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A Grounded Theory Investigation of Basic Psychological Needs A Grounded Theory Investigation of Basic Psychological Needs Theory as a F y as a Framework for E amework for Effective Mental Health Ref e Mental Health Referrals in Collegiate Sport Luna Ugrenović West Virginia University Follow this and additional works at: https://researchrepository.wvu.edu/etd Part of the Other Psychology Commons Recommended Citation Ugrenović, Luna, "A Grounded Theory Investigation of Basic Psychological Needs Theory as a Framework for Effective Mental Health Referrals in Collegiate Sport" (2024). Graduate Theses, Dissertations, and Problem Reports. 12694. https://researchrepository.wvu.edu/etd/12694 This Dissertation is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Dissertation in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Dissertation has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. A Grounded Theory Investigation of Basic Psychological Needs Theory as a Framework for Effective Mental Health Referrals in Collegiate Sport Luna Ugrenović, M.S., M.A. Dissertation submitted to the College of Applied Human Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Sport, Exercise, and Performance Psychology Dana K. Voelker, Ph.D., Chair Ashley Coker-Cranney, Ph.D. Johannes Raabe, Ph.D. Monica Leppma, Ph.D. School of Sport Sciences Morgantown, West Virginia 2024 Keywords: interpersonal behaviors, need supporting, need thwarting, sport support personnel, teammates, student-athletes Copyright 2024 Luna Ugrenović ABSTRACT A Grounded Theory Investigation of Basic Psychological Needs Theory as a Framework for Effective Mental Health Referrals in Collegiate Sport Luna Ugrenović Using a grounded theory approach, this study explored collegiate athletes’ mental health referral experiences and identified mechanisms explaining those experiences based upon perceptions of psychological need fulfillment and thwarting according to Basic Psychological Needs Theory (BPNT). Interviews were conducted with a purposive, maximum variation sample of 14 current and former collegiate athletes who were referred to mental health services by support personnel or other athletes. Analyses yielded three overarching theoretical categories/properties: prereferral factors, proactive and reactive referral conversations, and referral outcomes. Referral is often understood as an isolated conversation in which athletes are provided mental health resources in response to a crisis. Challenging this notion, the present study showed that proactive referral as a preventative approach, as well as intentional understanding athletes’ pre-referral experiences, were central to supporting athletes’ relationship with their mental health. Generally, referral experiences that resulted in helping athletes disconnect their mental health concerns from understandings of their self-worth, and ultimately pursue mental health services with hope for recovery, were linked to psychological need satisfaction throughout the referral process (e.g., autonomously choosing mental health services, relating to the referrer through a similar experience, mastering skills for pursuing therapy). Yet, in cases of positive referral experiences, some athletes re-internalized mental health stigma upon re-engaging with unsupportive sport and familial environments. Need thwarting amid the referral conversation was generally associated with poorer outcomes, in addition to cultural environments that deterred help-seeking. Together, the data suggest BPNT is a promising framework for effective referral guidance, though psychological needs are met uniquely for each athlete based upon their characteristics and context. MENTAL HEALTH REFERRALS IN SPORT iii Acknowledgments I cannot thank enough everyone from both sides of the ocean who have supported me on this journey. I would like to express my deepest gratitude to Dr. Dana K. Voelker, my advisor and committee chair, for her invaluable patience, guidance, and support. Her passion for the field and dedication to the highest excellence has pushed me to reach my potential. This endeavor also would not have been possible without my committee, who generously provided their knowledge and expertise. I thank Dr. Ashley Coker-Cranney for her methodological expertise and guidance that made this ambitious study possible. I thank Dr. Johannes Raabe for challenging me to reach the highest research standards and offering his theoretical expertise. I thank Dr. Monica Leppma for reminding me to trust my intuition and to practice self-compassion. I would also like to deeply thank my research assistant, Verena Zaisberger, for her dedication and perspective during each phase of the study – her curiosity and hard work were pivotal in creating the final product of this project. I am also so grateful for my colleagues and friends who read drafts, offered feedback, and were my moral support. Without them, my journey would not have been nearly as meaningful and fulfilling. I will be forever grateful to Dr. Tommy Minkler, Dr. Blake Costalupes, Dr. Sofía España Pérez, Dr. Zenzi Huysmans, Dr. Karly Casanave Phillips, Dr. Andrew Chip Augustus, Kim Tolentino, Jaxson Judkins, Kayla Hussey, Hannah Miller, Sarah Sadler, Hannah SilvaBreen, and Lindsey Leatherman. I thank my family, especially my parents, Maja and Vladan, and my sister, Mia. Their belief in me has kept my spirits and motivation high, while their unconditional love has offered me a sanctuary when I needed it. Lastly, I want to express special thanks to my husband, Salman, whose tireless support, love, and selflessness helped me overcome each and every obstacle along the way. Our shared passion for the topic and many long late-night discussions about the grounded theory have inspired me and reminded me of the opportunity to impact others with my research. I thank him for sharing this journey with me every step of the way. MENTAL HEALTH REFERRALS IN SPORT iv Table of Contents Introduction and Literature Review…………..…………………………………………….……..1 Basic Psychological Needs Theory………………………………………………………..4 Methods and Materials…………………………………………………………………………….7 Research Approach and Philosophical Assumptions..…...…………………...…….……..8 Methodological Approach………………………………..….………….………...………9 Participants………………………………………………………………………..……...10 Materials…………………………………………………………………………………11 Demographic Survey…………………………………………………………….11 Interviews………………………………………………………………………...11 Procedures………………………………………………………………………………..12 Data Analysis…………………………………………………………………………….14 Methodological Rigor……………………………………………………………………18 Results……………………………………………………………………………………………19 Pre-Referral Factors….…………………………………...……………………………...20 Participants’ Identities and Culture……………………………………………....20 Participants’ Family Environments………………………………………………22 Participants’ Sport Environments……………………...………………………...23 Reactive and Proactive Referral Conversations………………...…………………....…..25 Psychological Need Satisfaction and Thwarting………...………………………26 Autonomy Satisfaction and Thwarting…………...……………………...26 Relatedness Satisfaction and Thwarting………..….…………………….28 Competence Satisfaction and Thwarting…………….…..………………30 Referral Outcomes……………………………………………………………………….30 Perceptions of Self as Context……………………………………...….……...…31 Perceptions of Self as Content…………………………...……………………....32 Discussion………………………………………………………………………………………..36 Practical Implications…………………………………………………………………….42 Limitations and Future Directions………………………………………...