A Grounded Theory Investigation of Basic Psychological Needs : A Grounded Theory Investigation of Basic Psychological Needs
Theory as a F y as a Framework for E amework for Effective Mental Health Ref e Mental Health Referrals in
Collegiate Sport
Luna Ugrenović
West Virginia University
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A Grounded Theory Investigation of Basic Psychological Needs Theory as a Framework for
Effective Mental Health Referrals in Collegiate Sport
Luna Ugrenović, M.S., M.A.
Dissertation submitted
to the College of Applied Human Sciences
at West Virginia University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy in
Sport, Exercise, and Performance Psychology
Dana K. Voelker, Ph.D., Chair
Ashley Coker-Cranney, Ph.D.
Johannes Raabe, Ph.D.
Monica Leppma, Ph.D.
School of Sport Sciences
Morgantown, West Virginia
2024
Keywords: interpersonal behaviors, need supporting, need thwarting, sport support personnel,
teammates, student-athletes
Copyright 2024 Luna Ugrenović
ABSTRACT
A Grounded Theory Investigation of Basic Psychological Needs Theory as a Framework for
Effective Mental Health Referrals in Collegiate Sport
Luna Ugrenović
Using a grounded theory approach, this study explored collegiate athletes’ mental health referral
experiences and identified mechanisms explaining those experiences based upon perceptions of
psychological need fulfillment and thwarting according to Basic Psychological Needs Theory
(BPNT). Interviews were conducted with a purposive, maximum variation sample of 14 current
and former collegiate athletes who were referred to mental health services by support personnel
or other athletes. Analyses yielded three overarching theoretical categories/properties: prereferral factors, proactive and reactive referral conversations, and referral outcomes. Referral is
often understood as an isolated conversation in which athletes are provided mental health
resources in response to a crisis. Challenging this notion, the present study showed that proactive
referral as a preventative approach, as well as intentional understanding athletes’ pre-referral
experiences, were central to supporting athletes’ relationship with their mental health. Generally,
referral experiences that resulted in helping athletes disconnect their mental health concerns from
understandings of their self-worth, and ultimately pursue mental health services with hope for
recovery, were linked to psychological need satisfaction throughout the referral process (e.g.,
autonomously choosing mental health services, relating to the referrer through a similar
experience, mastering skills for pursuing therapy). Yet, in cases of positive referral experiences,
some athletes re-internalized mental health stigma upon re-engaging with unsupportive sport and
familial environments. Need thwarting amid the referral conversation was generally associated
with poorer outcomes, in addition to cultural environments that deterred help-seeking. Together,
the data suggest BPNT is a promising framework for effective referral guidance, though
psychological needs are met uniquely for each athlete based upon their characteristics and
context.
MENTAL HEALTH REFERRALS IN SPORT iii
Acknowledgments
I cannot thank enough everyone from both sides of the ocean who have supported me on
this journey. I would like to express my deepest gratitude to Dr. Dana K. Voelker, my advisor
and committee chair, for her invaluable patience, guidance, and support. Her passion for the field
and dedication to the highest excellence has pushed me to reach my potential. This endeavor also
would not have been possible without my committee, who generously provided their knowledge
and expertise. I thank Dr. Ashley Coker-Cranney for her methodological expertise and guidance
that made this ambitious study possible. I thank Dr. Johannes Raabe for challenging me to reach
the highest research standards and offering his theoretical expertise. I thank Dr. Monica Leppma
for reminding me to trust my intuition and to practice self-compassion. I would also like to
deeply thank my research assistant, Verena Zaisberger, for her dedication and perspective during
each phase of the study – her curiosity and hard work were pivotal in creating the final product
of this project.
I am also so grateful for my colleagues and friends who read drafts, offered feedback, and
were my moral support. Without them, my journey would not have been nearly as meaningful
and fulfilling. I will be forever grateful to Dr. Tommy Minkler, Dr. Blake Costalupes, Dr. Sofía
España Pérez, Dr. Zenzi Huysmans, Dr. Karly Casanave Phillips, Dr. Andrew Chip Augustus,
Kim Tolentino, Jaxson Judkins, Kayla Hussey, Hannah Miller, Sarah Sadler, Hannah SilvaBreen, and Lindsey Leatherman.
I thank my family, especially my parents, Maja and Vladan, and my sister, Mia. Their
belief in me has kept my spirits and motivation high, while their unconditional love has offered
me a sanctuary when I needed it. Lastly, I want to express special thanks to my husband, Salman,
whose tireless support, love, and selflessness helped me overcome each and every obstacle along
the way. Our shared passion for the topic and many long late-night discussions about the
grounded theory have inspired me and reminded me of the opportunity to impact others with my
research. I thank him for sharing this journey with me every step of the way.
MENTAL HEALTH REFERRALS IN SPORT iv
Table of Contents
Introduction and Literature Review…………..…………………………………………….……..1
Basic Psychological Needs Theory………………………………………………………..4
Methods and Materials…………………………………………………………………………….7
Research Approach and Philosophical Assumptions..…...…………………...…….……..8
Methodological Approach………………………………..….………….………...………9
Participants………………………………………………………………………..……...10
Materials…………………………………………………………………………………11
Demographic Survey…………………………………………………………….11
Interviews………………………………………………………………………...11
Procedures………………………………………………………………………………..12
Data Analysis…………………………………………………………………………….14
Methodological Rigor……………………………………………………………………18
Results……………………………………………………………………………………………19
Pre-Referral Factors….…………………………………...……………………………...20
Participants’ Identities and Culture……………………………………………....20
Participants’ Family Environments………………………………………………22
Participants’ Sport Environments……………………...………………………...23
Reactive and Proactive Referral Conversations………………...…………………....…..25
Psychological Need Satisfaction and Thwarting………...………………………26
Autonomy Satisfaction and Thwarting…………...……………………...26
Relatedness Satisfaction and Thwarting………..….…………………….28
Competence Satisfaction and Thwarting…………….…..………………30
Referral Outcomes……………………………………………………………………….30
Perceptions of Self as Context……………………………………...….……...…31
Perceptions of Self as Content…………………………...……………………....32
Discussion………………………………………………………………………………………..36
Practical Implications…………………………………………………………………….42
Limitations and Future Directions………………………………………...……………..44
Conclusion……………………………………………………………………………….46
References………………………………………………………………………………………..48
MENTAL HEALTH REFERRALS IN SPORT v
Appendix A: Extended Literature Review…………………………………………….……...….59
Collegiate Athlete Mental Health……………………………………………...……...…60
Mental Health Referrals………………………………………………………………….64
Mental Health Referrals in Sport………………………….……………...……...70
Rates of Mental Health Referrals in Collegiate Sport…..…………...…..72
Possible Barriers to Successful Mental Health Referrals in Sport……….74
Mental Health Referrals in Sport – Best Practices……………………….78
Basic Psychological Needs Theory………………………………………………………84
Basic Psychological Needs Theory and Collegiate Athletes…………………….87
Basic Psychological Needs Theory, Well-Being, and Mental Health….....……..90
References………………………………………………………………………………..92
Appendix B: Extended Methods and Materials………………………………………….…......106
Researcher’s Positionality and Background……………………………………………106
Appendix C: Recruitment Flyer………………………………………………………………...109
Appendix D: Cover Letter………………….………………………...………………....……...110
Appendix E: Demographic Survey……………………………………………..………………112
Appendix F: The Final Version of The Interview Guide…………………………….…………115
MENTAL HEALTH REFERRALS IN SPORT 1
Introduction
Mental health concerns are rising among collegiate athletes (Brown et al., 2021). Data
suggest the prevalence of stress, anxiety, sadness, mental exhaustion, anger, and sleep difficulties
are 1.5 to 2 times higher than pre-2021 reports (National Collegiate Athletic Association
[NCAA], 2022). Collegiate athletes experience signs and symptoms of various mental health
concerns (e.g., Brown et al., 2021; Gavrilova & Donohue, 2018) at greater frequencies than their
same-age, non-athlete peers (e.g., Donohue et al., 2018; Li et al., 2017). Despite collegiate
athletes’ reported frequency of mental health concerns, research suggests most do not pursue
mental health services. For example, the NCAA Well-Being Study (2022) found that less than
half of the collegiate athletes surveyed reported feeling comfortable seeking help from an oncampus mental health professional. There are various barriers to collegiate athletes’ willingness
and ability to pursue mental health services, such as stigma, limited knowledge of the supports
and resources available, negative help-seeking beliefs, concerns about confidentiality, and
perceived lack of time (e.g., Cox et al., 2017; Hilliard et al., 2020; Moore, 2016). To address this
problem, understanding how best to connect collegiate athletes with mental health services, in
ways they feel comfortable and motivated to pursue those services, is gravely needed.
