A growing body of anecdotal and empirical evidence sheds light on the fact that athletes are not impervious to mental health challenges or disorders.1 In recent years, many athletes have come forward to share their experiences with depression, anxiety, suicide, and abusive coaching. Athletes often compete within sport cultures that stigmatize mental health, discouraging help-seeking and contributing to sport dropout.2 Furthermore, many choose to suffer in silence because they are concerned that practitioners will not understand their unique needs and challenges. Ideally, athletes would have access to mental health professionals who know and understand competitive sport.3 Indeed, the European Federation of Sport Psychology (FEPSAC) recently advocated for models of mental health care that are evidence-based and include practitioners who are clinically trained and who have a thorough knowledge of the nature of high-performance contexts.4 Yet, very few psychiatrists, psychologists, and psychotherapists specialize in sport in Canada, representing an important gap in mental health care service provision for this population. With 7.2 million Canadians regularly engaging in sport,5 and one in 5 individuals annually experiencing a mental health disorder in Canada,6 there could be as many as 1.4 million Canadian athletes struggling with mental health challenges each year.
Integrated support teams (ISTs) are common in competitive sport. At a high-performance level, ISTs are built into Canadian sport models to ensure that athletes are positioned to achieve peak performances.7 Likewise, at a competitive level, athletes strive to maximize performance by assembling support teams and seeking the services of various practitioners in the community. However, these support teams seldom include practitioners who can address aspects of athletes' mental health and well-being beyond performance. Considering Sport Canada's commitment to athletes' physical, mental, and emotional well-being,8 and the objectives of the Physical Activity and Sport Act (S.C. 2003, c. 2) to encourage the full and fair participation of all Canadians in sport and to support the pursuit of excellence of those wishing to attain higher performance levels, one is left to wonder whether the Canadian sport system is adequately supporting its participants' mental health needs.
In September 2017, a multidisciplinary working group (herein “the group”) was established to investigate mental health care service provision for competitive and high-performance athletes in Canada, with the objective of identifying and addressing gaps in care. The group consists of 20 stakeholders from the realms of sport sciences, medicine, health, psychology, counseling, and philanthropy. The group adopted a Participatory Action Research (PAR) approach to collaboratively problematize, design, implement, and evaluate a novel sport-focused mental health care model (herein “the model”) housed within a Canadian Centre for Mental Health and Sport (CCMHS) that rests on 3 pillars of success: integrated care, research, and community engagement. As part of the problematizing and design phase, a 2-day research summit was organized to perform an environmental scan of the current Canadian sport and mental health care systems to assess the availability and effectiveness of mental health care services for competitive and high-performance athletes in Canada. Through this process, the group identified that misconceptions about the mental health of this population are widespread and these must be clarified before substantial advances can be made. The group believed that it was important to establish a common understanding on which to build effective models of mental health care, improved programming, and strategic education for Canada's competitive and high-performance athletes, coaches, and organizations. This provided the rationale for creating this position paper based on the findings of the 2-day summit.
Establishing common language among members of our Canadian sport and mental health communities was perceived by the group to be essential to advance both research and practice in this area. Language is a means of communicating shared values, beliefs, and customs.9 Moreover, language can be used to create or reduce stigmatization.10 This position statement first includes definitions of key concepts driving conversations of mental health and mental illness in sport. Such terminology can be used to align cultures in efforts to reduce stigma and engage practitioners to develop effective mental health care programs for competitive and high-performance athletes.
Competitive athletes are individuals who fulfill the following criteria (adapted from Araújo and Scharhag11 based on the Canadian context):
- They devote several hours to sport training and competitions throughout the week with the aim of improving their performance and results; the time they devote to sport(s) exceeds the time they spend pursuing other extracurricular activities.
- They actively and regularly participate in regulated sport competitions at the local/regional, provincial, national, international, or professional level.
- They are formally registered in a local/regional, provincial, national, or professional sport club or organization regulating the sport.
