Practitioner Response Framework – How to REACT to Your Athletes

THE NEED FOR “MENTAL HEALTH CPR”

Strength and conditioning coaches are encouraged to understand the mental health best practices that have been endorsed by the National Strength and Conditioning Association (NSCA) and are aligned with the National Collegiate Athletic Association’s (NCAA) mental health guidelines for student-athletes (3). As such, strength and conditioning coaches are seen as essential to promoting mental health, with responsibilities including fostering supportive team cultures and encouraging care-seeking behaviors among athletes (3). Additionally, they often take on psychological responsibilities, such as providing informal counseling and mentoring, especially in the absence of a psychologist (7). However, strength and conditioning coaches report having less than moderate training in sport psychology strategies (3). They frequently have limited strategies, such as goal-setting and self-talk, to use with athletes, suggesting a gap in formal education and training regarding athlete mental wellness (3). Considering strength and conditioning coaches feel unequipped to handle overall health promotion, a need exists to enhance their knowledge and confidence in using mental health strategies effectively with athletes (1,6). This need is arguably more critical when considering the various mental health crises athletes may encounter.

Few strength and conditioning coaches may hold requisite psychology/counseling credentials to provide mental health services, yet they may find themselves as the “first responders” in a moment of crisis. Imagine an athlete collapsing from a heart attack, a symptom of a potentially serious underlying heart condition. While most likely not a medically-certified cardiovascular expert, the bystander coach immediately starts CPR, buying time until paramedics arrive, who will then take over care of the individual. Similarly, when an athlete approaches a strength and conditioning coach with a psychological concern, it may indicate a deeper issue. Though not a mental health practitioner, the strength and conditioning coaches can offer “mental health CPR.” This article aims to equip strength and conditioning coaches with a framework of how to “REACT” to athletes’ psychological concerns. For this framework, REACT stands for: Respond, Evaluate, Act, Connect, and Track.

Prior to delving into this framework, it is important to first clarify and define critical terms. Similar to previous works exploring athletes’ mental health here the phrase “mental health” will be used to refer to an athlete’s overall psychological status (3,4). Paralleling evaluations of athletes’ physical health, the phrase “mental health” is thus distinct from “mental illness.” Furthermore, the proposed framework allows for a spectrum approach to assessing mental health (once again paralleling physical health) ranging from a mental health concern, to a mental health illness, or even mental health disorder or crisis.

RECOGNIZING THE GAP BETWEEN POLICIES AND PRACTICE

There are direct guidelines and methodologies directing how to physically develop athletes with strength, speed, and agility training. Yet, there is a significant gap in how to support the mental well-being of athletes. Strength and conditioning coaches have stated that, based on resources provided to athletes, the role of the strength and conditioning coach can expand as they may need to provide psychological skills to athletes (7).

Due to frequent interaction between athletes and strength and conditioning coaches, the strength and conditioning coach can promote positive mental health skills essential to athletes’ success (7). Arguably, the rapport generated through these frequent interactions can create favorable conditions for such opportunities. According to the Professional Code of Ethics through the National Strength and Conditioning Association (NSCA), section 3.2 states that strength and conditioning professionals may “only provide services that they are qualified to provide through education or experience and which are allowed by practice acts and other pertinent regulations,” (5). Arguably, some strength and conditioning coaches may view this guideline as rather broad. While established expectations for “education” may be commonly understood (e.g., course credit hours, continuing education, etc.) the parameters for qualifying experience may seem ambiguous. While diverse and varied experiences may allow a strength and conditioning coach to grow within the area of mental healthcare, this does not necessarily mean these experiences alone are proficient for providing proper care during an athlete’s mental health crisis. Similar to other aspects of professional development, through additional education and training, strength and conditioning coaches can be provided with the tools to properly aid in the transition between the occurrence of a mental health episode and referring athletes to a qualified mental health specialist.

R.E.A.C.T.

According to Gilham and Pirkl, there are four different categories describing mental health interactions between athletes and strength and conditioning coaches (4). These categories include: emergent threats, mental health concerns, applied performance concerns, and banter. The concerns are organized based on the immediacy of the threat. Emergent threat is the most immediate and involves behavior that must be addressed promptly due to the potential for harm to the athlete and/or others. Emergent threat topics include life and death situations, suicidal or homicidal thoughts, sexual assault, and the loss of contact with objective reality (4). Mental health concerns are the next most pertinent category and require the strength and conditioning coach to ask appropriate questions and refer the athlete to a mental health professional. Examples of mental health concerns include statements involving a lack of care, lack of motivation, irregular sleep, and unhealthy relationship with food. Applied performance concerns consist of the athlete specifically mentioning performance or sport concerns that do not stray into regular life concerns. Lastly, banter is the least concerning (in terms of mental health crisis) of the four categories and involves an athlete making well-meaning comments that may be part of the culture of the sport but may be either connected to as aspect of overall mental health or are adjacent to an athlete’s overall mental wellness. Even when not explicitly demonstrating the severity or concern in comparison with the other categories, engaging with athletes in banter provides opportunity to further rapport and actively demonstrate a concern for every aspect of the athlete’s holistic wellness.

