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Meeting the Mental Health Needs of Student-Athletes: A Meeting the Mental Health Needs of Student-Athletes: A Descriptive Study of Practitioners and their Perspectives Descriptive Study of Practitioners and their Perspectives William C. Way III West Virginia University, wcway@mix.wvu.edu Follow this and additional works at: https://researchrepository.wvu.edu/etd Part of the Kinesiology Commons Recommended Citation Way, William C. III, "Meeting the Mental Health Needs of Student-Athletes: A Descriptive Study of Practitioners and their Perspectives" (2021). Graduate Theses, Dissertations, and Problem Reports. 8018. https://researchrepository.wvu.edu/etd/8018 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. Meeting the Mental Health Needs of Student-Athletes: A Descriptive Study of Practitioners and their Perspectives William C. Way Dissertation submitted to the College of Physical Activity and Sport Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Doctorate of Philosophy in Sport, Exercise, and Performance Psychology Jack C. Watson II, Ph.D., Chair Samuel Zizzi, Ed.D. Monica Leppma, Ph.D. Ashley Coker-Cranney, Ph.D. Department of Sport Sciences Morgantown, WV 2021 Keywords: Mental health, Practitioners, Student-athletes, Counseling, Psychological services Copyright 2021 William Way ABSTRACT Meeting the Mental Health Needs of Student-Athletes: A Descriptive Study of Practitioners and their Perspectives William C. Way Efforts are being made to promote mental health awareness and destigmatize help-seeking behavior among student-athletes (e.g., Kern et al., 2017). The availability and visibility of practitioners with specialized training in sport psychology can facilitate these efforts (e.g., Flowers, 2007; Carr, 2007; McDuff et al., 2005). However, some student-athletes have observed that the clinical sport psychology (CSP) practitioners who are available to them are being stretched thin (Way et al., 2020). In the context of collegiate mental health more broadly, many campus counseling centers are struggling to meet the demand for clinical services (e.g., Kafka, 2019). Research on the experiences and perspectives of CSP practitioners in the collegiate setting has been scarce (cf. Schlimmer & Chin, 2018), and has neglected the vantage point of practitioners who support student-athletes at institutions that do not have access to sport psychology services (cf. Petrie et al., 1995). As such, the first objective of this study was to expand upon the work of Hayden and colleagues (2013) to identify the population of clinical and applied sport psychology practitioners from all NCAA member institution websites (Power 5 conferences, all other DI, DII, and DIII). The second objective was to survey the experiences of these practitioners and counseling/psychological services staff at institutions that did not list CSP personnel. As a whole, practitioners reported that some generalized services (e.g., personal counseling available to all students, crisis intervention) were more in-demand among student athletes than specialized sport-specific services. Sport psychology services were more common at P5 and other DI institutions, but also more likely to be stretched or exceeded by demand relative to similar services at DII and DIII institutions. At the risk of reducing service availability to a numerical tally of haves and have-nots, quantitative and qualitative data shed light on the ways in which practitioners experienced and were impacted by the structure, function, availability of, and institutional support for psychological services. In their open-ended responses, the most prevalent need that practitioners expressed was for more staffing (more staff, more diverse staff, and more multidisciplinary staff). Results invite athletics and institutional administration to consider the loads that are being shouldered by mental health and sport psychology staff at their institutions; the voice and support that is granted to these practitioners; and the value of robust mental health services/outreach for recruitment, retention, and risk management. Acknowledgments iii I am filled with emotion as I look back on my time at WVU through to the completion of this project. What a formative chapter in my life this has been! This document already has so many pages that I feel no pressure to be stingy here with my gratitude. First and foremost, I would like to thank my committee members. Your mentorship and guidance took root long before this project was even an idea, and will extend far beyond its completion. Dr. Watson, from the moment I arrived on campus as an anxious candidate during interview weekend, I felt that I could be my authentic self with you. During our interview, you asked me about my strengths and weaknesses. Mustering the confidence to stand in my strengths was hard enough, until you reminded me about the penalty flag that would be discharged in the event of cliché “weaknesses.” Perhaps caught off guard by the humor of the situation I blurted out (maybe in more detail than you were looking for!) that I can over-think things and get in my own way. You can now be the judge of the veracity of that response (: Through my time at WVU, your encouragement, support, and affirmation have helped me to stand more firmly in my strengths and to step back for a moment when my mind gets tangled. From essential readings and teaching observation, to research meetings, classes, career lunch, etc., you have taught me so much. In addition to disciplinary knowledge and professional practice wisdom that you have passed on, you have taught me (perhaps without meaning to) about hard work, balance, family, hula hooping, and the value of infectious laughter that echoes down the hall. I am so fortunate to have a mentor like you, and am beyond grateful for all that you have invested in me. Dr. Zizzi, you have helped this project to morph and take shape since dissertation seminar. Throughout this journey you have challenged me to remember that, oftentimes, less is more… that it’s okay to wander in the forest, so long as one can climb up above the trees thereafter. I have to admit that this document doesn’t strike me as a “win” in the less-is-more column (!!), and it may be that I will always have to wander further than most before I can climb up, but your voice of wisdom and pragmatism will always encourage me to do so. I should add that your health and exercise psych course sits high on my list of favorites, and was incredibly impactful for me. You have helped me to see the importance of “staying in your lane,” but also that an openness to peeking into other “lanes” can be incredibly instructive. You introduced me to program evaluation and stoked a systems-level curiosity within me. This energy and these ideas are cemented in the foundation of this project; and I have no doubt, in the foundation of my future career as a scholar-practitioner as well. Thank you. Dr. Leppma, from your Theories and Techniques class during my first semester, through to supervision during internship, and now to dissertation, you have been with me through every leg of my journey at WVU. Whether it was discussing course content and case studies, or sorting through the myriad thoughts, emotions, and questions that have come up through it all, you have always been willing to carve out extra time to help. Throughout my studies and training, you iv have helped me to identify and clarify my approach to practice as a clinician in training – a philosophy that fits authentically for me as a person, and infuses my research too. I have so deeply valued your insight and mentorship. Dr. Cranney, if I only had one word to describe you and your mentorship, it would be “brilliant.” First, I say “brilliant” because you are one of the sharpest and most intelligent thinkers I have ever met. You have a way of seeing and conceptualizing things from different angles and with a level of sophistication that – on several occasions – has left me flabbergasted. I also say “brilliant” because there is an intensity, a brightness to the energy and curiosity that seems to fill all that you do. Through your encouragement, and through the example you set, you inspire me to reach – to consider a different perspective, to ask questions, to go out on a limb every so often, and to never set limits on what I do. Outside of my committee, there are so many who I want to thank for their influence and support; so many who have made my time at WVU and this culminating project so meaningful. Dr. Etzel, I am beyond fortunate to have “snuck in” prior to your retirement, and you have been like a second advisor to me. I arrived on campus a bit starstruck, and this was perhaps most palpable in your ethics class during my first semester. Here I was learning ethics from “the ethics guy,” and I vividly recall choking on my nerves during what should have been a routine “what did you learn from the chapter” sort of presentation. It was awful. We talked about it in your office not long thereafter. “It was a bit tense,” you said with a warm grin, and we both had a good laugh about it. From that point on, I felt freed up to take myself a little less seriously and to remember that any moment can become a learning opportunity so long as we are mindful enough to see it as such. I must add that any knowledge of counseling college student-athletes I have accumulated, I owe to you. You taught me to notice the culture of athletics and to use a holistic, developmental lens in my work with student-athletes. Finally, it seemed like your door was always open for a quick question, a consult, a good joke, a thought-provoking quote, and/or a really, really good cup of coffee (“a speedy cup of Seattle’s Beast,” as you would put it). Thank you so much for all of your wisdom, guidance, and support. To all at the Carruth Center, my supervisors, and especially Layne, Missy, and T.Anne – I am grateful beyond words for the environment and the opportunities you offered me as a trainee. During a critical period in my professional development, I always had someone I could go to for help – from fumbling my way through Titanium for the first week (or month?!) and planning group sessions, to getting a second opinion on a risk assessment or processing transitions in my own life. I felt seen, held, affirmed, and encouraged, as well as challenged and extended. I emerged with a sense of growth, authentic confidence (or perhaps confidence in my authentic self), and inner certainty that “this is what I want to do with my life” unlike any I had known before. All of you, the work that you do, and the training you provide were in my heart during this study. v To all my classmates in the program – past and present – it is a great joy and privilege to call you friends and colleagues. This program is so special because of the collaboration, support, and togetherness we have shared. To my cohort partners… Bobby – My basecamp desk neighbor, there was never a dull moment! Perhaps spurred by some “unique” overheard choices in my headphones (“Bill, am I going crazy or are you listening to bird sounds?!”), you have introduced me to some great bands. I also have a newfound appreciation for Jeopardy from the mentorship of its greatest fan. Both of these things – music, and Jeopardy – have, to my surprise, been significant components of dissertating through quarantine. Finally, I think you are as close to a human database as one can get, and inspire me to consume more research. I sincerely hope that our collaboration will continue beyond our time in the program. Kate – I don’t think I could have survived multivariate without you! From all the classes we shared, to navigating internship, I always appreciated your insight and your sense of humor. I also recall you having the most beautiful, nutritious meals prepped for in between the myriad demands of the day. Even if I haven’t quite nailed it yet, you challenged me to consider the importance of properly fueling the mind and body throughout a busy day (perhaps one spent dissertating!). I would also be remiss if I didn’t add that I was blown away by your dissertation, and hope that I can stay current on the amazing things that you are going to do in the field. Spencer – MY MAN. Our friendship through these last several years has been a true treasure, and our shared adventures in your beautiful home state made for a season of my life that I will never forget. From wide-eyed counseling tapes, to bonking on the ascent of Mud Pike, demolishing Kroger’s supply of peanut butter, and the innumerable antics that we shared during your time with us at the Way Café, you helped this high-strung neurotic to remember that the fun/free child needs to get out to play every now and again. Your poised, mindful, and deliberate wisdom is an exceptional gift, and one that has helped me to great effect on more than one occasion. Your discerning eye and constructive feedback have been especially helpful and appreciated throughout this project. I feel so fortunate that our paths have converged and crossed, and I want to send my sincere gratitude your way. To Jeri, Wesley, and Shannon – My experiences with LeadWELL and WellWVU were incredibly valuable. Your mentorship and supervision helped to cultivate the campus-as community perspective that was foundational for this project. You also gave me space to think independently, creatively, and critically about student health and wellness. I have a new appreciation for the value of meeting and engaging students where they are; and my idea of what “outreach” is has been greatly enriched and expanded because of you. Last, and certainly not least, to my family… vi Mom – Your strength has always inspired me, and as I have matured, I have come to see more and more clearly just how strong you really are. Likewise, as I have grown and matured, so too has our relationship. Watching this metamorphosis through my young adulthood has been one of my greatest joys. Through it all, your listening ear, support, and unconditional love have made all the difference in my life. I could never have done this without you. Jason – Bro, your creativity and determination never cease to amaze me. All that you do, you do wholeheartedly, and I deeply admire this about you. I have tried to emulate your energy and passion in this project, and will continue striving to do so in my future work. Grandpop – You delight in simplicity and beauty as an artist, and navigate obstacles with the pragmatic ingenuity of an engineer. I used to see these two ways of being as incompatible, but have come to realize how harmonious they are for you. I can see your influence and example rubbing off on me as I look back on the journey of this dissertation. John and Donna – What a strange, tense place this world was during 2020. You have been saints to take me and Gabby in through this unexpected time of quarantine and “in between.” I could not be more grateful for your support and provision. Who knows, once you are rid of us, perhaps the extra space at “Club Kendall” could become a Bed and Breakfast retreat for frazzled writers or dissertation hopefuls like me (; Gabby – My love and my light, I could not imagine sharing this journey with anyone but you. From our breakfast breaks and plowing through websites, to long walks and deep talks, you have helped me through this project and this season in more ways than I can say. You have been my constant, and a voice of wisdom. With each passing day, I feel like I learn more and more about God’s love through you. In each chapter of our life together I find myself awestruck by how much we continue to learn and grow – as individuals, as a couple, and as a team. This chapter has been no exception, and I cannot wait to see what unfolds when we find ourselves, “on the road again.” vii Table of Contents Introduction ..................................................................................................................................... 