Sport-Specific Mental Health Interventions in Athletes: A Call for

Sport-Specific Mental Health Interventions in Athletes: A Call for Optimization Models Sensitive to Sport Culture

Yulia Gavrilova and Brad Donohue University of Nevada, Las Vegas

There is limited information available about the effects o f mental health interventions in athletes. Therefore, in this paper we (1) elucidate reasons athletes underutilize mental health interventions and highlight the need to develop and implement optimization-focused interventions that are capable o f engaging athletes into mental health and sport perfor mance intervention, (2) underscore mental and behavioral health targets fo r optimization planning in athletes, and (3) introduce a mental health and sport performance optimization model that incorporates evidence-supported protocols developed explicitly fo r athletes. The theoretical underpinnings o f this approach are grounded in optimization science, utilizing skill development to advance mental health and sport performance along a continuum o f op timization (non-optima! to optimal). Future directions, including the involvement o f profes sional and amateur sport organizations, are presented to assist development o f optimization programs within their unique cultures.

Address correspondence: Brad Donohue, Ph.D., University of Nevada, Las Vegas Department of Psychology, 4505 S. Maryland Parkway Las Vegas, NV 89154-5030. Email: [email protected] 283

284 /Journal o f Sport Behavior, Vol. 41, No. 3

Evidence-supported behavioral treatment programs have been developed to improve mental health in non-athlete clinical populations (Barlow, 2014). However, as indicated in other specialized populations, athletes appear to be underutilizing these treatments (Lopez, & Levy, 2013). Reasons for the underutilization of mental health services in athletes include the failure of providers to implement interventions that are supported by evidence and systematically adapted within the context of sport (Donohue, Pitts, Gavrilova, Ayarza, & Cintron, 2013). As we hope to indicate in this paper, the controlled development and dissemination of skill-based, optimization-oriented mental health interventions are needed in athlete populations, particularly those inclusive of family, coaches, and teammates and tailored to sport culture and the reduction of stigma. Along this vein, we (1) elucidate the need to develop and implement optimization-focused interventions that are capable of en gaging athletes into mental health and sport performance intervention, (2) underscore mental and behavioral health targets for optimization in athletes, and (3) introduce a mental health and sport performance optimization model that incorporates evidence-supported protocols developed explicitly for athletes. We espouse the position that focusing on the continuum of performance optimization (non-optimal to optimal) may circumvent perceptions of stigma that are often associated with pathologically based approaches, thus assisting mental health service engagement. Need for Optimization Interventions to Assist Mental Health and Sport Performance in Athletes Sport culture and social stigma often perpetuate mental health injury as a weakness, leading athletes to avoid mental health providers (Etzel & Watson, 2007). Indeed, confor mity to sport norms of toughness and resiliency seem to intensify underutilization of mental health services in athletes (Beauchemin, 2014; Watson, 2005). However, it is important to point out that there are other contributory factors to athletes not pursuing mental health inter ventions, including a lack of evidence-based intervention outcome studies involving athletes (Donohue et ah, 2013; Gross et al., 2016). In our controlled intervention trials involving engagement interventions for use in intramural, club and NCAA athletes (Donohue et al., 2004; Donohue et al., 2016b), we have interviewed athletes who have mentioned they did not pursue mental health treatments because they believed the providers of these services were not familiar with their culture, and that the interventions would be ineffective and not worth their time. Indeed, while ethnic and cultural sensitivity is often emphasized within mental health counseling centers (Baker, 1990), these principles are rarely incorporated into treatment planning within the athlete population (Cooper, 2006; Donohue et al., 2013)

SPORT-SPECIVIC MENTAL HEALTHINVERVENTIONS. .. /285

Therefore, mental health professionals should be familiar with the culture of sport and spe cialized needs of athletes, and mental health treatments for athletes should include cultural adaptations (Donohue et al., 2013; Lopez & Levy, 2013). Furthermore, inherent processes associated with the pursuit of mental health interven tion increase stigma and restrict access to care, particularly when these services are intended for use in difficult-to-reach populations, such as ethnic minorities and low-income individ uals (Sue & Sue, 2016). For instance, current practices customarily require individuals to evidence clinically significant impairment to receive mental health treatment (see Medical Review, 2015; Sabin & Daniels, 1994). Along this vein, commonly employed mental health assessment measures (e.g., Beck Depression Inventory-II, Beck, Steer & Brown, 1996; Symptom Checklist 90-Revised; Derogatis, 1994) are biased to determine the presence of impairments or problems. These biases are also evident in the assessment of factors inter fering with sport performance in both training and competition (e.g., Sport Interference Checklist; Donohue, Silver, Dickens, Covassin, & Lancer, 2007b). Of course, these mea sures do not permit assessment along the positive spectrum of optimization, as the healthiest responses to these assessments simply indicate the absence of pathology, potentially leading athletes to feel stigmatized (Donohue et al., 2016b). Mental health providers often consider treatment successful when pathology is no lon ger indicated or significantly reduced to functional levels that are arbitrarily deemed reason able. These standards have been promoted for some time, and were greatly influenced by the National Institute of Mental Health (NIMH). Since 1947, this agency has been the world’s leader in funding empirical research that primarily focused on pathology, including psycho logical disorders, clinical problems, and various hardships that humans encounter (American Psychological Association, APA, 2015; Seligman & Csikszentmihalyi, 2000). Exemplifying this influence, on August 18, 2015, the NIMH website indicated that out of 100 research funding opportunities, only 17 of these projects focused on prevention of problems (Notices and Announcements, 2015), and none focused on wellness. Researchers have argued that during the past half century, psychology has become too negative and focused on mental ill ness, thereby perpetuating stigma, emphasizing that mental health services are for those who are ill in some way, and overlooking the positive aspects of functioning (Hayes, Strosahl, & Wilson, 1999; Seligman & Csikszentmihalyi, 2000), including sport environments (Gardner & Moore, 2004). Therefore, mental health services for athletes should employ stigma-reduc ing strategies, such as emphasizing strengths and self-improvement. Seligman (2002) noted that there is a set of buffers, such as positive human traits and strengths that can be emphasized in psychological interventions to assist wellness. Positive psychology is refreshingly unique in that it targets well-being, and can be defined as the

