Scott Hamilton (Staff Counselor, Counseling Services)
Part I: National Collegiate Athletic Association (NCAA) Convention Panel Discussion on Student-Athlete Mental Health
I begin by expressing my appreciation to our athletic director, Stevie Baker-Watson, who reached out to me in early September 2017. Out of the blue I received an invitation from her to participate as a panelist at the NCAA convention to discuss student-athlete mental health. The invitation from Stevie to present at such a large and important convention made me feel both humbled and validated. I have been a clinical counselor at DePauw’s Counseling Center since 2010 and have found fortune in the open arms of our athletic department, where I have worked with athletes on mindfulness training and the psychological aspects of sport and performance. Having worked with several of our athletic teams in my time here, I have realized how great it must be for a coach or student–athlete to compete at DePauw.
Stevie’s invitation was an honor in and of itself but little did I realize that I would be sitting on an NCAA panel that included moderator Joe Walsh, president of the National Association of DIII Athletic Administrators; Emily Klueh, therapist on the Performance Psychology and Athletic Counseling team at the University of Michigan and former professional marathon swimmer for USA Swimming; Lisa Yenush, associate director of athletics and senior woman administrator at Wheaton College; and a student-athlete from a small school in Virginia, who courageously spoke about her personal struggles with an eating disorder. The significance of this session became very clear, very quickly. Our planning stages began in the early fall and in sharing our respective experiences with mental health and student-athletes, we quickly discovered how much overlap we have, despite our differing roles. We would have a semi-structured format where each of us could share our thoughts and ideas, knowing full well we would have an array of audience questions and discussion.
Fast forward to the convention. I couldn’t tell you how many people attended our session, but they filled two large rooms. It felt like a post-game press conference, in true NCAA form, with a couple tables on a stage and the logo banner behind us. There was a mixture of coaches, athletic directors, students and administrators in the audience. This was a heartening sight as it indicated the sense of curiosity and care surrounding mental health and college students. In the following summary, I’d like to cover some broad themes that came out of our data points as well as audience questions.
What We See
Anxiety and depression are typically the most prevalent concerns among college students, including athletes. However, we see many other difficulties – some comorbidly – such as complex trauma histories, disordered eating, adjustment issues, suicidal ideation, grief and loss, mood dysregulation, chaotic interpersonal conflict, family stress, financial strain, struggles related to identity development, drug/alcohol use and academic pressures, to name a few. For student-athletes the burden may or may not be intensified and there is an added component that is double-edged. Not only are these students devoting time and energy to their sport, most of them must also be just as engaged in their academics and their social life. For many athletes, sport can be either an outlet or a stressor, or both. At the end of the day, there is only so much time and energy. The question becomes, how are they responding to it all? Oftentimes a student-athlete must be able to evaluate how well he/she is functioning within the multiple roles; this is where coaches, counselors and staff can intervene to assist in this process. Fortunately, recovery from a mental illness or other stressful life circumstances does not have to end an athletic career. Ideally, sport can be used as a motivator and a resource, even if it means taking a break temporarily.
Stigma and Mental Health
Believe it or not, we have come a long way in reducing mental health stigma. But we clearly have a long way to go and sport and mental health is yet another layer. Many in our society still view seeking help (i.e. counseling) as a sign of weakness. Add in our stereotypes about gender and sexuality and how that plays a role in mental health. Furthermore, we continue to neglect the impact of mental health stigmas among marginalized groups, including people of color and the LGBT community. All of these are mutually involved with sport performance. These variables often compound the difficulties in addressing student-athlete mental health, let alone other subgroups of college students. Sport in particular has its own challenges. What is the athlete to do, bearing in mind our stigmas, when he/she is pushed to be “tough”, to “suck it up,” and to maintain the drive to be “the best?” These are factors that may, to varying degrees, enhance athletic performance, but these student-athletes are human too. A rigid approach may perpetuate stigmas around mental health and may inadvertently deter a student-athlete seeking the help he/she needs.