1 Service Availability and Providers .............................................................................................. 2 Demand for Services ................................................................................................................... 3 Practitioner Perspectives and Experiences .................................................................................. 4 Purpose ............................................................................................................................................ 6 Methods........................................................................................................................................... 8 Website Review Procedures ........................................................................................................ 8 Survey Development ................................................................................................................... 8 Survey Recruitment ................................................................................................................... 10 Data Analysis ............................................................................................................................ 11 Results ........................................................................................................................................... 12 Practitioner Frequencies (RQ 1a) .............................................................................................. 12 CSP Titles and Training (RQs 1b and 1c) ................................................................................. 13 Survey Descriptives................................................................................................................... 14 Perceived Demand for Services Among Student-Athletes (RQ 2a) ......................................... 15 Cross-Tabulations for Demand .............................................................................................. 15 Demand Cross-Tab: CSP. .................................................................................................. 16 Demand Cross-Tab: Applied Sport Psychology. ............................................................... 17 Demand Cross-Tab: General Counseling. ......................................................................... 17 Demand Cross-Tab: Mandated Counseling. ...................................................................... 17 Demand Cross-Tab: Crisis Intervention. ........................................................................... 18 Perceived Demand for Sport Psychology Services When Not Offered (RQ 2b) ...................... 18 Perceived Availability of Services for Students/Student-Athletes (RQ 2c) .............................. 19 Cross-Tabulations for Availability ........................................................................................ 20 Availability Cross-Tab: CSP and Applied Sport Psychology............................................ 20 Availability Cross-Tab: General Counseling. .................................................................... 21 Availability Cross-tab: Psychiatry, Mandated Counseling, and Crisis Intervention. ........ 21 Practitioner Experiences at High and Low Service Availability (RQs 3b and 3c) ................... 22 Adding Qualitative Detail to Scaled Survey Items ................................................................ 24 Caseload and Client Risk ................................................................................................... 24 Self-Care ............................................................................................................................ 27 viii Emotional Support ............................................................................................................. 28 Professional Development ................................................................................................. 29 On-Call Hours .................................................................................................................... 29 Additional Practitioner Perspectives (RQs 3a and 3c) .............................................................. 30 Campus Administration ......................................................................................................... 30 Diversity and Inclusion .......................................................................................................... 32 Visibility to and Rapport With Student-Athletes .................................................................. 35 Confidentiality ....................................................................................................................... 37 Stigma .................................................................................................................................... 38 Peer Consultation for Work With Athletics .......................................................................... 39 Summary and Segue .................................................................................................................. 40 Discussion ..................................................................................................................................... 41 Objective 1: Identify and Describe the Population of Collegiate CSP Practitioners ................ 41 Website Review: Practical Implications ................................................................................ 42 Objective 2: Describe Practitioner Perspectives on Service Availability ................................. 43 Demand for Unavailable Sport Psychology Services ............................................................ 44 Demand for Other Clinical Services Among Student-Athletes. ............................................ 45 Mandated Services. ............................................................................................................ 45 Psychiatry Services. ........................................................................................................... 46 Crisis Intervention Services. .............................................................................................. 46 Objective 3: Explore Practitioner Experiences ......................................................................... 47 Persistent Need ...................................................................................................................... 47 Practitioner Voice and Other Feedback Loops ...................................................................... 48 Mental Health Promotion in Athletics ................................................................................... 49 Survey Data: Potential Limitations ........................................................................................... 50 Conclusions ................................................................................................................................... 51 References ..................................................................................................................................... 56 Appendix A: Tables and Figures .................................................................................................. 