286 / Journal o f Sport Behavior, Vo/. 41, No. 3

study of human strengths and virtues that aid individuals in the achievement of life satisfac tion. The tenets of positive psychology are that humans want to lead meaningful and fulfill ing lives, foster what is best within themself and enhance various life experiences (Seligman & Csikszentmihalyi, 2000). Positive psychology researchers espouse change in contemporary psychology from the exclusive focus on fixing impairments and deficits to also cultivating positive qualities, such as strengths, optimism, and resilience; all of which function as protective factors against mental health problems (Brunwasser, Gillham, Kim, 2009; Masten, 2001). As reported by Csikszentmihalyi (2000), the field of psychology “is not just the study of pathology, weak ness, and damage; it is also the study of strength and virtue. Treatment is not just fixing what is broken; it is nurturing what is best” (p. 7). Some positive psychology interventions are built upon cognitive-behavioral therapy (e.g., Penn Resiliency Program; Brunwasser et al., 2009), with larger effects being demonstrated in programs that emphasize behavioral skills over cognitive skills, high dosage of sessions, and individual interventions as compared with group or self-help formats (Bolier et al., 2013; Brunwasser et ah, 2009; Jacobson et al., 1996; Sin & Lyubomirsky, 2009). These finding are consistent with the results of prevention studies examining strength-based mental health programs in college students, particularly cognitive-behavioral interventions (Conley, Durlak, & Dickson, 2013). Importantly, the te nets of positive psychology and cognitive behavior therapy align well with athletic training, as each of these approaches emphasizes strengths, motivation, and continued self-improve ment. Therefore, while positive psychology may be insufficient as a standalone intervention when psychiatric symptoms are relatively severe, it can certainly be used to supplement comprehensive evidence-supported interventions that promote strengths and well-being across the mental health spectrum of optimization (Seligman, Steen, Park, & Peterson, 2005). Mental and Behavioral Health Targets for Optimization in Athletes Prior to introducing an approach to mental health and sport performance optimization, we provide a brief description of mental and behavioral health factors that have been iden tified in the scientific literature to influence performance of athletes and that can be used as targets in optimization programs. These domains are often inter-related, with severity levels fluctuating across athletic careers, sometimes unpredictably. Stress. Athletes often experience demands that are vastly different from their non-ath lete counterparts (Brewer & Petrie, 2014), such as restricted social and occupational oppor tunities due to training commitments and travel, scheduling and time constraints, pressure to maintain superior fitness and performance, social isolation, maintenance of multiple

SP0RT-SPECIV1C MENTAL HEALTH INTERVENTIONS. . . /2 8 7

relationships, lack of energy and motivation due to physical fatigue, lack of money due to restricted financial opportunities, public criticism from others, and injuries (Birky, 2007; Filaire, Bonis, & Lac, 2004; Parham, 1993; Rushall, 1990; Smith, 1986; Waterhouse, Reilly, & Edwards, 2011). Stress may profoundly affect both physical and mental health, poten tially leading to the development of dysfunctional thought patterns, anxiety, depression, poor concentration and memory, sleep and appetite disturbances, substance use, gambling, social withdrawal and isolation, and deterioration of relationships (The American Institute of Stress, 2016). Stress has also been associated with disordered eating (Sundgot-Borgen & Torstveit, 2010) and academic problems (Broughton & Neyer, 2001). Therefore, given that stress can trigger mental health difficulties (Thompson & Sherman, 2007), optimization programs should include methods of managing life events in athletes (see Giacobbi, Foore, & Weinberg, 2004). Relationships. Poor relationships have been indicated to interfere with sport perfor mance and overall well-being in athletes. For instance, non-supportive coaching behaviors have been associated with athletes’ negative self-talk (Zourbanos, Hatzigeorgiadis, Tsiakaras, Chroni, & Theodorakis, 2010), and negative feedback from teammates has been shown to induce negative emotions and perceived stress in athletes (Campo, Mellalieu, Ferrand, Martinent, & Rosnet, 2012). In contrast, supportive teammate relationships buffer against performance-related stressors and predict self-confidence (Freeman & Rees, 2010), while parents have been indicated by athletes to be their greatest influence on performance (see Donohue, Miller, Crammer, Cross, and Covassin, 2007a; Dorsch, Lowe, Dotterer, & Lyons, 2016). Moreover, poor non-teammate peer relationships, influence perception of sup port and feelings of isolation in athletes, which can undermine performance (see Donohue et al„ 2007a). These results suggest coaches, teammates, family members, and friends should be strongly considered within mental health and sport performance optimization planning in athletes. Anxiety. Anxiety is commonly evidenced in athletes, and is among the most important factors influencing performance (Martin & Pear, 2011). For instance, elite athletes and their coaches ranked anxiety as the most prevalent mental health concern experienced by athletes (Biggin, Bums, & Uphill, 2017). Indeed, an optimal level of anxiety is important for perfor mance because under-arousal can decrease motivation and focus, and over-arousal can result in tension and negative thoughts (Balague, 2005). One of the most common anxiety disorders in athletes is Generalized Anxiety Dis order (i.e., excessive worry about everyday things). This disorder is experienced by 6% of athletes, which approximates the prevalence rates in the general population (Schaal et al., 2011). Another anxiety disorder of priority in athletes is Social Phobia (Reardon & Factor,


