When ‘Keep your head in the game’ goes too far: Student-athletes, mental health and the drug of expectation

Sept. 20, 2018, 5:25 p.m.

When an athlete tears their ACL, trainers and medics immediately rush to the scene. In the weeks that follow, a flood of coaches, trainers, physiotherapists, strength and conditioning staff and medical specialists are fully invested in getting that athlete physically healthy again. Injured athletes receive treatment and physiotherapy every day until they’re once more able to compete.

But competition-readiness encompasses much more than just basic physical ability: it includes both physical and mental well-being. And for all the resources that go into physical health, the latter half of that dichotomy — the mental side of things — often gets overlooked.

College athletes are at the top of the entertainment totem pole, raised on a pedestal where (seemingly) they “have it all.” The Cardinal-red backpacks slung nonchalantly over shoulders, the sponsored Nike gear filling lockers to the brim and the athlete-tailored high-protein meals served in dining halls all give the impression that student-athletes should have no reason to feel anything other than elated.

But they do. I did.

I am proud to say that I am a Stanford women’s basketball player, and that my coaches and teammates are phenomenal. I am also not afraid to say that I am a suicide survivor. My freshman year of college, I almost cut out early. I know I am not the only one. One in every four college athletes suffers from depression, according to a recent study.

There’s more to the picture than grinning headshots and game-day photos. The NCAA is so strict about the supplements that athletes are allowed to take that some have tested positive because of Advil for a cold — but what about the drug of expectation? The expectation to perform, and to exert consistent mental toughness at all times? This drug is legal and entirely undetectable by standard means.

Consider: the second leading cause of death among U.S. collegiate athletes is suicide, just after sudden cardiac arrest. Why is it so hard to ask for help? No one individual is at fault, but beginning to turn the stigma around will take a collective consciousness of the issue.

“The student body struggles with mental health, and athletes are going to be the same,” said Julia Axelrod ’20, peer counselor at The Bridge and mentor for Stanford’s student-run Forest Support group. “Mental health is important and maybe not as mainstream as it should be. Stigma is a pretty big barrier.”

Even as an experienced counselor at Stanford’s most well-established student-run peer counseling center, Axelrod admitted she doesn’t know whether this stigma is different for student-athletes compared to regular students.

Her admission sheds light on an important point: although athletes make up a significant proportion of Stanford’s student population, their issues are often overlooked within the mainstream campus discussion around mental health. Across campus, there is a large knowledge deficit about the mental health challenges athletes face on a daily basis — and, therefore, a corresponding stigma and lack of available resources.

‘A balancing act’

The day-to-day demands faced by student-athletes are as overwhelming as they are exhilarating: practice, class, more practice, more class, repeat. Somewhere in that line-up, you also need to eat nutritious foods and sleep.

To address these physical needs, Stanford provides student-athletes with an abundance of resources. These include the Stanford Sports Nutrition clinic, Oasis and Farmstand snack stations, physiotherapy, trainers, strength and conditioning coaches, high-performance dining hall meals, specialized academic advisors and the Athletic Academic Resource Center (AARC), to name just a few.

“If you have a question about what to eat before a big meet, you don’t think twice about sending the email [to ask a sports nutritionist],” said swimmer Jack Walsh ’19.

“But,” he continued, “if you have something that you’re struggling with — like you have to share something personal — it’s a lot harder.”

When combined with academic stress, those issues only compound. Matt Anderson ’19, swimmer and co-vice president of mental health awareness committee Cardinal Resilience, Health, and Emotional Development (RHED), spoke about the unique amalgamation of academics and athletics at Stanford.

“It boils down to a tremendous amount of pressure that we face, perhaps more so than [at] other institutions,” Anderson said.

Stanford holds all its students, including student-athletes, to an extremely high academic standard. We attend class, meet with advisors about our majors and minors, attend tutoring, write daunting papers and complete day-long problem sets.

At the same time, the level of sport played at Stanford University is arguably the highest in the nation. No NCAA athletics program has ever swept the men’s and women’s Capital One Cup — that is, until just this past July, when Stanford did it. After a year of 17 top-10 finishes and four NCAA championships, the standard becomes self-evident: Stanford’s athletes are to achieve nothing less than that. But this doesn’t lower the academic standards to which they are simultaneously held.