69 Table 1. Summary of sub-questions and planned analyses ....................................................... 69 Table 2. Sources that guided survey item development ............................................................ 70 Table 3. Sport psychology practitioner presence cross-tabulated by NCAA division level ..... 71 Table 4. Cross-tabulation of demand for mental health services by division level and proportion of clinical hours with student-athletes ..................................................................... 72 ix Table 5. Cross-tabulation of perceived mental health service availability for students/student athletes by division level and proportion of clinical hours with student-athletes ..................... 73 Table 6. Independent sample t-tests comparing experiential statements across low and high perceived service availability groups ........................................................................................ 74 Table 7. Themes, sub-themes, and initial codes from inductive thematic analysis .................. 75 Figure 1. Frequencies of perceived demand for services among student-athletes .................... 81 Figure 2. Frequencies of perceived availability of services ...................................................... 82 Appendix B: Text Version of Qualtrics Survey ............................................................................ 83 Appendix C: Pre-Proposal Reflections and Philosophical Assumptions ...................................... 88 Appendix D: IRB Approval Letter ............................................................................................... 94 Appendix E: Extended Results ..................................................................................................... 96 Appendix F: Extended Review of Literature. ............................................................................. 150 CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 1 Introduction At present, most institutions do not offer specialized services for the mental health and performance-related needs of student-athletes (Kornspan & Duve, 2006; Hayden et al., 2013; Connole et al., 2014; Sudano & Miles, 2017). Developing specialized services for athletics may not be practical or feasible when counseling and psychological services (CAPS) staff are already struggling to meet the needs of their campus communities. Many college counseling centers have not received additional resources during times of increased service utilization (Hodges, 2001; Eells et al., 2005), and are left to improvise amid heavy demands and unsustainable conditions (Much et al., 2010; Watkins et al., 2012; Schwartz, 2013). Kafka (2019) encapsulated these problematic conditions in his article title, Overburdened mental-health counselors look after students. But who looks after the counselors? The support needs of campus mental health practitioners may be in need of increased attention, and when a lone embedded practitioner is the only one providing for the mental health needs of an athletics department, the question of support needs could be equally significant. At present, collegiate student-athletes appear to be utilizing mental health services more frequently than ever. Some documented rates of service use have included < 2% by Pierce (1969), 9% by Bergandi and Wittig (1984), an estimated 15% by Bennett (2007), and an estimated 25% by Johnson (2017). Whether spurring this trend or following from it, a growing body of research has explored student-athletes’ preferences for sport psychology service providers (e.g., Lubker et al., 2012) and mental health services (e.g., López & Levy, 2013), suggestions for increasing mental healthcare accessibility (NCAA, 2017), and satisfaction with service availability (Way et al., 2020). Researchers have also explored the availability of mental health services for student-athletes from the viewpoints of athletic trainers (Sudano & Miles, CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 2 2017) and administrators (Connole et al., 2014; Moore, 2016), as well as through analysis of counseling center and athletic department websites (Hayden et al., 2013). However, the perspectives of mental health practitioners who work with student-athletes have been largely absent from this growing body of research (Schlimmer & Chin, 2018; Moreland et al., 2018). The vantage point of these practitioners could be an untapped source of information regarding the mental health needs of student-athletes and the extent to which these needs are currently being met. Furthermore, researchers have been working to identify strategies for supporting student-athletes through their unique experiences and stressors, but a question remains as to whether CAPS and clinical sport psychology (CSP) providers are feeling in need of support themselves, and if so, in what ways. Before proposing steps to gather more information about practitioner perspectives, it is necessary to first quantify the current landscape of service availability for student-athletes, the level of demand for those services, and the experiences of service providers (see also Appendix F). Service Availability and Providers NCAA Bylaws 16.4.2 and 16.4.2.1 recently required Division I Power 5 conference (hereafter abbreviated P5) institutions and all other Division I, II, and III (DI, DII, DIII) institutions to ensure that their student-athletes have access to mental healthcare (Brutlag Hosick, 2019; see also https://web3.ncaa.org/lsdbi/). At this important juncture it is difficult to pinpoint the number and type of practitioners who provide mental health services to student-athletes (Gross et al., 2020); and in order to assess any growth in service availability that follows from these legislative changes, this would be an important time to collect baseline data about practitioner presence across NCAA institutions. Before looking ahead to the future of service availability, however, it may be prudent to first look back. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 3 In an early study of service availability, Bergandi and Wittig (1984) polled 53 college counseling center directors and found that 49% (n = 26) offered some form of mental health services specifically for student-athletes. Their data did not detail what these services entailed. Since that time, surveys of service availability have sometimes lumped clinical and applied sport psychology services into one measured construct. Researchers have identified the presence of clinical and/or applied services at 23.4% (Kornspan & Duve, 2006) to 39.7% (Connole et al., 2014) of institutions across divisional levels. Sport psychology services defined as clinical in nature have been identified in 20.5% of DI athletic training rooms (Sudano & Miles, 2017) and 32.5% of DI FBS institution counseling centers (Hayden et al., 2013). Perceived service availability has typically been higher at DI institutions relative to DII and III institutions (Kornspan & Duve, 2006; Connole et al., 2014; cf. Moore, 2016). When embedded services are made available, they tend to be staffed by one practitioner (e.g., LeViness et al., 2018) who could be working to serve a department with as many as 800 to 1,000 student-athletes (Flowers, 2007; Carr, 2007). Demand for Services One third of counseling center directors recently indicated that they had waitlists in effect for services at their clinic, with an average of 51 students waiting for services (range = 2 – 300; LeViness et al., 2018). Researchers examining the demand for mental health services specifically among student-athletes have done so “with considerable variability” as to what this entails (Moreland et al., 2018, p. 64), and few have used clinical records to gauge rates of service use among this population. In