic eligibility), I was ultimately allowed to compete.

I was not the same. I began drinking alcohol daily, including when I woke up, before and after practice, and before I went to sleep. I finished the following semester with a 0.7 GPA, which led to me being declared academically ineligible and dismissed from the team.

Since then, I have had five surgeries on my knee, several injections and procedures, multiple therapies, and various forms of treatment for my brain injury and chronic pain. I barely graduated from MSU in 2012 with a Bachelor of Arts in psychology and a 2.1 overall undergraduate GPA. My hopes of going to graduate school were crushed when I received a denial letter from the school to which I had applied. After explaining my situation to the program director at the University of Detroit Mercy, I was admitted to the graduate certificate program in addiction studies. After successfully completing the program, I moved to Chicago to attend the Chicago School of Professional Psychology. It was during my clinical internship at Columbia College that I discovered an opportunity to get back into sports. I graduated with a Master of Arts in counseling psychology in 2017 and moved back to Michigan to begin working at MSU.

I am currently a licensed professional counselor at MSU’s Counseling & Psychiatric Services center. I have attempted to reshape my athletic identity by providing mental health services to athletes through advocacy, education and counseling. This has helped me to re-create a sense of purpose that is aligned in sports and consistent with my athletic identity. After learning about existential psychology through my coursework, I began to research its application in sports and have found it to be helpful, both personally and professionally.

Career-ending injuries

Career-ending sports injuries are representative of an existential crisis. They can have a devastating impact on the individual athlete, the athlete’s team, the athlete’s family and even sports fans. According to Stanley Herring et al. (2016), irritability, sleep/appetite changes, pain, depression and other adverse effects can occur following a sports injury. Not surprisingly, this can be a challenging adjustment for some athletes.

Participation in sports provides athletes with social connection and a sense of identity, meaning and belonging. Athletes are more than the tasks required of them in sports; athletes are also people. We as a species have yet to answer undeniably the big philosophical questions of life, one of which is “Why am I here?” This existential question has barely registered in the field of sports. However, from my perspective, the existential model would seem to be an appropriate fit when treating and supporting athletes who have been separated from their sport due to injury.

According to the National Safe Kids Campaign and the American Academy of Pediatrics, more than 3.5 million sports injuries are estimated to occur each year among children and teens. A career-ending injury can encompass an unexpected injury, illness or death that prevents an athlete from participating in a sport. An epidemiology study published in 2016 by Jill Tirabassi et al. found that career-ending injuries made up 6% of all injuries captured from 2005-2014 among high school athletes. Studies published in Athletic Insight: The Online Journal of Sport Psychology have suggested that sports career termination should be viewed as a transitional process occurring from the beginning of athletic involvement through post-athletic participation. This transitional process fits well within the existential sport psychology model.

Existential sport psychology

In a 2015 article, Noora Ronkainen and Mark Nesti discussed existential sport psychology being defined as the process of understanding the subjective reality of sport participation and the meaning assigned to experiences. They described the model as an attempt to understand and embrace the complexities of human life without attempting to “fix” or conquer them.

Existential psychology is centered on several major concerns: death, meaning, identity, isolation and freedom. Identity and meaning are especially important for elite athletes, given that their identity is generally tied to who they are as athletes. Meaning has sociocultural influences, and the culture of sports is embedded in the value placed on it by society. This would suggest that sports participants also have value and meaning assigned to their participation in sports.

However, consistent with themes described in 1980 in Irvin Yalom’s Existential Psychotherapy, athletes who experience career-ending injuries may experience a sense of meaninglessness, anxiety and a loss of identity. From this perspective, meaninglessness can be followed by behavioral patterns such as the misuse of alcohol and depression. This is often described as “existential neurosis.” These behaviors appear consistent with the symptomatology athletes can experience following separation from their sport.

As discussed in Nesti’s book Existential Psychology and Sport: Theory and Application, this model encourages people to accept freedom and responsibility in their lives and to live authentically despite experiences that increase anxiety. For injured athletes, this means beginning to accept the freedom in choosing to confront their injuries, and it provides them with a framework to view themselves as people who also identify as athletes.