An important step in the mental health help-seeking process, and that can be investigated
to address collegiate athletes’ growing mental health concerns, is referral. Defined as the process
of directing others to appropriate supports and resources to address their mental health needs
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2015), referral is
often made by peers or support personnel in collegiate athletes’ immediate performance
environments, such as academic advisors, strength and conditioning coaches, sport coaches,
sport dieticians, mental performance consultants, physiotherapists, physiologists, and athletic
MENTAL HEALTH REFERRALS IN SPORT 2
trainers (Cormier, 2014; Daltry et al., 2021; Neal et al., 2013; 2015; Sebbens et al., 2016; Van
Raalte et al., 2015). Unfortunately, support personnel report they are neither comfortable nor
confident in their ability to communicate with, refer, and support athletes experiencing mental
health concerns (Gayman & Crossman, 2006; McArdle et al., 2018; Moreland et al., 2018;
Sandgren et al., 2022). In a qualitative study, support personnel reported feeling anxious,
frustrated, underprepared, and unskilled to refer athletes, citing a critical need for guidance on
what and how to communicate with athletes experiencing mental health difficulties (McArdle et
al., 2016). Gayman and Crossman’s (2006) qualitative study found mental performance
consultants rarely discussed the possibility of referrals to mental health services during intakes,
did not maintain an updated referral list of available providers, and did not follow-up with the
athlete clients if a referral was made. Unsurprisingly, this discomfort with mental health
conversations is compounded by collegiate athletes also feeling the effects of this uncertainty
(Arthur-Cameselle et al., 2012). For example, Cutler and Dwyer’s (2020) study of 158 collegiate
athletes found that only half believed their coaching staff could offer support in an emotional
crisis. Clearly, a lack of preparedness and comfort with mental health has led to the avoidance of
referral-related behaviors among support personnel and is also impacting athletes.
Collectively, these data suggest that although support personnel can play a key role in
referrals given their proximity to and rapport with collegiate athletes (e.g., Daltry et al., 2021;
Neal et al., 2015; Sebbens et al., 2016), barriers to effective communication with athletes around
mental health concerns may impede the referral process, perpetuate negative help-seeking
attitudes and stigma, and in turn make it exceedingly difficult for collegiate athletes to seek
appropriate and timely help when needed. These communication barriers are not just limited to
the exchange between support personnel and athletes, as many athletic departments also do not
MENTAL HEALTH REFERRALS IN SPORT 3
sufficiently discuss the referral process, suggesting structural difficulties that some coaches have
described as “broken” and “dismantled” (Eckenrod et al., 2023, p. 7). Accordingly, support
personnel must be better equipped to support collegiate athletes through the development and
implementation of referral guidelines that ease and facilitate communication while empowering
athletes to pursue mental health supports and resources. This need extends to athlete peers, as
some literature suggests that, with adequate training, college student peers generally, and athlete
peers specifically, can act as helpful sources of mental health referrals (e.g., Kalkbrenner et al.,
2019; Van Raalte et al., 2015).
Yet, extant referral guidelines designed for athletes are limited. Vella at al.’s (2021)
systematic review and meta-synthesis of mental health position statements in sport found the
overall quality of the guidelines to be low. Specifically, although many policy statements discuss
the importance of referrals, they lack clear referral guidelines, such as when, how, and to whom
to refer. Guidelines solely focused on policy and procedure (i.e., what to do) but not process (i.e.,
how to do it) are limited in their effectiveness (Tod & Anderson, 2014) as they fail to support the
application and implementation of their referral policies and procedures to specific contexts. This
not only refers to the sport environment context but also to collegiate athletes’ identities and
cultural backgrounds, as collegiate athletes working with support personnel reportedly value
when their identities beyond sport are acknowledged and honored (Bejar et al., 2019). Further, as
culture influences the likelihood of engaging with mental health care in unique ways (Abdullah
& Brown, 2011), athletes’ identities and cultural contexts may also impact referral outcomes.
More recently, the NCAA (2024) released a mental health best practices consensus document,
yet their recommendations are also on referral pathways and not processes. Although such efforts
MENTAL HEALTH REFERRALS IN SPORT 4
are timely and important, there remains a need to delineate specific steps and actions that support
personnel and other athletes can utilize when engaging in the mental health referral conversation.
Recommendations that do explicate process are largely based on accounts of experienced
practitioners and include: (a) building rapport with athletes and communicating care for their
well-being; (b) facilitating a team approach to athlete care; (c) preparing athletes for referrals; (d)
showing support and normalizing mental health concerns; (e) referring in (i.e., inviting therapists
to meetings with athletes and support personnel); (f) explaining reasons for referrals; (g)
describing what working with therapists entails; (h) following up with athletes; and (i) being
prepared to offer alternative coping options and to revisiting referral after giving athletes time to
consider the recommendations (Andersen et al., 1994; Neal et al., 2013; 2015; Tod & Andersen,
2014; Van Raalte & Andersen, 2014). Such practitioner-informed guidelines can be further
strengthened by centering athletes’ voices on effective and ineffective referral experiences,
considering athletes’ identities and unique needs, and studying the interpersonal components
with referrers that may affect athletes’ willingness and ability to pursue mental health
recommendations. Further, using well-established conceptual frameworks to explore and explain
the referral process would provide additional structure to future research in this area, particularly
with respect to predicting athletes’ willingness to engage in the recommendations they are
provided, while providing clarity and focus to key targets of intervention that would improve the
referral experience.