As already mentioned, there exists great ambiguity in navigating mental health crises in terms of literature, practice, and even terminology. The phrase “mental health crisis” for example, may be used to describe multiple situations athletes experience while simultaneously rating differently on this spectrum ranging from “banter” to “emergent threat.” For some athletes, a season-altering injury may create a mental health “crisis” where they experience psychological or emotional distress beyond their coping capabilities. Even if the athlete is in no immediate danger to themself or others, their distressed mental state may require acknowledgment and support. Simple, yet profound, nuances to such a situation (e.g., season-ending injury, loss of financial benefits, little to no coping skills, previous trauma, etc.) could drastically alter the level of danger or harm to the athlete, as well as resulting concern on the part of the strength and conditioning coach. During such mental health crises, strength and conditioning coaches must deftly navigate this milieu to ensure the athlete receives requisite care, whether it is encouraging remarks, active listening, or safety, between the time the event occurs to when they receive support from the appropriate care provider. It is towards addressing this gap in the literature and potential ambiguity that the authors have created an action plan based on relevant literature and best practices for strength and conditioning coaches. This has been done using an easy-to-remember, concise, and simple acronym for strength and conditioning coaches to keep on hand: REACT. The REACT framework provides a guide for strength and conditioning coaches to follow to safely help athletes transition from a mental health episode to the appropriate mental healthcare provider.

PRACTICAL APPLICATIONS – THE FOUR-MODEL APPROACH

To further illustrate the REACT model and its implementation, the following are a few scenarios that illustrate potential situations strength and conditioning coaches may encounter and the corresponding levels of concern. It is important to realize how critical rapport is with the athletes, precisely because those relationships help the strength and conditioning coach decern what is being said and what actions to take. Building upon the scenarios offered by Gillham and Pirkl, these examples demonstrate how strength and conditioning coaches might utilize REACT to navigate each level of athlete interaction (4).

EMERGENT THREAT

During a lifting session, the strength and conditioning coach notices that an athlete seems off that day, so approaches them and asks how they are. The athlete says, “I am totally overwhelmed due to all of the pressure from everyone. I just wish I wouldn’t even wake up. Just end it all.”

• Respond – “I hear you. I am sorry that you feel like there is so much pressure on you. Thank you for sharing this with me.”
  
  
• Evaluate – This scenario would be categorized as an emergent threat, as the statement “I wouldn’t even wake up” could indicate potential suicidal ideation.
  
  
• Act – Immediately refer to a qualified individual, stay with the athlete, and continue to be with and appropriately support them to monitor their safety. » “I think that it would be helpful for you to talk with someone who is more qualified than I am about this. Let me walk you over to the psychologist. How does that sound?”
  
  
• Connect – Walk with the athlete to the appropriate resource.
  
  
• Track – Immediately after the interaction is over, track it by documenting the event, including all pertinent information, including, but not limited to, the individuals involved, what all parties said, what actions were taken, and who the athlete was recommended to speak with.

MENTAL HEALTH CONCERN

After a lift, while everyone grabs some food, an athlete approaches and says for the third time this week, “I don’t need any of that food. Look at me, I don’t need to eat for days. I wish I just looked like everyone else on the team.”

• Respond – “Having a good relationship with food can be challenging. It sounds like you are seeking to change your body composition through changing how much you are eating.”
  
  
• Evaluate – This scenario would be categorized as a mental health concern, as the statement “Look at me, I don’t need to eat for days” could indicate an eating disorder.
  
  
• Act – Refer to an appropriate resource, such as a Registered Dietitian.
  • “I think it would be very beneficial for you to go talk to the Registered Dietitian about this. They are very knowledgeable about relationships with food. I will have them reach out to you.”
    
    
• Connect – Talk with the Registered Dietitian about that particular interaction, what the athlete said, and concerns they may have about an unhealthy relationship with food leading to negative downstream effects.
  
  
• Track – Immediately after the interaction is over, track it by documenting the event, including all pertinent information, including, but not limited to, the individuals involved, what all parties said, what actions were taken, and who the athlete was recommended to speak with.

APPLIED PERFORMANCE CONCERN

Prior to a training session, an athlete approaches and says, “I am really struggling with my confidence on the field, I don’t think the coaches understand me, and I’m not playing at the same level I was before I got here.”