A Path Toward Workability
The pressure to perform as a student-athlete is not inherently bad. However, the way she/he/they responds to that pressure will lead to effective or ineffective outcomes (both on and off the field). What if we could turn our traditional views of toughness in sport into a flexible approach of mind and competition? After all, flexibility is an essential feature to playing a sport. For instance, many athletes struggle with psychological disorders but within that — and likely at the root of it — is a struggle and fusion with negative self-talk (e.g., “I’m not good enough,” “I’m too slow,” “I can’t do this,” “I’ll never be…”) and we call this a weakness. Our tendency as humans is to attempt at all costs to get rid of that “weakness.” This is a perpetual cycle that often is reinforced unintentionally by coaches, teammates, parents and the athlete himself/herself. It becomes more of a task to get rid of the problem, while we lose focus on what matters: in this case, having a fulfilling student-athletic career. An alternative approach, which many athletic departments have taken, is to teach athletes skills that help them be mindful, use workable positive psychology approaches and other methods that strengthen the mind in a flexible way. Athletes tend to like this because sport entails an ability to adapt and shift on the move. Athletic performance in this way is also a metaphor for how student-athletes can apply the strength of seeking help. We can work the mind in the counseling room symbolically like we work the body on the field or court. To make this possible, it could mean we use the power of language to our advantage because what happens within sport filters outside of it. We can learn to use the voice of wisdom and compassion, which is prevalent in sport, as a strength that can be generalized in multiple life domains, including overcoming barriers to seeking help.
Where Do We Go From Here?
These ideas are limitless. We must understand and address the impact that mental health plays among student-athletes of color, the LGBT community, international students and others. Coaches and administrators have a duty to promote a culture of inclusion and respect for diversity, and mental health professionals must be diligent in multicultural competence in clinical practice. To be a member of an already marginalized group within the spectrum of sport, can come with its own challenges whether that relates to mental health stigmas or being a member of a team. As their leaders, we can choose to place importance on these aspects of student-athlete identity. Many campuses have centers for multicultural/diversity engagement that can be strong allies for athletic departments.
Colleges and universities can and should build strong relationships between their athletic departments and on-campus counseling centers. Many athletic departments can invite staff counselors to come in and talk about their services, provide outreach programming for athletes and coaches on how to manage stress and reduce the stigma so that student-athletes can more effectively make a valued choice in seeking help. This goes a long way when they see and hear from their coaches and administrators that their mental health is as important as their physical health. Many colleges and universities have begun hiring in-house mental health professionals who work directly in the athletic department. This can allow for ease of access for all involved. Additionally, it is important for multiple departments to understand HIPAA and the ethics of confidentiality and how they apply to coordination of care for student-athletes who are referred to counseling.
Finally, outreach programming can be an essential tool to bridge the gap between student and access to the care they could receive. There are many ways to do suicide prevention training, mental health screenings and awareness events for issues such as depression, anxiety, alcohol and drug use, disordered eating, and other common issues college students face.
Part II: American College Counseling Association (ACCA) pre-conference workshop – Using Acceptance and Commitment Therapy in College Counseling
Charlotte, North Carolina
Preface: I am a proud member of a large organization called the Association for Contextual Behavioral Science, which is made up of psychologists, counselors, social workers and other health professionals from around the world. Our organization seeks to promote the alleviation of human suffering through contextual behavioral approaches and supportive research. We use therapeutic models that aim toward building psychological flexibility and processed-based approaches to behavioral change. Acceptance and Commitment Therapy (ACT), or as we call it, “ACT,” (pronounced as the word, not the acronym). ACT is a third-wave behavior therapy built on the philosophy of functional contextualism and a theory of language and cognition called Relational Frame Theory (RFT). All of this falls under the umbrella of contextual behavioral science. Check out the ACBS website to learn more: www.contextualscience.org
In 2017, I co-presented with two fellow ACT colleagues, Giovanna Rivano-Gomez, PsyD, staff psychologist, Student Health and Counseling Services at the University of Chicago, and Leslie Veach, M.S., LPCS, staff counselor, Center for Counseling and Student Development at East Carolina University, on the use of ACT with college students. This took place at the annual meeting of the American College Counseling Association (ACCA) in Tampa, Florida, and we had a great turnout for our two-part, half-day workshop. Feedback was positive enough that this past summer, the ACCA invited the three of us back to present a full-day, pre-conference workshop on ACT in February in Charlotte. My colleagues and I jumped right on board and we had an incredible experience this year with a group of thirty-two other college/university mental health professionals. We trained this group who came from public and private universities and community colleges from around the country. These mental health professionals brought with them their own experiences in practice, including common themes such as therapist burnout, working with diverse student populations, operating with limited resources in their respective centers, and working with students with dynamic and widespread concerns. Our attendees also ranged from seasoned professionals to new therapists who were just a few years removed from their graduate work.
Talking at ACCA, we tailored our approach to the context of college students. All three of us have been doing ACT in practice for quite some time. We feel ACT is a therapy model that allows students to gain perspective and make rapid change from an experiential approach. You see, ACT is a process-based model that incorporates mindfulness, experiential practice, metaphor and language itself as intervention. This in many ways goes beyond our traditional approaches of “problem-solving” and orients our students in counseling toward appreciating the experience or process of their lives, rather than “fixing” something or controlling their thoughts and emotions. This gets them to really consider what their values are and how they want to “act” in their life. This model creates an opportunity for students to choose effective, values-driven behaviors even in the face of what we often consider obstacles (e.g., difficult thoughts and emotions, painful memories or other aspects of their experience that take them away from the kind of life they want to live). We find that our student clients catch on well and fairly quickly.