2010). Anxiety disorders, in general, are more common in athletes who participate in aes thetic sports (e.g., gymnastics, synchronized swimming, figure skating) and female athletes (Schaal et ah, 2011). Therefore, optimal arousal should be a primary goal in the development of optimization planning involving athletes, particularly those with eating disorders. Substance use. Substance misuse has been identified to be a distinct problem within the athlete population (Martens, Dams-O’Connor, & Beck, 2006). For instance, in compar ison to the general population of college students, collegiate athletes usually report higher levels of substance use (Ford, 2007a), more frequently engage in heavy episodic drinking, consume more alcohol, and experience more severe alcohol-related negative consequences (Martens et ah, 2006). For example, illegal substances may result in sport-specific con sequences, such as suspension from sport participation and loss of scholarship (Mottram, 2010). Athletes report alcohol, marijuana, smokeless tobacco, and stimulants as the most frequently used substances (Green, Uryasz, Petr, & Bray, 2001; Hainline, Beall, & Wilfert, 2014). Alcohol use in athletes has been found to be positively correlated with illicit drug use (McCabe, Brower, West, Nelson, & Wechsler, 2007). Problems associated with marijuana use may become increasingly complex because it is now legal for individuals who are 21 years-old to use marijuana in some states of America, but remains prohibited accord ing to the National Collegiate Athletic Association (NCAA) policies (Kilmer & Flolten, 2014) and illegal in most developed countries. Moreover, athletes sometimes report positive effects due to moderate use of substances (relaxation, socialization, increased energy, stress and pain relief, reduction of anxiety) (Ev ans, Weinberg, & Jackson, 1992; Green et al., 2001; Martens, Cox, & Beck, 2003). Although substance use resulting in negative consequences is likely to be a primary target to assist mental health and sport performance, the relationship between these variables is understud ied in athletes (Donohue et ah, 2013). Therefore, professionals working with athletes will need to balance the tension between positive and negative effects of substance use on an individual basis. Depression. Although athletes are often perceived to be at decreased risk for de pressive symptomatology due to their exercise involvement (Paluska & Schwenk, 2000), approximately 24% of athletes experience clinically significant depression (Wolanin, Hong, Marks, Panchoo, & Gross, 2016). This rate is substantially higher than the general popula tion, which is approximately 9% (Watson & Kissinger, 2007). Depression increases risk of injury due to fatigue, poor concentration, slower decision-making (Thompson & Sherman, 2007), and suicide (Rao & Hong, 2016). Depressive triggers in athletes are generally similar to the general population (e.g., intimate partner break-ups, genetic predisposition, poor grades, financial stressors), but may also include sport-specific triggers, such as overtraining,

SPORT-SPECIVIC MENTAL HEALTH INVERVENTIONS... /289

injuries, performance criticism, and times of transition (Reardon & Factor, 2010). Athletes may feel apprehensive endorsing symptoms of depression due to social stigma and sport culture (Etzel & Watson, 2007). Therefore, chief targets of optimization programs in athletes should be positive mood, interest or pleasure in activities, feelings of fulfillment, confidence, hopefulness, optimal food intake and sleep, satisfaction, energy, motivation, participation in social activities, and thoughts of self-improvement, all of which have been indicated to prevent or alleviate depression (Barlow, 2014). Eating disorders. Sundgot-Borgen and Torstveit (2004) determined that 14% of elite athletes reported clinical or subclinical levels of eating disorders compared to 5% in the general population. Among female athletes, 26% have reported symptoms of subclini cal eating disorder while only 2% have been indicated to meet diagnostic criteria for eating disorder (Greenleaf, Petrie, Carter, & Reel, 2009). Among male collegiate athletes, 19% reported subclinical symptoms of eating disorders, but no athletes qualified for a clinical diagnosis (Petrie, Greenleaf, Reel, & Carter, 2008). The prevalence rates of eating disorders are much lower than mood and substance use disorders, but demand attention because they are also potentially fatal (Hendelman, 2017; Tan, Bloodworth, McNamee, & Hewitt, 2014) and are associated with severe negative consequences. For instance, athletes affected by dysfunctional eating typically experience negative thoughts and feelings about body weight and appearance (Voelker, Gould, & Reel, 2014), leading to restricted dieting, self-induced purging, excessive training (Reardon & Factor, 2010), energy deficiency, dehydration, loss of bone mass, injuries, and poor athletic performance (Thompson & Sherman, 2007). Some sport environments may influence athletes to be at greater risk of developing eating disorders, such as aesthetic sports (e.g., gymnastics) that promote particular body shapes and weight standards (Reardon & Factor, 2010; Sundgot-Borgen & Torstveit, 2010). As a result, eating disorders are more prevalent in aesthetic sports (42%) compared to en durance (24%), technical (17%), and ball game sports (16%) (Sundgot-Borgen & Torstveit, 2004). Athletes who suffer from eating disorders are often reluctant to disclose their diffi culties or seek treatment (Tan et al., 2014). Therefore, effective screening and optimal food intake and nutrition (Bratland-Sanda & Sundgot-Borgen, 2013) should be emphasized when implementing performance optimization programs in athletes. Relationship of self-talk to mental health and sport performance. Self-defeating self-talk is commonly evidenced in mood, anxiety, and eating disorders (Wright, Basco, & Thase, 2006). In athletes, negative self-talk can significantly undermine mental preparation, evaluation of self, and performance (Hewitt, 2009). Optimizing self-talk may therefore assist both mental health symptoms and sport performance in athletes (Hatzigeorgiadis,


Zourbanos, Galanis, & Theodorakis, 2011). Indeed, positively-framed self-talk can produce a positive attitude and prevent negative affect, such as depression and anxiety (Otten, 2009; Seligman, Schulman, DeRubeis, & Hollon, 1999). Furthermore, constructive self-talk and various other mental preparation techniques have strong links to self-confidence, moti vation, and anxiety control (Hardy, Gammage, & Hall, 2001), and they can help athletes control their mood, stop negative thoughts, correct bad habits, and improve focus, plan ning, problem-solving ability, and skill acquisition (Williams & Leffingwell, 2002; Zinsser, Bunker, & Williams, 2006), all of which impact sport performance. Furthermore, self-talk can be generalized to optimize other areas of life that impact athletes’ well-being, such as academics (e.g., anxiety before an exam) and relationships (e.g., asking someone for a date) (Donohue, Dickens, & Del Vecchio, 2011). To provide effective training for athletes, performance-based programs should incorporate optimization of self-talk into curriculum by teaching athletes how to establish optimum mindsets throughout practice and competition and apply these skills to contexts outside of sport (Hatzigeorgiadis et al., 2011). Confidence is essential for enhancement of sport performance, stress management, and prevention of mental health problems (Vealey, 2009). Athletes who lack confidence, as compared with those athletes evidencing high confidence, self-criticize more often, adopt inadequate decision-making styles, dwell on problems when attempting to identify solutions, and are less able to think positively once negative thoughts or problems have occurred. In contrast, athletes who are more confident in their abilities are able to think positively even when negative thoughts or problems occur, and tend to focus on solutions to a problem, rather than the problem (Grove & Heard, 1997; Hatzigeorgiadis, Zourbanos, Mpoumpaki, & Theodorakis, 2009). Additionally, individuals with low confidence have been indicated to evidence poor social skills, leading to social anxiety and avoidance behaviors (de Jong, 2002). In turn, poor social support and intimate relationships may trigger depression (Teo, Choi, & Valenstein, 2013) and substance abuse (Thornton et al., 2012). Lastly, low confi dence can induce maladaptive behaviors due to peer pressure to “fit in” (Kosten, Scheier, & Grenard, 2013). Therefore, mental health and sport performance optimization programs in athletes may be particularly effective when interventions are focused on confidence building grounded in accurate self-talk. An Optimization Intervention Model to Assist Mental Health and Sport Performance We espouse an optimization intervention model to mental health and sport perfor mance (Donohue et al., in press) that emphasizes multiple intervention targets regardless of the extent of problem severity. As the aforementioned literature review indicates, optimi zation models are likely to be effective in athletes if they fit the culture of sport, include a

