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International Journal of Sport and Exercise Psychology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rijs20
Pathways through acute athlete care during
training and major tournaments: a multi-national
conceptualised process
Robert J. Schinke, Kristoffer Henriksen, Brennan Petersen, Paul Wylleman,
Gangyan Si, Liwei Zhang, Sean McCann & Athanasios Papaioannou
To cite this article: Robert J. Schinke, Kristoffer Henriksen, Brennan Petersen, Paul Wylleman,
Gangyan Si, Liwei Zhang, Sean McCann & Athanasios Papaioannou (2021): Pathways through
acute athlete care during training and major tournaments: a multi-national conceptualised process,
International Journal of Sport and Exercise Psychology, DOI: 10.1080/1612197X.2021.1892940
To link to this article: https://doi.org/10.1080/1612197X.2021.1892940
Published online: 03 Mar 2021.
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Pathways through acute athlete care during training and
major tournaments: a multi-national conceptualised process
Robert J. Schinke
a
, Kristoffer Henriksen
b
, Brennan Petersen
a
, Paul Wylleman
c,d
,
Gangyan Si
e
, Liwei Zhang
f
, Sean McCann
g
and Athanasios Papaioannou
h
a
School of Human Kinetics, Laurentian University, Sudbury, Canada;
b
Institute of Sport Science and Clinical
Biomechanics, University of Southern Denmark, and Team Denmark, Odense, Denmark;
c
Olympic
Committee of the Netherlands NOC*NSF / TeamNL;
d
Faculty of Physical Education and Physiotherapy/
Faculty of Psychology and Pedagogical Sciences, Vrije Universiteit Brussel;
e
Hong Kong Sport Institute,
People’s Republic of China;
f
Beijing Sport University, People’s Republic of China;
g
United States Olympic
Committee, Colorado Springs, CO, USA;
h
School of Physical Education and Nutrition, University of Thessaly,
Greece
ABSTRACT
There have been growing discussions across international societies
since 2017 focused on athlete wellness and athlete care. The
human condition of high-performance athletes requires life
balance, holistic personhood, and a functional athletic career with
the support of integrative resources from sport organisations.
During two successive International Society of Sport Psychology
Think Tanks on Athlete Mental Health in 2018 and 2019, an
international group of practitioners from Olympic and professional
sport organisations discussed topics spanning what athlete mental
health should look like, while problematising an overly narrow
focus on athlete mental ill-health (i.e., an unbalanced approach to
the topic), how it is being diagnosed, and how it is understood
through research. Discussions have advanced into structural
suggestions regarding standards of care for athletes in their daily
training environments and at major international tournament
events. Within this consensus statement, the authors focus our
discussions onto athlete acute care. Emphasis is placed on how an
integrated support team can work efficiently with high-
performance athletes when acute care is required in two general
contexts: (1) within the training environment, and (2) onsite at
major events. A model is proposed to spur discussions and better
standards to guide the athlete acute care process.
Recommendations are provided for sport psychology practitioners,
researchers, and high-performance sport organizations.
KEYWORDS
Acute care; athlete mental
health; high performance
sport; mental health literacy
During Autumn 2017, a sub-group of the International Society of Sport Psychology’s (ISSP)
recently appointed Managing Council launched a think tank programme focusing on
pressing issues and emerging topics. The concept of an ISSP International Think Tank
about athlete mental health followed earlier position stands on the topic, developed
by the International Society of Sport Psychology (Schinke et al., 2017) and furthered by
© 2021 International Society of Sport Psychology
CONTACT Robert J. Schinke rschinke@laurentian.ca School of Kinesiology and Health Sciences, Laurentian University,
935 Ramsey Lake Road, Sudbury, Ontario, Canada P3B-2C6
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY
https://doi.org/10.1080/1612197X.2021.1892940
the European Federation of Sport Psychologists (Moesch et al., 2018) and the International
Olympic Committee (Reardon et al., 2019). The series began in 2018 with practitioners
nominated by key continental sport psychology societies, including the Asian South
Pacific Association of Sport Psychology, the Association for Applied Sport Psychology,
the European Federation of Sport Psychology, and the International Society of Sport Psy-
chology. The participants met in Odense, Denmark, hosted locally by Team Denmark and
the University of Southern Denmark for two days. The reasoning behind the meeting was
that, in the field of sport psychology, there had yet to be an opportunity for identified
experts to converge in one location and share their experiences and views about
athlete mental health in high-performance sport. Furthermore, the group identified a
need within the international sport community, especially within high-performance
sport organisations, for improved mental health literacy practices (see Stirling & Kerr,
2009,2013). The primary (i.e., daily) points of contact for high-performance athletes
have often been personal coaches and teammates, both of whom have been found to
lack in mental health literacy (Bissett et al., 2020). The consequence of the aforementioned
gap has and, in many instances, still contributes to social (i.e., lack of social and emotional
support in time of need) and structural (i.e., lack of access forethought, leading to efficient
access to care resources) stigma surrounding athlete mental ill-health (Rice et al., 2016).