Basic Psychological Needs Theory
A promising framework for understanding how to facilitate effective referrals for
collegiate athletes, is basic psychological needs theory (BPNT; Ryan & Deci, 2017), a wellresearched theoretical guide for successful interpersonal interactions toward future behavior.
MENTAL HEALTH REFERRALS IN SPORT 5
BPNT may be especially helpful in this context as it has been widely used in sport research to
explore the impact of interpersonal behaviors on motivation (e.g., Raabe & Zakrajsek, 2017).
Specifically, as one of the mini theories within the larger framework of self-determination theory
(SDT; Ryan & Deci, 2017), BPNT has helped explain antecedents to initiating and maintaining
behaviors in sport (e.g., Raabe et al., 2016), work (e.g., Parfyonova et al., 2019), health care
(e.g., Ryan at al., 2008), and other settings.
According to BPNT, an individual’s innate and basic psychological needs are autonomy,
competence, and relatedness, all three of which are influenced through social interactions and are
considered essential for psychological growth (Ryan & Deci, 2017). Autonomy refers to
perceptions of self-governance and volition and the degree to which one values these behaviors.
While autonomy support involves conveying value of one’s perspective and encouraging selfdirectedness over one’s decisions, autonomy controlling behaviors involve the use of external
controls, like rewards and punishments, that promote need thwarting and undermine motivation.
Competence refers to perceptions of self-mastery in one’s interactions with their environment.
Supporting another’s need to feel competent involves providing education, guidance, feedback,
and structure to assist in the development of mastery and efficacy. Conversely, thwarting
another’s need to feel competent involves highlighting faults and lack of abilities, demonstrating
doubt in the ability to improve, and discouraging engagement in difficult tasks. Finally,
relatedness pertains to a sense of belonging in which one feels connected to, and valued by,
others. With respect to relatedness, need support constitutes genuine interest, care, acceptance,
and companionship from others, whereas need thwarting constitutes treatment from others that is
distant, emotionally unavailable, exclusionary, and characterized by a failure to listen. As others’
behaviors influence the extent to which one perceives these needs to be satisfied, or thwarted,
MENTAL HEALTH REFERRALS IN SPORT 6
this in turn determines the likelihood of initiating and maintaining a behavior and informs
wellbeing. Although specific ways basic needs are satisfied or frustrated differ based on context,
culture, and social setting, they are considered to universally apply to all humans (Ryan & Deci,
2017). In a recent meta-analysis (Slemp et al., 2024), perceived need satisfaction, coupled with
interpersonal support, was associated with optimal motivation, wellbeing, and performance.
Conversely, negative interpersonal behaviors informed perceptions of need thwarting that, in
turn, were associated with ill-being, poorer performance, and diminished motivation.
Researchers have used BPNT to understand the wellbeing and mental health of diverse
groups of young adults (e.g., Akbag et al., 2017; Campbell et al., 2018; Cantarero et al., 2021),
including athletes. For instance, in a sample of over a thousand collegiate students from four
countries (i.e., Belgium, China, USA, and Peru), Chen at al. (2015) found need-satisfaction
predicted well-being, and need-thwarting predicted ill-being, irrespective of students’ nationality,
their reported importance of each need, and their willingness to satisfy them. This evidence
highlights the utility of a BPNT framework in understanding mechanisms for supporting mental
health among college students. BPNT has been also used in collegiate sport to explore athletes’
fulfilment and frustration of the three basic psychological needs in both academic and athletic
settings (e.g., Raabe at al., 2022; Raabe & Readdy, 2016), and coaches’ and teammates’ impact
on collegiate athletes’ need-satisfaction (e.g., Raabe & Zakrajsek, 2017).
Some studies have specifically examined the role of support personnel (e.g., coaches and
athletic trainers) in injured athletes’ need satisfaction and thwarting during their recovery and
return to sport. Bejar et al.’s (2019) study of NCAA Division I collegiate athletes with an injury
found greater motivation during injury rehabilitation when they perceived their athletic trainers
supported their needs for autonomy, competence, and relatedness (Bejar et al., 2019).
MENTAL HEALTH REFERRALS IN SPORT 7
Specifically, participants reported that athletic trainers facilitated their motivation to engage in
rehabilitation recommendations when they provided (a) information, clear expectations and
goals, encouragement, and reassurance (facilitating their competence); (b) scheduling availability
and flexibility, focus on both health and performance goals, receptivity to feedback, and choice
in treatment (facilitating their autonomy); and (c) approachability, rapport-building, and curiosity
about athletes’ lives beyond sport (facilitating relatedness; Bejar et al., 2019). The findings of
this study suggest BPNT may be a useful framework for investigating the role of support
personnel in collegiate athletes’ motivations to pursue recommendations around their care.
Specifically, behaviors of support personnel and athlete peers may similarly influence collegiate
athletes’ motivation to follow-through on referral recommendations by interacting with their
psychological needs and, in turn, impacting their wellbeing.
Situated within their identities and cultural contexts, this study explored (a) collegiate
athletes’ experiences receiving mental health referrals from support personnel and their athlete
peers, and (b) the mechanisms, informed by perceptions of psychological need supporting and/or
thwarting, that explained the experiences and their associated outcomes. The findings are used to
inform theoretically-grounded, data-driven, and athlete-centered recommendations for referral in
collegiate sport environments.
Methods and Materials
Research Approach and Philosophical Assumptions
The researchers adopted a multiparadigm approach integrating constructivist and critical
realist research paradigms (Bogna et al., 2020; Voelker et al., 2024) to fully achieve the research
aims. As proposed by Bogna et al. (2020), a constructivist paradigm allowed the researchers to
explore the domain of the empirical, as guided by (a) relativist ontology whereby researchers
MENTAL HEALTH REFERRALS IN SPORT 8
assumed there were multiple and socially constructed realities (Sale et al., 2002); (b) subjective
epistemology in that meaning was believed to be socially- and culturally-informed through
interactions with one’s environment (Moon & Blackman 2014), and (c) the axiological aim was
to understand and communicate co-constructed realities between the researchers and the
participants (Biedenbach & Jacobsson, 2016). Toward the first study aim, a constructivist
paradigm was used to first give voice to participants themselves, and in that way, understand
their mental health referral experiences and meaning. Specifically, participants’ referral beliefs
and experiences were perceived as products shaped by social and cultural contexts associated
with their unique identities and collegiate sport environments and were considered as multiple
and individual truths.
A critical realist paradigm allowed the researchers to explore the domain of the real
(Bogna et al., 2020), as guided by (a) realist ontology that assumed an objective reality existed
independent of one’s perception of it (Wynn & Williams, 2012); (b) interpretivist epistemology
or the assumption that relationships, ideas, and knowledge interacted to shape causal
mechanisms, events, and experiences that resulted in specific tendencies (Peters et al., 2013); and
(c) the axiological goal to understand mechanisms and causal regularities (Bogna et al., 2020).
Toward the second study aim, the researchers explored structures, mechanisms, and conditions
associated with a well-established and empirically supported theoretical framework, BPNT, that
shaped these experiences using a critical realist paradigm.