what may be the most extensive records of student-athletes’ mental health service use, the Penn State Center for Collegiate Mental Health (CCMH) studies have found that student-athletes comprised about 7% of campus counseling center clients over the last CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 4 eight years (CCMH, 2012-2019). However, with the full and demanding schedules that student athletes frequently balance, they may not be available to utilize the campus counseling center during its normal operating hours (Etzel et al., 2006). To provide for the unique needs of student athletes, and when resources permit, some institutions create the specialized or embedded services outlined above. In these instances, the demand for CSP services can steadily increase in the years after these services are first offered (McDuff et al., 2005; Bennett, 2007; Flowers, 2007). In Chamberlain’s (2007) experience, rates of service use had only plateaued because all available appointment times were filled. Offering an indirect clue as to what this might be like for a practitioner, a student-athlete shared with Way and colleagues (2020) that, There [aren’t] enough psychological services for athletes. I regularly go to [our sport psychologist] and most of the time she is booked two weeks in advance and she looks exhausted by the time in the day when I can see her because I’ve seen her schedule and the athletic department is running her thin. (p. 315) Practitioner Perspectives and Experiences To date there has only been one study to examine practitioners’ experiences of providing mental health services to student-athletes (Schlimmer & Chin, 2018). Apart from this, insight to the experiences of CSP practitioners must be gleaned from a few firsthand accounts (JCSP vol. 1, iss. 3; McDuff et al., 2005; Johnson, 2017), all of which have come from the DI context. This has neglected the experiences of mental health practitioners who work with DII and DIII student athletes (cf. Rancourt et al., 2020), and the experiences of CAPS staff who support student athletes at institutions that do not have access to CSP services (cf. Petrie et al., 1995). Consequently, including the perspectives of practitioners from all levels of athletic competition presents an important gap in the research. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 5 In the absence of broader data, experiential accounts from CSP personnel show some interesting similarities and differences to those of other practitioners in the milieu of college counseling. For example, CAPS and CSP personnel can both experience tension and role ambiguity with administrators (Chamberlain, 2007; Hack, 2007; Jodoin & Ayers, 2013; Johnson, 2017). Likewise, just as there can be tugs on the confidentiality of student-athletes’ mental health service use (Bennett, 2007; Chamberlain, 2007; Etzel & Watson II, 2007; Hack, 2007; Loughran et al., 2014; Schlimmer & Chin, 2018), maintaining client confidentiality can also be a challenge for CAPS staff working in small campus counseling centers (Vespia, 2007) or in the context of increasingly intrusive campus administrators (Grayson & Meilman, 2013). Confidentiality is especially important in light of student risk factors, campus tragedies, or high-profile cases. Clinical administrators have remarked on the increasing visibility and scrutiny of CAPS on college campuses, particularly with students who may be a danger to themselves or others (Watkins et al., 2012; Grayson & Meilman, 2013). Speaking to an additional form of risk that can present for mental health practitioners who work in or with collegiate athletics, Zillmer and Gigli (2007) shared that student-athlete conduct (e.g., hazing, sexual misconduct, substance abuse) “can become a major problem not only for the athletic department but also for the university’s image as a whole” (p. 220). As a result, they said, “sport psychologists may have a special entrée within this context of reducing the risk of negative publicity, while adding important life skills lessons to student-athletes” (p. 220; see also Bennett, 2007; Flowers, 2007). It could be helpful to have broader data about practitioners’ experiences of risk and risk management because of the stress it can impose. Recent research has focused on sport psychology practitioners’ professional quality of life, coping strategies, and self-care (e.g., CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 6 Cropley et al., 2016; Quartiroli et al., 2019a, 2019b), but less so on topics of practitioner mental health and use of personal counseling. Some twenty years ago, Andersen and colleagues (2000) suggested counseling and therapy for the personal/professional development of sport psychology practitioners as well as for the prevention of impairment. This suggestion could still carry some weight today, and for the broader population of collegiate mental health staff as well (Kafka, 2019). Despite the personal and professional benefits, little is known about the extent to which sport psychology practitioners engage in their own personal therapy. In sum, CAPS staff face a variety of challenges, as do those working within the unique environment of athletics. Amid myriad stressors there are also many sources of enrichment, meaning, and enjoyment for CAPS and CSP practitioners (Kadambi et al., 2010; Chamberlain, 2007; Flowers, 2007; Wolanin, 2007; Zillmer & Gigli, 2007). During an era in which more and more attention is being drawn to the mental health needs of student-athletes, and the availability of campus mental health services more broadly, the field could benefit from more inclusive data about the views and experiences of practitioners who work in this context. Purpose Three objectives (see Table 1) contribute to the overarching purpose of this study, which was to explore practitioner perspectives on the provision of mental health services to student athletes in the broader context of collegiate mental health. At a historically relevant time point, the field lacks a broad picture to illustrate who is providing mental health services to student athletes (Gross et al., 2020), and this is especially true in the context of DII and III athletics. Therefore, the first objective of this study was to expand upon the work of Hayden and colleagues (2013) to identify and describe the population of CSP personnel from all NCAA member institution websites. Within this objective, attention was devoted to the credentials and CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 7 clinical titles held by these practitioners, as these can be pertinent factors for student-athletes’ attitudes towards and intentions to engage in help-seeking behavior (Maniar et al., 2001; Lubker et al., 2012; López & Levy, 2013; Woolway & Harwood, 2015; Way et al., 2020). The second objective of this study was to describe practitioner perceptions of the demand for mental health services among student-athletes at their institution, and the relative availability of those services. This objective was rooted in the observation that researchers have rarely examined demand and availability as distinct but related constructs (cf. Connole et al., 2014), and have under-utilized the firsthand experiences of service providers (Moreland et al., 2018; cf. Bergandi & Wittig, 1984; Schlimmer & Chin, 2018). Further, although scholars have attended to where CSP and other mental health services are available, few have detailed where they are not available and the need that might exist in their absence (cf. Rancourt et al., 2020). A sub objective aims to address these omissions in extant research. Finally, in their provision of mental health services to student-athletes, some practitioners have commented on experiences of personal/professional support, relationships with athletics staff/administration, and other logistical aspects of service delivery (e.g., JCSP vol. 1, iss. 3; Schlimmer & Chin, 2018). Similar experiences have also been voiced by practitioners serving the mental health needs of campus communities more broadly (e.g., Vespia, 2007; Jodoin & Ayers, 2013). As such, the third objective of this study was to explore the pertinence of these topics for a broader sample of practitioners (see Table 2). In light of rising demands for clinical services, some have recently questioned the support that collegiate mental health staff are receiving (e.g., Kafka, 2019). From this observation, sub-objectives included exploring practitioner experiences at high versus low levels of service availability and what practitioners see as current needs to facilitate their work. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 8 Methods Website Review Procedures Building upon Hayden and colleagues (2013), CAPS and athletics websites were reviewed for all NCAA member institutions. As listed in April, 2020 (ncaa.org/directory/), this included 352 DI institutions (65 of which were sub-grouped as P5 conference institutions), 320 DII institutions, and 449 DIII institutions. Directories and sub-pages were analyzed for any sport psychology staff, as well as for any description of sport psychology or mental health services for student-athletes. The number of CAPS staff, CAPS trainees, CSP staff, CSP trainees, and applied staff/trainees were recorded in mutually exclusive categories. Educational degrees, licensures, and certifications were recorded for clinical/applied sport psychology personnel. Sport psychology staff/trainees were also coded as being listed on the CAPS website, the athletics website, or both. Email addresses were recorded for survey distribution. CSP staff/trainees were operationally defined as practitioners who held or were pursuing a mental health degree and had a clinical title that alluded to a role with student-athletes (clinicians listed on athletics websites were presumed to work with student-athletes in some capacity), were a member of the Association for Applied Sport Psychology (AASP) or a Certified Mental Performance Consultant (CMPC), listed a sport psychology degree or concentration (clinical or applied), or listed an interest in sport psychology or working with student-athletes in their online bio. Applied sport psychology practitioners were identified using the same criteria, but in the absence of a clinical degree or mental health credential. Survey Development The online survey for this project was developed using subjectivist epistemological assumptions (e.g., Romm, 2007; Lincoln et al., 2011; see Appendices B & C). Recognizing the CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 9 co-constructed nature of data that would be collected (Romm, 2013, 2014), the survey was written and re-written with an effort “to ‘think’ oneself into the perspective” of participants (Fielding, 1993, p. 157). In its final draft, the survey was conversational in tone, relatively concise, and transparent. The first section of the survey presented a series of statements based on experiences of campus mental health and sport psychology providers that have been documented in the academic literature (see Appendix B). Participants could agree/disagree with each statement based on their own experiences using a five-point Likert scale (“disagree,” “slightly disagree,” “slightly agree,” “agree,” and “can’t say from my experience”). The statements sought to gauge participants’ experiences in a general sense (e.g., “My caseload is too large,” “My institution promotes diversity and inclusion”) and their experiences of providing services to student-athletes more specifically (e.g., “I could build rapport with student-athletes during my work with them”). The second section of the survey asked about the demand for various mental health services specifically among student-athletes at their institution. Participants were asked to rate the perceived demand prior to COVID-19 regardless of whether or not the services were offered (i.e., there could have been demand for a service that was not offered). A brief note was included to define non-clinical applied sport psychology services. Response options were “no demand,” “low,” “moderate,” “high,” and “not sure”. Listed services included mental health counseling offered by a sport psychology specialist, mental health counseling offered by other clinical staff, applied sport psychology, mandated counseling (substance abuse/conduct), psychiatry, and crisis intervention. These services were selected for inclusion based on best practice recommendations (NCAA, 2016), emphases that campus clinics have placed on crisis intervention services (Kitzrow, 2009; Gallagher, 2012), the high demand for psychiatric services at present (LeViness CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 10 et al., 2018), and the service delivery experiences of sport psychology practitioners working in collegiate athletics (e.g., JCSP vol. 1, iss. 3; Johnson, 2017). A single item was used to assess how practitioners thought COVID-19 impacted the demand for services among student-athletes. Next, participants rated the perceived availability of each service for students and/or student-athletes. Participants were asked to respond with the perceived availability prior to COVID-19 and while considering both on campus resources and off campus referral networks (King Lyn, 2017a). A six-point scale was used for these items: “Availability exceeded demand,” “Availability comfortably satisfied demand,” “Demand was met but stretched available resources,” “Demand exceeded available resources,” “Service was not offered,” and “Not sure.” A single item was used to assess how practitioners thought COVID-19 impacted the availability of services for students and/or student-athletes. In the final portions of the survey, participants were invited to comment on what they were currently needing as a person/practitioner to facilitate their work. Demographic information was collected, and, consistent with the subjectivist epistemological approach to survey development (Romm, 2013), participants were invited to share their feedback or any points of clarification. Survey Recruitment Following IRB approval (Appendix D), all sport psychology providers (clinical and applied) identified during the website review were invited to participate in the survey. At institutions where clinical sport psychology services were not offered or could not be discerned, up to three mental health staff were invited to participate. In the event that CSP services were offered exclusively through athletics, up to three CAPS staff from the institution were also invited to participate. When CAPS had more than three practitioners, recruitment prioritized staff members other than directors. All recruitment correspondence took place via email. After an CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 11 initial invitation was sent in late August, reminders were sent at 15, 28, and 42 days thereafter until the survey closed in mid-October. To incentivize participation, practitioners were invited to enter a random drawing for one of six Mastercard gift cards (one valued at $100, five valued at $20 each) and/or opt-in to receive a synopsis of results from the study. Data Analysis Research questions and analyses are summarized in Table 1. For the first objective of this study, frequencies of sport psychology personnel identified during the website review were reported in a cross-tabulated format by division level (P5, DI, DII, DIII). Clinical titles and credentials listed for CSP staff/trainees were descriptively summarized. For the second objective, the