These limitations further delay response rates to treatment when athletes need acute
care and follow-up support (Reardon et al., 2019).
The Think Tank members produced a consensus statement (see Henriksen et al., 2020),
in which they offered six recommendations for how to reinforce and augment athlete
mental health. The group agreed that (1) mental health is a core component of a
culture of excellence; (2) mental health within sport contexts needs to be clearly
defined; (3) the assessment of athletes’mental health needs to expand in terms of meth-
odological approaches and lines of inquiry; (4) mental health is an essential resource for
athletes during and post-athletic career; (5) environments can nourish and malnourish
athletes’mental health; and, central to the current contribution and most pertinent to
this statement, (6) athletes’mental health is everybody’s business, but should be overseen
by one or a few key, well-informed organisational resources, termed mental health officers
(i.e., termed MHOs). The necessity for an MHO was further clarified in the subsequent 2019
ISSP Athlete Think Tank, where the topic was situated in relation to the Olympic quadren-
nium (Henriksen et al., 2020). Building upon athlete mental health being everybody’s
business, the authors identified current limitations in mental health literacy, starting
within training environments and continuing into the competition environment (i.e.,
Games phase). The implementation of athlete support could then be offered through
interdisciplinary mental health care teams (see Van Slingerland et al., 2019). Furthermore,
the aforementioned think tank also clarified that athlete mental health needs could vary
in terms of stressors and treatment, contingent on whether a performer was struggling
within a training or Olympic environment.
The oversight of athlete acute care is an essential process in high-performance sport
organisations. Acute care refers to the immediate support provided by one or a few desig-
nated service providers in response to an athlete’s mental health crisis, standing in con-
trast to longer-term support that fortifies the athlete’s resilience or coping skills. Access to
resources varies dependent on the time of season and specific year in relation to a major
event (McCann et al., 2020, apr. 1). When major events draw nearer, access to
2R. J. SCHINKE ET AL.
psychological and broader mental health resources tend to increase to help buffer the
athlete against increased performance demands and expectations. When major events
are completed and new training cycles begin, the disbursement of funds is often allocated
to essential services most pertinent at the time, such as athlete relocation in and out of
the organisation, equipment, new technology, and the launch into international travel
and tournament entry fees. Examining proposition six, the discussants began to consider
the role of organisational resources when acute care is needed. Staffin high-performance
organisations understand each athlete’s human condition is compromised in times of
acute stress, which compound life stressors with pre-existing athletic and personal con-
ditions (see also Henriksen et al., 2020; Reardon et al., 2019). When athletes are overloaded
with demands they can reach a point where they require critical care (Stambulova et al.,
2020). Proposition six was developed for when a treatment process is required.
What follows is the result of email and video-conferencing exchanges and the consen-
sual formulation of a conceptual diagram, developed to spur how a high standard of care
toward an athlete in crisis might be implemented systematically and efficiently, integrat-
ing the entire support team’s resources. The conceptual diagram was developed with the
specific intention of demonstrating how to provide acute care to individual athletes and
emphasising singular athlete cases. We recognise providing efficient care to organis-
ational staffmembers (e.g., coaches) in crisis, or teams facing a collective crisis (e.g., a
sexual abuse allegation) is also necessary, but beyond the scope of the developed
diagram. Our objectives with the acute athlete care model are to streamline and optimise
how an athlete moves through the acute stage, the alignment of longer-term support
resources, and the intended outcome of a more resilient individual and organisation.