Competitive sport involves activities in which athletes have the opportunity to systematically improve and measure their performance against others in competition in a safe and ethical manner.12,13
High-performance sport involves activities in which athletes systematically achieve world class results at the highest levels of international competition through fair and ethical means.10
Mental health is characterized by a state of psychological, emotional, and social well-being in which individuals are capable to feel, think, and act in ways that allow them to enjoy life, realize their potential, cope with the normal stresses of life, work productively, and contribute to their community.14,15
Mental Health Disorders
Mental health disorders (syn. mental illness) are characterized by alterations in individuals' feeling, thinking, and behaving, leading to significant distress and impaired functioning in personal and professional activities. It collectively refers to all diagnosable mental disorders such as depression, anxiety disorders, schizophrenia, eating disorders, and substance use disorders.14,16
Mental Health Literacy
Mental health literacy refers to individuals' knowledge and beliefs about mental disorders, which assist in the recognition, management, or prevention of their symptoms or that of others.17
Psychiatrists are medical doctors (MDs) who are licensed to practice and who are certified in psychiatry by the Royal College of Physicians and Surgeons of Canada or by a provincial college, or they hold other specialist qualifications in psychiatry as recognized by the Canadian Psychiatric Association. Psychiatrists are qualified to diagnose mental health disorders and often use medication to help manage these disorders. Some psychiatrists also do psychotherapy, similar to psychologists.18
Psychologists hold a master's and/or doctoral degree in psychology and are certified by the College of Psychology for the province in which they practice. They are trained to use psychological tests to assess and diagnose mental health disorders, as well as problems in thinking, feeling, and behaving. They help people overcome or manage these problems using a variety of treatments or psychotherapies.19
Psychotherapists typically hold a master's degree in psychology or counseling, and are trained to assess (but not diagnose) and treat cognitive, emotional, or behavioral disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or nonverbal communication.20
Mental Performance Consultants
Mental Performance Consultants (MPCs) hold a master's and/or doctoral degree in sport psychology or a related field. They have knowledge and skills in sport sciences, psychology, and counseling. Mental Performance Consultants provide individual or group consultations geared toward improving sport performance and overall functioning and well-being. They do not diagnose or treat mental health problems, unless they have received the same training as that of psychologists or psychotherapists.21
Sport-Integrated Support Teams
Integrated support teams are multidisciplinary teams of sport science, sport medicine, and sport performance professionals supporting coaches and athletes in their goal for international success. Integrated support teams include experts in exercise physiology, mental performance, biomechanics and performance analysis, sport nutrition, strength and conditioning, sport medicine, and sport administrators.7
REVIEW OF LITERATURE
For decades, the public and health care professionals alike assumed there was a low prevalence of mental illness in athletes.22 However, as more evidence accrues, it is increasingly clear that athletes are not immune to experiencing mental health disorders.4,23 Indeed, athletes suffer from mental illness (eg, mood and anxiety disorders) at the same rate as the general population.24 For example, athletes experience depression25 and also die by suicide.26 Sport-specific factors (eg, pressure to win, abusive coaching, injury, and transition in and out of sport) can exacerbate existing psychological challenges or trigger the development of new ones,27,28 including eating disorders,21,29 substance abuse,30 and exercise addiction.31 For example, when psychologically abusive coaching behaviors are normalized as contributing to team or individual success, athletes can suffer from posttraumatic stress disorder.32 Furthermore, physical injury can trigger problematic emotional reactions in athletes, including depression, sleep disturbances, and disordered eating.33 Concussions, caused by a sudden impact to the head or body, may increase athletes' risk of depression34 and suicide.35 Although the causation between concussions or repeated impacts and chronic traumatic encephalopathy remains unproven, there continues to be case reports suggesting a possible correlation.36 Finally, career termination can cause difficult and potentially traumatic changes for athletes, which may lead to the experience of distress warranting psychological assistance.37,38
