By Chris Carr and Jamie Davidson

Intercollegiate athletics embodies a unique and demanding culture. The pressures and demands on 18- to 21-year-old student-athletes are great. Their wins and losses are seen by many, questioned by many, and often criticized publicly.

Even within the athletics environment, student-athletes' time demands are enormous – daily practices, competitions that may involve travel (some across time zones), a full academic course load, strength and conditioning programs, and sports medicine/rehab appointments present a demanding schedule indeed. Social interactions and relationships often take a back seat to the athletically related challenges and commitments.

It is no surprise that these pressures can affect a student-athlete's mental health. A well-trained psychologist with expertise in sport psychology is an ideal resource to provide care and services. But over the past 20 years, the sports psychologist's role in college sports has evolved more slowly than student-athletes' needs.

The ways colleges and universities use sport psychologists also vary, often depending on resources and how well the athletics department understands how to incorporate these services.

The following explains both the challenges related to the integration of sport psychologists within college athletics, and the models schools currently use when they do take advantage of such expertise.

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First, here are the challenges related to the slow growth of psychologists in the arena of student-athlete mental health care.

The ongoing "stigma" within the sport context. Student-athletes, coaches and staff tend to minimize mental disorders or psychological distress because of the expectations of strength, stability and "mental toughness" inherent in the sports culture. As a result, student-athletes often avoid disclosing a mental health concern, especially if the perceived negative consequence includes being rejected by teammates or coaches due to the disclosure. In many ways, this stigma further exacerbates the problem of student-athlete mental health as it inhibits effective dialogue, education and development of resources to address these issues.

Once a mental health issue is identified, resources may be limited or difficult to access. As sports medicine and athletic training have evolved, it is now common for a Division I athletics department to employ four or more full-time certified athletic trainers. Some schools even have in-house sports medicine physicians specifically providing medical care for student-athletes. Additionally, more and more athletics departments employ registered dietitians/sport nutritionists to provide optimal nutritional care for their athletes. However, not many programs employ full-time or even part-time licensed psychologists. Instead, they depend on campus resources such as student counseling centers to refer for mental health issues. The problem there is that few student counseling centers employ a psychologist who has the training/education to address student-athletes' unique psychological needs.

The issue of "sport" psychology vs. "clinical/counseling" psychology is often confusing to athletics department personnel. In most of the 50 states, if not all, the term "psychologist" (in any form) is protected as a licensed profession. If professionals identify themselves as "sport psychologists," then they should be able to produce their license number within their state of practice. The "sport" designation, for those licensed psychologists, should denote a competency in their training. Competency, as defined in most states, includes academic preparation, training, supervision and experience within a specific domain (for example, child psychology, forensic psychology). Therefore, a licensed psychologist identifying as a "sport psychologist" should also be able to demonstrate training (such as graduate coursework, or perhaps a master's degree in physical education and ongoing supervised experiences) in sport psychology. Further clarifying this distinction in training and competency is a key element in enhancing the ongoing development of providers for collegiate student-athletes.

The competency of licensed mental health providers/psychologists to understand the unique nature of the collegiate athletics environment. Whether it be a Division I, II or III athletics department, it is important for the provider to understand the culture of the athletics environment to best understand the external stressors, motivations and dynamics (team, for example) within that athletics environment. This often requires that a licensed provider have previous experience as perhaps a student-athlete or coach, or a prior role within an athletics department (like an academic adviser), or have supervised experience during their training (for example, as a pre-doctoral intern with a rotation in sport psychology/athletics). This immersive experience offers observational and experiential learning opportunities for the psychologist, which builds competency to provide care for the athlete.

Lack of training models for psychologists and mental health providers in the domain of sport and performance psychology. As the role of psychologists within collegiate athletics has increased, it is important to note that many clinical/counseling psychology programs do not typically offer graduate coursework in the domain of sport and performance psychology. However, a few programs train students to be doctoral-level psychologists and provide graduate training/experience in the domain of sport psychology (the University of North Texas and Indiana University, Bloomington, do so, for example, both in counseling psychology).

Professional "contamination" and disruption of current services. Because collegiate athletics continues to focus on concepts such as "performance excellence" and "mental toughness," the realm of "motivational gurus" and "mental coaches" finds college athletics a prime target for their services, and they may very well ignore, minimize or neglect the real issues of psychological health. Individuals not trained in mental health/psychology often say they will refer any athlete with a personal issue, but if they are not trained in diagnostic interviewing, then they are not likely to identify potential issues. Thus, the athletics administrator must struggle with the challenge of providing effective mental health services for student-athletes, as well as providing a resource to teach coaches and student-athletes psychological skills to enhance sports performance. Competent and well-trained licensed psychologists can often provide both services within a collegiate athletics department. They also may be able to supervise and coordinate an effective "sport psychology team" for both performance and personal counseling services.

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With those challenges as a backdrop, here are the models college athletics departments currently use to provide student-athlete mental health services. The depth and breadth of these models of course depend on the commitment of the athletics administration, sports medicine, academic services, compliance and coaching staffs to optimize psychological resources for their student-athletes.