SP0RT-SPECIV1C MENTAL HEALTH INTERVENTIONS... /291

relatively high dosage of meetings, are skill-based, incorporate evidence-supported cogni tive behavior therapy and positive psychology interventions, and involve significant others (i.e., coaches, family, teammates, peers, athletic administrators) in the optimization plan (see Martens et ah, 2006 for outstanding review of significant other involvement). Similar to positive psychology, the end goal is to achieve a positive state of physical and mental well-being beyond the absence of problems and psychopathology. Unique to pathologically focused treatment models, the theoretical underpinnings of this approach are grounded in optimization science, utilizing skill development to advance achievement in relevant mental health and sport performance situations along a continuum of optimization (non-optimal to optimal). Therefore, the stigmatizing dichotomy of pathology or non-pathology is avoided, assisting proponents of this model in providing intervention to a broader population of ath letes with and without mental health disorders or sport performance problems. The performance optimization model we propose is based on the tenets of CBT, which postulates thoughts, feelings and behaviors interact with one another and with environmen tal events/stimuli (see diagram A in Figure 1; Wright et ah, 2006). This conceptual model was adapted in diagram B of Figure 1 to more clearly show athletes how performance is an environmental event that reciprocally interacts with thoughts, behaviors, and feelings to influence future performance. For example, a critical comment from a coach might trigger negative thoughts (e.g., “I’m never going to be good enough”) and feelings (e.g., frustra tion), which may lead to behavioral withdrawal (e.g., missing practice), thus potentially decreasing future performance. The model assumes that thoughts, behaviors, and emotions interact with performance on a dynamic basis. To assure optimum performance, thoughts, behaviors, and emotions must be in homeostatic state of wellness. Complementing this model, all behavioral and cognitive skills are conceptualized to occur on an optimization scale with non-optimal and optimal endpoints (see Figure 2) rather than a dichotomous view of pathology (present/absent) typically employed in traditional treatment models. In the optimization intervention model, cognitive and behavioral skills are targeted to assist performance optimization, holistically leading to positive feelings that are associated with mental health and prevention of stress. Important to the reduction of stigma, the level of impairment is irrelevant in this model, as the athlete can enter intervention at any point along the continuum of optimization. There is no assumption that the athlete is presenting with pathology or impairment, unlike in traditional treatment models. This optimization approach to intervention can be used in any goal-oriented and strength-based program for athletes. Indeed, in our original testing of this model, we mod ified Family Behavior Therapy (see Azrin et al„ 1994 for original outcome evaluation) to assist college student-athletes with mental health and sport performance goals (Donohue et

292 / Journal o f Sport Behavior, Vol. 41, No. 3

Feelings

Feelings

Figure 1. Cognitive-Behavioral Triangle Adapted to Accommodate Performance

SPORT-SPECIVIC MENTAL HEALTHINVERVENT10NS... /293

al., in press). The intervention was coined The Optimum Performance Program in Sports (TOPPS) by the Associate Athletic Director of the institution to further reduce stigma as sociated with the pursuit of mental health intervention. This optimization intervention was developed with support from the National Institute on Drug Abuse (NIDA) and includes many components that are consistent with positive psychology, but with greater emphasis on skill development. Providers of TOPPS view mental health as an “optimal regulation of thoughts, feelings/emotions, and behaviors that are consistent with a positive outlook and state of well-being” (Donohue et al., 2015, p. 2). Athletes who participate in TOPPS are taught to initially perceive problems with a positive bent and examine performance scenarios objectively in all aspects of life to produce an automatic bias to think optimistically. Consistent with the culture of athletics, the TOPPS clinic looks much like an athletic facility, as there are pictures of university athletes, university paraphernalia, team schedules and motivational posters on the walls. Upon arrival at the facility there is a sign that indi cates, “If you are looking for optimum performance, knock on the door, you’ve arrived at The Optimum Performance Program in Sports.” Staff, usually students, is trained to greet athletes at the door in t-shirts sporting the TOPPS brand (see Figure 3). Prior to meeting a performance coach in the aforementioned evidence-supported engagement meeting (Dono hue et al., 2016b), athletes are engaged in conversation about sports and offered items with the TOPPS brand that have been indicated in surveys to be important to student-athletes, including pens, t-shirts, key rings, water bottles, and backpacks. The intervention consists of 12 outpatient performance meetings of approximately 60 to 90 minutes duration that are implemented by a Performance Coach. Performance meetings are scheduled to occur across a four-month period, and each meeting may include several intervention components from a menu of intervention options chosen by the athlete and participating significant others of the athlete (e.g., coaches, teammates, family, peers). The intervention components include Orientation, Cultural Enlightenment, Dynamic Goal and Rewards, Performance Planning, Goal Inspiration, Self-Control, Environmental Con trol, Communication Skills Training, Job Getting Skills Training, Financial Management Skills Training, Career Development, Performance Timeline, and Pre-Performance Mindset Training and Post-Performance Mindset Training (see Appendix for summary and Donohue et al., in press for details). Performance Coaches implementing TOPPS provide introductory rationales for each intervention, descriptive instructions and materials (e.g., handouts, work sheets) during intervention implementation, and homework assignments to practice skills prior to future sessions. To facilitate skill acquisition, behavioral strategies are utilized, in cluding modeling, behavioral rehearsal, role-playing, and imagery. The intervention package also includes innovative features, such as engagement intervention meetings and phone calls


Non-optimal

Cognitive & Behavioral Skill Performance

Optimal

◄-----------------------------------------------------------------------------------------

Figure 2. Performance Optimization Scale.