Despite an identified risk and need for mental health interventions, athletes tend not to seek help for mental health challenges.2 Several barriers have led to this tendency, including stigma and a lack of specialized support. Stigma refers to the devaluation, disgracing, and disfavoring of individuals with a mental illness.39 Stigma exists at the individual (ie, self-stigmatization), interpersonal (ie, social stigma), and systemic levels.40 Self-stigmatization occurs when individuals with negatively stereotyped characteristics (eg, mental illness) adopt negative attitudes toward themselves and is associated with hopelessness, reduced self-esteem, disempowerment, and decreased quality of life.41 Social stigma (ie, interpersonal) is expressed through interpersonal behavior and creates a social standard of acceptable ways of behaving toward members of an oppressed group.38 Research examining the experiences of people living with mental illness shows the subtle yet significant expressions of stigma that occur across multiple domains of these individuals' lives.42 Structural stigma refers to the “rules, policies, and practices of social institutions that arbitrarily restrict the rights of, and opportunities for, people with mental illness.”38 Sport is one such institution where the dominant cultural ideology (driven by historical, social, and financial factors) can result in the exclusion, bullying, or harassment of athletes experiencing symptoms of mental illness.43
As a result of stigmatizing attitudes and beliefs held by leaders (eg, coaches and teammates), athletes who seek psychological support face perceived or actual risk of losing playing time, their starting position, or even their place on a team.44 This sort of bullying, harassment, and discrimination is prohibited under Canadian human rights legislation (Canadian Human Rights Act, S.C. 2008). However, because most athletes are not considered employees, the duty of care owed to them by coaches and athletic organizations is not well established. Although internal policies and procedures prohibiting these forms of maltreatment may exist within sport organizations, power inequities between athletes, coaches, and sport organizations are a strong deterrent to athletes enacting such processes.45 It is therefore unsurprising that athletes reported in one particular study that the fear of stigma for seeking mental health services, the fear of teammates finding out that they are in treatment, and the fear of being considered weak prevented them from getting assistance.3 Similarly, Zakrajsek and Zizzi46 found that the fear of being negatively labeled as having psychological problems predicted coaches' intentions to refuse sport psychology services for themselves or their athletes.
Athletes who do seek help face the same challenges that prevent 50% of Canadians from receiving adequate treatment,47 including prolonged wait times,48 the unaffordability of private care,49 limited access to transportation or treatment centers, and a shortage of mental health professionals.50 Moreover, for gifted and talented populations such as competitive and high-performance athletes, the perception that practitioners generally lack understanding of their specialized characteristics and environmental demands is a significant deterrent to help-seeking.51,52 Indeed, student–athletes identified a familiarity with or participation in sport as their number one preferred quality in a counselor.12 Unfortunately, very few psychotherapists, clinical psychologists, and psychiatrists in Canada specialize in sport. Although MPCs have knowledge and competencies in the areas of sport, counseling, and psychology, most of them are not clinically trained and can therefore not diagnose or treat mental health disorders. As a result, the availability of practitioners with dual competencies in clinical psychology and sport sciences in Canada is extremely limited.
Mental illness diagnoses can be complicated by the very nature of sport. For instance, what may be considered pathological food monitoring in nonathletes, can be adaptive and even necessary for high-performance athletes.53 Glick and Horsfall54 highlighted the need for specialized mental health care services for athletes to address issues such as athletic identity, competitive pressure, and obsessive passion, which can pose unique threats to practitioners attempting to make accurate diagnoses. Furthermore, athletes may be reluctant to adhere to regimens of psychotropic medication once they experience side effects such as weight gain and ataxia (ie, reduced coordination of movement), which could threaten their athletic performance.52 They may also fear taking prescribed medications that are actually banned by the World Anti-Doping Agency, as this could result in their disqualification or embargo from competition without proper therapeutic use exemptions.