Below is a brief rundown of the three pillars of ACT that encompass the six core processes of the model. It may resemble in kind how we present it to college counselors. This is important for faculty and staff alike because it applies to how we look at human behavior, especially in the context of the classroom, age groups, family structures, cultural practice on campus and identity development. Our students come to campus with histories of how they were taught and shaped to view themselves and the world around them. They come with experiences, both joyful and painful, that we might never imagine. In the process of teaching our students how to move toward a more flexible sense of self, might we too engage in that endeavor.
Letting Go of Control
One of the initial steps in ACT, something we revisit throughout the course of therapy, is a process called creative hopelessness. It is the paradoxical quest to see that our ongoing effort to engage in control/avoidance may actually be the problem. Problem-solving is the problem?! Say it isn’t so! Many of life’s struggles, including our so-called diagnosable disorders, can in some way boil down to what we call experiential avoidance — specifically, avoidance of our inner, private experiences in the form of thoughts, emotions, memories, urges, sensation and so on. The more we try to fight or run away from what shows up underneath our skin, the more it can and will intensify. Our efforts might seem to be effective short-term but they end up being futile. Like a pendulum, the more you push, the more it comes right back at you. The mind’s agenda for control gets us in to this trap. Jonathan Bricker does a great talk on this, “The secret to self-control, is to give up control”: https://www.youtube.com/watch?v=tTb3d5cjSFI&t
It comes to a point of work-ability. In ACT, we are not overly concerned about whether a thought or feeling is right or wrong, rational or irrational, good or bad; rather, we are more focused on how our whole experience (thoughts and feelings included) can function in way that orients us toward workable action in a values-driven manner. This entails dropping the struggle with our “problems” and turning toward and going in. It is about getting unstuck by slowing down and creating some wiggle room.
ACT’s core processes are diagrammed in what the creators called the hexaflex, which depicts processes (not techniques per se) that interact with each other and are instilled with the components of RFT and functional contextualism. A good video on RFT application is found here: https://www.youtube.com/watch?v=GnSHpBRLJrQ&t
The two processes that we help our clients navigate in this area are acceptance and cognitive defusion. Acceptance is about cultivating a willingness to have an experience as it is, to be fully in contact with our internal and external experiences. This process asks us to willingly approach our thoughts and feelings with a sense of allowance and permission to be as they are, even if we don’t like or approve of what shows up. You could say this is a radical step to meet with what is difficult to us; dare we say with a little curiosity and even some compassion. This experience is very closely overlapped with cognitive defusion, which is the process of watching our thoughts. As we can look up at the sky and watch the clouds come and go, being aware of our position on the ground, so too can we watch our thoughts show up and pass by without being carried off by them. There’s no need to replace or “correct” a thought (that might reinforce our entanglement with them). This is a very teachable skill for our students to help them understand, “if I can notice my thoughts, I cannot be my thoughts.” This opens us to experience a sense of space between “I” and the content of the mind. Both acceptance and defusion are processes that help soften the grip of control that our minds have evolved to favor. Being able to just notice our experience gives us a gap in which we can choose how we want to respond: do I buy in to this thought, “I am not good enough” or do I see it for what it is — a thought – and reorient my attention on what is workable and important.
In the “middle” of ACT is the practice of mindfulness and the process of self-as-context. Mindfulness is the art of paying attention, on purpose and non-judgmentally, to the present moment, here and now, just as it is, as it unfolds moment to moment. There’s a flavor of acceptance and defusion in this when we become aware of what happens within and without. Mindfulness is a doorway for appreciation of what happens in our life now. Mindfulness, as it is practiced in its essential form, can gives us access to the wisdom and purpose inside a given moment of experience, even if that includes reflecting on the memory of the past or considering the idea of the future. In the same way we can be on a mountaintop and behold its beauty, we can also be fully present in the difficult moments of loss, despair, and pain, without avoidance but with a stance of dignity and honor. Can we equally take it all in and be with it? This practice exposes us to the many dimensions of what we call self. In ACT terms we refer to self-as-context, or as we often call it the observing self. If we could rise above the clouds and storms that represent our ever-changing thoughts, feelings, memories, and sensations, we could sit and rest in the sky that is the space that holds it all. This transcendent sense of self points at “I am”; it is the context, the place from which we view it all. Self-as-context doesn’t necessarily have anything to say (we’ll let the mind do the talking), but it is a seat of “zooming out”, of seeing the whole picture. We become conscious of this perspective-taking self by stepping out of the lens of the content of our minds. From there we can see more than just what the mind is saying. We can consider how we want to live our lives and sort out what works and what doesn’t.