Q \ ptim u m e rfo rm a n c e ro g ra m in

p o rts

Figure 3. The Optimum Performance Program in Sports (TOPPS)Logo.

F B T In te rv e n tio n s M enu

SPORT-SPECIVIC MENTAL HEALTH INTERVENTIONS... / 295


(Donohue et al., 2016b; Donohue et ah, 2006), periodic text messages to athletes to increase retention (e.g., intervention session reminders, statements of support), positive nomenclature to replace stigmatizing terminology (e.g. performance programming instead of treatment, performance coaches instead of mental health counselors), opportunities for in-situ interven tion implementation (e.g., playing field; Donohue et ah, 2013), and focus on the optimiza tion of performance rather than remediation of pathology. The optimization intervention approach has preliminarily demonstrated significant outcome improvements in several important domains (i.e., mental health, relationships, factors that interfere with sport performance, days of substance use and unprotected sex) in both controlled (Chow et ah, 2015) and uncontrolled (Donohue et ah, 2015; Pitts et ah, 2015) clinical case trials involving college athletes with substance use disorders. Most re cently, marked improvements in mental health and mental and relationship factors affecting sport performance were found from pre- to 5-months post-intervention in a college athlete who was formally assessed in a structured clinical interview to evidence no mental health disorders during baseline (Gavrilova, Donohue, & Galante, 2017). Future Directions While there is evidence indicating that psychological interventions can enhance athlet ic performance (Meyers, Whelan, & Murphy, 1996; Weinberg & Comar, 1994), evaluations of behavioral interventions to address mental health in athletes are conspicuously absent. Indeed, only two active interventions (TOPPS and Mindfulness - Acceptance - Commit ment) have been found to concurrently show improvements in mental health/substance use and sport performance in controlled clinical trials involving athletes with (Chow et al, 2015) and without (Gross et al., 2016) formal mental health conditions. These interventions appear to offer promise, and both emphasize the reduction of stigma, evidence-supported protocols, and sport-specific programming. Indeed, a NIDA-funded controlled clinical trial, that was recently accepted for publication (Donohue et al., in press), examined the TOPPS approach as compared with services as usual in collegiate athletes who were assessed to use alcohol or illicit drugs. This trial has shown outcomes favoring the TOPPS approach in mental health, mental health and relationship factors affecting sport performance, and substance use, partic ularly in athletes evidencing greater diagnostic severity. However, more treatment outcome studies are needed to assist athletes in their achievement of optimum mental health and sport performance. Along this vein, no mental health interventions have been examined in controlled clinical trials among pre-college athletes or professional athletes evidencing men tal health conditions. However, professional and amateur sport organizations are initiating studies to better understand mental health intervention development. For instance, among

SPORT-SPECIVIC MENTAL HEALTH INTERVENTIONS. ..1 2 9 1

other efforts, the National Collegiate Athletic Association (NCAA) is funding small grants to prevent substance abuse in collegiate athletes (Anderson & Rajnik, 2004), and the National Football League has contributed substantial funds to better understand and prevent concus sions that often lead to mental health difficulties (Foundation for the National Institutes of Health, 2017). We believe the next step will be for professional and amateur sport organizations to become actively involved in the development of optimization interventions that fit their unique cultures. For instance, in an applied research initiative, the world-renowned Cirque du Soleil and National Circus School (Ecole Nationale de Cirque) (both headquartered in Montreal, Quebec) have collaborated with our research team at the University of Nevada, Las Vegas to empirically develop optimization-focused mental health and circus perfor mance screening, referral, and intervention methods to assist their artists (Donohue et al., 2017a). In this approach, we have empirically identified clinical guidelines, utilizing the Sport/Circus Interference Checklist (Donohue et al., 2007b) scores, to identify circus stu dents and professionals who are likely to benefit from optimization programming targeting circus performance. Based on these scores, it is additionally possible to empirically identify those who may be particularly likely to benefit from mental, social, and physical health screening, and subsequently involved in standardized, empirically-supported interviews to assist appropriate service engagement (see Donohue et al., 2016b). Using these tools, the circus artists are safely screened with an enhanced likelihood they will be interested in pur suing optimization-focused intervention for circus performance and/or mental, social, and physical health. References American Psychological Association, APA. (2015). Most popular topics. Retrieved June 15, 2015, from http://www.apa.org/topics/index.aspx Anderson, D. S., & Rajnik, D. (2004). NCAA CHOICES Evaluation o f Grants: 1998-2004 final report. Retrieved August 18, 2017, from http://www.ncaa.org/sites/default/files/ CHOICES_Evaluation04.pdf Azrin, N. H., McMahon, P. T., Donohue, B„ Besalel, V. A., Lapinski, K. J., Kogan, E. S., & ... Galloway, E. (1994). Behavior therapy for drug abuse: A controlled treatment outcome study. Behaviour Research and Therapy, 52(8), 857-866. Baker, K. A. (1990). The importance of cultural sensitivity and therapist self-awareness when working with mandatory clients. Family Process, 38, 55-67. Balague, G. (2005). Anxiety: From pumped to panicked. In S. Murphy (Ed.), The sport psych handbook (pp. 73-92). Champaign, IL: Human Kinetics.