……………..44 Conclusion……………………………………………………………………………….46 References………………………………………………………………………………………..48 MENTAL HEALTH REFERRALS IN SPORT v Appendix A: Extended Literature Review…………………………………………….……...….59 Collegiate Athlete Mental Health……………………………………………...……...…60 Mental Health Referrals………………………………………………………………….64 Mental Health Referrals in Sport………………………….……………...……...70 Rates of Mental Health Referrals in Collegiate Sport…..…………...…..72 Possible Barriers to Successful Mental Health Referrals in Sport……….74 Mental Health Referrals in Sport – Best Practices……………………….78 Basic Psychological Needs Theory………………………………………………………84 Basic Psychological Needs Theory and Collegiate Athletes…………………….87 Basic Psychological Needs Theory, Well-Being, and Mental Health….....……..90 References………………………………………………………………………………..92 Appendix B: Extended Methods and Materials………………………………………….…......106 Researcher’s Positionality and Background……………………………………………106 Appendix C: Recruitment Flyer………………………………………………………………...109 Appendix D: Cover Letter………………….………………………...………………....……...110 Appendix E: Demographic Survey……………………………………………..………………112 Appendix F: The Final Version of The Interview Guide…………………………….…………115 MENTAL HEALTH REFERRALS IN SPORT 1 Introduction Mental health concerns are rising among collegiate athletes (Brown et al., 2021). Data suggest the prevalence of stress, anxiety, sadness, mental exhaustion, anger, and sleep difficulties are 1.5 to 2 times higher than pre-2021 reports (National Collegiate Athletic Association [NCAA], 2022). Collegiate athletes experience signs and symptoms of various mental health concerns (e.g., Brown et al., 2021; Gavrilova & Donohue, 2018) at greater frequencies than their same-age, non-athlete peers (e.g., Donohue et al., 2018; Li et al., 2017). Despite collegiate athletes’ reported frequency of mental health concerns, research suggests most do not pursue mental health services. For example, the NCAA Well-Being Study (2022) found that less than half of the collegiate athletes surveyed reported feeling comfortable seeking help from an oncampus mental health professional. There are various barriers to collegiate athletes’ willingness and ability to pursue mental health services, such as stigma, limited knowledge of the supports and resources available, negative help-seeking beliefs, concerns about confidentiality, and perceived lack of time (e.g., Cox et al., 2017; Hilliard et al., 2020; Moore, 2016). To address this problem, understanding how best to connect collegiate athletes with mental health services, in ways they feel comfortable and motivated to pursue those services, is gravely needed. An important step in the mental health help-seeking process, and that can be investigated to address collegiate athletes’ growing mental health concerns, is referral. Defined as the process of directing others to appropriate supports and resources to address their mental health needs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015), referral is often made by peers or support personnel in collegiate athletes’ immediate performance environments, such as academic advisors, strength and conditioning coaches, sport coaches, sport dieticians, mental performance consultants, physiotherapists, physiologists, and athletic MENTAL HEALTH REFERRALS IN SPORT 2 trainers (Cormier, 2014; Daltry et al., 2021; Neal et al., 2013; 2015; Sebbens et al., 2016; Van Raalte et al., 2015). Unfortunately, support personnel report they are neither comfortable nor confident in their ability to communicate with, refer, and support athletes experiencing mental health concerns (Gayman & Crossman, 2006; McArdle et al., 2018; Moreland et al., 2018; Sandgren et al., 2022). In a qualitative study, support personnel reported feeling anxious, frustrated, underprepared, and unskilled to refer athletes, citing a critical need for guidance on what and how to communicate with athletes experiencing mental health difficulties (McArdle et al., 2016). Gayman and Crossman’s (2006) qualitative study found mental performance consultants rarely discussed the possibility of referrals to mental health services during intakes, did not maintain an updated referral list of available providers, and did not follow-up with the athlete clients if a referral was made. Unsurprisingly, this discomfort with mental health conversations is compounded by collegiate athletes also feeling the effects of this uncertainty (Arthur-Cameselle et al., 2012). For example, Cutler and Dwyer’s (2020) study of 158 collegiate athletes found that only half believed their coaching staff could offer support in an emotional crisis. Clearly, a lack of preparedness and comfort with mental health has led to the avoidance of referral-related behaviors among support personnel and is also impacting athletes. Collectively, these data suggest that although support personnel can play a key role in referrals given their proximity to and rapport with collegiate athletes (e.g., Daltry et al., 2021; Neal et al., 2015; Sebbens et al., 2016), barriers to effective communication with athletes around mental health concerns may impede the referral process, perpetuate negative help-seeking attitudes and stigma, and in turn make it exceedingly difficult for collegiate athletes to seek appropriate and timely help when needed. These communication barriers are not just limited to the exchange between support personnel and athletes, as many athletic departments also do not MENTAL HEALTH REFERRALS IN SPORT 3 sufficiently discuss the referral process, suggesting structural difficulties that some coaches have described as “broken” and “dismantled” (Eckenrod et al., 2023, p. 7). Accordingly, support personnel must be better equipped to support collegiate athletes through the development and implementation of referral guidelines that ease and facilitate communication while empowering athletes to pursue mental health supports and resources. This need extends to athlete peers, as some literature suggests that, with adequate training, college student peers generally, and athlete peers specifically, can act as helpful sources of mental health referrals (e.g., Kalkbrenner et al., 2019; Van Raalte et al., 2015). Yet, extant referral guidelines designed for athletes are limited. Vella at al.’s (2021) systematic review and meta-synthesis of mental health position statements in sport found the overall quality of the guidelines to be low. Specifically, although many policy statements discuss the importance of referrals, they lack clear referral guidelines, such as when, how, and to whom to refer. Guidelines solely focused on policy and procedure (i.e., what to do) but not process (i.e., how to do it) are limited in their effectiveness (Tod & Anderson, 2014) as they fail to support the application and implementation of their referral policies and procedures to specific contexts. This not only refers to the sport environment context but also to collegiate athletes’ identities and cultural backgrounds, as collegiate athletes working with support personnel reportedly value when their identities beyond sport are acknowledged and honored (Bejar et al., 2019). Further, as culture influences the likelihood of engaging with mental health care in unique ways (Abdullah & Brown, 2011), athletes’ identities and cultural contexts may also impact referral outcomes. More recently, the NCAA (2024) released a mental health best practices consensus document, yet their recommendations are also on referral pathways and not processes. Although such efforts MENTAL HEALTH REFERRALS IN SPORT 4 are timely and important, there remains a need to delineate specific steps and actions that support personnel