The most common models include:

Full-time athletics department sport psychologist. This position is typically held by a licensed counseling/clinical psychologist with graduate training (often a master's degree) in physical education/sport psychology. The sport psychologist usually provides:

Individual counseling for student-athletes (mental health concerns such as anxiety disorders, mood disorders, and performance-related counseling for issues related to performance anxiety and confidence issues);

Coordination of substance abuse/eating disorder services for student-athletes (often being involved with NCAA and institutional drug-testing referrals); team consultations for both clinical (for example, grief counseling) and performance (for example, team-building) issues;

Staff education and consultation; and

Consultation with athletics administrators on psychological care issues within the athletics department (for example, establishing postgraduate support programs for former student-athletes).

These positions are typically housed in the athletics department, either within sports medicine, academic services or an office affiliated with athletics.

Schools that have incorporated this model include Oklahoma, Virginia, Ohio State, Virginia Tech, Arizona, Southern California, Washington, Iowa, Arkansas, LSU, Missouri, Kansas and New Mexico.

Part-time consultation model. Some athletics departments retain external consultants or counseling center staff psychologists who are given time to work within the athletics department. These people typically provide the same services as their full-time counterparts, though with less time per week (about 10-30 hours as opposed to 40-50), there is less service provision.

Athletics departments wanting to develop sport psychology/psychological care for their student-athletes but do not have the budget to develop a full-time position with benefits often choose this model. It's economically more efficient and allows an athletics department with limited funds or resources to provide "in-house" services for their student-athletes.

A skilled provider on a part-time consulting contract may also be able to coordinate a sport psychology services "program" that identifies specific individuals (for example, substance abuse counselor at counseling center, mental skills consultant in physical education department) to be part of the team that the primary consultant coordinates, supervises and directs.

Most of these providers have an office within athletics to provide the services, and the department often will market this position within its department website/directory.

Among schools incorporating this model include Purdue, Wisconsin, Stanford, Oregon State, Minnesota, Nevada, Maryland and Oklahoma State.

Referral model of services. This model does not employ or retain an "in-house" provider; rather, it identifies a specific provider within the community or counseling center that will take referrals for student-athlete psychological issues.

This model tends to be more of an "intervention" (rather than prevention/education), as the student-athlete often has to present with psychological distress or self-referral in order to access this system.

The provider typically does not have an "in-house" office, so the student-athlete is referred to the provider's office for services. This is not an immersive model of care, but rather a "referral" model in which the athletics department can indicate that it provides services, but only through external referral. (For more on how to make the referral model effective, see Chris Klenck's article in Chapter 6.)

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So, which of these models is the best fit? It is important that schools explore all the options for a psychological services model for their student-athletes.

Clearly, an immersed program with full-time or part-time licensed psychologists allows for better service, communication and delivery of services. Having an immersed sport psychologist allows the athletics department to best address the variety of psychological issues (individual, team, staff) that may be present. Providing a psychologist as part of the support staff also helps to de-stigmatize and normalize the issues related to student-athlete mental health.

Just as having a full-time sports medicine physician and athletic training staff does not eliminate musculoskeletal injuries, having an immersed full-time/part-time sport psychologist will not eliminate mental health issues. However, as sports medicine care has greatly enhanced prevention, intervention and rehabilitation of athletics injuries, an immersed and comprehensive sport psychology program can enhance the prevention, intervention/counseling and care of student-athlete mental health/psychological issues.

A key element in improving student-athletes' emotional well-being is to establish a strong working alliance with the university counseling center, regardless of whether an athletics department has the services of a sport psychologist available.

University counseling centers offer unique services and benefits to student-athletes, including professionals who are highly skilled in treating the mental health concerns common to college students and who are of diverse backgrounds and embrace all walks of life. Counseling centers also offer student-athletes a high level of confidentiality.

To properly address student-athletes' psychological concerns, it is best to incorporate the services of a sport psychologist into your mental health team. Student-athletes will reap the benefit of this collaboration through improved emotional well-being.

The good news in all of this is that the role of the licensed counseling/clinical psychologist in the mental health care of collegiate student-athletes continues to evolve in a positive direction.

As more athletics departments create sport psychologist positions (either full-time or part-time) that are immersed within the department, there will be greater education opportunities, greater awareness of student-athlete mental health concerns, greater opportunities for coaches/staff to have positive interactions with psychologists, and greater training opportunities in the future for aspiring psychologists who desire to work with athletes as clients.

Chris Carr is a psychologist at St. Vincent Sports Performance in Indianapolis and a counseling sport psychologist and coordinator of sport psychology services for the Purdue University athletics department. Carr also provides individual counseling and consultation services, and he is a licensed psychologist in the state of Indiana. He is currently the consulting sport psychologist for the Indiana Pacers and has previously been the counseling sport psychologist for Indiana University, Bloomington, The Ohio State University and Washington State University. Carr played football while receiving his B.A. in psychology at Wabash College. He has an M.A. in counseling psychology from Ball State University, where he was a graduate assistant football coach from 1983 to 1984. He completed his Ph.D. in counseling psychology (with a doctoral minor in sport and exercise psychology) at Ball State and did a one-year clinical research assistant position in sport psychology at the United States Olympic Training Center in Colorado Springs, Colorado.

Jamie Davidson is a licensed psychologist with more than 20 years of clinical practice in higher education. He serves as the associate vice president for student wellness at the University of Nevada, Las Vegas, after having previously been the director of student counseling and psychological services there. Under Davidson's leadership, the UNLV student wellness center has received national and regional awards for innovation and excellence in the delivery of integrated medical and mental health services. Most recently, UNLV was one of only 30 universities in the country to receive an award for providing comprehensive mental health services and suicide prevention programming from the Jed Foundation.