Research published in 2016 by the Scandinavian Journal of Medicine & Science in Sports found that many athletes have been defined by descriptors such as age, gender, level of performance or type of sport. From an existential perspective, these descriptors are very limiting. Athletes are a diverse group of human beings who have dedicated themselves to participating in a sport. Sports participation can be an outlet for developing life skills, building community and social relationships, becoming leaders and much more.

Furthermore, athletes belong to a culture of competitors and sport participants that is centered on a common identity. This identity is not an athlete’s only identity, but neither does this identity cease to exist following an injury. Therefore, existentialism in sport may present an opportunity for athletes to discover how their athletic identity is expressed outside of competition and sports participation.

The Application of existential psychology in sport

The application of existential psychology in sport appears to be a model that can empower injured athletes to view themselves as more than athletes separated from their sport. Some may label themselves as “former athletes” who are still elite members of society possessing unique characteristics, talents and skills developed from participation in sports. The years of training, effort and energy expended in the process of becoming elite athletes can be transferred and applied outside of the sports context.

Although research in this field is limited, existential psychotherapy is a well-documented approach to treatment that is gaining interest in sport psychology. This rehabilitative process involves encouraging athletes to be more authentic in the therapeutic relationship. Encouraging athletes to be more of their authentic selves may help to reveal characteristics about their identity not expressed in the sports environment.

If an athlete is separated from a sport due to injury, their sense of identity may be lost as they transition. Practitioners can assist in this process by facilitating an environment that encourages athletes to explore their meaning and purpose. The athlete’s beliefs and assumptions regarding the injury and what it means to be separated from their sport can be discussed to continue the existential process. Uncovering beliefs and assumptions associated with being injured may also help the athlete conceptualize thoughts, feelings and attitudes that contribute to maladaptive experiences.

As athletes gain more insight, they begin to identify how their beliefs and assumptions are contributing to the distress they may be experiencing. They can be invited to confront the conflict associated with being injured, the change in their identity, the loss of meaning/purpose, and how it all fits within their role in society. Elite and recreational athletes may have their identities shaped by the daily activities associated with sports participation, the social connections made within their sport community and the cultural expression involved in the sport community. These athletes’ purpose in life was heavily influenced by the interaction of these factors, and their injuries may have completely disrupted how they view themselves in society.

Strategies organizations can offer

The organizational sports environment influences athletes’ well-being and sense of community. In an ideal world, organizations would assist athletes separated from their sport by providing helpful resources. Offering these tools can help athletes better adjust to and deal with the uncertainty associated with career-ending injuries. Organizations can foster an atmosphere that is supportive of their injured athletes by continuing to celebrate their contributions and achievements once they are no longer participating in sports.

Further action can be taken by recognizing that injured athletes are still athletes and that their community belonging does not change because they have sustained an injury. This could be demonstrated through messaging in the organization’s mission/vision, by offering roles to injured athletes upon separation from their sport, by providing support groups, and by encouraging the intentional development of life skills. Counselors in this role can facilitate this process by helping athletes and other stakeholders to identify how they relate to society as a whole. Preventive methods can be implemented by maintaining sport participation safety, taking steps to reduce burnout and overtraining, providing psychoeducation, ensuring a safe return to play from previous injuries, and promoting athlete wellness.

Practitioner strategies

Athletes are often taught to accept the realization that they are no longer able to participate in sports following injury or health concerns. But life after sport doesn’t always have to be about “letting go” of the athletic identity. Being an athlete is about more than having the ability to compete at the same level experienced prior to injury. It means that one has committed to a lifelong journey of self-improvement while striving to bring out the best in others. Given the tasks required in sports, this is typically focused on the activities necessary for sport performance.

However, many options can still exist for athletes separated from their primary sport. Practitioners can encourage options such as adaptive sports, which can provide a sense of purpose that aligns with the athlete’s sports identity. This also creates the opportunity to normalize participation in adaptive sports. Not every injury leads to permanent dysfunction, but the existence of adaptive sports challenges the idea that injured athletes are no longer able to participate in competitive sports.