and other athletes can utilize when engaging in the mental health referral conversation. Recommendations that do explicate process are largely based on accounts of experienced practitioners and include: (a) building rapport with athletes and communicating care for their well-being; (b) facilitating a team approach to athlete care; (c) preparing athletes for referrals; (d) showing support and normalizing mental health concerns; (e) referring in (i.e., inviting therapists to meetings with athletes and support personnel); (f) explaining reasons for referrals; (g) describing what working with therapists entails; (h) following up with athletes; and (i) being prepared to offer alternative coping options and to revisiting referral after giving athletes time to consider the recommendations (Andersen et al., 1994; Neal et al., 2013; 2015; Tod & Andersen, 2014; Van Raalte & Andersen, 2014). Such practitioner-informed guidelines can be further strengthened by centering athletes’ voices on effective and ineffective referral experiences, considering athletes’ identities and unique needs, and studying the interpersonal components with referrers that may affect athletes’ willingness and ability to pursue mental health recommendations. Further, using well-established conceptual frameworks to explore and explain the referral process would provide additional structure to future research in this area, particularly with respect to predicting athletes’ willingness to engage in the recommendations they are provided, while providing clarity and focus to key targets of intervention that would improve the referral experience. Basic Psychological Needs Theory A promising framework for understanding how to facilitate effective referrals for collegiate athletes, is basic psychological needs theory (BPNT; Ryan & Deci, 2017), a wellresearched theoretical guide for successful interpersonal interactions toward future behavior. MENTAL HEALTH REFERRALS IN SPORT 5 BPNT may be especially helpful in this context as it has been widely used in sport research to explore the impact of interpersonal behaviors on motivation (e.g., Raabe & Zakrajsek, 2017). Specifically, as one of the mini theories within the larger framework of self-determination theory (SDT; Ryan & Deci, 2017), BPNT has helped explain antecedents to initiating and maintaining behaviors in sport (e.g., Raabe et al., 2016), work (e.g., Parfyonova et al., 2019), health care (e.g., Ryan at al., 2008), and other settings. According to BPNT, an individual’s innate and basic psychological needs are autonomy, competence, and relatedness, all three of which are influenced through social interactions and are considered essential for psychological growth (Ryan & Deci, 2017). Autonomy refers to perceptions of self-governance and volition and the degree to which one values these behaviors. While autonomy support involves conveying value of one’s perspective and encouraging selfdirectedness over one’s decisions, autonomy controlling behaviors involve the use of external controls, like rewards and punishments, that promote need thwarting and undermine motivation. Competence refers to perceptions of self-mastery in one’s interactions with their environment. Supporting another’s need to feel competent involves providing education, guidance, feedback, and structure to assist in the development of mastery and efficacy. Conversely, thwarting another’s need to feel competent involves highlighting faults and lack of abilities, demonstrating doubt in the ability to improve, and discouraging engagement in difficult tasks. Finally, relatedness pertains to a sense of belonging in which one feels connected to, and valued by, others. With respect to relatedness, need support constitutes genuine interest, care, acceptance, and companionship from others, whereas need thwarting constitutes treatment from others that is distant, emotionally unavailable, exclusionary, and characterized by a failure to listen. As others’ behaviors influence the extent to which one perceives these needs to be satisfied, or thwarted, MENTAL HEALTH REFERRALS IN SPORT 6 this in turn determines the likelihood of initiating and maintaining a behavior and informs wellbeing. Although specific ways basic needs are satisfied or frustrated differ based on context, culture, and social setting, they are considered to universally apply to all humans (Ryan & Deci, 2017). In a recent meta-analysis (Slemp et al., 2024), perceived need satisfaction, coupled with interpersonal support, was associated with optimal motivation, wellbeing, and performance. Conversely, negative interpersonal behaviors informed perceptions of need thwarting that, in turn, were associated with ill-being, poorer performance, and diminished motivation. Researchers have used BPNT to understand the wellbeing and mental health of diverse groups of young adults (e.g., Akbag et al., 2017; Campbell et al., 2018; Cantarero et al., 2021), including athletes. For instance, in a sample of over a thousand collegiate students from four countries (i.e., Belgium, China, USA, and Peru), Chen at al. (2015) found need-satisfaction predicted well-being, and need-thwarting predicted ill-being, irrespective of students’ nationality, their reported importance of each need, and their willingness to satisfy them. This evidence highlights the utility of a BPNT framework in understanding mechanisms for supporting mental health among college students. BPNT has been also used in collegiate sport to explore athletes’ fulfilment and frustration of the three basic psychological needs in both academic and athletic settings (e.g., Raabe at al., 2022; Raabe & Readdy, 2016), and coaches’ and teammates’ impact on collegiate athletes’ need-satisfaction (e.g., Raabe & Zakrajsek, 2017). Some studies have specifically examined the role of support personnel (e.g., coaches and athletic trainers) in injured athletes’ need satisfaction and thwarting during their recovery and return to sport. Bejar et al.’s (2019) study of NCAA Division I collegiate athletes with an injury found greater motivation during injury rehabilitation when they perceived their athletic trainers supported their needs for autonomy, competence, and relatedness (Bejar et al., 2019). MENTAL HEALTH REFERRALS IN SPORT 7 Specifically, participants reported that athletic trainers facilitated their motivation to engage in rehabilitation recommendations when they provided (a) information, clear expectations and goals, encouragement, and reassurance (facilitating their competence); (b) scheduling availability and flexibility, focus on both health and performance goals, receptivity to feedback, and choice in treatment (facilitating their autonomy); and (c) approachability, rapport-building, and curiosity about athletes’ lives beyond sport (facilitating relatedness; Bejar et al., 2019). The findings of this study suggest BPNT may be a useful framework for investigating the role of support personnel in collegiate athletes’ motivations to pursue recommendations around their care. Specifically, behaviors of support personnel and athlete peers may similarly influence collegiate athletes’ motivation to follow-through on referral recommendations by interacting with their psychological needs and, in turn, impacting their wellbeing. Situated within their identities and cultural contexts, this study explored (a) collegiate athletes’ experiences receiving mental health referrals from support personnel and their athlete peers, and (b) the mechanisms, informed by perceptions of psychological need supporting and/or thwarting, that explained the