We also recognise that the model and description that follow are developed in relation
to organisations with vast resources. Smaller organisations would potentially necessitate
providers adopting multiple roles, again, to streamline treatment plans. The forthcoming
model is sequenced chronologically into (1) interventions occurring in training environ-
ments, and (2) acute care transpiring at, and in the aftermath of, major sporting events.
The authorship team
The contributors were approached by the first author. Each author is an active mental per-
formance consultant (termed an MPC), who works weekly with Olympic athletes as part of
national sport organisations or as multisport appointments employed by a national
Olympic committee. The authors include mental performance consultants from clinical
psychology and sport science. The authors have infused a multinational series of perspec-
tives, synthesised into a shared vision of acute athlete care, found in Figure 1. The contri-
butors are from Canada, China, Denmark, the Netherlands, Greece, and the United States.
They have each worked with Olympic and Paralympic athletes in their respective
countries for a minimum of two decades.
The authors followed a systematic process in the conceptualisation of Figure 1. First,
the lead author worked closely with a PhD candidate and identified prospective resources,
based on the first author’s experiences as an integrated support team lead and mental
performance consultant. The components were then diagrammatically developed into
three phases. Phase one targets the people and steps associated with identifying con-
cerns and crises. Phase two applies to the mental health officer’s (termed MHOs)
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 3
Figure 1. Mental health services organisation plan. SPC = sport psychology consultant; MHO = mental health officer; MPC = mental performance consultant; HPD
= high-performance director; NSO = national sport organisation.
4R. J. SCHINKE ET AL.
assignment to a best fit service professional, delivery of immediate care services to the
athlete, and organisational updates and actions. Phase three highlights augmentations
in the athlete’s and the organisation’s long-term development. Once the three phases
were identified, stakeholders within and beyond the integrated support team (termed
ISTs) were placed inside the schematic. The contributing authors then engaged in discus-
sion over email about the sequence of phases, key stakeholders, and their placement.
Next, the authors were tasked with considering the ISSP Executive Report (McCann
et al., 2020, apr. 1) in lieu of their own national experiences. The report and experiences
mentioned above were weighed in relation to how acute athlete care and organisational
processes surrounding said care would apply in the contexts of (1) daily training environ-
ments, and (2) major tournament events. Next, the initial draft was developed and distrib-
uted to the authors. The group was asked to consider the model in terms of two athlete
environments (i.e., training environment, onsite at major tournaments), refining the tem-
poral process and the role of identified stakeholders during the three phases of treatment
until the model was believed to align with their respective nations’services or the aspira-
tion of their nations’services.
Acute care in the training environment
High-performance athletes spend much of their time developing and refining their tech-
nical, tactical, and psychological skills in training environments. Training environments
provide athletes with a staffof consistent, accessible human resources. Hence, acute
athlete care within the daily training environment includes resources that become
known to the high-performance athletes as they become established members.
Context demands and expectations. The contextual factors associated with daily training
vary dependent on where athletes reside in their yearly training plans and quadrennial
cycles. When athletes enter into high-performance sport organisations in the first year
of an Olympic cycle, an emphasis is placed on settlement into an unfamiliar training
environment, acclimation to training load, potential settlement in a new city and
region, potential financial strain associated with the heightened commitment level to
the sport organisation and full-time training, elevated performance demands, leaving
family and partners behind, and the forging of new relationships inside and beyond train-
ing environments. Though organisations often provide transitional support, the stressors
and demands experienced during transitions present a challenging period for athletes.
Once athletes are familiarised with their system and established within the organisation,
demands evolve to performance expectations at international tournaments and continu-
ously solidifying one’s spot in the sport organisation, while simultaneously developing
one’s technical, tactical, and psychological skills to a level commensurate with increasing
competition demands. Athletes then progress to qualification event preparation, where
all of the identified contextual requirements are tested at events that permit progress
onward to the major event or alter the athlete’s career trajectory, involving a commitment
to retain one’s position or a career transition into lower-level competitive sport or retire-
ment and a transition to the next career within our outside of sport (Schinke et al., 2015).
Phase one: Identifying the crisis. Athletes enter into crisis for various reasons, which span
pre-existing mental health conditions, poor life habits, personal relationships, training
demands, abuse by coaches or organisational staff, and in relation to the above,
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 5
unhealthy coping responses (e.g., substance misuse, rumination, further types of self-
harm). The entry into the acute care process focuses on immediate crisis identification.