Barlow, D. H. (Ed.). (2014). Clinical handbook o f psychological disorders: A step-by-step treatment manual. New York, NY: Guilford publications. Beauchemin, J. (2014). College student-athlete wellness: An integrative outreach model. College Student Journal, 48(2), 268-280. Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck Depression Inventoiy 11 manual. San Antonio, TX: The Psychological Corporation. Biggin, I. R., Burns, J. H., & Uphill, M. (2017). An investigation of athletes’ and coaches’ perceptions of mental ill-health in elite athletes. Journal o f Clinical Sport Psychology, 11(2), 126-147. Birky, I. (2007). Counseling student athletes: Sport psychology as a specialization. In J. A. Lippincott & R. B. Lippincott (Eds.), Special populations in college counseling (pp. 2135). Alexandria, VA: American Counseling Association. Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F„ & Bohlmeijer, E. (2013). Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13(1), 1-20. Bratland-Sanda, S„ & Sundgot-Borgen, J. (2013). Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal o f Sport Science, 13(5), 499-508. Brewer. B. W., & Petrie, T. A. (2014). Psychopathology in sport and exercise. In J. L. Van Raalte & B. W. Brewer (Eds.), Exploring sport and exercise psychology (3rd ed., pp. 311335). Washington, DC: American Psychological Association. Broughton, E., & Neyer, M. (2001). Advising and counseling student athletes. New Direc tions for Student Services, 93, 47-53. Brunwasser, S. M., Gillham, J. E., Kim, E. S. (2009). A meta-analytic review of the Penn Resiliency Program’s effect on depressive symptoms. Journal o f Consulting and Clinical Psychology, 77(6), 1042-1054. Campo, M., Mellalieu, S., Ferrand, C., Martinent, G., & Rosnet, E. (2012). Emotions in team contact sports: A systematic review. The Sport Psychologist, 26, 62-91. Chow, G., Donohue, B., Pitts, M., Loughran, T., Schubert, K., Gavrilova, Y., & Diaz, E. (2015). Results of a single case controlled study of The Optimum Performance Program in Sports in a collegiate athlete. Clinical Case Studies, 14, 191-209. Conley, C. S., Durlak, J. A., & Dickson, D. A. (2013). An evaluative review of outcome research on universal mental health promotion and prevention programs for higher educa tion students. Journal o f American College Health, 61, 286-301. Cooper, S. E. (2006). Evidence-based psychotherapy practice in college mental health. Binghamton, NY: The Haworth Press.

SP0RT-SPEC1V1C MENTAL HEALTHINVERVENTIONS... /2 9 9

de Jong, P. J. (2002). Implicit self-esteem and social anxiety: Differential self-favouring effects in high and low anxious individuals. Behaviour Research and Therapy, 40(5), 501-508. Derogatis, L. R. (1994). Symptom Checklist 90-R: Administration, scoring, and procedures manual (3rd ed.). Minneapolis, MN: National Computer Systems. Donohue, B., Chow, G. M., Pitts, M., Loughran, T., Schubert, K. N., Gavrilova, Y., Allen, D. N. (2015). Piloting a family-supported approach to concurrently optimize mental health and sport performance in athletes. Clinical Case Studies, 14, 159-177. Donohue, B., Dickens, Y. L., & Del Vecchio, P. (2011). Cognitive assessment in behavior al sport psychology. In J. K. Luiselli, D. D. Reed (Eds.), Behavioral sport psychology: Evidence-based approaches to performance enhancement (pp. 79-95). New York, N Y: Springer Science + Business Media. Donohue, B., Dickens, Y., Lancer, K., Covassin, T., Hash, A., Miller, A., & Genet, J. (2004). Improving athletes’ perspectives of sport psychology consultation: A con trolled evaluation of two interview methods. Behavior Modification, 28(2), 182-193. doi: 10.1177/0145445503259399 Donohue, B., Gavrilova, Y., Galante, M., Bumstein, B., Aubertin, P., Gavrilova, E., ... & Benning, S (2018). Wellness screening in circus: Mental, social and physical health fa c tors interferring with performance. Manuscript submitted for publication. Donohue, B., Gavrilova, Y., Galante, M., Loughran, T., Plant, C., Scott, J., ... & Allen, D. N. (in press). Controlled evaluation o f an optimization approach to mental health and sport performance. Journal o f Clincal Sport Psychology. Donohue, B„ Loughran, T., Pitts, M., Gavrilova, Y., Chow, G. M., Soto-Nevarez, A., & Schubert, K. (2016a). Preliminary development of a brief intervention to prevent alcohol misuse and enhance sport performance in collegiate athletes. Journal o f Drug Abuse, 2, 3-26. Donohue, B., Miller, A., Crammer, L., Cross, C., & Covassin, T. (2007a). A standardized method of assessing sport specific problems in the relationships of athletes with their coaches, teammates, family, and peers. Journal o f Sport Behavior, 30, 375-397. Donohue, B„ Pitts, M., Gavrilova, Y., Ayarza, A., & Cintron, K. I. (2013). A culturally sen sitive approach to treating substance abuse in athletes using evidence-supported methods. Journal o f Clinical Sport Psychology, 7(2), 98-119. Donohue, B., Plant, C. P., Dowd, A., Phillips, C., Loughran, T., Gavrilova, Y. (2016b). Controlled evaluation of a method to assist recruitment of participants into treatment outcome research and engage student athletes into substance abuse intervention. Journal o f Clinical Sport Psychology, 10, 272 -288.