With a lack of specialized sport-focused mental health care teams in Canada, the current provision of mental health services for athletes likely does not account for the important aforementioned sport-related factors nor the complexities of diagnosis and treatment that are unique to this population.17,52 Rice et al2 advocated for the development of models of mental health care that are specific to the athlete population to foster improved mental health, effective treatment of mental illness, and gains in athletic performance.
It is noteworthy that several groups have taken positions to protect the mental health of athletes (eg, International Society of Sport Psychology, FEPSAC, and National Collegiate Athletic Association). However, none have considered the Canadian context. Furthermore, although these groups discussed clinical and nonclinical symptoms in elite athletes, optimal treatment models, and interventions applicable at the individual level, they have not addressed system-level changes required to reduce stigma, improve help-seeking, and increase psychological safety in competitive and high-performance sport. With this in mind, a working group was created to explore this and to develop an integrated sport-focused mental health care model for Canadian athletes.
THE WORKING GROUP AND COLLABORATIVE PARTICIPATORY ACTION RESEARCH APPROACH
A group of 20 stakeholders (Table 1) was strategically assembled to provide perspectives from multiple key sectors associated with and contributing to participation in competitive and high-performance sport in Canada. The group of 11 women and 9 men spanning the age of 18 to 65+ years includes: (1) competitive and high-performance athletes, coaches, and support staff (eg, youth and Paralympic athlete, sport medicine physician, athletic therapist, and MPCs), (2) mental health care practitioners (eg, psychologist, psychiatrist, and psychotherapist), and (3) expert researchers, administrators, and managers in the fields of sport and mental health (eg, university professors, directors of sport services and mental health organizations).
A PAR methodology guided the research conducted by this group. As a collaborative form of inquiry, PAR is based on the assumption that knowledge is embedded in the lives and experiences of individuals55 and should be coproduced by those in the community that will be affected by the outcomes of the research.56 Considered experts by experience,57 the stakeholders work in the sport and mental health sectors and have lived experience in these domains (eg, as practitioners, coaches, service users, and parents), enabling them to understand key factors that should be considered when designing sport-focused mental health care interventions. They have signed a collective agreement to mutually work together to generate knowledge with the aim of improving practice.58
The 2-day research summit was held on November 30 and December 1, 2017, from 9:00 AM to 4:30 PM at the University of Ottawa where the 2 lead researchers (first 2 authors) currently work. In advance of the summit, the stakeholders were provided with substantial background documentation, including a comprehensive literature review on what is known to date about mental health and mental illness in athletic populations, the Canadian health care and sporting contexts, and collaborative models of care.
The following research questions guided discussions during the summit:
- What are the issues/experiences of stakeholders regarding the availability and effectiveness of mental health services for Canadian competitive and high-performance athletes?
- What specialized collaborative mental health service delivery model can be feasibly designed and implemented in a Canadian Centre for Mental Health and Sport (CCMHS) to promote mental health and treat mental illness in this population?
Day 1: Focus Group Discussions
To address the research questions, 2 focus group sessions (morning and afternoon) were conducted. The morning session focused on the availability and effectiveness of mental health care services for Canadian athletes. The afternoon session focused on stakeholders' perceptions of the strengths, weaknesses, opportunities, and threats associated with creating a CCMHS and sport-focused mental health service delivery model. To allow every stakeholder to contribute to discussions and in keeping with recommended focus group sizes,59 the larger group (N = 20) was split into 3 focus groups (n ≈ 6-7) for both the morning and afternoon sessions. The composition of these groups differed between sessions to allow stakeholders to interact with different members. One member from each group was provided a semistructured interview guide60 to facilitate the discussion. All group discussions were audio-recorded and a graduate student took notes and highlighted major themes on flip chart paper that emerged within each group. After the small group discussions in both morning and afternoon sessions, the larger group reassembled to discuss, challenge, and identify the most salient themes in response to the research questions. The lead researchers then ensured that there were no redundancies between the themes and included a final list in one document, which they shared with each stakeholder that evening in preparation for day 2.