Crisis identification can originate with the athlete, who then seeks assistance from a
coaching staffmember, the mental performance consultant, a teammate, or a supportive
person outside of the training environment (e.g., family members, partners). The crisis
may also be identified by someone other than the athlete, such as a consultant conduct-
ing a regular mental health screening or during regular interaction with athletes, a
member of the team’s staff, a teammate, or a non-team contact (e.g., a family member,
close friend). Following identification, the athlete in crisis is then to be brought into
contact with the MHO for triage.
The MHO is the organisation’s triaging designee based on a combination of mental
health literacy and the organisation’s diverse athlete needs, derived from their athlete
demographics and existing needs patterns. For example, within a sport environment
where athletes engaging in substance abuse is the prevailing concern the team physician
may be best armed to serve as MHO and provide acute interventions or access to treat-
ment facilities. Alternatively, in an environment where athletes often experience heigh-
tened anxiety, a clinical psychologist may be the most likely MHO to identify
symptoms of extreme anxiety or provide appropriate counselling. Within some national
contexts, the MHO is one person, and in other contexts, a small mental health care
team is developed. The assignment of responsibilities must be clear for athletes and
staff. Though the MHO may be the designee within a sport context, all skilled health pro-
fessionals remain important to the acute care model given the athlete’s connectivity with
several concurrent, integrated resources. A physician as MHO managing athletes’sub-
stance abuse issues may rely upon a mental performance consultant to help educate ath-
letes on alternative mental skills to cope with their stressors in relation to the training
environment. Working within their scope of practice, all service providers contribute in
an interdisciplinary way to acute athlete care and developing the strength of the organ-
isation, guided by the MHO. The MHO serves as the communication conduit, linking the
coaching staffand management with the acute service provider and the athlete under
care in phase two.
Phase one example. Having transitioned into a new training environment in preparation
for the upcoming Olympics in four years, an athlete struggled with leaving family and the
increased pressure during training sessions. While getting taped for practice by the team’s
physiotherapist, the athlete mentioned experiencing consistently decreased mood that
impacted the ability to train, furthering to a belief that the sport career was over in an
athlete with a singular identity, leading to thoughts of suicide. Recognising that the
athlete was entering a crisis, the physiotherapist facilitated a meeting between the
athlete and the team’s MPC, who in this case was the designated MHO, who had a
readily available list of crisis resources.
Phase two: Assignment, immediate treatment plan and updates. The MHO is tasked with
gathering information in a tight time frame from the athlete and collateral contacts, such
as personal coaches, teammates, and family members. The objective is to contextualise
the information and assign a best suited acute care professional. The acute care service
provider(s) in a training environment, tasked with the acute treatment plan, require
specific credentials (i.e., scope of practice) to assist the athlete. The service providers
within proximity to the training environment ideally include one or more physicians,
6R. J. SCHINKE ET AL.
dependent on the athlete’s needs, a psychiatrist who is either sport specialised or general,
dependent on the country where the athlete is being treated, a clinical psychologist when
psychology is required without immediate medication, or a social worker, when the acute
crisis pertains to familial abuse or domestic violence. The designated provider is then
tasked with athlete treatment and acute care, while reporting back to the MHO. As
enabled by their professional code of conduct, the flow of information from the MHO
to the acute service provider and then back to the MHO permits an integrative and itera-
tive athlete care model that can carry forward from an immediate crisis to long-term
athlete and organisational strengthening.
Once acute treatment has begun, the MHO becomes the immediate conduit to the
national sport organisation’s staffwith stake in the athlete’s psychological needs, particu-
larly the high-performance director (termed HPD), head coach, and MPC, denoted as the
core staffconsistently focused on athlete oversight in the training environment. The core
staffare then tasked with determining the flow of information to the team’s sport scien-
tists, followed by a specificflow of information to each provider relevant to the execution
of services. During acute treatment, service providers may recommend or require the
athlete to be removed from the training environment to address the crisis at hand
(e.g., drug induced psychosis, suicidal ideation). Other crises (e.g., domestic violence, a
family death) may not require athletes to take time away from the training environment.
One should consider whether removing the athlete from the training environment is
necessary, as taking away a significant part of the athlete’s daily structure may further
impact their ability to cope with the crisis. Simultaneous with acute treatment for the
athlete in crisis, the MHO must facilitate mental health literacy within the training environ-
ment to properly support athlete mental health and reduce stigma (Bapat et al., 2009).