experiences and their associated outcomes. The findings are used to inform theoretically-grounded, data-driven, and athlete-centered recommendations for referral in collegiate sport environments. Methods and Materials Research Approach and Philosophical Assumptions The researchers adopted a multiparadigm approach integrating constructivist and critical realist research paradigms (Bogna et al., 2020; Voelker et al., 2024) to fully achieve the research aims. As proposed by Bogna et al. (2020), a constructivist paradigm allowed the researchers to explore the domain of the empirical, as guided by (a) relativist ontology whereby researchers MENTAL HEALTH REFERRALS IN SPORT 8 assumed there were multiple and socially constructed realities (Sale et al., 2002); (b) subjective epistemology in that meaning was believed to be socially- and culturally-informed through interactions with one’s environment (Moon & Blackman 2014), and (c) the axiological aim was to understand and communicate co-constructed realities between the researchers and the participants (Biedenbach & Jacobsson, 2016). Toward the first study aim, a constructivist paradigm was used to first give voice to participants themselves, and in that way, understand their mental health referral experiences and meaning. Specifically, participants’ referral beliefs and experiences were perceived as products shaped by social and cultural contexts associated with their unique identities and collegiate sport environments and were considered as multiple and individual truths. A critical realist paradigm allowed the researchers to explore the domain of the real (Bogna et al., 2020), as guided by (a) realist ontology that assumed an objective reality existed independent of one’s perception of it (Wynn & Williams, 2012); (b) interpretivist epistemology or the assumption that relationships, ideas, and knowledge interacted to shape causal mechanisms, events, and experiences that resulted in specific tendencies (Peters et al., 2013); and (c) the axiological goal to understand mechanisms and causal regularities (Bogna et al., 2020). Toward the second study aim, the researchers explored structures, mechanisms, and conditions associated with a well-established and empirically supported theoretical framework, BPNT, that shaped these experiences using a critical realist paradigm. The two paradigms were merged to explore the domain of the actual, where mutually constructed meanings and associated occurrences and events were shaped by structures, mechanisms, and conditions, and therefore, allowed a more complete and deeper understanding of the studied phenomenon (Bogna et al., 2020; i.e., referral experiences). In other words, the MENTAL HEALTH REFERRALS IN SPORT 9 multiparadigm approach allowed exploration of the what, using constructivism, and the how, using critical realism, regarding mental health referrals in collegiate sport. Methodological Approach Consistent with a multiparadigm approach that aimed to explore the domain of the actual (Bhaskar, 1978), a constructivist grounded theory methodology (Charmaz, 2000; 2006, 2014) was integrated with a critical realist, or retroductive, grounded theory methodology (Looker et al., 2021), both of which share eight common elements (Weed, 2009). According to Charmaz (2014), a constructivist grounded theory methodology acknowledges “subjectivity and the researcher’s involvement in the construction and interpretation of the data” (p. 14). Hence, this methodology allowed for exploration of what are the referral experiences and what are the realities of collegiate athletes within relevant culture and context, while considering the researchers’ role, including experiences, privileges, and biases, in the construction of that knowledge. Rooted in classical grounded theory (Glaser and Strauss, 1967), retroductive grounded theory aims to develop understanding of mechanisms, or causal powers, that produce the studied phenomenon (Hoddy, 2019; Kempster & Parry, 2011; Looker et al., 2021). According to Kempster and Parry (2011), because the critical realism paradigm suggests knowledge is valueladen, retroductive grounded theory is a context-rich, versus context-free, approach to studying phenomena. Unique from other grounded theory approaches, drawing upon existing theories while analyzing the data is encouraged with a retroductive approach (Kempster & Perry, 2011). Hence, this retroductive methodology was used to explore the role of BPNT in clarifying the possible mechanisms that affected mental health referral in sport; or in other words, the how behind collegiate athletes’ referral experiences. Together, constructivist and retroductive MENTAL HEALTH REFERRALS IN SPORT 10 grounded theory methodology captured the lived experiences and meanings of collegiate athletes who were referred to mental health services, and mechanisms that shaped these experiences. Participants Participants were 14 current (n = 8) and former (n = 6) collegiate athletes aged 18 to 25 years (M = 21.28, SD = 2.23). Participants were referred one to three times within the past four years by athletic trainers (n = 8), coaches (n = 7), collegiate athlete peers (n = 5), nutritionists (n = 2), mental performance consultants (n = 2), and physicians (n = 1). Table 1 provides sample demographics. Table 1 Participants’ Self-Identified Demographic Characteristics Characteristic n % Sex and Gender Cisgender Woman 10 71.4 Cisgender Man 4 28.6 Race and Ethnicity *White 12 85.7 Latina 1 7.1 White and Asian 1 7.1 Nationality American 11 78.6 English 1 7.1 German 1 7.1 Mexican 1 7.1 Annual Family Income $25,000-$50,000 3 21.4 $50,000-$75,000 3 21.4 $75,000-$100,000 2 14.3 $100,000 or more 5 35.8 Did not know 1 7.1 Religion and Spirituality Nondenominational Christian 3 21.4 Catholic Christian 3 21.4 Spiritual but not religious 2 14.3 Agnostic 1 7.1 Atheist 1 7.1 Easter Orthodox Christian 1 7.1 MENTAL HEALTH REFERRALS IN SPORT 11 Characteristic n % Methodist Christian 1 7.1 Pentecostal/Assembly of God Christian 1 7.1 Protestant Christian 1 7.1 Sport Rifle 2 14.3 Soccer 2 14.3 Swimming 2 14.3 Triathlon 2 14.3 Diving 1 7.1 Lightweight rowing 1 7.1 Rowing 1 7.1 Track and Field; Softball 1 7.1 Competitive Level NCAA DI 10 71.4 NCAA DII 1 7.1 NCAA DIII 3 21.4 Note. NCAA = National Collegiate Athletic Association; DI/DII/DIII = Divisions I, II, and III *5 participants who identified as white American also reported identifying as: Bulgarian, German/Polish/Irish/Italian, Irish/German, Irish/Wales, and Polish. Materials Demographic Survey. A demographic survey (see Appendix E) was administered via Qualtrics software and asked when participants were referred to mental health services and who referred them, as well as their age, sex, gender identity, sexual orientation, race, ethnicity, nationality, SES (socioeconomic status), religion, collegiate sport organization, division, and sport(s). Interviews. Individual in-depth, semi-structured, online, video-recorded interviews started with rapport-building, followed by open-ended and follow-up questions to generate conversation as recommended by Charmaz (2014) and Hoddy (2019). The first author, who conducted the interviews, continuously engaged in self-reflexivity according to guidelines established by Tracy (2010), to examine her assumptions about referrals in collegiate sport and communicate, both verbally and via open body language, a willingness to learn and understand MENTAL HEALTH REFERRALS IN SPORT 12 participants’ lives from their perspective. These experiences were processed with a critical friend with each subsequent interview to