Day 2: Group Concept Mapping Exercise
On day 2, the 20 stakeholders participated in a group concept mapping exercise that was informed by the major themes derived on day 1. The aim of this participant-led process was to transform thoughts and ideas (ie, themes) and their interrelationships into an objective visual conceptual model.61 It served to identify and conceptualize key elements of the mental health service delivery model and CCMHS to guide the planning and implementation phases of the overall research project.62 The concept mapping exercise was performed “live” using CS Global MAX software63 that each stakeholder installed on their personal laptop computer. It unfolded throughout the day based on the following 6 steps61: (1) preparation (ie, establishment of research goals, focal question, and rating scales), (2) generation (ie, initiation and management of brainstorming process followed by synthesis of generated statements to produce a set of approximately 100 statements for subsequent sorting and rating), (3) structuring (ie, sorting of statements into logical/meaningful piles and rating of statements based on their perceived importance), (4) representation (ie, generation of point map, cluster map, and cluster rating map based on similarity matrix generation, multidimensional scaling analysis, and hierarchical cluster analysis performed using software), (5) interpretation (ie, discussion and selection of cluster solution and labels deemed to be the most relevant for project goals and future practical application of conceptual model), and (6) utilization (ie, discussion of use of the conceptual model to inform next phases of the research project).
The 2 lead researchers completed training to facilitate this exercise and a Concept Systems support staff was available throughout the exercise for assistance. The exercise led to 104 unique statements regrouped under 6 specific clusters: (1) Service Delivery (41 statements), (2) Communications and Promotion (21 statements), (3) Business, Policy, and Operations (20 statements), (4) Partnerships (9 statements), (5) Education and Training (7 statements), and (6) Research (6 statements). The in-depth results of the concept mapping exercise, which are addressed in another paper, led to the development of 6 principles to improve mental health services, programing, and policy in Canadian sport.
The following 6 principles are intended to challenge stigma and to provide guidance for individuals, teams, organizations, and practitioners working within Canadian competitive and high-performance sport. The principles complement the values set out in Canada's Sport for Life framework8 (eg, physical, mental, cognitive, and emotional factors contribute to athletes' holistic development and success), and align with the strategic directions of Canada's Mental Health Strategy64 (eg, promotion and prevention, recovery and rights, access to services, and leadership and collaboration). They serve to contribute to the fulfillment of policies and mandates set out in the Physical Activity and Sport Act [(S.C. 2003, c.2, s 3(c), s 4(1))] (eg, to assist in reducing barriers faced by all Canadians that prevent them from being active; to facilitate a sport environment where all persons are treated with fairness and respect, and are provided the opportunity for full and fair participation). Finally, these principles take into consideration the ethical principles and obligations that guide professional associations whose members provide care and support for athletes (eg, sport medicine physicians, psychiatrists, psychologists, psychotherapists, and MPCs).
Principle 1: Athletes Are Susceptible to Experiencing Mental Health Challenges and Disorders
Sport organizations, health professionals, coaches, parents, and athletes must acknowledge that:
- Athletes are at risk of experiencing mental health challenges and disorders.
- Mental health and mental illness are separate constructs that influence each other but do not preclude one another (ie, athletes with a mental illness who receive appropriate care can have a high level of mental health).
- Athletes' mental health impacts their performance and daily functioning.
- To optimally perform, athletes with mental health challenges and disorders should be provided the same level of support they receive when they are physically injured.
- Athletes should engage in regular self-care to maintain optimal mental health, in the same way they strive to maintain their physical health.
Principle 2: Sport Organizations Have a Duty to Protect the Mental Health of Athletes
- Sport organizations must support and provide opportunities for athletes, coaches, and staff to increase their mental health literacy.