“It’s a balancing act for sure,” said water polo player and Cardinal RHED co-vice president Kat Klass ’19.

Although she isn’t directly involved with Stanford Athletics, Axelrod attested to having witnessed the daily hustle of being a student-athlete through her peers.

“I do have some friends who are athletes, and from what I’ve seen, it kind of seems like balancing a full-time job, on top of being a Stanford student,” Axelrod said. “I have a lot of respect for student-athletes … In terms of workload, it seems like a ridiculous amount.”

According to Anderson, the pressure to uphold Stanford’s intense standards of athletic success, compounded by a lack of mental health education, contributes to a system where athletes often internalize their mental health challenges rather than seek external help.

“You combine [athletic pressure] with a lack of education that student-athletes have for their own mental struggles,” Anderson said. “You get a lot of people dealing with stuff that they don’t realize or characterize as something they could improve on or should/could be addressed.”

The question is then: what is working and what can be fixed? According to Klass, the degree to which teams promote mental health advocacy varies widely across campus. While her own teammates and coaches do check-ins about classes and life outside of athletics, others do not.

In some ways, coaches can be helpful support systems for their players: “Coaches have been student-athletes themselves, so I think they kind of get it,” Walsh said. “I think they are pretty receptive in understanding our struggles because they have been through it themselves.”

But in other ways, they can fall short on the proactivity side of things: “There’s not a whole lot of coaches I’ve heard of that don’t listen to their kids when stuff’s going on,” Anderson said. “But for any host of reasons, athletes aren’t always gonna start that conversation, and I think that it’s all too easy for coaches to see someone just a little bit off-kilter and not really think anything of it.”

To Anderson, this brings to light an educational oversight: mental health is not a priority among the entire student-athlete community, including coaches, support staff and athletes themselves.

“Some of it may not even be clinical,” he continued. “Someone might just be dealing with an extraordinary amount of stress and it’s just killing them on the inside … and that’s something that needs to be addressed, whether clinically or not.”

But that’s easier said than done — and in this case, also easier noticed than acted on. According to Director of Sport Psychology for Stanford Athletics and sport psychologist Dr. Kelli Moran-Miller, this general oversight stems from a variety of causes.

“One is a lack of knowledge and awareness — I think a lot of student-athletes may not have ever met with a psychologist or sport psychologist before, so they have no idea of what to expect,” she said.

She added that the demand to maintain a “game face” at all times compounds pressure on student-athletes. This mentality that Moran-Miller points to is often perpetuated by coaches. It is no secret that stress builds up, especially when coaches make it explicit that they don’t want to hear about students’ non-athletic stressors during practice. Often, student-athletes are expected to simply “suck it up” in the name of focusing on their sport.

To this point, many coaches offhandedly throw around the phrase, “Fake it ’til you make it” —  a casual enough colloquialism, but with greater implications for student-athletes. Under this mentality, many athletes believe there will be large repercussions if they are unable to compete or perform.

Put short: If you’re not able to hide everything you’re feeling internally, then you’re not tough enough. You’re not strong enough. You can’t be a Stanford student-athlete.

For student-athletes, if a conversation occurs at all, it tends to happen in the proximity of teammates. Of course, peers are not always equipped with the resources or knowledge to help, and may not be trained to provide proper support in more serious circumstances.

“From what I’ve heard, teams seem like a good family,” Axelrod asked. “But of course, when there’s team drama, where do you go?”

Coaches aside, Klass added that there is generally a positive mental health community among student-athletes on campus, and that she leans on her teammates and family for a majority of support.

In the past, it’s been teammates noticing something [was] wrong and asking if there is anything you need to talk about,” Walsh said. “[But there’s still] this attitude to battle through it. It’s hard to make that first step on their own.”

“And that’s still often too late, too,” Anderson added.

The resource deficit

On campus, Stanford offers professional resources including Counseling and Psychological Services (CAPS), Vaden Health Center, Sport Psychology Services, Sports Psychiatry as well as student-run peer counseling services including The Bridge and Forest Support.

“[The Bridge] is a nice resource because it is student-to-student,” Axelrod said. “It feels a little less scary because they’re not some professional counselor, it’s just another kid.”