also deepen reflexivity. The first version of the interview guide was developed based on previous literature on mental health referrals in sport (e.g., Sebbens et al., 2016; Van Raalte et al., 2015), BPNT (e.g., Ryan & Deci, 2017), prior experiences interviewing collegiate athletes about mental health concerns (e.g., Coker-Cranney et al., 2018), as well as guidance on constructing questions aligned with both constructivist (Charmaz, 2014) and critical realist aims (Brönnimann, 2022). Broadly, questions explored collegiate athletes’ experiences being referred to mental health services with intentional exploration of their identities and culture in connection with those experiences. Participants were then provided a cursory overview of the three psychological needs and asked their perceptions of needs satisfaction and thwarting amid their referral experiences. Consistent with Glaser and Strauss (1967), the interview guide evolved as data were collected to support the process of theoretical sampling and consequent development of grounded theory (see Appendix F for the final version). Initial interviews ranged from 55 to 105 minutes in duration (M = 86 minutes). Procedures After receiving IRB approval (Protocol #2302727613), participants were purposively sampled according to the eligibility criteria (i.e., at least 18 years of age, current or former collegiate athlete, was referred to mental health services in the past four years by support personnel or other athletes). Maximum variation sampling was used to garner the widest range of experiences, to the extent possible, with respect to several key factors found to play a role in collegiate athletes’ mental health concerns and/or help seeking behaviors (e.g., Ballesteros & Tran, 2020; Brown et al., 2021; NCAA, 2022; Li et al., 2017); these variables included sex, MENTAL HEALTH REFERRALS IN SPORT 13 gender identity, sexual orientation, race and ethnicity, and SES. Further maximum variation was sought with respect referral experience (i.e., positive and negative) and referral source (e.g., mental performance consultant, athletic trainer, sport dietician, academic advisor, strength and conditioning coach, sport coach, or athlete peer). Nationality, sport, year in college, collegiate sport organization, division, and religion were also considered. As suggested by Charmaz (2014) and Hoddy (2019), interviews were transcribed and evaluated as they were completed to support a theoretical sampling process that informed the type of data sought in subsequent interviews as a theory emerged, such as revising interview guide questions (e.g., re-ordering questions about basic psychological needs) and/or recruiting participants with certain experiences (e.g., perceiving to have a lack of choice during referral experience) or attributes (e.g., man-identified collegiate athletes) to explore a gap in the developing theory. Recruitment, then, was an iterative process continuously informed by the purposive, maximum variation, and theoretical sampling processes to obtain a sample with rich and wide-ranging experiences that meaningfully informed a substantive grounded theory. Recruitment approaches included multiple flyer (see Appendix C) distributions via social media outlets (e.g., LinkedIn) and email to colleagues, sport support personnel (e.g., mental performance consultants, athletic trainers), and or collegiate sport teams. Interested participants who voluntarily contacted the first author were provided additional information about the study outlined in a cover letter (see Appendix D), including the purpose of the study, what participation would entail, the possible benefits and risks of participation, and participation incentives, and then screened for inclusion criteria. Eligible participants were offered an opportunity to read the cover letter, ask questions, and then complete a demographic survey. The first author conducted initial interviews and invited the participant for a member reflection on a MENTAL HEALTH REFERRALS IN SPORT 14 second date following the initial coding of the participant’s first interview. Although each member reflection was unique, they broadly included a summary of main takeaways, followed by a discussion of participant’s impressions and conclusions from the initial interview, and new understandings and experiences since the initial interview. Thirteen participants completed the follow-up, lasting between 10 and 29 minutes (M = 19.7). Participants who completed the study received a $50 Amazon gift card in modest appreciation of their time. To protect participants’ confidentiality, all interviews were de-identified, and participants were assigned pseudonyms. Data Analysis Data analysis was guided by both constructivist (Charmaz, 2014) and retroductive grounded theory approaches (Looker et al., 2021). Prior to and during data collection and analysis, a two-person data analysis team continuously explored theoretical sensitivity – examining the studied phenomenon with an open mind to explore and compare different perspectives as well as evolve original ideas (Glaser, 1978). Theoretical sensitivity allowed the data analysis team to explore the participants’ perspectives about referrals in novel and original ways. To support this process, the data analysis team consulted with a larger research team, comprised of applied practitioners and academic researchers in sport psychology and clinical mental health, during bi-weekly hourly meetings for several months. According to Glaser and Strauss (1967), grounded theory methodology involves an iterative process of engaging in data collection and analysis simultaneously. Accordingly, analysis started, and continued, as each new interview was conducted and transcribed. Analysis of each interview began with the data analysis team reading each transcript and then verbally processing their insights with one another. The first author then conducted the initial coding (constructivist grounded theory) using a line-by-line coding approach to define the phenomenon MENTAL HEALTH REFERRALS IN SPORT 15 and allow the data to speak (Charmaz, 2014). The goal of the initial coding was to remain open and curious to all possible theoretical directions suggested by participants’ perceptions of the referral process. Charmaz suggested focusing on exploration of the actions and processes that define the phenomenon (i.e., collegiate athletes’ experience being referred to mental health services) was crucial at the beginning stages of the data analysis because it helped provide evidence of fit (i.e., capturing the essence of the participants’ experiences via codes and categories) and relevance (i.e., creating a framework that captures what was happening and relationships between implicit and explicit processes) of the emerging theory. Then, the first author conducted focused coding (constructivist grounded theory), also called open coding (retroductive grounded theory) – a process through which the goal was to conceptualize the phenomenon by choosing the most significant and or frequent initial codes that categorized the data inclusively and completely, and then comparing them to additional data (Charmaz, 2014; Looker et al., 2021). During focused/open coding, the first author moved across interviews to compare participants’ referral experiences, actions, and meanings (the dolman of empirical) to synthesize the main themes across large amounts of data while also exploring the structures and mechanisms that may have underscored these experiences and meanings (the domain of real). Theoretical categories (constructivist