- Sport organizations must reflect upon their structures, processes, and policies in an effort to understand and rectify any inherent issues contributing to mental health stigmatization, harassment, bullying, and discrimination.
- Stakeholders in Canadian sport must collaborate to establish clear and inclusive mental health policies and best practice guidelines that protect athletes with mental health challenges and illnesses.
Principle 3: Coaches Have a Duty to Foster the Mental Health of Their Athletes
- Coaches must safeguard the mental health of their athletes as well as their own to provide and sustain a healthy training and competitive environment.
- Coaches must be aware of the definition, causes, and manifestation of psychological, emotional, and physical abuse, and ensure that their coaching philosophy and strategies are not abusive and harmful to athletes.
- Sport organizations must invest resources to help coaches integrate appropriate mental health standards and practices in their coaching.
Principle 4: Competitive and High-Performance Athletes Seeking Care for Mental Health Challenges or Disorders Are Best Served by a Specialized Interdisciplinary Mental Health Care Team
- Athletes have unique sport demands that influence their mental health care needs. These must be taken under consideration in mental health care initiatives.
- Collaborative mental health care teams integrating certified/registered practitioners with knowledge and experience in sport, psychology, and psychiatry must be created to best assess and address athletes' mental health needs in a timely and reliable manner.
- Given the dynamic and diverse contexts in which competitive and high-performance athletes perform (eg, time and geographical constraints), members of specialized interdisciplinary mental health care teams must be flexible and offer both in-person and telehealth services.
Principle 5: Truly Comprehensive Integrated Support Teams in Sport Include at Least One Practitioner Who Can Address Mental Health Challenges and Mental Illness in Athletes
- Existing or newly created ISTs in competitive and high-performance sport must include a qualified mental health care practitioner who can address clinical or subclinical symptoms as they arise (eg, psychologist, psychiatrist, physician, psychotherapist, and MPC).
- Unqualified individuals who do not have an official degree or diploma in a mental health–related field (eg, psychology, counseling, and psychiatry) from an accredited institution must not be allowed to provide mental health care and counseling to athletes.
Principle 6: Institutions Offering Programs to Train Mental Health Professionals Have a Duty to Provide Opportunities to Develop Sport-Specific Competencies
- Academic institutions (eg, universities and colleges) must expand their educational programs to allow practitioners to specialize and develop competencies in sport, similar to other existing areas of specialization (developmental psychology, correctional psychology, counseling psychology, experimental psychology, forensic psychology, organizational psychology, and neuropsychology).
- Specialized sport psychology programs providing education and training to mental health professionals must address foundational elements of sport sciences, and include extensive internship opportunities in sport that are supervised by qualified individuals who have experience working in this environment.
This position statement serves to address concepts and principles deemed vital to improve mental health and mental illness in competitive and high-performance sport in Canada. By laying a foundation for a unified discourse, the Canadian sport community can more actively challenge the status quo and move from mental health TALK to mental health ACTION. The 6 principles highlighted in this article were elicited from the first phase of a multidisciplinary PAR project, of which the ultimate aim is to offer an effective, evidence-based, collaborative, and sport-focused mental health care model within the CCMHS to address the mental health and mental illness needs of competitive and high-performance athletes.
The CCMHS will be the first of its kind in Canada. It will provide important opportunities to test theory and advance knowledge and practice in a crucial area of health that warrants attention. Notably, the CCMHS will address a significant gap in mental health care available to Canadian competitive and high-performance athletes. Through both mental health care and preventative streams, the CCMHS will contribute to Sport Canada's mandate to develop healthy Canadian athletes across the lifespan. It is hoped that the CCMHS and this position statement will be used to inform the policies and actions of leading sport organizations (eg, the Canadian Olympic Committee, the Canadian Paralympic Committee, USports, and the Canadian Sport Psychology Association), who have identified mental health as an increasing unmet area of concern for athletes. Improving the mental health of athletes through effective coaching, support teams, and programs should be a TOP priority for the entire Canadian sport system.