Clinicians can also continue to implement strategies and techniques that reaffirm the athlete’s identity and purpose. Athletes can be encouraged to take ownership of their freedom to make choices and transform their injury experience into new meaning. This can be accomplished through the therapeutic relationship by fostering an empathic and authentic environment that assists the athlete in confronting the choices associated with their injury.

An additional strategy clinicians can use involves incorporating concepts of spirituality into the existential sport psychology practice. Athletes can be encouraged to define spirituality, which may provide an opportunity for them to reflect on their relationship with themselves, others and that which is beyond our understanding.

Applying the athlete’s mindset

Life after sport does not have to mean “acceptance” of a life that fails to provide the same level of renown as sports. From personal and professional experience, I can confirm that being an athlete means that you compete against the odds, and as an athlete, you recognize that you cannot allow self-defeating thoughts or negative feedback to dictate your performance. Instead, you must use it as fuel to reach the next level.

Having an athletic identity means striving to become the best at what you do and doing what needs to be done to get there. It’s about the process. It’s about becoming a better version of yourself by exercising the determination and motivation to become the best. Because as an athlete, you know there is always a chance that you will fail or lose, but you do not let that stop you. That’s why you were able to reach the level of success that you attained — because you did not give up. You continued to be relentless in pursuit of your goal, even with the knowledge that you might have to enlist a backup plan. You may no longer be directly involved in the activity that once gave your life meaning, but the mentality you developed along the way is still a part of you and can be applied in various situations.

Regardless of whether you are still able to participate in your chosen sport, you are, and always will be, an athlete.

lzf/Shutterstock.com

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Kris Amos is a licensed professional counselor and national certified counselor practicing in Michigan. He works full time as a staff counselor at Michigan State University’s Counseling & Psychiatric Services center and is the founder and owner of Precision Counseling PLLC, a private practice dedicated to providing professional counseling services. Kris provides individual counseling, group counseling, couples counseling, biofeedback, neurofeedback, mental performance training and educational workshops to the Michigan State community. Contact him at amoskris@msu.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Game, set, mental health

By Lindsey Phillips July 13, 2021

Naomi Osaka in 2015. Mai Groves/Shutterstock.com

Tennis superstar Naomi Osaka joined the growing list of athletes who are putting their mental health first when she decided to withdraw from the French Open in May, a few days after being fined for refusing to participate in post-match news conferences with the media. She shared on social media that her decision was made to protect her mental well-being, noting that she has suffered with depression since 2018 and experiences anxiety over speaking with the media.

In a recent New York Times article, Alan Blinder says that Osaka’s decision to withdraw from the French Open was “a potent example of a movement among elite athletes to challenge the age-old notion that they are, and must be, as peerless in mind as they are in body, untroubled by the scourge of mental illness.”

Osaka also decided not to participate in Wimbledon and will instead focus on representing Japan at the Tokyo Olympics later this summer.

Athletes are often held up to unobtainable standards and viewed as superhuman because of their amazing physical talents, says Michele Kerulis, who is a licensed clinical professional counselor with a private practice in Illinois and holds a doctorate in counselor education and supervision. People expect them to be “perfect, excellent, exquisite and all those unbreakable things,” she explains. “But athletes are people who have the same spectrum of feelings that we all have. They feel anxiety, depression, guilt, shame, embarrassment, and so on, and … they are put under a microscope when they have any kind of a feeling that the media or the public doesn’t perceive as fitting within that sport.”

Overcoming the stigma

The stigma attached to depression, anxiety and other psychological conditions often prevents athletes from discussing their mental health needs out of fear they will be seen as weak. And for some college and professional athletes, there’s an added worry that their mental health may cost them their scholarship or contract, points out Kerulis, a professor of counseling at Northwestern University who specializes in sports, exercise and the impact of media on sport psychology.