grounded theory) or emergent properties (retroductive grounded theory; i.e., core elements in a theory) emerged during focused/open coding and memo writing as well as constant comparison between the data (Charmaz, 2014; Looker et al., 2021). This process was not linear; later interviews made some processes clearer and incited reanalysis of earlier interviews. Following focused/open coding, the first author engaged in theoretical coding – a process that hypothesized possible relationships among MENTAL HEALTH REFERRALS IN SPORT 16 theoretical categories/emergent properties (constructivist grounded theory; Charmaz, 2014), with retroductive coding that explored generative and context-specific causal mechanisms that helped explain those relationships (retroductive grounded theory; Looker et al., 2021). Consistent with constructivist and retroductive grounded theory, this phase involved constant comparison between the new data, memos, and codes as well as possible reanalysis (Charmaz, 2014; Looker et al., 2021) toward exploration of the domain of the actual. To support the process of describing and conceptualizing the phenomenon, the first author engaged in consistent memo writing described as an analytic process in both constructivist and retroductive grounded theory (Charmaz, 2014; Looker et al., 2021). Broadly, memo writing allowed the first author to generate ideas, develop and connect theoretical categories/emergent properties, gain insights early in the research process, and explore the possible causal mechanisms that explain the relationships between theoretical categories/emergent properties (Charmaz, 2006; 2014; Looker et al., 2021). Memo writing supported iterative data analysis as it allowed the first author to explore and discover ideas freely and spontaneously (Weed, 2009). When needed, memos were discussed with the research team to support the exploration of the phenomenon. An important part of memo writing was raising focused/open codes to theoretical categories/emergent properties (Charmaz, 2014; Hoddy, 2019). This was done by choosing focused/open codes that best capture what was happening in the data and why it was happening though comparison between the data, incidents, contexts, and other categories/properties. Via memo writing, the first author defined and explored characteristics of tentative theoretical categories/emergent properties, explored their relationships with other theoretical categories/emergent properties, and possible causal mechanisms that explained these MENTAL HEALTH REFERRALS IN SPORT 17 relationships (Charmaz, 2014; Looker et al., 2021). In advanced memos, the first author traced and categorized data to achieve the purpose of the study, describe how theoretical categories/emergent properties and possible causal mechanisms emerge and change, identify the beliefs and assumptions that supported them, explore various perspectives of the memo topic, and engage in constant comparisons. Throughout each phase of the study, the first author conducted constant comparison iteratively between data and data, data and codes, codes and theoretical categories/emergent properties, and theoretical categories/emergent properties and BPNT literature. The first author started theoretical sampling once there were preliminary theoretical categories/emergent properties from which to collect subsequent data that expanded and improved theoretical categories/emergent properties and related causal mechanisms informing the emerging theory (Weed, 2009). Theoretical sampling was facilitated by memo writing that helped identify incomplete theoretical categories/emergent properties and causal mechanisms, and gaps in the analysis. Weed (2009) argued theoretical sampling, based on tentative theoretical categories/emergent properties, continued until no new characteristics of theoretical categories/emergent properties and no new causal mechanisms emerged from new data (i.e., theoretical saturation; Charmaz, 2014; Hoddy, 2019). Based on what emerged from the existing data, theoretical sampling involved recruiting new participants with specific experiences, or collecting follow-up data collection from the existing participants (Charmaz, 2014; Hoddy, 2019). The first author regularly consulted with the research team about decisions regarding the specific approaches to theoretical sampling. To deepen the analysis and construction of the emerging theory, the first author engaged in theoretical sorting, comparing/diagramming, and integrating memos (Charmaz, 2014). This MENTAL HEALTH REFERRALS IN SPORT 18 involved comparing memos and exploring how the order and logic of memos capture the referral experiences of collegiate athletes. Additionally, drawing diagrams assisted in establishing and solidifying theoretical categories/emergent properties, their relationships, and causal mechanisms that explain them. Together, these strategies provided insight toward an emerging theoretical framework on referring collegiate athletes to mental health services. To support the process of theory development, the first author met with expert consultants regularly during each phase of the analysis regarding the quality and rigor of the analysis and relevance to the BPNT framework. Follow up member reflections and the research team interpretations were transcribed and analyzed with the rest of the data to refine the theoretical categories/emergent properties and emerging theory (Albas & Albas, 1988; 1993; Charmaz, 2014; Looker et al., 2021). Methodological Rigor To support the process of investigating, interrogating, and deepening different interpretations of the data (Harper, 2011), the research team included individuals with a variety of experiences in the collegiate sport and mental health fields. Some of the shared experiences of the research team involved completing post-secondary education in either sport psychology, mental health counseling, or both. Additional commonalities among the research team included being an athlete, a coach, a mental performance consultant, and a mental health counselor in various sport and clinical settings in the United States and Europe. Some of the unique experiences of the research team included identifying with different nationalities (i.e., American, German, Austrian, and Serbian) and gender identities (i.e., woman- and man-identified), competing and working for different sports and sport levels (i.e., high school and collegiate), and interacting with collegiate athletes in different capacities (e.g., as a therapist, a professor, a mental performance consultant, a supervisor, a former collegiate athlete). Additionally, the MENTAL HEALTH REFERRALS IN SPORT 19 research team had diverse experiences, expertise, and formal training regarding conducting qualitative research in sport psychology and counseling, BPNT, and making and receiving collegiate athletes’ mental health referrals. The approaches used to support data trustworthiness, credibility, and confirmability were engaging in self-reflexivity both in written (i.e., memo writing) and verbal (i.e., discussions with the critical friend) forms as well as regular consultations with the research team experts regarding conceptual and methodological decisions, and conducting member reflections, as previously discussed. Additionally, Carcary (2020) recommendations for audit trail best practices were followed (i.e., documenting the research process in all phases of the study, including key methodological decisions, and tracing how researchers’ thinking evolved during each phase). Results Data analysis resulted in a substantive grounded