But Axelrod added that despite this advantage, The Bridge is still no substitute for extended care services.

“The niche that it fills is pretty specific — it is really good for one-time issues, something you need to talk out,” she said. “[However,] it is not a long-term thing.”

In the past, it has taken up to three months for students seeking counseling appointments at CAPS to even be considered for a one-on-one counselling session, simply because they weren’t suicidal. But all students’ cases are important, even if they’re not immediately life-threatening.

Stanford’s Sport Psychology program, meanwhile, is relatively new. Moran-Miller’s sport psychologist position was created in 2015. Before her position was created, Moran-Miller said, the general sentiment at Stanford was that its programs were behind. Other schools had already implemented sport psychology programs. She believes that in recent years, though, Stanford has made progress.

“In terms of providing mental health resources, I think we are doing a really good job,” she said. “But of course there is always more we could be doing … around the culture, reducing stigma, improving help, seeking and increasing awareness.”

Anderson lauded the high quality of the University’s nutrition and strength and conditioning programs, but added that when athletes are injured, the first and only thing they are told to do is go to physiotherapy. Yet athletes also face mental challenges after an injury, such as separation from teammates, lack of motivation and withdrawal from their sport.

“Going to Sport Psych isn’t even on their radar because of stigma and lack of education,” Anderson said. “That’s one of the things that’s really striking to me. We have all these programs … [with] probably mental being by far the most important, [but] that gets the least attention from student-athletes when they are injured or sick.”

He added, “There [are] a lot of people out there that may be dealing with stuff, clinical or nonclinical, and they don’t even know if it’s a mental problem or not.”

Speaking on behalf of Vaden Health Center, Moran-Miller and Director of Sports Medicine in Psychiatry Dr. Lisa Post, Athletics Communications Director Brian Risso wrote in an email to The Daily that the University’s Sports Psychiatry and Psychology program distinguishes itself from similar initiatives at other institutions in that “the team of sport psychologists available [at Stanford] are one prong of a larger group of psychologists and psychiatrists who specialize in athlete mental health.”

But despite the “team of sport psychologists” Risso referenced, up until the 2018-2019 school year, Stanford employed just one sport psychologist on campus — Moran-Miller herself — to serve the approximately 900 students who participate in Stanford athletics.

Beginning this fall, Moran-Miller will be joined by one full-time and one part-time sports psychologist, along with two part-time clinical psychology postdoctoral fellows.

“We are constantly evaluating the needs of our student-athletes in an effort to provide the best possible resources and comprehensive care while collaborating closely with the University,” Risso wrote.

There’s a long list of resources available at Stanford’s Sports Psychiatry Clinic, located a few miles off campus: confidential personal counseling, performance psychology consulting, psychological rehabilitation from injury, career counseling, medication evaluation and management, specialized care referrals, team-centered workshops for varsity teams, crisis intervention and consultation with coaches and athletic department staff.

But nobody knows about these resources, and nobody has any time to seek them out — especially when they’re tucked away off-campus.

As an athlete with around four hours of class and four hours of practice each day on top of other responsibilities, it becomes easy to say, “I don’t have time.”

Risso declined to provide The Daily with data on how widely campus mental health resources geared toward student-athletes are used, but stated that the University does track these figures internally.

Most athletes have at least heard of Moran-Miller and will seek her help. But up until this upcoming year, she was just one person on a campus with approximately 900 student-athletes of all different backgrounds and experiences. One person can’t help everyone.  

“Dr. Kelli is one person — no one person is ever gonna mesh with everyone,” Anderson said. “I know people who have gone to Kelli and not enjoyed their experience, for any host of reasons that are certainly not personal. Dr. Kelli just might not be the right person for everyone.”

Although campus mental health resources outside of Moran-Miller exist, Klass added that it might be difficult for student-athletes to speak with someone who doesn’t necessarily understand the specific struggles they face, such as counselors from CAPS or The Bridge who serve as more general practitioners.

“Someone who is able to relate to me in my experience might be what people are looking for, rather than someone just to listen, who doesn’t have the same perspective necessarily,” she said.