Within the current model, mental health literacy is differentiated sequentially as
“immediate literacy and stigma reduction”during acute care (phase two) and “enhanced
learning”as part of long-term education and literacy (phase three). Within the immediate
literacy and stigma reduction phase, the MHO will collate the flow of information pro-
vided by service providers in collaboration with the MPC (should these two entities be
distinct) to develop a mental health literacy information session pertinent to the crisis
at hand. The mental health literacy information session would be developed drawing
upon what is known to the context in terms of the particular and parallel examples of
crisis, how and why these transpire, and what can be learned to augment the athletes’
daily functioning. Staffand athletes will be provided with relevant information to
ensure the athlete in crisis is effectively supported. Discussions can pertain to life
balance, communication, the psychological challenges associated with the athlete-
human condition, self-care, and the effective use of support resources to buffer the
athlete from these demands. Due to the different roles athletes and staffmembers play
in supporting an athlete in crisis, information would be shared with the athletes as one
group and the team’s staffand leadership separately, as the lived experience would be
managed differently dependent on one’s vantage and role in the organisation. Athletes
can learn more about the particular crisis their teammate is experiencing, granting
empathy and a sense of understanding, while team staffmembers may be informed of
ways to create a more supportive environment, drawing upon their professional inter-
actions. Despite differing mental health literacy information sessions, all discussions
should be framed to normalise mental health crises, reinforcing to athletes, staff, and
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 7
administration that a breadth of life challenges can overwhelm athletes, but that they will
be supported by teammates, staffand the organisation via openness, transparency, a
caring, structure, and consistency. The inverse response would be dysfunction,
whereby crises are not discussed, causing and exemplifying alienation, leading to athletes
being stigmatised when they are most compromised (Coyle et al., 2017).
Phase two example. Following their initial meeting, the team’s MHO contacted the
teammates and family of the athlete in crisis to discuss any recent indications of
mental ill-health. Having determined that it was not the first time the athlete had indi-
cated suicidal ideation the MHO recognised that aiding the athlete was beyond their
scope of practice and accessed a clinical psychologist that had worked with the team pre-
viously to provide acute athlete care. Serving as the team’s MPC, the MHO worked with
the high-performance director and coach to discuss improvements to the team’s tran-
sition processes for athletes. Concurrently, the MHO prepared separate information ses-
sions for athletes and team staffto discuss how transitions and increased pressure can
impact athletes’mental health, including leading to depression and suicidal ideations.
The prepared sessions focused on education, identifying symptoms, how to interact
with and support athletes, and normalising mental ill-health in athletes.
Phase three: Individual and organisational long-term education. Successfully managing
mental health crises can present long-term opportunities for athletes and organisations
to grow, providing the availability of support providers and approaches are managed sys-
tematically and efficiently. Inversely, when any structures or processes available to ath-
letes are unclear or inefficient, they leave the athletes and first responders with less
clear response pathways. The consequence could result in structural stigmatisation,
meaning an impression from the athletes’vantages that acute athlete care is not an
organisational priority, culminating in feelings and beliefs of abandonment and devalua-
tion. The journey through phases one and two should address each athlete’s immediate
circumstances, whilst considering the organisation’s role in the case. Once the immediacy
of the situation has passed, the athlete, teammates, and organisation can reflect on their
understanding and executional functioning of the managed crisis. When the acute
response to athlete treatment is successful, the athlete is no longer in crisis, teammates
have become aware of, or reacquainted with, the high level of care from their staff,
and the organisation has grown from the experience whilst testing their acute care pro-
cesses. If the athlete was removed from the training environment during treatment, the
athlete is reintegrated into the daily training environment and the training environment
resumes the responsibility of broader athlete career development. The athlete’s return to
play marks a transition into the final phase of athlete and organisational care, termed
long-term education.