• Respond – “The transition from playing in high school to college can be very stressful and challenging for many athletes. It sometimes can take time for coaches and athletes to learn each other and figure out the best approach to produce the proper results for that individual.”
  
  
• Evaluate – This scenario would be categorized as an applied performance concern, as the statement “I am really struggling with my confidence on the field, I don’t think the coaches understand me and I’m not playing at the same level I was before I got here.” does not stray into regular life concerns.
  
  
• Act – Ask clarifying questions such as:
  • “How long have you been feeling this way?”
  • “Have you tried to talk with your coach about how you’re feeling?”
  • “Would you feel comfortable talking with a sport psychologist about your concerns and feelings?”
    
    
• Connect – Refer to an appropriate source, such as a sport psychologist certified through the Association for Applied Sport Psychology (AASP) as a Certified Mental Performance Consultant (CMPC), or similarly qualified mental healthcare professionals.
  • “I think that it would be helpful for you to speak with the team sport psychologist. They are knowledgeable in this area and can help bridge that gap between you and your coach.”
    
    
• Track – Immediately after the interaction is over, track it by documenting the event, including all pertinent information, including, but not limited to, the individuals involved, what all parties said, what actions were taken, and who the athlete was recommended to speak with.

BANTER

Prior to the training session, the athlete says “We just got done with practice 30 minutes ago, do we really have to do another warm-up?”

• Respond – “Yes, we do need to warm-up to ensure that your body is prepped and ready to go for the lift.”
  
  
• Evaluate – This scenario would be categorized as banter, as the statement “We just got done with practice 30 minutes ago, do we really have to do another warm-up?” has more of a joking nature and there are no indications of a mental health crisis.
  
  
• Act – Shift the athlete’s focus away from warming up again and highlight the reasons why it is important.
  • “Yes, we do need to warm up again to ensure that you guys are prepped and ready to go for the lift. The last thing I want you to do is pull something because you got cold between the practice and lift.”
    
    
• Connect – In situations of banter, the strength and conditioning coach does not need to connect the individual to any further resources outside of fostering a positive environment.
  
  
• Track – In situations of banter, the strength and conditioning coach does not need to track or document any information.

CONCLUSION

Strength and conditioning coaches often face situations where they need to provide direction, foster a positive environment, and informally counsel athletes regarding mental health, resilience, and general well-being. Sadly, many strength and conditioning coaches report having less than moderate training to do so, suggesting a current gap in literature and formal training for how strength and conditioning coaches navigate these situations of providing “mental health CPR.” Even when institutions or athletic departments have capabilities for addressing athletes’ mental health needs, strength and conditioning coaches may view such resources as external to their domain of practice, potentially delaying (if not hindering) athletes receiving the help they need.

Using Gilham and Pirkl’s four-category model of mental health, the REACT framework provides a plan of action for strength and conditioning coaches to use when aiding athletes’ transition from a mental health episode to visiting the appropriate provider. The framework is flexible enough to guide strength and conditioning coaches regardless of institutional size and level. Where no institutional or department procedures exist, the REACT framework provides specific guidelines for strength and conditioning coaches. For strength and conditioning coaches at institutions with established resources (e.g., sports psychologists, dietitians, etc.) the REACT framework can serve as a collaborative roadmap, referring to existing supports and connecting athletes with support with minimal delay. Through familiarization with REACT and the use of the framework as situations arise, strength and conditioning coaches can experience increased confidence with navigating the challenging domain of athletes’ mental health and well-being. More importantly, using REACT will ensure athletes receive the appropriate (and at times critical) mental health support they require.

This article originally appeared in NSCA Coach, a quarterly publication for NSCA Members that provides valuable takeaways for every level of strength and conditioning coach. You can find scientifically based articles specific to a wide variety of your athletes’ needs with Nutrition, Programming, and Youth columns. Read more articles from NSCA Coach »

References

Gearity, B, and Moore, E. National Strength and Conditioning Association’s endorsement of the National Collegiate Athletic Association Sport Science Institute’s “mental health best practices: Inter-association consensus document best practices for understanding and supporting student-athlete mental wellness.” Strength and Conditioning Journal 39: 1–3, 2017.

Quartiroli, A, Moore, E, and Zakrajsek, R. Strength and conditioning coaches’ perceptions of sport psychology strategies. Journal of Strength and Conditioning Research 36: 1327-1334, 2020. 

Radcliffe, J, Comfort, P, and Fawcett, T. The perceived psychological responsibilities of a strength and conditioning coach. Journal of Strength and Conditioning Research 32: 2853-2862, 2016.