300 / Journal of Sport Behavior, Vol. 41, No. 3 Donohue, B., Silver, N., Dickens, Y., Covassin, T., & Lancer, K. (2007b). Development and initial psychometric evaluation of the Sport Interference Checklist. Behavior Modifica tion, 31(6), 937-957. Donohue, B., Strada, M. J., Rosales, R., Taylor-Caldwell, A., Hise, D., Ahman, S., & ... Laino, R. (2006). The Semistructured Interview for Consideration of Ethnic Culture in Therapy Scale: Initial psychometric and outcome support. Behavior Modification, 30(6), 867-891. Dorsch, T. E., Lowe, K., Dotterer, A. M., & Lyons, L. (2016). Parent involvement in young adults’ intercollegiate athletic careers: Developmental considerations and applied recom mendations. Journal o f Intercollegiate Sport, 9(1), 1-26. Etzel, E. F., & Watson, J. C. (2007). Ethical challenges for psychological consultations in intercollegiate athletics. Journal o f Clinical Sport Psychology, 1, 304-317. Evans, M., Weinberg, R., & Jackson, A. (1992). Psychological factors related to drug use in college athletes. Sport Psychologist, 6(1), 24-41. Filaire, E., Bonis, J., & Lac, G. (2004). Relationships between physiological and psycholog ical stress and salivary immunoglobulin A among young female gymnasts. Perceptual & Motor Skills, 99(2), 605-617. Ford, J. A. (2007a). Alcohol use among college students: A comparison of athletes and non athletes. Substance Use & Misuse, 42, 1367-1377. Foundation for the National Institutes of Health (2017). Sports and Health Research Pro gram. Retrieved August 18, 2017, from https://fnih.org/what-we-do/current-research-programs/shrp Freeman, P., & Rees, T. (2010). Perceived social support from team-mates: Direct and stress-buffering effects on self-confidence. European Journal o f Sport Science, 10( 1), 59-67. Gardner, F. L., & Moore, Z. E. (2004). A mindfulness-acceptance-commitment-based approach to athletic performance enhancement: Theoretical considerations. Behavior Therapy, 55(4), 707-723. Gavrilova, Y„ Donohue, B., & Galante, M. (2017). Mental health and sport performance programming in athletes who present without pathology: A case examination supporting optimization. Clinical Case Studies, 1-20. Giacobbi, P., Foore, B., & Weinberg, R. S. (2004). Broken clubs and expletives: The sources of stress and coping responses of skilled and moderately skilled golfers. Journal o f Ap plied Sport Psychology, 16(2), 166-182. Green, G. A., Uryasz, F. D., Petr, T. A., & Bray, C. D. (2001). NCAA study of substance use and abuse habits of college student-athletes. Clinical Journal o f Sport Medicine, 11, 51-56.

SPORT-SPECIV1C MENTAL HEALTHINVERVENT10NS. . . /301

Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female collegiate athletes: prev alence of eating disorders and disordered eating behaviors. Journal o f American College Health, 57(5), 489-495. Gross, M., Moore, Z. E., Gardner, F. L., Wolanin, A. T., Pess, R., & Marks, D. R. (2016). An empirical examination comparing the Mindfulness-Acceptance-Commitment approach and Psychological Skills Training for the mental health and sport performance of female student athletes. International Journal o f Sport and Exercise Psychology, 1-21. Grove, R. J., & Fleard, P. J. (1997). Optimism and sport confidence as correlates of slump-related coping among athletes. The Sport Psychologist, 11, 400-410. Hainline, B., Beall, L., & Wilfert, M. (2014). Substance use and abuse. In G. T. Brown (Ed.), Mind, body and sport: Understanding and supporting student-athlete mental wellness (pp. 40-45). Indianapolis, IN: National Collegiate Athletic Association. Hardy, J., Gammage, K., Hall, C. (2001). A descriptive study of athlete self-talk. The Sport Psychologist, 15, 306-318. Hatzigeorgiadis, A., Zourbanos, N., Galanis, E., & Theodorakis, Y. (2011). Self-talk and sport performance: A meta-analysis. Perspectives on Psychological Science, 6, 348-356. Hatzigeorgiadis, A., Zourbanos, N., Mpoumpaki, S., & Theodorakis, Y. (2009). Mechanisms underlying the self-talk performance relationship: The effects of motivational self-talk on self-confidence and anxiety. Psychology o f Sport and Exercise, 10, 186-192. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: The Guilford Press. Hendelman, J. V. (2017). Eating disorders: A maladaptive coping mechanism. In S. Wadhwa, S. Wadhwa (E ds.), Stress in the modern world: Understanding science and society (pp. 403-412). Santa Barbara, CA, US: Greenwood Press/ABC-CLIO. Hewitt, J. P. (2009). The social construction of self-esteem. In S. Lopez & C. R. Snyder (Eds.), Oxford handbook o f positive psychology (rev. ed., pp. 217-225). Oxford, NY: Oxford University Press. Kilmer, J., & Holten, K. (2014). Marijuana and the intercollegiate student-athlete: Impli cations fo r prevention. Retrieved August 14, 2015, from http://www.ncaa.org/healthand-safety/sport-science-institute/marijuana-and-intercollegiate-student-athlete-implications-prevention. Kosten, P. A., Scheier, L. M., & Grenard, J. L. (2013). Latent class analysis of peer confor mity: Who is yielding to pressure and why?. Youth & Society, 45(4), 565-590. Lopez, R. L., & Levy, J. J. (2013). Student athletes’ perceived barriers to and preferences for seeking counseling. Journal o f College Counseling, 76(1), 19-31.


Martens, M. P, Cox, R. H., & Beck, N. C. (2003). Negative consequences of intercollegiate athlete drinking: The role of drinking motives. Journal o f Studies on Alcohol and Drugs, 64(6), 825-828. Martens, M. P., Dams-O’Connor, K., & Beck, N. C. (2006). A systematic review of college student-athlete drinking: Prevalence rates, sport-related factors, and interventions. Jour nal o f Substance Abuse Treatment, 31, 305 - 316. Martin, G. L., & Pear, J. J. (2011). Behavior modification: What it is and how to do it (9th ed.). Upper Saddle River, NJ: Pearson-Prentice Hall. Masten, A. (2001). Ordinary magic: Resilience processes in development. American Psy chologist, 56, 227-238. McCabe, S. E., Brower, K. J., West, B. T., Nelson, T. R, & Wechsler, H. (2007). Trends in non-medical use of anabolic steroids by U.S. college students: Results from four national surveys. Drug Alcohol Dependence, 90, 243-251. Medical Review and Education (2015). In Centers fo r Medicare and Medicaid Services. Retrieved August 18, 2015, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/ Meyers, A. W., Whelan, J. P., & Murphy, S. M. (1996). Cognitive behavioral strategies in athletic performance enhancement. Progress in Behavior Modification, 30, 137-164. Mottram, D. R. (2010). Drugs in sport (5th ed). New York, NY: Routledge. Notices and Announcements. (2015). In National Institute o f Mental Health. Retrieved Au gust 18, 2015, from http://www.nimh.nih.gov/funding/grant-writing-and-application-process/foas.jsp?type=ALL Otten, M. (2009). Choking vs. clutch performance: A study of sport performance under pres sure. Journal o f Sport & Exercise Psychology, 31, 583-601. Paluska, S. A., & Schwenk, T. L. (2000). Physical activity and mental health. Sports Medi cine, 29(3), 167-180. Parham, W. D. (1993). The intercollegiate athlete: A 1990s profile. The Counseling Psychol ogist, 27(3), 411-429. Petrie, T. A., Greenleaf, C., Reel, J., & Carter, J. (2008). Prevalence of eating disorders and disordered eating behaviors among male collegiate athletes. Psychology o f Men & Mas culinity, 9(4), 267. Pitts, M., Donohue, B., Schubert, K., Chow, G., Loughran, T., & Gavrilova, Y. (2015). A sys tematic case examination of The Optimum Performance Program in Sports in a combat sport athlete. Clinical Case Studies, 14, 178-190. Rao, A. L„ & Hong, E. S. (2016). Understanding depression and suicide in college athletes: emerging concepts and future directions. British Journal o f Sports Medicine, 50, 136-137. Reardon, C. L., & Factor, R. M. (2010). Sport psychiatry. Sports Medicine, 40(11), 961-980.