Long-term education is a dynamic process, where educational content intended for
athletes, staff, and organisations is built to strengthen the system. While mental health
literacy is the obvious focus of the educational processes, we wish to stress that positive
sport environment literacy should also be part of the feedback loop. The long-term lit-
eracy phase of the model will integrate knowledge garnered from the resolved crisis
with general literacy education to increase the competency of athletes, staff, and organ-
isations. Content may focus on the normalcy of crises as part of being an elite performer,
daily hazards, symptoms, and early warning signs, but also on characteristics of environ-
ments the support or jeopardise athlete mental health. This could include explaining why
8R. J. SCHINKE ET AL.
mental health does not necessarily exclude possible mental ill-health challenges in ath-
letes who function well on a daily basis. When the immediate crisis has resulted from
the accumulation of poor self-care, an overloaded daily schedule, and impeded communi-
cation processes between athletes and staff(i.e., there is often more than one reason why
an athlete enters into the acute care process), regular presentations can be developed to
discuss the catalysts and how these could be navigated effectively. The MHO would be
best acquainted with the specific information of the acute case and the educational
topics ought then to be discussed with the MPC and they, if two different people, can col-
laboratively identify the educational stakeholder to develop and deliver educational
content to the aforementioned groups. The content will vary in how it might be used
by athletes as compared to coaches or sport science staff. The delivery of the content
might also be provided by a different presenter by audience, dependent on the nature
of the topic. The MPC might be closest to the athletes, due to regular exchanges
related to daily mental performance, whereas the integrated support team lead, who
might not be the MPC, would have a more regular connection with the sport scientists
as the person they report to. The topic matter should be presented by the best versed
staffmember. The first step in long-term education is the determination by the MHO
and MPC of who the educator will be and the subsequent oversight of content
development.
General presentations pertaining to athlete mental health literacy, accompanied by
follow-up presentations and group discussions focused on pressing topics chosen in
relation to the yearly training plan should be scheduled as progressive steps toward
organisational education. The feedback from athletes and daily operations staff(e.g.,
strength and conditioning coaches, athletic therapists, nutritionists) beyond inside knowl-
edge from coaches and MPCs will generate proactive initiatives that are responsive to ath-
letes’needs and status during each season and during specific times in a multi-season
cycle. Foreseeable yearly content can be mapped out in advance, while it is also the
MHO’s and MPC’s responsibility to act efficiently to emerging topics through regularly
scheduled discussions.
The discussions regarding education to this point have focused on standards of care
within an organisation, defined as athletes, staff, and administrators. Family members
ought also to be integrated within the educational process. They are identified for the
first time in this model in phase three, only because it represents long-term education,
and not because it reflects the culmination of an acute care process. Hence, family and
close friends are an essential outreach by each National Sport Organization (NSO)
throughout an athlete’s career. Depending on the athletes’age and status, they may
include members of the family of origin, partners, and close friends. When personal
support systems are well versed in high-performance athletes’demands, they can
provide parallel, congruent support throughout athletes’careers. Reciprocally, when per-
sonal support resources become part of the organisational system, they also become an
integral source of information regarding each athlete’s past and current status. Examples
of familial and personal support resource training might include how to support the
athlete during acclimation to the sport organisation, and how to support the athlete in
life balance before, during, and post-career.
Phase three example. Following resolution of the athlete’s crisis, the MHO prepared the
knowledge garnered through the acute care process for dissemination to athletes,
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 9
coaches, organisational members, and the athlete’s personal contacts (e.g., family
members, partners). The MHO then decided who the optimal educator was in the long-
term education process and scheduled sessions. The sessions reacquainted attendees
with the crisis managed, discussed specific antecedents of the team’s environment that
can lead to depression and suicidal ideations, described how the acute care process
unfolded to manage the crisis, and normalised the experiences of mental ill-health and
crises in athletes as part of an athletic career. Building from the information gained
during the acute care process, discussions within the long-term education sessions
shifted to developing changes to prevent future instances of crises, including environ-
mental improvements the team can make to alleviate or prevent mental ill-health
issues in the future. In this case, the team introduced a peer-mentoring process to aid ath-
letes transitioning into the training environment, low-pressure training sessions during
periods of transition, and familial education on the strains of a high-performance athletic
career.
Acute care at major tournaments
The context of major tournaments presents a second environment where athletes can
experience acute crises. The athletes might arrive at a major event in a compromised
state, or the crisis could emerge as a result of individual responses to onsite catalysts
or emerging personal crises unrelated to the sport environment. Several of the acute pro-
viders named in the training environment plan might be available onsite, depending on
the type of major tournament. World championships are often single sport events that
typically integrate support from a limited, sport specific onsite staff. Within multisport
events, athletes’services are more diverse, comprised of sport specific staffand national
games committee staff, available to complement the aforementioned. The available
resources vary further depending on the country and the sport. The acute process
would typically necessitate onsite support, followed by the preparation of further acute
resources, available once the athlete transits home to the training environment. Hence,
the onsite model would be a hybrid version of the previously discussed training environ-
ment application. Within this section, we consider how providers and the sequential pro-
cesses from Figure 1 fit, starting inside a competition environment and resolving post-
return.