theory (Figure 1) that described and explained participants’ experiences of being referred to mental health services by support personnel and other athletes. Three overarching theoretical categories/properties emerged: (a) pre-referral factors (i.e., conditions and dynamics prior to referrals informing referral conversations); (b) referral conversations (i.e., interactions in which referrers recommended athletes seek appropriate mental health resources); and (c) referral outcomes (i.e., consequences of referral conversations). Figure 1 illustrates subcategories identified within each category, and the relationships between them, that together described participants’ experiences and mechanisms explaining those experiences. Figure 1 A Substantive Grounded Theory of Referring Collegiate Athletes to Mental Health Services MENTAL HEALTH REFERRALS IN SPORT 20 Note. White boxes represent experiences, and gray boxes represent mechanisms. Pre-Referral Factors Prior to the initiation of referrals, pre-referral factors shaped how referral conversations unfolded and, ultimately, the referral outcomes. These factors included aspects of participants’ identities and cultures and interactions with their family and sport environments. Although basic psychological needs were not explicitly explored with participants at this stage of the interview, pre-referral factors clearly also influenced autonomy, competence, and relatedness when shaping participants’ relationships with, and attitudes toward, mental health and, ultimately, the referral. Participants’ Identities and Culture Participants described how aspects of their identities and culture, such as their nationality, race, ethnicity, SES, religion, and gender identity, influenced their perceptions of mental health concerns and help-seeking behaviors that, in turn, informed their willingness to pursue referral MENTAL HEALTH REFERRALS IN SPORT 21 recommendations. For example, Fin referenced that “in Germany, we are…more private, very distant people” which is “probably also one of the reasons why I never really looked at [therapy] before.” Mia, on a different note, commented on SES status: “Growing up, the money aspect was hard. So, that’s why I never went [to therapy].” Other participants described how binary gender norms, informed by their upbringing and traditional sport culture, influenced their help-seeking attitudes. Gia reported that “girls are seen as weaker…guys [are] trying to be the strongest” and that “coaches would see you as weaker” for seeking mental health resources. Tom described how a lack of representation contributed to his mental health concerns and deterred him from seeking help: “I think not only is it hard to be a queer person [in the] outside world, but also being a queer person inside of athletics is incredibly difficult.” Further, some participants cited their religious background and spirituality as both a barrier and facilitator to seeking mental health services. Bri explained, “[My religious community is] very supportive…It gave me an opportunity…to talk about [my mental health] more.” Zoe similarly discussed how “the guiding principles of religion” encouraged her to “find the healthiest version of myself, mentally and physically.” Ana stated why she went to therapy: I realized there was a spiritual element to this… The enemy was telling me, ‘You’re a failure.’ And I was believing it… I need to get my faith back in order. This is a lie… This is not who God says I am… That faith…was HUGE because that was the catalyst that started changing things. Other participants believed religion sufficed as therapy and, accordingly, avoided facing their difficulties as a way to cope (i.e., spiritual bypassing). Mia reported, “I always just thought I could just pray it off…Why isn’t praying enough for me? I didn’t want it to feel like I couldn’t do it on my own with just God.” MENTAL HEALTH REFERRALS IN SPORT 22 Some participants reported ways their intersecting identities shaped their views on helpseeking. Ana described her “quite emotionally unavailable” English culture and “the culture of being an athlete” as making her “incredibly reluctant” to seek help. Others explained that support personnel failed to honor their intersecting identities, exacerbating their mental health concerns and unwillingness to seek help. Tom explained that, in his sport environment, the term “athlete” was used to generalize “a group of people that can be incredibly diverse.” He noted, “As someone who has been athletic since I was five years old, I just took onto that [athlete] title and didn’t allow other things in my life to define who I was.” He added, “[Sport personnel] don’t really talk too much about sexuality…It was never really a topic of conversation.” For the participants who recognized having privileged identities, representation in mental health settings was often not a concern. Ana stated, “I’m heterosexual, [that is] why I don’t feel there [were] any barriers in terms of those parts of my identity.” Ana also acknowledged her teammates may have had a different experience: “We had a couple of lesbians on the team. I could see how they wouldn’t want to go to a Christian counselor for fear that they would be judged.” For some participants who belonged to minoritized groups, representation was key to their willingness to seek mental health services. As a member of “the international community,” Lea reported noticing “more of a need for cross-cultural specialists… Our counseling center… has been staffed by older white people.” Lea suggested “having…knowledge of various backgrounds and…cultures…helps with the referral process” as professionals may “understand your experience and you feel represented in them.” Participants’ diverse identities and culture had strong effects on their help-seeking attitudes and behaviors, and, consequently, their openness to referral recommendations. Participants’ Family Environments MENTAL HEALTH REFERRALS IN SPORT 23 Participants in family environments that encouraged help-seeking were more likely to have positive attitudes toward help-seeking themselves. Max stated, “I’ve never thought [seeking therapy] was a bad thing… I’ve always been told…if you’re struggling mentally, there’s nothing wrong with talking to [psychotherapists].” Ana noted, “My parents didn’t see seeking counseling as a sign of weakness… I know my dad had gone…and…it was helpful for him… If anything, it encouraged me… They’re not gonna judge me…” Contrarily, negative attitudes toward help seeking in their immediate family deterred other participants from wanting to seek mental health services. Mia mentioned, “My parents are very against being mentally weak… [My extended family] don’t believe in therapy at all… I would never say [to them]…that I’m in therapy.” Some participants also said that help-seeking attitudes were passed down generationally, making it harder to shift their own attitudes. Lea reported, “[My mother] moved from [another country]… With my grandparents it very much was like, ‘You don’t need anything. It’ll be fine’…The cultural mindset travels with you.” Among these participants, some discussed slow but important shifts in intergenerational help-seeking attitudes. Gia reported that her “transition generation” is growing up in a time when they are “actually…listened to” instead of being told to just “toughen up,” and that younger generations will benefit from further shifts in this direction. Family members’ attitudes towards mental health help-seeking, whether positive or negative, strongly influenced participants’ own attitudes yet