This fear is not unfounded. Taunya M. Tinsley, a licensed professional counselor and owner of Transitions Counseling Services in Paoli, Pennsylvania, has heard coaches refer to players’ struggles with mental health in a critical or belittling way by making comments such as, “What’s wrong with you? Are you not on your medications?” This attitude further discourages athletes from being open about their mental health.

“Just because somebody has strong athletic skills does not mean they’re not going to suffer from mental health challenges, so [counselors] have to help put the humanistic aspect back in,” stresses Tinsley, a member of the American Counseling Association who specializes in sports counseling, multicultural and social justice issues, and spiritual and Christian interventions. Clinicians must help “athletes and those who work with athletes understand that … we can’t separate the mental and emotional wellness from the physical wellness.”

Mental training

Athletes often ask Kerulis, an ACA member and an Association for Applied Sport Psychology fellow, to help them “get in the zone” a few days before a big game or event, and she lets them know that mental training takes time.

Coaches help athletes with the physical and strategic techniques, Kerulis notes, and trainers ensure athletes’ muscles are strong and prepared for the movement required in their sport. “The next piece is practicing those physical techniques [and] developing the muscle memory. When they are learning new skills or techniques, part of it is understanding they’re not going to ace this the first time they try it, and that’s part of what practice is — repetition and trying over and over,” she says. “And it’s the same thing with any psychological skills that athletes are learning. You integrate that into their practice setting.”

Like a strength trainer, Kerulis slowly works with clients using therapeutic approaches such as mindfulness, cognitive behavior therapy, imagery, relaxation and arousal control to help them improve their mental focus.

A basketball player, Kerulis explains, spends most of the game sprinting up and down the court, sweating and elevating their heart rate. But when the player gets fouled, they must quickly transition from this accelerated state to a calm one to successfully hit the free throw. That process requires mindfulness and body awareness, Kerulis notes. She might work with the basketball player for a few weeks to develop a progressive muscle relaxation (PMR) script (slowly tensing and relaxing muscles throughout the body) and help them learn how to scan their body and notice bodily sensations. Then, when they are at the free-throw line, they can do a quick body scan, release any tension and shoot.

“What you might see in a split second could takes weeks of preparation,” she points out.

Anxiety and interpersonal skills

It’s common for athletes to suffer from performance anxiety. Kerulis, the Association for Multicultural Counseling and Development (AMCD) Midwest Region representative and outgoing chair of the Midwest Region of ACA, once worked with a teenager who was a runner. Before every meet, he felt nauseated and dizzy, and no matter how he did, he felt distraught after it was over. He had already been medically cleared to participate and wanted help overcoming these physiological responses to his anxiety.

In session, they used the cognitive behavior therapy technique of thought stopping to help the client disrupt the negative thoughts he often had a few days before each meet and replace them with positive mantras or statements.

Kerulis’ client was scared to tell his coach about his anxiety because he thought the coach might not let him race. Kerulis asked if the coach had noticed his anxiety and the change in his behavior, and the client said, “Yes, absolutely.” So, they discussed how the coach was probably already wondering why the teenage runner was behaving differently.

This conversation helped the client realize that asking for help was a sign of strength, not weakness, and would show his desire to improve, Kerulis says. With her help, the client prepared talking points to lessen his anxiety around having that conversation with his coach.

The teenager also improved his communication with his parents by explaining that he wanted to have more positive thoughts going into his races. His parents were supportive and checked in with him before each meet, asking, “How are you feeling today? How’s your mantra?”

Identity development

It’s important for counselors to assess where athletes are in terms of their identity development and tailor treatment plans to help them explore identities outside of their sport, says Tinsley, the clinical director of the Mount Ararat Baptist Church Counseling Center in Pittsburgh.

Some individuals may have a foreclosed identity and only see themselves as an athlete without exploring other aspects of their identity, she says. Then a career-ending injury or retirement will cause them to question their identity: Who am I without this sport?

Kerulis finds that if someone’s sole perspective of themselves is being an athlete, they tend to have a more detrimental response when something upsetting happens in the sport. Whereas an athlete with a foreclosed identity may feel extreme disappointment after losing a game, for example, another athlete who has a more open identity would not be as devastated because they have other interests in life and feel more balanced.