The two paradigms were merged to explore the domain of the actual, where mutually
constructed meanings and associated occurrences and events were shaped by structures,
mechanisms, and conditions, and therefore, allowed a more complete and deeper understanding
of the studied phenomenon (Bogna et al., 2020; i.e., referral experiences). In other words, the
MENTAL HEALTH REFERRALS IN SPORT 9
multiparadigm approach allowed exploration of the what, using constructivism, and the how,
using critical realism, regarding mental health referrals in collegiate sport.
Methodological Approach
Consistent with a multiparadigm approach that aimed to explore the domain of the actual
(Bhaskar, 1978), a constructivist grounded theory methodology (Charmaz, 2000; 2006, 2014)
was integrated with a critical realist, or retroductive, grounded theory methodology (Looker et
al., 2021), both of which share eight common elements (Weed, 2009). According to Charmaz
(2014), a constructivist grounded theory methodology acknowledges “subjectivity and the
researcher’s involvement in the construction and interpretation of the data” (p. 14). Hence, this
methodology allowed for exploration of what are the referral experiences and what are the
realities of collegiate athletes within relevant culture and context, while considering the
researchers’ role, including experiences, privileges, and biases, in the construction of that
knowledge.
Rooted in classical grounded theory (Glaser and Strauss, 1967), retroductive grounded
theory aims to develop understanding of mechanisms, or causal powers, that produce the studied
phenomenon (Hoddy, 2019; Kempster & Parry, 2011; Looker et al., 2021). According to
Kempster and Parry (2011), because the critical realism paradigm suggests knowledge is valueladen, retroductive grounded theory is a context-rich, versus context-free, approach to studying
phenomena. Unique from other grounded theory approaches, drawing upon existing theories
while analyzing the data is encouraged with a retroductive approach (Kempster & Perry, 2011).
Hence, this retroductive methodology was used to explore the role of BPNT in clarifying the
possible mechanisms that affected mental health referral in sport; or in other words, the how
behind collegiate athletes’ referral experiences. Together, constructivist and retroductive
MENTAL HEALTH REFERRALS IN SPORT 10
grounded theory methodology captured the lived experiences and meanings of collegiate athletes
who were referred to mental health services, and mechanisms that shaped these experiences.
Participants
Participants were 14 current (n = 8) and former (n = 6) collegiate athletes aged 18 to 25
years (M = 21.28, SD = 2.23). Participants were referred one to three times within the past four
years by athletic trainers (n = 8), coaches (n = 7), collegiate athlete peers (n = 5), nutritionists (n
= 2), mental performance consultants (n = 2), and physicians (n = 1). Table 1 provides sample
demographics.
Table 1
Participants’ Self-Identified Demographic Characteristics
Characteristic n %
Sex and Gender
Cisgender Woman 10 71.4
Cisgender Man 4 28.6
Race and Ethnicity
*White 12 85.7
Latina 1 7.1
White and Asian 1 7.1
Nationality
American 11 78.6
English 1 7.1
German 1 7.1
Mexican 1 7.1
Annual Family Income
$25,000-$50,000 3 21.4
$50,000-$75,000 3 21.4
$75,000-$100,000 2 14.3
$100,000 or more 5 35.8
Did not know 1 7.1
Religion and Spirituality
Nondenominational Christian 3 21.4
Catholic Christian 3 21.4
Spiritual but not religious 2 14.3
Agnostic 1 7.1
Atheist 1 7.1
Easter Orthodox Christian 1 7.1
MENTAL HEALTH REFERRALS IN SPORT 11
Characteristic n %
Methodist Christian 1 7.1
Pentecostal/Assembly of God Christian 1 7.1
Protestant Christian 1 7.1
Sport
Rifle 2 14.3
Soccer 2 14.3
Swimming 2 14.3
Triathlon 2 14.3
Diving 1 7.1
Lightweight rowing 1 7.1
Rowing 1 7.1
Track and Field; Softball 1 7.1
Competitive Level
NCAA DI 10 71.4
NCAA DII 1 7.1
NCAA DIII 3 21.4
Note. NCAA = National Collegiate Athletic Association; DI/DII/DIII = Divisions I, II, and III
*5 participants who identified as white American also reported identifying as:
Bulgarian, German/Polish/Irish/Italian, Irish/German, Irish/Wales, and Polish.
Materials
Demographic Survey. A demographic survey (see Appendix E) was administered via
Qualtrics software and asked when participants were referred to mental health services and who
referred them, as well as their age, sex, gender identity, sexual orientation, race, ethnicity,
nationality, SES (socioeconomic status), religion, collegiate sport organization, division, and
sport(s).
Interviews. Individual in-depth, semi-structured, online, video-recorded interviews
started with rapport-building, followed by open-ended and follow-up questions to generate
conversation as recommended by Charmaz (2014) and Hoddy (2019). The first author, who
conducted the interviews, continuously engaged in self-reflexivity according to guidelines
established by Tracy (2010), to examine her assumptions about referrals in collegiate sport and
communicate, both verbally and via open body language, a willingness to learn and understand
MENTAL HEALTH REFERRALS IN SPORT 12
participants’ lives from their perspective. These experiences were processed with a critical friend
with each subsequent interview to also deepen reflexivity.
The first version of the interview guide was developed based on previous literature on
mental health referrals in sport (e.g., Sebbens et al., 2016; Van Raalte et al., 2015), BPNT (e.g.,
Ryan & Deci, 2017), prior experiences interviewing collegiate athletes about mental health
concerns (e.g., Coker-Cranney et al., 2018), as well as guidance on constructing questions
aligned with both constructivist (Charmaz, 2014) and critical realist aims (Brönnimann, 2022).
Broadly, questions explored collegiate athletes’ experiences being referred to mental health
services with intentional exploration of their identities and culture in connection with those
experiences. Participants were then provided a cursory overview of the three psychological needs
and asked their perceptions of needs satisfaction and thwarting amid their referral experiences.
Consistent with Glaser and Strauss (1967), the interview guide evolved as data were collected to
support the process of theoretical sampling and consequent development of grounded theory (see
Appendix F for the final version). Initial interviews ranged from 55 to 105 minutes in duration
(M = 86 minutes).
Procedures
After receiving IRB approval (Protocol #2302727613), participants were purposively
sampled according to the eligibility criteria (i.e., at least 18 years of age, current or former
collegiate athlete, was referred to mental health services in the past four years by support
personnel or other athletes). Maximum variation sampling was used to garner the widest range of
experiences, to the extent possible, with respect to several key factors found to play a role in
collegiate athletes’ mental health concerns and/or help seeking behaviors (e.g., Ballesteros &
Tran, 2020; Brown et al., 2021; NCAA, 2022; Li et al., 2017); these variables included sex,
MENTAL HEALTH REFERRALS IN SPORT 13
gender identity, sexual orientation, race and ethnicity, and SES. Further maximum variation was
sought with respect referral experience (i.e., positive and negative) and referral source (e.g.,
mental performance consultant, athletic trainer, sport dietician, academic advisor, strength and
conditioning coach, sport coach, or athlete peer). Nationality, sport, year in college, collegiate
sport organization, division, and religion were also considered.