1. Schinke RJ, Stambulova NB, Si G, et al. International society of sport
psychology position stand athletes
' mental health
, performance, and development. Int J Sport
Ex Psychol. 2018;38:1–18.
2. Rice SM, Purcell R, De Silva S, et al. The mental health
of elite athletes
: a narrative systematic review. Sport
3. Lopez R, Levy J. Student athletes
' perceived barriers to and preferences for seeking counseling. J Coll Couns. 2013;16:19–31.
4. Moesch K, Kenttä G, Kleinert J, et al. FEPSAC position statement: mental health
disorders in elite athletes
and models of service provision. Psychol Sport
10. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness
stigma: concepts, consequences, and initiatives to reduce stigma. Euro Psych. 2005;20:529–539.
11. Araújo CGS, Scharhag J. Athlete: a working definition for medical and health sciences research. Scand J Med Sci Sports. 2016;26:4–7.
17. Jorm AF, Korten AE, Jacomb PA, et al. “Mental health
literacy”: a survey of the public's ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Med J Aust. 1997;166:182–186.
22. Bär KJ, Markser VZ. Sport
specificity of mental disorders: the issue of sport
psychiatry. Euro Arch Psychiatry Clin Neurosci. 2013;263:205–210.
23. Van Slingerland KJ, Durand-Bush N, Rathwell S. Levels and prevalence of mental health
functioning in Canadian university student-athletes
. Can J High Ed. [epub ahead of print].
24. Cornejo BJ. Mindfulness, attention, and flow in the treatment of affective disorders in athletes
. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. 1st ed Hoboken, NJ: John Wiley & Sons; 2013:124–131.
25. Doherty S, Hannigan B, Campbell MJ. The experience of depression during the careers of elite male athletes
. Front Psychol. 2016;7:1–11.
26. Baum AL. Suicide in athletes
. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. 1st ed. Hoboken, NJ: John Wiley & Sons; 2013:79–88.
27. Neal T, Diamond AB, Goldman S, et al. Inter-association recommendations in developing a plan for recognition and referral of student athletes
with psychological concerns at the collegiate level: a consensus statement. J Athl Train. 2013;48:716–720.
28. Stirling AE, Kerr GA. The perceived effects of elite athletes
' experiences of emotional abuse in the coach-athlete relationship. Int J Sport
Ex Psychol. 2013;11:87–100.
29. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes
is higher than in the general population. Clin J Sport
30. Morse E. Substance use in athletes
. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. 1st ed. Hoboken, NJ: John Wiley & Sons; 2013:1–12.
31. Kurimay T, Griffiths MD, Berczik K, et al. Exercise addiction: the dark side of sports and exercise. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. 1st ed. Hoboken, NJ: John Wiley & Sons; 2013:33–43.
32. Wenzel T, Zhu LJ. Posttraumatic stress in athletes
. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. 1st ed. Hoboken, NJ: John Wiley & Sons; 2013:102–114.
33. Putukian M. The psychological response to injury in student-athletes
: a narrative review with a focus on mental health
. Br J Sport
34. Chen JK, Johnston KM, Petrides M, et al. Neural substrates of symptoms of depression following concussion in male athletes
with persisting post-concussion symptoms. Arch Gen Psychiatr. 2008;65:81–89.
35. Fralick M, Thiruchelvam D, Tien HC, et al. Risk of suicide after a concussion. Can Med Assoc J. 2016;188:497–504.
36. Gardner A, Iverson GL, McCroy P. Chronic traumatic encephalopathy in sport
: a systematic review. Br J Sports Med. 2014;48:84–90.
37. Taylor J, Ogilvie BC, Lavallee D. Career transition among athletes
: is there life after sports? In: Williams JM, ed. Applied Sport
Psychology. New York, NY: McGraw Hill; 2006:595–615.