And according to Anderson, the University struggles with making more general resources accessible to student-athletes. In some instances, he said, the SARA Office may be the most appropriate resource for a student-athlete’s needs, but by default they’re almost always referred to Sport Psychology instead.

“I think Sport Psychology does a good job, but they are grossly understaffed for the demand that we have,” Anderson said. “One thing I’d like to see more of is [a] push for students to seek other resources that are more specialized, even if they are supposedly for the general student population.”

The push for campus mental health awareness — among both athletes and non-athletes — still seems to come primarily from students.

“The cultural shift by students has to kickstart what the University does, forcing action,” Axelrod said. “I think the University does a lot of talk. I think a lot of the resources — at least the first line of defense — [are] students.”

Established in 2016, Cardinal RHED is a student-run sub-committee of the Student-Athlete Advisory Committee (SAAC) on campus. SAAC consists of student-athletes who provide the student voice in NCAA, Pac-12, University and Stanford Athletics decisions. It includes the subcommittees Cardinal RHED, Community Service, Special Projects and Social Events.

According to Anderson, Klass and Walsh, Cardinal RHED’s mission within SAAC is pretty simple.

“The main thing is planning and implementing and really trying to create conversations around mental health,” Klass said. “It’s something that is being talked about a little more now that we are establishing a bit of a presence on campus, but I [still] don’t think it’s talked about enough.”

Cardinal RHED aims to break this stigma through its annual GameFACES speaker event. Much like the FACES of Community program that occurs each year during New Student Orientation, GameFACES is a night that features student-athlete speakers who share their unique stories of triumph and adversity with the public.

Klass believes that the University does a great job with GameFACES. However, Stanford’s simultaneous promotion of the opposing narrative — one of student-athletes who always bounce back from hardship — can be counterproductive.

“It’s hard where they have to do the ‘Stanford Athletics thing,’ where they say, ‘These are how many Olympians we have, and here [are] incredible stories of people who have bounced back from some kind of adversity to do great things,’” Klass said.

The thing Klass loves most about GameFACES, though, is how it pushes up against this public relations narrative with its human factor. “Not every story has to be, ‘And then I won a national championship,’” she said.

Looking ahead

Despite existing programs and resources provided by students and administrators alike, mental health resources at Stanford — and, in particular, those for student-athletes — continue to fall short.

“We are full-time students and full-time athletes,” Anderson said. “There’s only so much one group can do.”

Axelrod admitted to being guilty herself of not asking for help, even as a mental health advocate and peer counselor. Making the first step is the hardest — and maybe the most challenging — hurdle.

“You’ve got to start somewhere,” Axelrod said. “Having more resources so that there are people available is really important. Having mandatory check-ins would be really valuable. If we had the capacity for that, it would be really awesome.”

Klass proposed a similar idea for team trips to away games.

“When we’re traveling, it feels very us-versus-[the coaches]; we don’t usually travel with a team doctor [or psychologist],” Klass said.

She added that establishing a pipeline between student-athletes and mental health providers at the start of the year would be beneficial in incentivizing students to use their resources. To this point, Moran-Miller proposed using initial team meetings to introduce sport psychology resources and increase the visibility of available mental health services, citing studies that show student-athletes feel most comfortable when talking to a provider they have already met. With more practitioners, it will be more possible to provide that face time.

Walsh concurred. “If it was made more normal to seek help earlier, I think you’d find a lot less people digging themselves deeper and deeper [into a hole],” he said.

Ultimately, it might boil down to an issue of size. Stanford offers 36 varsity sports teams, double the nationwide Division I average of 19.

“We have more athletic teams than all but [a few] universities, and we have more student-athletes by default,” Anderson said.

At the end of the day, despite Stanford Management Company CEO Robert Wallace’s statement that Stanford’s nearly $25 billion endowment — which ranks among the top 5 in the nation — “is not a tool for social activism,” the issues seem to speak for themselves. Stanford can and should do better. A ratio of two full-time sports psychologists to 900 student-athletes is not enough. “Fake it ’til you make it” only goes so far.

“We are extraordinarily high achieving in academics at one of the top universities in the world — and, if anything, we should be the most staffed sport psych program out there,” said Anderson.


Contact Mikaela Brewer at mbrewer8 ‘at’ stanford.edu.

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