were noted as malleable. Participants’ Sport Environments Many participants similarly described their sport environments as supportive or unsupportive of mental health help. These participants were more likely to have positive attitudes toward help-seeking when athletic department cultures encouraged it. Joy felt “really good” about seeking services after noticing that “no one looked twice” when her teammate disclosed MENTAL HEALTH REFERRALS IN SPORT 24 pursuing therapy. Gia did not originally value mental health services, but because her head coach “wants to talk about mental health…it’s not uncomfortable.” Gia also described several benefits of mental health services being accessible and frequently promoted in her sport environment. Per Gia, coaches pointed to “posters with [the psychotherapist’s] contact information,” and athletic trainers frequently offered to “help you set up an appointment.” These participants also discussed having better access to services when mental health providers were integrated into sport. For Max, “the fact that [the psychotherapist in athletics] is around us and really looks out for us…definitely helped. Max noted, “I don’t know if it was some random person if I would have [sought therapy].” Conversely, some participants noted several barriers when athletic department cultures failed to promote mental health. Ana’s teammate “didn’t believe what was going on with me was a big deal… It made me feel like, ‘Oh, maybe she’s right. Maybe there’s nothing wrong with me. Maybe I’m just being dramatic,’ which was very painful.” Ana further noted, “Before that conversation [about referrals] even happens, …there’s more that can be done with the culture around [mental health],” explaining that requiring a referring athletic trainer to “deal with this” is “unfair…when there is not a culture already in place that makes those conversations accessible and comfortable.” Fin “wasn’t really aware of [existing therapy resources for athletes]… that wasn’t really too public that I would have the option to talk to [psychotherapists]…. That message never really came from the main coaches.” Ella had “never heard someone who goes to [the psychotherapist in athletics] and has a good experience… She’s trained…just…not very good.” Contrarily, some participants indicated that an overemphasis on mental health was also an issue. Ella described this as an “overcorrection,” as her coach’s efforts to normalize mental health made the coach “too emotionally involved”, thus “hindering…[team] performance.” Ella MENTAL HEALTH REFERRALS IN SPORT 25 also felt that some of her teammates were “too annoying and loud about mental health.” As with family environments, participants’ sport environments, including cultural messaging about mental health, impacted their pre-referral attitudes and intentions toward help-seeking. Reactive and Proactive Referral Conversations Participants’ identities, cultural backgrounds, and family and sport environments informed the help-seeking attitudes they, figuratively, brought with them to their referral conversations with support personnel and other collegiate athletes. In these referral conversations, referrers broached their concerns with participants and recommended mental health resources or services. Many participants described these conversations as having occurred reactively (i.e., in response to an experienced mental health crisis) or proactively (i.e., with the aim to prevent concerns from beginning or worsening). Participants further discussed ways they perceived their basic psychological needs to be supported or thwarted amid these interpersonal exchanges. Most participants reported being referred reactively, as a result of “hitting rock bottom” (Tom) or in response to crisis, such as sexual assault, suicidality, and panic. Referrals following a crisis that were experienced positively involved the referrers who promptly provided support, information, and choices to help them feel safer and more in control. Liz stated it “was helpful to know what I was walking into.” She further explained, “[The athletic trainer] said, ‘[The boyfriend]…can sit in [the session] with you…,’ prepared me it was going to be a guy [the psychotherapist],” and gave “me the basics of what I was going to experience.” In rare cases, some participants were referred proactively as a preventive measure to help them cope with upcoming stressors. Gia, who “had never done triathlon before”, explained that her head coach referred her “to make sure that you’re not feeling you’re in over your head.” Being referred MENTAL HEALTH REFERRALS IN SPORT 26 proactively increased some participants’ openness to services and reduced mental health stigma. For Gia, this approach showed her that “anyone can be referred… [Therapy] can be helpful for anybody” and “preventative.” Lea described being referred proactively as “a welcome little push to get me to take care of myself and prioritize wellbeing,” with others stating that it helped them overcome ambivalence or avoidance. Bri noted, “Had I not had that [referral] conversation with [the athletic trainer], I probably would have never gone to see anybody.” Such examples exemplified the importance of approaching each referral differently based on an athlete’s unique needs. Psychological Need Satisfaction and Thwarting In addition to the proactive/reactive nature of referral conversations, participants discussed ways in which the interpersonal exchanges with referrers supported, or thwarted, their basic psychological needs. These included participants’ autonomy (i.e., sense of selfgovernance), relatedness (i.e., sense of connection), and competence (i.e., sense of mastery). Autonomy Satisfaction and Thwarting. Many participants explained that common hierarchical power structures influenced their referral conversations and, subsequently, their decisions to pursue mental health services. When asked about what it was like to be referred by their teammates, two participants voluntarily compared it to referrals by coaches, stating it felt “more like my own decision… Athlete to coach is more a sense of authority” (Eva). Mia echoed, “If [the coach] were to suggest [therapy]… I would not have a comfortable conversation” and “would just go…feel I had no choice” and “be doing it for him.” For Ari, “Having [the athletic trainer and the coach]…reach out to [the psychotherapist] before I even gave consent…or approval…was upsetting. So, I didn’t feel I had the autonomy because it was not brought forward to me.” In contrast, a few participants discussed how financial privilege was another MENTAL HEALTH REFERRALS IN SPORT 27 form of power that supported autonomy during and following the referral. Bri reported she “went out and found [a psychotherapist] on my own… It’s privileged to be able to afford that… Privilege does create autonomy.” Many participants reported feeling autonomous when their referrers asked them for their thoughts and preferences and provided control around referral outcomes, including the opportunity to contemplate and choose whether to pursue services. Bri stated, “it was my choice” because the athletic trainer informed her about resources and said “It’s completely up to you. We’re not going to force you into it or judge you if you decide not to.” Fin reported, “[Therapy] was…brought up…[as] an option. And I was like, ‘Okay, I’m gonna give it a thought…’ It was never the end of the conversation and then a fixed, ‘Yeah, I’m gonna…[seek therapy].’” Fin further explained, “After a week… based on my own evaluation… [and] taking into consideration… what [the r