The Spring/Summer Sports Medicine Legal Digest features a Q&A with NATA Mental Health America liaison Timothy Neal, LLMSW, ATC, CCISM, about mental health, substance abuse and the AT’s responsibility. The following is a continuation of this Q&A.
Q. What's the best way to start a discussion with an athlete that an AT suspects as a mental health or substance abuse issue?
What may work is to have an open dialogue with the athlete about how things are going for the athlete. This discussion should be done in private, and the AT should express a concern for the athlete as a person, not as an athlete.
In my counseling practice, I often use “describe for me” questions to start a conversation with a client or student. So, an AT suspecting an athlete may have a mental health and/or substance abuse issue may start off the conversation with “Can you describe for me, or paint me a picture, of how things are going for you right now?” or “Describe for me how your day/week is going for you.”
If one-word answers are given, ask the athlete what that word means. For example, if the athlete is asked, “Can you describe for me, or paint me a picture, of how things are going for you right now?” and they respond, “OK,” I would then ask, “So describe for me what does ‘Ok’ mean or look like?”
You are attempting to have the athlete describe in some detail what is going on, and if something sounds difficult, the AT can reflect on the emotional challenge the athlete has expressed in order to empathize with the athlete.
Therapeutic alliance when attempting to help anyone, either in athletic training or counseling, is a critical skill to possess. I also recommend approaching the discussion slowly. Learn to respond rather than react to something told to you by the athlete. After being told some information, I try to look away briefly for a few seconds, nod my head to indicate I am listening, and then come back with a paraphrasing of what I just heard and/or a follow up question. I would then provide examples of behavior of the athlete that has concerned me for them as a person and want to understand what is going on so I may help. I have used this technique over the years with athletes, clients, students in my classes and others, and have discovered some deeply personal traumas that have been perpetrated on people that have resulted in their mental health and substance abuse disorders that have impaired their lives immeasurably.
Once the therapeutic alliance has been established to build trust without judging the athletes for their behavior, you can learn what is going on with the athlete in order to assist them. In my opinion, the therapeutic alliance is the most critical skill to have as an AT, team physician or counselor. Without trust, there is little communication, and without open and honest communication, little assistance can be provided to the athlete for their physical or mental health.
Q. What should you do if a friend of the athlete they suspect has a substance abuse issue or mental health crisis and asks you to talk to the athlete?
I would ask the friend why they suspect there is a concern for another athlete’s mental health or substance abuse disorder. I would ask the friend if they have spoken to the athlete about their concern and, if so, how did that conversation go.
What is striking is that, as a society, we don’t educate nor foster the ability of a person to have difficult conversations. There is a mental and practical approach to these difficult moments, yet we don’t teach these skills to people, in general, and with health care professionals, specifically.
After understanding the person’s concern to the degree possible, I would schedule a time to sit down with the athlete and again go through the “descriptive” questions with the athlete that I outlined earlier. If need be, and without revealing the source of the concern of the other person, I would explain I’m aware of incident(s) by the athlete that may indicate something is bothering them. I usually don’t report back to the initial person who raised the concern out of my confidentiality responsibility to the athlete and will tell the concerned person that during our earlier conversation.
Q. Anything else to add?
I think it’s important to keep in mind several considerations when the AT is involved in the areas of mental health and substance abuse disorders.
First, the AT should be able to recognize potential mental health and substance abuse disorders and know the legal and ethical referral mechanisms to assist the athlete. Continue to learn about these areas as much as learning about musculoskeletal injuries and concussion management because information is evolving all the time, and the AT should try and stay current. In my opinion, and backed by surveys I have seen, more mental health education is needed for athletic trainers.
Secondly, the AT, unless they hold an additional credential as a mental health professional, should refrain from counseling or treating the athlete for their mental health. While the AT is educated on the psychosocial elements of an athlete, performing psychotherapeutic modalities should legally and ethically be left to those of us who are educated and have training in these modalities.
As a long-time athletic trainer, I had a passion for recognizing and referring athletes into mental health care and always refrained from trying to counsel them for their particular psychopathology. Then, as my passion in this area evolved into desiring to provide that therapy, I went back to graduate school and obtained my Master of Social Work degree, which took three and a half years to obtain, of which I performed for final two and a half years 140 hours or more of therapy each semester year-round to clients and athletes under the supervision of a licensed social worker whom I discussed my therapeutic assessments and modalities for that client’s particular psychopathology.
Upon graduation, I obtained my LLMSW license to practice therapy with clients and athletes, and continue to learn continuously on other forms of modalities and psychoeducational information to use in therapy sessions. The MSW degree process was a time-consuming, labor-intensive endeavor that I am so pleased to have gone through in order to pursue this great passion I have to help others with their mental health and wellness – be it athletes or the general public because more people than you would believe struggle greatly with mental health challenges.
What I learned is if the client is open to receiving assistance, and if the therapeutic alliance is strong, great things can and do happen for those struggling. I have seen it many times and in many stages with those I provide therapy, and realize it’s a fine line that needs to be navigated ethically and legally by earning the proper mental health care degree.
Thirdly, the AT should keep in mind the legal and ethical duty they owe the public and the athlete they are caring for. Be sure to communicate with legal counsel and/or risk manager whenever they’re unsure of the appropriate steps they need to take and have protocols on mental health and substance abuse disorders examined and approved by the general counsel.
Lastly, the NATA Code of Ethics is the open expression of our profession’s values and the contract we have with the public to act in their best interest. I suggest all AT facilities post the NATA Code of Ethics and keep ethical practice as the forefront of our duties. Athletic training excellence starts with ethics and should always be a part of daily approach with all patients be the concern be physical injury, substance abuse or mental health disorders.