SP0RT-SPEC1VIC MENTAL HEALTH INVERVENTIONS. . . / 303

Rushall, B. (1990). A tool for measuring stress tolerance in elite athletes. Journal o f Applied Sport Psychology, 2(1), 51-66. Sabin, J. E., & Daniels, N. (1994). Determining ‘medical necessity’ in mental health prac tice. Hastings Center Report, 24(6), 5. Schaal, K„ Tafflet, M., Nassif, H., Thibault, V., Pichard, C., Alcotte, M .,... Toussaint, J. (2011). Psychological balance in high level athletes: Gender-based differences and sport-specific patterns. PLoS ONE, 6(5). Seligman, M. E. P. (2002). Positive psychology, positive prevention, and positive therapy. In C. R. Snyder & S. J. Lopez (Eds.), The handbook o f positive psychology (pp. 3-11). New York, NY: Oxford University Press. Seligman, M. E. P., Schulman, R, DeRubeis, R. J., Hollon, S. D. (1999). The prevention of depression and anxiety. Prevention & Treatment, 2(1), 8a. Seligman, M. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5-14. Seligman, M. P., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410-421. Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal o f Clinical Psychology, 65(5), 467-487. Smith, R. E. (1986). Toward a cognitive-affective model of athletic burnout. Journal o f Sport Psychology, 8, 36-50. Sue, D. W., & Sue, D. (Eds.). (2016). Counseling the culturally diverse: Theoty and prac tice. (6th ed.) Hoboken, NJ: John Wiley & Sons Inc. Sundgot-Borgen, J. J., & Torstveit, M. K. (2010). Aspects of disordered eating continuum in elite high-intensity sports. Scandinavian Journal o f Medicine & Science in Sports, 20, 112- 121. Sundgot-Borgen, J., & Torstveit, M. K. (2004). Prevalence of eating disorders in elite ath letes is higher than in the general population. Clinical Journal o f Sport Medicine, 74(1), 25-32. Tan, J., Bloodworth, A., McNamee, M., & Hewitt, J. (2014). Investigating eating disorders in elite gymnasts: Conceptual, ethical and methodological issues. European Journal o f Sport Science, 74(1), 60-68. Teo, A. R., Choi, H„ & Valenstein, M. (2013). Social relationships and depression: Ten-year follow-up from a nationally representative study. Plos One, 5(4), e62396.

304 / Journal of Sport Behavior, Vol. 41, No. 3 The American Institute of Stress. (2016). Effects o f Stress. Retrieved August 27, 2016 from http://www.stress.org/stress-effects/ Thompson, R. A., & Sherman, R. T. (2007). Managing student-athletes’mental health is sues. Bloomington Center for Counseling and Human Development: Bloomington, IN. Thornton, L. K., Baker, A. L., Lewin, T. J., Kay-Lambkin, F. J., Kavanagh, D., Richmond, R... Johnson, M. P. (2012). Reasons for substance use among people with mental disor ders. Addictive Behaviors, 57(4), 427-434. Vealey, R. S. (2009). Confidence in sport. In B.W. Brewer (Ed.), Sport Psychology (pp. 4352). New York, NY: Wiley. Voelker, D. K., Gould, D„ & Reel, J. J. (2014). Prevalence and correlates of disordered eat ing in female figure skaters. Psychology o f Sport and Exercise, 75(6), 696-704. Waterhouse, J., Reilly, T., & Edwards, B. (2011). The stress of travel. Journal o f Sports Sciences, 22(10), 946-966. Watson, J. C. (2005). College student-athletes’ attitudes towards help-seeking behavior and expectations of counseling services. Journal o f College Student Development, 46(A), 442449. Watson, J. C., & Kissinger, D. B. (2007). Athletic participation and wellness: Implications for counseling college student-athletes. Journal o f College Counseling, 10, 153-162. Weinberg, R., & Comar, W. (1994). The effectiveness of psychological interventions in com petitive sport. Sports Medicine, 18(6), 406-418. Williams, J. M„ & Leffingwell, T. R. (2002). Cognitive strategies in sport and exercise psychology. In J. L. Van Raalte, B. W. Brewer, J. L. Van Raalte, B. W. Brewer (Eds.), Ex ploring sport and exercise psychology (2nd ed.) (pp. 75-98). Washington, DC: American Psychological Association. Wolanin, A., Hong, E., Marks, D„ Panchoo, K„ & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal o f Sports Medicine, 50(3), 167-171. Wright, J. H„ Basco, M. R., & Thase, M. E. (2006). Learning cognitive-behavior therapy: An illustrated guide. Washington, DC: American Psychiatric Pub. Zinsser, N., Bunker, L., & Williams, J. M. (2006). Cognitive techniques for building con fidence and enhancing performance. In J. M. Williams (Ed.), Applied sport psychology: Personal growth to peak performance (5th ed., pp. 349-381). New York, NY: Mc Graw-Hill. Zourbanos, N., Hatzigeorgiadis, A., Tsiakaras, N., Chroni, S., & Theodorakis, Y. (2010). A multimethod examination of the relationship between coaching behavior and athletes’ inherent self-talk. Journal o f Sport & Exercise Psychology, 52(6), 764-785.

Copyright of Journal of Sport Behavior is the property of University of South Alabama and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.