As suggested by Charmaz (2014) and Hoddy (2019), interviews were transcribed and
evaluated as they were completed to support a theoretical sampling process that informed the
type of data sought in subsequent interviews as a theory emerged, such as revising interview
guide questions (e.g., re-ordering questions about basic psychological needs) and/or recruiting
participants with certain experiences (e.g., perceiving to have a lack of choice during referral
experience) or attributes (e.g., man-identified collegiate athletes) to explore a gap in the
developing theory. Recruitment, then, was an iterative process continuously informed by the
purposive, maximum variation, and theoretical sampling processes to obtain a sample with rich
and wide-ranging experiences that meaningfully informed a substantive grounded theory.
Recruitment approaches included multiple flyer (see Appendix C) distributions via social
media outlets (e.g., LinkedIn) and email to colleagues, sport support personnel (e.g., mental
performance consultants, athletic trainers), and or collegiate sport teams. Interested participants
who voluntarily contacted the first author were provided additional information about the study
outlined in a cover letter (see Appendix D), including the purpose of the study, what
participation would entail, the possible benefits and risks of participation, and participation
incentives, and then screened for inclusion criteria. Eligible participants were offered an
opportunity to read the cover letter, ask questions, and then complete a demographic survey. The
first author conducted initial interviews and invited the participant for a member reflection on a
MENTAL HEALTH REFERRALS IN SPORT 14
second date following the initial coding of the participant’s first interview. Although each
member reflection was unique, they broadly included a summary of main takeaways, followed
by a discussion of participant’s impressions and conclusions from the initial interview, and new
understandings and experiences since the initial interview. Thirteen participants completed the
follow-up, lasting between 10 and 29 minutes (M = 19.7). Participants who completed the study
received a $50 Amazon gift card in modest appreciation of their time. To protect participants’
confidentiality, all interviews were de-identified, and participants were assigned pseudonyms.
Data Analysis
Data analysis was guided by both constructivist (Charmaz, 2014) and retroductive
grounded theory approaches (Looker et al., 2021). Prior to and during data collection and
analysis, a two-person data analysis team continuously explored theoretical sensitivity –
examining the studied phenomenon with an open mind to explore and compare different
perspectives as well as evolve original ideas (Glaser, 1978). Theoretical sensitivity allowed the
data analysis team to explore the participants’ perspectives about referrals in novel and original
ways. To support this process, the data analysis team consulted with a larger research team,
comprised of applied practitioners and academic researchers in sport psychology and clinical
mental health, during bi-weekly hourly meetings for several months.
According to Glaser and Strauss (1967), grounded theory methodology involves an
iterative process of engaging in data collection and analysis simultaneously. Accordingly,
analysis started, and continued, as each new interview was conducted and transcribed. Analysis
of each interview began with the data analysis team reading each transcript and then verbally
processing their insights with one another. The first author then conducted the initial coding
(constructivist grounded theory) using a line-by-line coding approach to define the phenomenon
MENTAL HEALTH REFERRALS IN SPORT 15
and allow the data to speak (Charmaz, 2014). The goal of the initial coding was to remain open
and curious to all possible theoretical directions suggested by participants’ perceptions of the
referral process. Charmaz suggested focusing on exploration of the actions and processes that
define the phenomenon (i.e., collegiate athletes’ experience being referred to mental health
services) was crucial at the beginning stages of the data analysis because it helped provide
evidence of fit (i.e., capturing the essence of the participants’ experiences via codes and
categories) and relevance (i.e., creating a framework that captures what was happening and
relationships between implicit and explicit processes) of the emerging theory.
Then, the first author conducted focused coding (constructivist grounded theory), also
called open coding (retroductive grounded theory) – a process through which the goal was to
conceptualize the phenomenon by choosing the most significant and or frequent initial codes that
categorized the data inclusively and completely, and then comparing them to additional data
(Charmaz, 2014; Looker et al., 2021). During focused/open coding, the first author moved across
interviews to compare participants’ referral experiences, actions, and meanings (the dolman of
empirical) to synthesize the main themes across large amounts of data while also exploring the
structures and mechanisms that may have underscored these experiences and meanings (the
domain of real).
Theoretical categories (constructivist grounded theory) or emergent properties
(retroductive grounded theory; i.e., core elements in a theory) emerged during focused/open
coding and memo writing as well as constant comparison between the data (Charmaz, 2014;
Looker et al., 2021). This process was not linear; later interviews made some processes clearer
and incited reanalysis of earlier interviews. Following focused/open coding, the first author
engaged in theoretical coding – a process that hypothesized possible relationships among
MENTAL HEALTH REFERRALS IN SPORT 16
theoretical categories/emergent properties (constructivist grounded theory; Charmaz, 2014), with
retroductive coding that explored generative and context-specific causal mechanisms that helped
explain those relationships (retroductive grounded theory; Looker et al., 2021). Consistent with
constructivist and retroductive grounded theory, this phase involved constant comparison
between the new data, memos, and codes as well as possible reanalysis (Charmaz, 2014; Looker
et al., 2021) toward exploration of the domain of the actual.
To support the process of describing and conceptualizing the phenomenon, the first
author engaged in consistent memo writing described as an analytic process in both
constructivist and retroductive grounded theory (Charmaz, 2014; Looker et al., 2021). Broadly,
memo writing allowed the first author to generate ideas, develop and connect theoretical
categories/emergent properties, gain insights early in the research process, and explore the
possible causal mechanisms that explain the relationships between theoretical
categories/emergent properties (Charmaz, 2006; 2014; Looker et al., 2021). Memo writing
supported iterative data analysis as it allowed the first author to explore and discover ideas freely
and spontaneously (Weed, 2009). When needed, memos were discussed with the research team
to support the exploration of the phenomenon.
An important part of memo writing was raising focused/open codes to theoretical
categories/emergent properties (Charmaz, 2014; Hoddy, 2019). This was done by choosing
focused/open codes that best capture what was happening in the data and why it was happening
though comparison between the data, incidents, contexts, and other categories/properties. Via
memo writing, the first author defined and explored characteristics of tentative theoretical
categories/emergent properties, explored their relationships with other theoretical
categories/emergent properties, and possible causal mechanisms that explained these
MENTAL HEALTH REFERRALS IN SPORT 17
relationships (Charmaz, 2014; Looker et al., 2021). In advanced memos, the first author traced
and categorized data to achieve the purpose of the study, describe how theoretical
categories/emergent properties and possible causal mechanisms emerge and change, identify the
beliefs and assumptions that supported them, explore various perspectives of the memo topic,
and engage in constant comparisons. Throughout each phase of the study, the first author
conducted constant comparison iteratively between data and data, data and codes, codes and
theoretical categories/emergent properties, and theoretical categories/emergent properties and
BPNT literature.
The first author started theoretical sampling once there were preliminary theoretical
categories/emergent properties from which to collect subsequent data that expanded and
improved theoretical categories/emergent properties and related causal mechanisms informing
the emerging theory (Weed, 2009). Theoretical sampling was facilitated by memo writing that
helped identify incomplete theoretical categories/emergent properties and causal mechanisms,
and gaps in the analysis. Weed (2009) argued theoretical sampling, based on tentative theoretical
categories/emergent properties, continued until no new characteristics of theoretical
categories/emergent properties and no new causal mechanisms emerged from new data (i.e.,
theoretical saturation; Charmaz, 2014; Hoddy, 2019). Based on what emerged from the existing
data, theoretical sampling involved recruiting new participants with specific experiences, or
collecting follow-up data collection from the existing participants (Charmaz, 2014; Hoddy,
2019). The first author regularly consulted with the research team about decisions regarding the
specific approaches to theoretical sampling.