perceived demand for and availability of each service was cross-tabulated by NCAA division level as well as by the proportion of clinical hours that practitioners reported spending with student-athletes/athletics. Using the sub-sample of participants who indicated that sport psychology services were not offered at their institutions, perceived demand for those services was cross-tabulated by division level. For the final objective, data for each experiential statement were descriptively analyzed. To examine potential differences in practitioner experiences at higher and lower levels of perceived service availability, two sub-samples were created based on the number of services that practitioners indicated were stretched or exceeded by demand at their institutions. Independent-sample t-tests were used to compare high and low availability groups on their experiences of satisfaction with professional development, having reasonable on call expectations, having caseloads that were too large, engaging in enough self-care, feeling overstretched by client risk factors, and wanting more emotional support for their work as practitioners. As the independent variable of high versus low service availability was run on six dependent variables, a Bonferroni correction set alpha at .008. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 12 Qualitative data was analyzed using inductive thematic analysis (Braun & Clarke, 2006). This was an iterative and recursive process that involved building familiarity with the data set as a whole, coding distinct meaning units within participant responses, and identifying themes across participants’ responses (Braun & Clarke, 2006). Brief notes and memos were recorded to serve as an audit trail during analysis (e.g., Tracy, 2010). Coding primarily took place at a semantic level, and memos documented inferences made about latent content that moved beyond the surface of participant responses. In striving to provide a credible and trustworthy account of the data, an effort was made to provide a thick and transparent report of participants’ experiences (Tracy, 2010). Appendix E details qualitative data analysis in a theme-by-theme progression. However, in the results section that follows, qualitative data was integrated to add detail and specificity to the broader generality of quantitative data across this sample of participants. Results Practitioner Frequencies (RQ 1a) Using the operational definitions outlined in the methods section, clinical sport psychology (CSP) staff were identified at 271 (24.2%) institutions, CSP trainees were identified at 64 (5.7%) institutions, and applied sport psychology staff/trainees (with non-clinical sport/performance psychology backgrounds) were identified at 49 (4.4%) institutions. Only 20 institutions (1.8%) listed both CSP and applied practitioners. In total, the website review identified 507 CSP staff, 85 CSP trainees, and 68 applied staff/trainees. Across divisions, the number of schools with any, one, two, three, four, or five or more practitioners in each category are presented in Table 3. All (100%) P5 institutions had at least one CSP staff member listed, relative to 42% of DI institutions, 12% of DII institutions, and 11% of DIII institutions (see Table 3). Whereas no DIII institutions had more than two CSP staff, over half (55.4%) of P5 CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 13 institutions had at least three. On a smaller scale, the listing of CSP trainees followed a similar trend as CSP staff when compared across divisions. Applied practitioners were listed at 1 – 2% of DII and DIII institutions and about 10% of DI and P5 institutions. CSP Titles and Training (RQs 1b and 1c) Of all 592 CSP staff/trainees identified during the website review, 40% had clinical titles that referenced sport psychology or work with athletics (see extended results for additional detail on how titles were coded). Cross-tabulated by division, greater proportions of CSP staff/trainees had clinical titles that referenced sport psychology or athletics at P5 (48.2%) and DI (40.8%) institutions relative to DII (29.4%) and DIII (20.7%) institutions. Over half (56.6%) of CSP practitioners identified during the website review held a doctoral degree, 23.7% listed a master’s degree as their highest level of education, and 3.4% held degrees in medicine (i.e., MD/DO). Trainees included both doctoral and master’s students (11.0% and 3.2% of all CSP practitioners, respectively). Terminal or current degrees were not listed for 2.2% of CSP practitioners. When biographical information was available online, CSP staff/trainees listed their highest degrees in a variety of disciplines, the most common of which were clinical (30.9%) and counseling psychology (22.5%), social work (10.1%) and counseling/clinical mental health (8.9%). CSP practitioners identified during the website review were cross-referenced in CMPC and AASP membership listings. Of all CSP staff/trainees, 13.7% held CMPC status and another 7.4% were current AASP members who were not certified. Across divisions, there were similar proportions of CSP practitioners with CMPC status at P5 (17.0%), DI (14.5%), and DII (13.7%) institutions compared to DIII institutions (2.4%). CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 14 Survey Descriptives From recruitment (n = 2,819), 495 completed surveys were returned, along with another 20 partially completed surveys (> 30% complete) for a total response rate of 18.3%. Of all 515 respondents, 0.4% preferred to self-describe their gender identity, 1.0% identified as nonbinary, 27.6% identified as men, and 66.2% identified as women. Participants’ racial/ethnic backgrounds included Native American (0.2%), Native Hawaiian or Pacific Islander (0.2%), Asian American/Asian (2.7%), Hispanic or Latino/Latina/Latinx (3.7%), biracial, multiracial, or multiethnic backgrounds (4.3%), Black or African American (12.6%), and White (70.3%). Respondents included senior staff members (31.7%), clinical staff members (52.9%), and trainees (4.0%). Another 11.3% of survey respondents described their role using other descriptors. On average, participants worked 36.5 hours/week (range = 3 – 70) and represented P5 (n = 74, 15.3%), DI (n = 146, 30.2%), DII (n = 96, 19.9%), and DIII institutions (n = 167, 34.6%). About half of the sample reported that they were affiliated with athletics as either trainees/employees of the institution (n = 210, 42.7%) or external consultants (n = 44, 8.9%). During a typical semester, participants spent about 30% of their clinical hours with student athletes (M = 29.61, Range = 0 – 100). The median proportion of clinical hours with student athletes was 20% (IQR = 10 – 40). When asked about specialties or areas of expertise (open ended), 350 participants responded. The most common specialties listed included trauma (n = 98, 28.0%), sport/performance psychology and/or student-athletes (n = 84, 24.0%), anxiety or mood disorders (n = 76, 21.7%), specific modalities or theoretical approaches (n = 72, 20.6%), disordered eating or body image (n = 47, 13.4%), and alcohol or other drug counseling (n = 43, 12.3%). Eighteen respondents (5.1%) identified with a specialty in crisis counseling/suicidality and five (1.4%) identified with a specialty in psychiatry. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 15 Perceived Demand for Services Among Student-Athletes (RQ 2a) Participants were asked about the perceived demand for various mental health services among student-athletes prior to the COVID-19 pandemic. Respondents saw general mental health counseling as the most in-demand service among student-athletes (see Figure 1), and less than 1% of all respondents saw no demand for this service. Perceived demand was higher for CSP than for applied sport psychology, but practitioners appeared to be less certain about the demand for these services. One quarter indicated that they were unsure about the demand for CSP and one third felt unsure about the demand for applied services. Similar proportions of practitioners saw moderate-to-high demand for CSP (48.3%) and psychiatry (46.7%) services among student-athletes. Likewise, similar proportions of practitioners saw moderate-to-high demand for applied sport psychology (36.1%) and mandated counseling (substance or conduct related, 35.7%). Of note, 53.3% of respondents perceived a moderate to high demand for crisis intervention services among student-athletes. Participants were also asked about how they thought the COVID-19 pandemic impacted the overall demand for mental health services among student-athletes. Relative to perceived demand pre-pandemic, 35.3% of participants saw increased demand, 12.0% saw decreased demand, 18.0% saw no change, and 34.7% were unsure. Cross-Tabulations for Demand Perceived demand frequencies (i.e., the count of high, moderate, low, no demand, and not sure responses) were cross-tabulated by NCAA division and by the proportion of clinical hours that participants reported spending with student-athletes. For a more parsimonious display of cross-tabulations, P5 and DI status were combined into one categorical grouping, as were DII and DIII status. Three categories were developed for the proportion of clinical hours that CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 16 practitioners spent with student-athletes/athletics based on the quartiles of data for the variable: practitioners who spent the least amount of time with student-athletes (defined as less than 10% of clinical hours with student-athletes, corresponding with the first quartile), practitioners who spent a moderate amount of time with student-athletes (defined as 10% to 40% of clinical hours with student-athletes, corresponding with the IQR), and practitioners who spent the largest amount of time with student-athletes (defined as at least 41% of clinical hours with student athletes, corresponding with the fourth quartile). Demand Cross-Tab: CSP. Within the P5/DI grouping, the proportion of practitioners who saw a high demand for CSP services increased steadily as they spent more of their time with student-athletes (see dark gray highlighted cells, Table 4). Among participants who spent the least amount of time with student-athletes, 17.0% saw high demand for CSP services as compared to 34.8% of practitioners who spent a moderate amount of time with student-athletes, and 48.6% of practitioners who spent the most time with student-athletes. This increase was far less drastic in the DII/DIII grouping, and a lower proportion of practitioners saw high demand for CSP services (see light gray highlighted cells, Table 4). The proportion of P5/DI practitioners who were unsure about the demand for CSP services decreased in a relatively linear fashion moving from low to moderate to large amounts of time with student-athletes (see dark gray cells). On the contrary, the proportion of DII/DIII practitioners who were unsure about demand increased slightly among those who spent more time with student-athletes (see light gray cells). Finally, compared to the overall proportion for the sample (see purple cell), there was relatively little variation in the proportions of practitioners who saw moderate demand for CSP services across divisional groupings and time spent with student-athletes (lighter purple cells). CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 17 Demand Cross-Tab: Applied Sport Psychology. Overall, a smaller proportion of practitioners saw high demand for applied sport psychology services, but demand was heightened in the P5/DI context relative to the DII/DIII context (see dark blue highlighted cells relative to light blue highlighted cells, Table 4). For instance, of participants who spent the least amount of time with student-athletes, 27.7% saw moderate-to-high demand in the P5/DI grouping relative to 18.5% in the DII/DIII grouping. Among those who spent the most time with student-athletes, 79.2% saw moderate-to-high demand in the P5/DI grouping relative to 31.6% in the DII/DIII grouping. Across divisional groupings and the amount of time spent with student athletes, shifts in the proportions of practitioners who were unsure about the demand for applied services followed a similar pattern as for CSP services (see dark blue cells relative to light blue cells). Demand Cross-Tab: General Counseling. The proportions of practitioners who saw a high demand for general counseling services among student-athletes were relatively similar when comparing divisional groupings and appeared to increase as practitioners spent more of their clinical hours with student-athletes (see yellow relative to green relative to red highlighted cells, Table 4). Of those who spent the least time with student-athletes, high demand for general counseling was reported by 25.5% of P5/DI participants and 29.6% of DII/DIII participants. This increased to 41.7% of P5/DI participants and 47.4% of DII/DIII participants who spent the most time with student-athletes. Demand Cross-Tab: Mandated Counseling. Within the DII/DIII grouping, the proportion of practitioners who saw moderate-to-high demand for mandated counseling increased steadily as they spent more of their time with student-athletes (see dark red highlighted cells, Table 4). Moderate-to-high demand for mandated counseling was reported by 25.9% of CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 18 DII/DIII practitioners who spent the least time with student-athletes, 34.9% of DII/DIII practitioners who spent a moderate amount of time with student-athletes, and 44.7% of DII/DIII practitioners who spent the most time with student-athletes. There was a different pattern of responses in the P5/DI grouping. Specifically, the proportion of practitioners who saw moderate to-high demand for mandated counseling was lowest among those who spent the most time with student-athletes (see light red cells, Table 4). Demand Cross-Tab: Crisis Intervention. As a final note, among practitioners who spent the most time with student-athletes, a greater proportion of those in the DII/DIII grouping (71.0%) saw moderate-to-high demand for crisis intervention services relative to those in the P5/DI grouping (45.8%; see dark orange relative to light orange highlighted cells, Table 4). Perceived Demand for Sport Psychology Services When Not Offered (RQ 2b) A total of 214 participants indicated that CSP services were not offered at their institution, about a third (32.2%) of whom saw moderate to high demand for those services. A slightly greater proportion (40.2%) saw no or low demand for CSP services, and another 27.6% felt unsure about demand. The demand for CSP services (again, when unavailable) was cross tabulated by division level. Nine participants from P5 institutions reported that CSP services were unavailable (recall that, per operational definitions used during the website review, all P5 institutions had at least one CSP practitioner), along with 48 DI participants, 53 DII participants, and 99 DIII participants (five who indicated that CSP services were unavailable did not report their institution’s division level). Of these respondents, 22.2% of practitioners from P5 institutions perceived moderate-to-high demand for CSP services, as did 43.8% from DI institutions, 32.1% from DII institutions, and 27.3% from DIII institutions. CAMPUS MENTAL HEALTH PRACTITIONER PERSPECTIVES 19 Of 133 participants who indicated that applied sport psychology services were not available at their institutions, the majority were either unsure about the demand fo