This part of the model is about values and committed action. Our values are the things that are important to us, what matters and/or what we want our lives to look like and stand for. These are statements we could make about the freely chosen direction(s) we want to go. They are like a compass, always pointing us toward what matters, no matter if we get off track. These aren’t goals or tasks to accomplish. In fact, there is no real end to values and they could be a path traveled until the day we die. When we identify our values, we can translate them into committed actions or ongoing behaviors that reflect what is important to us. For instance, if a student were to identify his/her value of caring for others, we could help him/her explore what that would look like within the context of his/her interpersonal relationships or what that could look like in his/her chosen career path. Values need not be justified, nor do they need to be determined by others. Take a student who is on a pre-med track. Some pre-med students say, “I am majoring in biology only because my parents want me to be a doctor.” It also could be true that the student chooses this as well because it is what he/she wants. But ultimately our values come down to our own effort to determine what matters to us and to do what it takes to live that out. Often, when we enter the other processes, we see that inside our pain we find our values.
Psychological flexibility is the act of all the above processes dancing together. According to ACT co-founder Steven Hayes, Ph.D., “psychological flexibility means contacting the present moment fully as a conscious human being and, based on what the situation affords, changing or persisting in behavior in the service of chosen values.” Dr. Hayes’ first TED talk is available at https://www.youtube.com/watch?v=o79_gmO5ppg.
Putting It All Together
As college counselors we have the chance to help students during a very particular period of their lives. These are four years that, for most, are the first time they are away from what they call home, on a semi-permanent basis. Many students for the first time are afforded the opportunity to identify their values and to ask themselves what they want their lives to look like, in the context of higher education and a newly found sense of independence. With this comes their own histories and their thoughts and their view of themselves. Many students come in to college with a variety of psychological struggles, including but not limited to anxiety and depression, suicidal and self-harm behaviors, trauma, obsessive-compulsive behavior, and alcohol/drug addictions. Some of these issues develop after they get to campus. On top of this they encounter the expectations of academic rigor and pressures to make friends, be social and keep up to par all the behaviors that are governed by the rules of their minds.
But…what if our students’ experience itself – past and present – could show them that their histories didn’t have to call the shots in their lives? In our experience, ACT has helped our students understand that just because they think it, that doesn’t mean their thoughts are true or that they need to buy in to them (e.g., “I’m a failure,” “no one likes me,” “I’m not cut out for this”). Students get to learn that, when the storyteller between their ears starts to push them around, they can respond in effective ways that keep them in the driver’s seat of their lives. Students who engage in ACT learn that life is happening now. It is not some set of experiences they must wait for, that exists out there in some other world and at some other time. Indeed, life IS happening NOW. And right now. And right now. We often hear students talk about getting in to the “real world” once they graduate, as if to dismiss their current experience as a student. I encourage them to consider that they indeed are in the real world; it just looks a certain way, given the context in which they live. This gets them to be more mindful and engaged in the experience they find themselves in now. All in all, it is refreshing to see a student do the following:
- Open up to his/her difficulties and let the struggle loosen; to see that he/she is not his/her thoughts.
- Find his/her sense of self that goes beyond thought and get grounded in his/her rich experience.
- Move around in the psychological space that he/she has created in order to look at what matters to he/she; to see for himself/herself, through a freely chosen paths, acting on his/her life regardless of what difficulties show up along the way.
What Is Next?
ACBS: In July 2019, the ACBS will hold its annual world conference in Montreal. We are looking forward to some sneak peaks at some sessions. I will be co-presenting for the second time with a colleague from Argentina, so we are very excited! #ACBSWC
ACCA: In February 2019 the annual conference will be held in sunny San Diego!
ACT podcast: Leslie and Giovanna and I are hoping to start an ACT podcast in the near future, covering many topics relevant to our work, especially as it pertains to ACT and college counseling. Stay tuned!
Harris, R. (2009). ACT Made Simple: An Easy-To-Read Primer on Acceptance and Commitment Therapy. Oakland, Calif.: New Harbinger.
Hayes, S.C, Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd edition). New York, N.Y.: The Guilford Press.
Veach, L., Hamilton, S., & Rivano-Gomez, G. (2018). Acceptance and Commitment Therapy (ACT) on campus: Introducing ACT and its effectiveness in counseling, outreach, and university programming. Pre-conference workshop presented at the annual meeting of the American College Counseling Association, Charlotte, N.C.
Villatte, M., Villatte, J. L., & Hayes, S. C. (2016). Mastering the clinical conversation: Language as intervention. New York: The Guilford Press.