To deepen the analysis and construction of the emerging theory, the first author engaged
in theoretical sorting, comparing/diagramming, and integrating memos (Charmaz, 2014). This
MENTAL HEALTH REFERRALS IN SPORT 18
involved comparing memos and exploring how the order and logic of memos capture the referral
experiences of collegiate athletes. Additionally, drawing diagrams assisted in establishing and
solidifying theoretical categories/emergent properties, their relationships, and causal mechanisms
that explain them. Together, these strategies provided insight toward an emerging theoretical
framework on referring collegiate athletes to mental health services. To support the process of
theory development, the first author met with expert consultants regularly during each phase of
the analysis regarding the quality and rigor of the analysis and relevance to the BPNT
framework. Follow up member reflections and the research team interpretations were transcribed
and analyzed with the rest of the data to refine the theoretical categories/emergent properties and
emerging theory (Albas & Albas, 1988; 1993; Charmaz, 2014; Looker et al., 2021).
Methodological Rigor
To support the process of investigating, interrogating, and deepening different
interpretations of the data (Harper, 2011), the research team included individuals with a variety
of experiences in the collegiate sport and mental health fields. Some of the shared experiences of
the research team involved completing post-secondary education in either sport psychology,
mental health counseling, or both. Additional commonalities among the research team included
being an athlete, a coach, a mental performance consultant, and a mental health counselor in
various sport and clinical settings in the United States and Europe. Some of the unique
experiences of the research team included identifying with different nationalities (i.e., American,
German, Austrian, and Serbian) and gender identities (i.e., woman- and man-identified),
competing and working for different sports and sport levels (i.e., high school and collegiate), and
interacting with collegiate athletes in different capacities (e.g., as a therapist, a professor, a
mental performance consultant, a supervisor, a former collegiate athlete). Additionally, the
MENTAL HEALTH REFERRALS IN SPORT 19
research team had diverse experiences, expertise, and formal training regarding conducting
qualitative research in sport psychology and counseling, BPNT, and making and receiving
collegiate athletes’ mental health referrals.
The approaches used to support data trustworthiness, credibility, and confirmability were
engaging in self-reflexivity both in written (i.e., memo writing) and verbal (i.e., discussions with
the critical friend) forms as well as regular consultations with the research team experts
regarding conceptual and methodological decisions, and conducting member reflections, as
previously discussed. Additionally, Carcary (2020) recommendations for audit trail best practices
were followed (i.e., documenting the research process in all phases of the study, including key
methodological decisions, and tracing how researchers’ thinking evolved during each phase).
Results
Data analysis resulted in a substantive grounded theory (Figure 1) that described and
explained participants’ experiences of being referred to mental health services by support
personnel and other athletes. Three overarching theoretical categories/properties emerged: (a)
pre-referral factors (i.e., conditions and dynamics prior to referrals informing referral
conversations); (b) referral conversations (i.e., interactions in which referrers recommended
athletes seek appropriate mental health resources); and (c) referral outcomes (i.e., consequences
of referral conversations). Figure 1 illustrates subcategories identified within each category, and
the relationships between them, that together described participants’ experiences and
mechanisms explaining those experiences.
Figure 1
A Substantive Grounded Theory of Referring Collegiate Athletes to Mental Health Services
MENTAL HEALTH REFERRALS IN SPORT 20
Note. White boxes represent experiences, and gray boxes represent mechanisms.
Pre-Referral Factors
Prior to the initiation of referrals, pre-referral factors shaped how referral conversations
unfolded and, ultimately, the referral outcomes. These factors included aspects of participants’
identities and cultures and interactions with their family and sport environments. Although basic
psychological needs were not explicitly explored with participants at this stage of the interview,
pre-referral factors clearly also influenced autonomy, competence, and relatedness when shaping
participants’ relationships with, and attitudes toward, mental health and, ultimately, the referral.
Participants’ Identities and Culture
Participants described how aspects of their identities and culture, such as their nationality,
race, ethnicity, SES, religion, and gender identity, influenced their perceptions of mental health
concerns and help-seeking behaviors that, in turn, informed their willingness to pursue referral
MENTAL HEALTH REFERRALS IN SPORT 21
recommendations. For example, Fin referenced that “in Germany, we are…more private, very
distant people” which is “probably also one of the reasons why I never really looked at [therapy]
before.” Mia, on a different note, commented on SES status: “Growing up, the money aspect was
hard. So, that’s why I never went [to therapy].” Other participants described how binary gender
norms, informed by their upbringing and traditional sport culture, influenced their help-seeking
attitudes. Gia reported that “girls are seen as weaker…guys [are] trying to be the strongest” and
that “coaches would see you as weaker” for seeking mental health resources. Tom described how
a lack of representation contributed to his mental health concerns and deterred him from seeking
help: “I think not only is it hard to be a queer person [in the] outside world, but also being a
queer person inside of athletics is incredibly difficult.”
Further, some participants cited their religious background and spirituality as both a
barrier and facilitator to seeking mental health services. Bri explained, “[My religious
community is] very supportive…It gave me an opportunity…to talk about [my mental health]
more.” Zoe similarly discussed how “the guiding principles of religion” encouraged her to “find
the healthiest version of myself, mentally and physically.” Ana stated why she went to therapy:
I realized there was a spiritual element to this… The enemy was telling me, ‘You’re a
failure.’ And I was believing it… I need to get my faith back in order. This is a lie… This
is not who God says I am… That faith…was HUGE because that was the catalyst that
started changing things.
Other participants believed religion sufficed as therapy and, accordingly, avoided facing their
difficulties as a way to cope (i.e., spiritual bypassing). Mia reported, “I always just thought I
could just pray it off…Why isn’t praying enough for me? I didn’t want it to feel like I couldn’t
do it on my own with just God.”
MENTAL HEALTH REFERRALS IN SPORT 22
Some participants reported ways their intersecting identities shaped their views on helpseeking. Ana described her “quite emotionally unavailable” English culture and “the culture of
being an athlete” as making her “incredibly reluctant” to seek help. Others explained that support
personnel failed to honor their intersecting identities, exacerbating their mental health concerns
and unwillingness to seek help. Tom explained that, in his sport environment, the term “athlete”
was used to generalize “a group of people that can be incredibly diverse.” He noted, “As
someone who has been athletic since I was five years old, I just took onto that [athlete] title and
didn’t allow other things in my life to define who I was.” He added, “[Sport personnel] don’t
really talk too much about sexuality…It was never really a topic of conversation.”
