By Sports Medicine Concepts
About 21% of athletes, or 1 in 5, between 13 – 18yrs of age will experience a mental health crisis1. Mental health has always been a concern in athletics, but SMC has observed a recent and notable spike in requests for mental health crisis management strategies for inclusion in emergency action plans. Like all other aspects of an emergency action plan, a mental health crisis management plan must be outcome driven and evidence-based. Many of the mental health crisis management plans we have reviewed recently fail to meet basic outcome and evidence-based criteria even though there is ample peer-reviewed literature and expert opinion available to inform such a plan. An appropriate mental health crisis management plan must include more than the names and number of counselors and mental health clinics.
In this issue of the Sports Emergency Care Digest we offer the essential elements of a mental health crisis management plan, including assessment, de-escalation, and categorizing and response offered by the National Alliance on Mental Illness (NAMI) and the National Athletic Trainers’ Association (NATA).
Later in the month sports psychologist Kellie Peiper, University of Buffalo Assistant Athletics Director and Sports Psychology Consultant, will join us on Skull Sessions to expand the topic and offer even more insight. Be sure to subscribe to Sports Medicine Concepts on YouTube to be notified when this content becomes available.
Step 1: Assess The Situation
According to the National Alliance on Mental Illness (NAMI), if you are concerned that an athlete is in crisis, take immediate action to assess the situation so you can determine the most appropriate management1. Make sure to assess the immediacy of the situation to help determine where to start or who to call. To begin assessing the situation ask yourself the following questions:
- Is the person in danger of hurting themselves, others or property?
- Do you need emergency assistance?
- Do you have time to start with a phone call for guidance and support from a mental health professional?
Step 2: De-Escalation
During a mental health crisis it may be hard for the athlete to express their feelings. Remain calm, demonstrate empathy, and attempt to de-escalate and further assess and categorize the situation by using the following NAMI techniques1:
- Keep your voice calm
- Avoid overreacting
- Listen to the person
- Express support and concern
- Avoid continuous eye contact
- Ask how you can help
- Keep stimulation level low
- Move slowly
- Offer options instead of trying to take control
- Avoid touching the person unless you ask permission
- Be patient
- Gently announce actions before initiating them
- Give them space, don’t make them feel trapped
- Don’t make judgmental comments
- Don’t argue or try to reason with the person
Step 3: Categorize and Respond
Once you have had a chance to assess the situation, use the National Athletic Trainers’ Association (NATA) mental health guidelines to categorize the crisis and determine the appropriate response2.
Red Flag Emergency – Potential Violence
A “yes” answer to any of the following questions indicates an emergency requiring activation of your emergency action plan and a 911 call.
- Are you concerned the athlete may harm himself/herself?
- Are you concerned the athlete may harm others?
- Are you concerned about the athlete being harmed by someone else?
- Does the athlete have access to a weapon?
- Has the athlete made verbal threats?
- Is the athlete exhibiting unusual ideation/thought disturbance?
- Is there potential for danger/harm in the future?
- Remain calm.
- Call 911 and get help if the situation is potentially violent.
- Keep yourself and others safe.
- Get help if the situation is volatile, but do not leave the athlete alone.
- Keep others at a safe distance.
- Continue attempts to de-escalate until EMS arrives.
- Alert school officials (counselor/nurse/administrator) and have them contact the athlete’s designated parent, guardian, or emergency contact.
Yellow Flag Emergency – Non-Violent
If the athletes responds “no” to the above questions and violence is not a concern, take the athlete to a quiet, secure, and safe place; and ask the following questions:
- Can you tell me what is troubling you?
- Are you thinking of hurting yourself?
- Is someone hurting you?
- Have you thought about suicide? (*Talking about suicide will NOT give the person the idea – this is a safe and necessary question to ask)
- If they are expressing suicidal ideation:
- Determine if he/she has formulated a plan
- Emphasize ensuring the athlete’s safety while being aware of your own.
- Do NOT leave the athlete alone.
- If they are expressing suicidal ideation:
- Remain calm and show your genuine concern.
- Listen to the athlete – let them be heard. Silent moments are ok! Do not judge the athlete.
- Help the athlete understand that he/she is not alone and others have been through this too.
- Alert school officials (counselor/nurse/administrator) & have them contact the athlete’s parent(s)/guardian(s)/emergency contact.
- Document and communicate your concerns and refer to the school counselor.
- *With suicidal thoughts, the athlete should seek help immediately*
Green Flag Non-Emergency – Anxiety/Depression
If the athlete responses “no” to all of the above questions and there is no threat of violence or suicidal ideation, take the athlete to a quiet place where you can talk to them. Some signs and symptoms to ask the athlete about are:
- Sad, hopeless, empty
- Anxious, apprehensive
- Worrying too much, feeling powerless, indecisive
- Restless, Irritable, having a sense of impending doom, danger, or panic
- Document and communicate your concerns and refer to the school counselor. If not available immediately (after hours), contact the athlete’s designated parent, guardian, or emergency contact.
Don’t forget to Subscribe to Sports Medicine Concepts on YouTube to be notified of the release of our Skull Sessions podcast with Kellie Peiper, University of Buffalo Assistant Athletics Director and Sports Psychology Consultant when we will further unpack mental health crisis emergency action plans. Skull Sessions is available on our YouTube channel and wherever you download podcasts.