In other cases, athletes may have discovered additional interests outside of their sport, but their primary identity as an athlete prevents them from pursuing those interests, says Tinsley, a past president of AMCD. For example, an athlete might want to major in health sciences in college, but their sport schedule hinders them from taking the required classes or putting in the necessary work.

Tinsley begins her sessions by asking questions unrelated to the client’s sport so she can get to know the person, not the athlete. She may ask, “What are your interests when you aren’t playing the sport? Who do you have a good relationship with in your family?”

Kerulis also encourages athletes to maintain diverse interests unrelated to sports. “That’s not to decrease the importance of preparing mentally for [their] sport,” she says. “It’s to help create a more well-rounded individual so if and when they experience difficulties, tough times or roadblocks in their sport, they have this balance … and [can] reset.”

Prevention

Counselors should focus on the prevention of mental health problems with the athlete population, Tinsley stresses. Part of that involves creating life-skills programs that help athletes plan for retirement before it happens so the transition is not a shocking, traumatic event.

Tinsley has worked with the National Football League (NFL) and the Pittsburgh Steelers to provide mental health services to athletes and to train former NFL players to serve as transition coaches between current athletes and mental health professionals. This work introduced her to LaMarr Woodley, a former linebacker for the Steelers who had already started thinking about his transition from the NFL by launching a Sack Attack Program in 2009. Through pledges, every sack Woodley made raised money for youth charities in Pittsburgh and his hometown of Saginaw, Michigan.

Woodley explains in a recent interview with Tinsley how despite some people’s insistence that he focus solely on football, he knew he needed to start preparing for life after his NFL career. He notes how parents and coaches are pushing kids to become professional athletes at younger ages, and this pressure can lead to burnout, stress, anxiety, substance use and other mental health concerns.

Counselors can help prepare athletes for these transitions, Tinsley says. She worked with Woodley to consider his next career options, and eventually, he decided to earn his master’s in sport management studies with a sports counseling concentration and continue to help athletes as they navigate the internal and external pressures that can affect their mental health.

In a Time magazine essay, Osaka stresses the importance of athletes (like other career professionals) being able to take mental health days without scrutiny or explanation, and she reminds us that “it’s OK not to be OK.” Going forward, perhaps more athletes will follow Osaka’s example of putting her well-being above her sport.

Kerulis applauds Osaka’s choice to prioritize her mental health. “It’s so hard for people to admit difficulties,” Kerulis says. “Some people are calling [her decision] a failure, but … it may be one of the biggest successes of an athlete’s career to be able to put themselves first and say, ‘I understand the importance of this competition, and at the same time I know that I need to take care of myself or else I cannot be the outstanding athlete that I know I am.’”

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American Counseling Association members: Interested in exploring connections between sports and mental health? Join ACA’s Sports Counseling Interest Network.

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Team sports vs. solo exercise: Which is better for your mental health?

By Bethany Bray December 3, 2018

Professional counselors often recommend exercise to clients as a way to improve mood and overall wellness. In addition to boosting serotonin, a neurotransmitter connected to feelings of well-being, exercise offers the chance to unplug from the busyness of daily life and process one’s thoughts.

A recent journal study in The Lancet Psychiatry takes that recommendation one step further, connecting team sports to improved mental health. A cohort of researchers studied four years of recent survey data from more than 1 million American adults.

They found that individuals who exercised experienced 43 percent fewer days of poor mental health in a one-month period than did people who didn’t exercise at all. Individuals who experienced the greatest mental health benefits, however, were those who participated in team sports, followed by those who rode bicycles or did aerobic and gym activities (in durations of 45 minutes, three to five times weekly).

Jude and Julius Austin, American Counseling Association members who played soccer both in college and at the professional level, stress that the study’s correlational findings do not mean causation.

“We think further research needs to be done regarding the lived experience of athletes in team sports who struggle with mental health issues,” said the brothers in a co-written statement to Counseling Today on the Lancet findings.