For the participants who recognized having privileged identities, representation in mental
health settings was often not a concern. Ana stated, “I’m heterosexual, [that is] why I don’t feel
there [were] any barriers in terms of those parts of my identity.” Ana also acknowledged her
teammates may have had a different experience: “We had a couple of lesbians on the team. I
could see how they wouldn’t want to go to a Christian counselor for fear that they would be
judged.” For some participants who belonged to minoritized groups, representation was key to
their willingness to seek mental health services. As a member of “the international community,”
Lea reported noticing “more of a need for cross-cultural specialists… Our counseling center…
has been staffed by older white people.” Lea suggested “having…knowledge of various
backgrounds and…cultures…helps with the referral process” as professionals may “understand
your experience and you feel represented in them.” Participants’ diverse identities and culture
had strong effects on their help-seeking attitudes and behaviors, and, consequently, their
openness to referral recommendations.
Participants’ Family Environments
MENTAL HEALTH REFERRALS IN SPORT 23
Participants in family environments that encouraged help-seeking were more likely to
have positive attitudes toward help-seeking themselves. Max stated, “I’ve never thought [seeking
therapy] was a bad thing… I’ve always been told…if you’re struggling mentally, there’s nothing
wrong with talking to [psychotherapists].” Ana noted, “My parents didn’t see seeking counseling
as a sign of weakness… I know my dad had gone…and…it was helpful for him… If anything, it
encouraged me… They’re not gonna judge me…” Contrarily, negative attitudes toward help
seeking in their immediate family deterred other participants from wanting to seek mental health
services. Mia mentioned, “My parents are very against being mentally weak… [My extended
family] don’t believe in therapy at all… I would never say [to them]…that I’m in therapy.”
Some participants also said that help-seeking attitudes were passed down generationally,
making it harder to shift their own attitudes. Lea reported, “[My mother] moved from [another
country]… With my grandparents it very much was like, ‘You don’t need anything. It’ll be
fine’…The cultural mindset travels with you.” Among these participants, some discussed slow
but important shifts in intergenerational help-seeking attitudes. Gia reported that her “transition
generation” is growing up in a time when they are “actually…listened to” instead of being told to
just “toughen up,” and that younger generations will benefit from further shifts in this direction.
Family members’ attitudes towards mental health help-seeking, whether positive or negative,
strongly influenced participants’ own attitudes yet were noted as malleable.
Participants’ Sport Environments
Many participants similarly described their sport environments as supportive or
unsupportive of mental health help. These participants were more likely to have positive attitudes
toward help-seeking when athletic department cultures encouraged it. Joy felt “really good”
about seeking services after noticing that “no one looked twice” when her teammate disclosed
MENTAL HEALTH REFERRALS IN SPORT 24
pursuing therapy. Gia did not originally value mental health services, but because her head coach
“wants to talk about mental health…it’s not uncomfortable.” Gia also described several benefits
of mental health services being accessible and frequently promoted in her sport environment. Per
Gia, coaches pointed to “posters with [the psychotherapist’s] contact information,” and athletic
trainers frequently offered to “help you set up an appointment.” These participants also discussed
having better access to services when mental health providers were integrated into sport. For
Max, “the fact that [the psychotherapist in athletics] is around us and really looks out for
us…definitely helped. Max noted, “I don’t know if it was some random person if I would have
[sought therapy].”
Conversely, some participants noted several barriers when athletic department cultures
failed to promote mental health. Ana’s teammate “didn’t believe what was going on with me was
a big deal… It made me feel like, ‘Oh, maybe she’s right. Maybe there’s nothing wrong with me.
Maybe I’m just being dramatic,’ which was very painful.” Ana further noted, “Before that
conversation [about referrals] even happens, …there’s more that can be done with the culture
around [mental health],” explaining that requiring a referring athletic trainer to “deal with this” is
“unfair…when there is not a culture already in place that makes those conversations accessible
and comfortable.” Fin “wasn’t really aware of [existing therapy resources for athletes]… that
wasn’t really too public that I would have the option to talk to [psychotherapists]…. That
message never really came from the main coaches.” Ella had “never heard someone who goes to
[the psychotherapist in athletics] and has a good experience… She’s trained…just…not very
good.” Contrarily, some participants indicated that an overemphasis on mental health was also an
issue. Ella described this as an “overcorrection,” as her coach’s efforts to normalize mental
health made the coach “too emotionally involved”, thus “hindering…[team] performance.” Ella
MENTAL HEALTH REFERRALS IN SPORT 25
also felt that some of her teammates were “too annoying and loud about mental health.” As with
family environments, participants’ sport environments, including cultural messaging about
mental health, impacted their pre-referral attitudes and intentions toward help-seeking.
Reactive and Proactive Referral Conversations
Participants’ identities, cultural backgrounds, and family and sport environments
informed the help-seeking attitudes they, figuratively, brought with them to their referral
conversations with support personnel and other collegiate athletes. In these referral
conversations, referrers broached their concerns with participants and recommended mental
health resources or services. Many participants described these conversations as having occurred
reactively (i.e., in response to an experienced mental health crisis) or proactively (i.e., with the
aim to prevent concerns from beginning or worsening). Participants further discussed ways they
perceived their basic psychological needs to be supported or thwarted amid these interpersonal
exchanges.
Most participants reported being referred reactively, as a result of “hitting rock bottom”
(Tom) or in response to crisis, such as sexual assault, suicidality, and panic. Referrals following
a crisis that were experienced positively involved the referrers who promptly provided support,
information, and choices to help them feel safer and more in control. Liz stated it “was helpful to
know what I was walking into.” She further explained, “[The athletic trainer] said, ‘[The
boyfriend]…can sit in [the session] with you…,’ prepared me it was going to be a guy [the
psychotherapist],” and gave “me the basics of what I was going to experience.” In rare cases,
some participants were referred proactively as a preventive measure to help them cope with
upcoming stressors. Gia, who “had never done triathlon before”, explained that her head coach
referred her “to make sure that you’re not feeling you’re in over your head.” Being referred
MENTAL HEALTH REFERRALS IN SPORT 26
proactively increased some participants’ openness to services and reduced mental health stigma.
For Gia, this approach showed her that “anyone can be referred… [Therapy] can be helpful for
anybody” and “preventative.” Lea described being referred proactively as “a welcome little push
to get me to take care of myself and prioritize wellbeing,” with others stating that it helped them
overcome ambivalence or avoidance. Bri noted, “Had I not had that [referral] conversation with
[the athletic trainer], I probably would have never gone to see anybody.” Such examples
exemplified the importance of approaching each referral differently based on an athlete’s unique
needs.
Psychological Need Satisfaction and Thwarting
In addition to the proactive/reactive nature of referral conversations, participants
discussed ways in which the interpersonal exchanges with referrers supported, or thwarted, their
basic psychological needs. These included participants’ autonomy (i.e., sense of selfgovernance), relatedness (i.e., sense of connection), and competence (i.e., sense of mastery).
Autonomy Satisfaction and Thwarting. Many participants explained that common
hierarchical power structures influenced their referral conversations and, subsequently, their
decisions to pursue mental health services. When asked about what it was like to be referred by
their teammates, two participants voluntarily compared it to referrals by coaches, stating it felt
“more like my own decision… Athlete to coach is more a sense of authority” (Eva). Mia echoed,
“If [the coach] were to suggest [therapy]… I would not have a comfortable conversation” and
“would just go…feel I had no choice” and “be doing it for him.” For Ari, “Having [the athletic
trainer and the coach]…reach out to [the psychotherapist] before I even gave consent…or
approval…was upsetting. So, I didn’t feel I had the autonomy because it was not brought
forward to me.” In contrast, a few participants discussed how financial privilege was another
MENTAL HEALTH REFERRALS IN SPORT 27
form of power that supported autonomy during and following the referral. Bri reported she “went
out and found [a psychotherapist] on my own… It’s privileged to be able to afford that…
Privilege does create autonomy.”