Phase one: Identifying the crisis. Participating in a major competition can be an experi-
ence of intense stress. Pressure can come from high expectations, performance pressure,
a sudden severe injury before or during competition, media scrutiny, increased social
media engagement, conflicts within the team, lack of ability to sleep, and layered (i.e.,
multiple competing) complexities. The issues listed above may exacerbate existing
athlete mental health challenges and existing diagnoses or be the catalyst of new
acute concerns. Identifying athletes in need of assistance and coordinating support can
be challenging. The level of support will vary, as credentials may be scarce, coaches
and support staffmay themselves be under pressure, and the available support may be
more focused on performance than mental health. Further, athletes may be reluctant
to show weakness and ask for help, because they fear to lose their spot on the team
during a crucial career moment or because they might suppress mental ill-health in
pursuit of confidence and performance results. These challenges underscore the
10 R. J. SCHINKE ET AL.
importance of a clear support structure and protocol for coordination and provision of
mental health care.
As outlined in the model, the identification can originate with the athlete, a teammate,
a coach, a member of staffor even a family member or a friend. Once the concern is ident-
ified, the first point of contact will often be someone in the sport organisation’s support
staff, very often the MPC. During a tournament, a quick response is even more essential
than usual, and it is of utmost importance that a clear support structure and readily avail-
able lines of communication allow for an immediate contact with the MHO or an onsite
designee for triage, should the MHO not be in attendance, such as in the case of a primary
care physician.
Phase two: Assignment, immediate treatment plan and updates. In the calm and comfort
of their home training environment, most coaches and staffin high performance sport will
agree that athletes’mental health is always more important than their performances. At
an important tournament with added performance pressure, however, motives may
conflict and cloud judgements. There might be the struggle between meeting perform-
ance objectives during a summit event and foregoing a potentially contributive perform-
ance result to tend to immediate care needs. In some cases, an athlete must leave the
stressful sport environment and go home for acute treatment, to physically remove the
athlete from a performance environment to reduce anxiety and tend to care as the exclu-
sive focus. With other cases, an athlete can receive help onsite or online, where athletes
can be presented with a solid treatment plan that begins onsite in the midst of perform-
ance and with a clear course of action upon return to the training environment. Athletes,
coaches, and performance staffare not impartial in such questions. Ideally, therefore, a
qualified service provider with whom the athletes have established rapport and trust
should be designated MHO, be present at the tournament, and take the lead in making
care decisions and liaising on the treatment plan. The MHO serves as the communication
conduit, setting up links between the athlete and service providers to make sure all staff
have some degree of understanding for the acute care process and how to support the
athlete(s) in question. Discussions among athletes and staffshould normalise crises,
given the need for athletes under pressure to be supported by teammates and staff
with openness and compassion via established foundations in mental health literacy to
reduce stigma (Bapat et al., 2009).
Phase three: Individual and organisational long-term education. The onset of phase
three will not be at the tournament but rather upon return and successful reintegration
of the athlete in the sport environment. For this reason, phase three will not differ from
the one described above (previous section –phase three) related to acute care in the
training environment. The focus remains on normalising and reducing stigma through
providing education to improve mental health literacy among athletes and staff.
However, returning from the major event environment allows organisations the
unique opportunity to reflectively evaluate the onsite support setup and implemen-
tation, followed by implementing any relevant adjustments. Further, it is worth men-
tioning that after major tournaments, most notably the Olympic and Paralympic
Games, athletes may be at increased risk of mental health issues due to isolation and
a lack of purpose, meaning, and direction. Scholars have recognised the immediate
post-Olympics / major event as a meta-transition (see Schinke et al., 2015). The
increased vulnerability may unfortunately coincide with support staffbeing exhausted
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 11
and less attentive to athletes’needs (Henriksen et al., 2020). Importance must be placed
on the post-tournament protocols and ongoing support until athletes have transitioned
back to daily training or have shifted from a sport cycle meta-transition to a more elab-
orate post-athlete career.