38. Lavallee D, Nesti M, Borkoles E, et al. Intervention strategies for athletes
in transition. In: Lavallee D, Wylleman P, eds. Career Transitions in Sport
: International Perspectives. Morgantown, WV: Fitness Information Technology Inc; 2000:111–130.
39. Abdullah T, Brown TL. Mental illness
stigma and ethnocultural beliefs, values, and norms: an integrative review. Clin Psychol Rev. 2011;31:934–948.
40. Livingston JD. Mental Illness
-related Structural Stigma: The Downward Spiral of Systemic Exclusion. Calgary, AB: Mental Health
Commission of Canada; 2013.
41. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness
: a systematic review and meta-analysis. Soc Sci Med. 2010;71:2150–2161.
42. Suto M, Livingston JD, Hole R, et al. Stigma shrinks my bubble: a qualitative study of understandings and experiences of stigma and bipolar disorder. Stigma Res Act. 2012;2:85–92.
43. Delenardo S, Lennox-Terrion J. Suck it up: opinions and attitudes about mental illness
stigma and help-seeking behaviour of male varsity football players. Can J Community Ment Health. 2014;33:43–56.
44. Bauman JN. The stigma of mental health
: are mental toughness and mental health
seen as contradictory in elite sport
? Br J Sport
45. Tomlinson P, Strachan D. Power and Ethics in Coaching. Gloucester, ON: Coaching Association of Canada; 1996.
46. Zakrajsek RA, Zizzi SJ. Factors influencing track and swimming coaches' intentions to use sport
psychology services. Athletic Insight. 2007;9:1–21.
47. Patten SB, Williams JV, Lavorato DH, et al. Major depression in Canada: what has changed over the past 10 years? Can J Psychiatry. 2016;61:80–85.
49. Mohr DC, Ho J, Duffey J, et al. Perceived barriers to psychological treatments and their relationship to depression. J Clin Psychol. 2010;66:394–409.
50. van der Vaart R, Witting M, Riper H, et al. Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study. BMC Psychiatry. 2014;14:355–365.
51. Givens JL, Tjia J. Depressed medical students' use of mental health
services and barriers to use. Acad Med. 2002;77:918–921.
52. Levy JJ, Plucker JA. Assessing the psychological presentation of gifted and talented clients: a multicultural perspective. Couns Psychol Quart. 2003;16:229–247.
53. Reardon C, Factor R. Sport
psychiatry: a systematic review of diagnosis and medical treatment of mental illness
. Sports Med. 2010;40:961–980.
54. Glick I, Horsfall JL. Psychiatric conditions in sports: diagnosis, treatment, and quality of life. Physician Sports Med. 2009;3:29–34.
55. Borg M, Karlsson B, Kim HS, et al. Opening up for many voices in knowledge construction. Forum Qual Soc Res. 2010;13:1–16.
56. Bergold J, Thomas S. Participatory research methods: a methodological approach in motion. Forum Qual Soc Res. 2010;13:1–31.
57. Cromby J, Harper D, Reavey P. Psychology, Mental Health
and Distress. 1st ed. Basingstoke, United Kingdom: Palgrave Macmillan; 2013.
58. Cook T. Where participatory approaches meet pragmatism in funded (health) research: the challenge of finding meaningful spaces. Forum Qual Soc Res. 2012;13:Article 18.
59. Rio-Roberts MD. How I learned to conduct focus groups. Qual Rep. 2011;16:312–315.
60. Castillo-Montoya M. Preparing for interview research: the interview protocol refinement framework. Qual Rep. 2016;21:811–831.
61. Kane M, Trochim WM. Concept Mapping for Planning and Evaluation. Thousand Oaks, CA: Sage; 2007.
62. Trochim WMK. An introduction to concept mapping for planning and evaluation. Eval Program Plan. 1989;12:1–16.
63. Concepts Systems Inc. The Concept System Global Max Software Guide. Ithica, NY; 2017.