Although mental health improvements are not caused by exercise, physical activity does, when done appropriately, have biological, cognitive and social benefits — which Jude, an assistant professor in the counseling program at the University of Mary Hardin-Baylor in Texas, and Julius, an assistant professor in the marriage and family therapy and counseling studies program at the University of Louisiana Monroe, say they experienced as soccer players.

“It is exciting to see [researchers] investigating things we believe most athletes can collectively, albeit anecdotally, agree on,” wrote Jude, a licensed professional counselor in residency and Julius, a provisionally licensed professional counselor. “In our experience playing team sports, it feels great to survive a particularly tough practice. Pushing ourselves through seemingly impossible physical tasks with others reinforced that we have everything we need to handle life’s challenges. There is something healing about being swept away by the team’s mentality during a game; pressing or absorbing pressure, counterattacking or keeping possession, the ebb and flow of defense to offense, being in the zone. Even if it’s only for a moment, those sweeping moments were where we received social support, affirmation, genuineness, empathy and unconditional positive regard. These are all therapists’ offered conditions in an effective therapeutic relationship. We could not say this with empirical certainty, but we would imagine that receiving these conditions from a team can cause lessening of mental health issues.”

ACA member Sarah Fichtner, a former Division I women’s soccer player for the University of Maryland (UMD), has mixed feelings about the Lancet study. While there is little doubt that exercise in general benefits both mental and physical health, it can be taken to the extreme when sports are played at a high level, she says.

“I am a firm believer that exercise improves an individual’s mental health, as it produces feel-good endorphins and releases chemicals such as norepinephrine which alleviate stress and anxiety,” Fichtner says. “As an exercise and health enthusiast myself, there is not a doubt in my mind that exercise has many positive implications. However, I am a bit skeptical of the [Lancet] findings pertaining to team sports. I do see the benefits of exercise groups [in] that they provide accountability, comradery and support, but in terms of competitive team sports — particularly at the collegiate level — the environment is extremely different.”

Fichtner is a counselor intern at Hackensack Meridian Behavioral Health and is working on completing a master’s degree in clinical mental health counseling at Kean University in New Jersey. After her experience as a DI athlete, she calls for balance when it comes to competition and team sports.

“During my time as a student-athlete and captain at the University of Maryland, I saw firsthand the detrimental consequences of the collegiate world. When a player is recruited to play at the DI level, he or she is expected to perform. Coaches have one goal in mind, and that is to win,” she explains. “Practices are intense, to say the least, and the idea of healthy competition goes out the window. A player is competing against his or her teammates every day to secure a starting position. They are competing to be the fastest, fittest, slimmest and most technical or tactical player. And every day, their coaches are telling them, ‘You are not good enough,’ ‘You need to lose five more pounds to be in the running for a starting position,’ ‘Your teammates are working harder than you’ and ‘Ask your teammate so-and-so for help. She is outperforming you. She has great skills.’ This high-intensity environment can lead to many mental health challenges such as eating disorders, anxiety, depression and low self-esteem, which I witnessed during my four years at UMD. Thus, when I think about team sports, specifically at the collegiate level, the word balance comes to mind.”

“Aside from the intense environment, there were many positives takeaways from my time as a student-athlete,” Fichtner adds. “I made lifelong friendships, competed at the highest level of collegiate sports, was privileged to visit many states, had top-notch gear, learned important life lessons and would do it all over again in a heartbeat. Nevertheless, now as a mental health counselor, I see the collegiate world through a different lens. Many of the challenges we athletes faced on a daily basis seemed both normal and absolute. But now as I grow both personally and professionally, I realize that colleges need to establish a balance between a healthy competitive environment, where athletes are pushed and held accountable, and a debilitating, harmful environment, in which athletes are placed in harm’s way [of] mental health challenges. Balance is key to any exercise regimen, especially in the collegiate world.”

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Read the Lancet study in full: thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30227-X/fulltext#seccestitle10

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ACA members: Interested in exploring connections between sports and mental health? Join ACA’s Sports Counseling Interest Network.

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.