Practice to research
The current model has been conceptualised based on processes the practitioners and
their organisations utilise in their respective environments and protocols. However, the
systematic implementation of a comprehensive acute mental health care plan for high-
performance athletes is a relatively recent approach to acute care. Currently, there is a
lack of feedback loops that are brought forth through systematic research. It is at each
organisation’s discretion whether to utilise qualitative (for in-depth, rich descriptions),
quantitative (to rate finite aspects of the model, leading to revision), or hybrid mixed
methods approaches. However, we propose that a vast array of systematic research
approaches must be gathered by a lead researcher tasked within or assigned to the
organisation. The intention is to iteratively refine each national and organisation
specific model of acute athlete care, integrating feedback from athletes and the various
participants identified in the model.
Summary points
We conclude this consensus statement with six summary points. The summary points cen-
tralise practical applications, but also extend to evidence based practices, and so, bridging
practitioners and researchers.
Point one: there are three phases of care
There are three phases to the acute care process. The sequential phases are: (1) crisis
identification, (2) developing an immediate treatment plan and relative mental health lit-
eracy update, and (3) the individual and organisational long-term educational plan. These
three phases provide a standard of care with immediacy and longevity.
Point two: triage to acute treatment must be efficient
The purpose of an acute athlete care model is to provide each sport organisation with
clear pathways to an efficient resolution from the immediacy of crisis to athletes’and
organisational growth. An effective and expedited triaging process is necessary and
necessitates either a direct report from the athlete or indirect report from the first
contact to the mental health officer. The MHO requires considerable mental health lit-
eracy to provide efficient assignment to a suitable service provider.
Point three: athletes in crisis benefit from a core mental health care team
Within the organisation’s integrated support team, a core sub-group should be in place
to develop education and literacy programmes, whilst concurrently supporting the
12 R. J. SCHINKE ET AL.
athletes, with guidance from the MHO. The core sub-group should, at very least, tie in
the head coach and MPC, as these designees have an existing history supporting the
athlete with the psychological requirements of their sport and their careers.
Point four: mental health literacy is an acute and sustained project
Mental health literacy ought to be considered in two steps. Acute literacy pertains to
what is learned by the organisation’s stakeholders, including its leadership, staff, and
athletes, in the short-term. The acute literacy process reduces social stigmatisation
among athletes and staff, culminating in a more comfortable and accepting return of
the athlete to the environment. Longer-term literacy pertains to organisational
enhancements, informed by the recent crisis, improving upon the organisation’s and
athletes’long-term functioning. Longer-term literacy should extend to at least one
immediate point person from the athlete’s personal support system (i.e., a family
member or partner).
Point five: A mental health officer or designee is necessary
A MHO is required as part of the daily operational plan of a high-performance sport
organisation. The MHO is tasked with the process of triaging and oversight of acute
information translation within the organisation. During major sport events, the MHO
might not be in attendance, dependent on if the MHO’s role is redundant within a
broader multisport sport environment, such as an Olympics. The sport organisation,
in collaboration with the MHO, should then assign an onsite MHO designee. The
onsite MHO will adopt the role typically expected of an MHO, whilst liaising with the
MHO located in the training environment. MHOs require athlete, coach, and support
staffmental health literacy. However, the form of literacy is broad based to manage
crises in training environments, whereas an onsite designee would be literate in
athlete mental health and competent in managing crises in major tournament
events, as a contextual expert.
Point six: acute care models must be refined through iteration
Henriksen et al. (2020) proposed that researchers seeking to understand athlete mental
health must expand on the use of appropriate and strongly validated instruments and
create novel approaches to understand the topic. The current model has been conceptu-
alised to spur systematic and efficient athlete acute care processes. Research is needed in
order to refine acute care models. We propose that there will not be a perfect, universal
model of care. Rather, each nation and organisation should continue to refine its own
model, with evidence-based approaches. Some nations have already produced idiosyn-
cratic plans and the authors of this consensus statement encourage other nations to
develop similar action plans, employing Figure 1 as a foundation. The approaches to
research can span all forms of methodologies and ontologies but should be iterative
and inclusive of the organisation’s key members who are involved with, and touched
by, acute athletes’crises.
INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 13
Disclosure statement
No potential conflict of interest was reported by the author(s).
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