Many participants reported feeling autonomous when their referrers asked them for their
thoughts and preferences and provided control around referral outcomes, including the
opportunity to contemplate and choose whether to pursue services. Bri stated, “it was my choice”
because the athletic trainer informed her about resources and said “It’s completely up to you.
We’re not going to force you into it or judge you if you decide not to.” Fin reported, “[Therapy]
was…brought up…[as] an option. And I was like, ‘Okay, I’m gonna give it a thought…’ It was
never the end of the conversation and then a fixed, ‘Yeah, I’m gonna…[seek therapy].’” Fin
further explained, “After a week… based on m
Les avis et les commentaires de OpenAI
Living Your Best Life: The Mindful Pursuit of Student-Athlete : Living Your Best Life: The Mindful Pursuit of Student-Athlete
Thriving
Andrew Augustus
West Virginia University, ana00006@mix.wvu.edu
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Part of the Health Psychology Commons, Other Psychology Commons, and the School Psychology
Commons
Recommended Citation
Augustus, Andrew, "Living Your Best Life: The Mindful Pursuit of Student-Athlete Thriving" (2023).
Graduate Theses, Dissertations, and Problem Reports. 11689.
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Living Your Best Life: The Mindful Pursuit of Student-Athlete Thriving
Andrew N. Augustus, MEd.
Dissertation submitted
to the College of Applied Human Sciences
at West Virginia University
School of Sport Sciences
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy in
Sport, Exercise, and Performance Psychology
Sam Zizzi, Ed.D., Chair
Dana Voelker, PhD.
Scott Barnicle, PhD.
Vanessa Shannon, PhD.
School of Sport Sciences
Morgantown, West Virginia
2023
Keywords: Mindfulness, Well-Being, Performance, Self-Compassion, Thriving
Copyright 2023 Andrew Augustus
Abstract
Living Your Best Life: The Mindful Pursuit of Student-Athlete Thriving
Andrew N. Augustus, MEd.
Thriving, or the concurrent experience of healthy well-being and high-level performance,
may serve as a valuable construct when studying the optimal student-athlete experience and
mindfulness-based interventions (MBIs) have been shown to positively impact well-being and
performance. The purpose of the present study began to examine the impact of an MBI for
improving student-athlete experiences of thriving via a quasi-experimental longitudinal design.
NCAA Division II student-athletes (n = 55) from three sports were randomly assigned to either a
control or a 7-session MBI. While comprehensive measures of thriving did not yield significant
change for those in the MBI relative to the control, multiple thriving characteristics and
outcomes were improved. MBI participants reported quantitative significant improvement for
subjective performance satisfaction, mindful awareness, and the use of mindfulness to regulate
emotions. Exploratory analysis revealed those in the MBI, relative to the control, experienced
improvements of optimism and a sense of meaning and purpose. Within the program evaluation,
student-athletes qualitatively reported sport and life benefits related to thriving (e.g., self
regulation, focus, awareness, vitality, intentional actions) while also suggesting improving MBIs
with systematic reminders to meditate, more meditation opportunities within the sport
environment, and autonomy-supportive instruction. These preliminary data support the use of
MBIs to facilitate characteristics and outcomes of thriving, while also offering suggestions for
practical improvements when implementing MBIs with student-athletes.
Acknowledgements
iii
I am grateful for the support and guidance I have received throughout this process. Thank
you to my committee for your critical feedback and invaluable perspectives. Each of you have
tremendously impacted this dissertation from conceptualization to submission. Thank you to my
family, friends, and classmates for encouraging, listening, and empowering me throughout this
journey. Most of all, thank you to my parents for your endless love and support.
“There is a road, no simple highway. Between the dawn and the dark of night. And if you go, no
one may follow. That path is for your steps alone.” – Robert Hunter
iv
Living Your Best Life: The Mindful Pursuit of Student-Athlete Thriving ............................. 1
Method ........................................................................................................................................... 6
Research Design .......................................................................................................................... 6
Participants .................................................................................................................................. 6
Instruments .................................................................................................................................. 6
Background and Demographic Information ............................................................................ 6
Thriving ................................................................................................................................... 7
Subjective Performance ........................................................................................................... 8
Mindfulness ............................................................................................................................. 8
Program evaluation ................................................................................................................ 10
Procedures ................................................................................................................................. 10
Pilot Intervention ................................................................................................................... 11
Intervention Details ............................................................................................................... 12
Data Analysis ............................................................................................................................ 14
Results .......................................................................................................................................... 15
Descriptive Statistics and Baseline Characteristics ............................................................... 15
Intervention Engagement and Effects: Manipulation Check ................................................. 16
Impact on Thriving: Between-Groups Differences ............................................................... 17
Program Evaluation Feedback ............................................................................................... 18
Discussion..................................................................................................................................... 19
Sport Performance Satisfaction via Mindful Awareness and Self-Regulation...................... 20
Impact on Thriving: Optimism and Purpose for Sport and Beyond ...................................... 21
Practical Implications ............................................................................................................ 24
Limitations and Future Considerations.................................................................................. 26
Conclusion ................................................................................................................................. 28
References .................................................................................................................................... 30
Tables ........................................................................................................................................... 42
Table 1: Overview and Intervention Details for Sport-Adapted MBI ................................... 43
Table 2: Baseline Descriptives, T-Tests, and Chi-Squares (Time 1) .................................... 44
Table 3: Manipulation Check: Between-groups RM ANOVA Interaction Results and
Estimated Marginal Means (Times 1-2) ................................................................................ 47
Table 4: Between-groups RM-MANOVA and RM-ANOVA Results and Estimated
Marginal Means (Times 1-3) ................................................................................................. 48
Mindfulness and Thriving v
Table 5: Exploratory Analysis of CIT Subcomponents- RM-ANOVA Results and Estimated
Marginal Means (Times 1-3) ................................................................................................. 49
Table 6: Summary of Program Evaluation Open Response Answers ................................... 51
Appendix A: Extended Literature Review ............................................................................... 52
Thriving ..................................................................................................................................... 53
Facilitators of Thriving .......................................................................................................... 54
Thriving Interventions ........................................................................................................... 58
Measures of Thriving ................................................................................................................ 60
Mindfulness ............................................................................................................................... 62
Features and Historical Influences ........................................................................................ 62
Benefits for Mental Health and Well-Being .......................................................................... 63
Dosage. .................................................................................................................................. 65
Formal and Informal Approaches .......................................................................................... 66
Mindfulness Interventions for Sport ...................................................................................... 68
Connections Between Mindfulness and Thriving ..................................................................... 70
Accomplishments and Performance ...................................................................................... 71
Vitality, Meaning, and Eudaimonistic Enlightenment .......................................................... 75
Learning ................................................................................................................................. 76
Flow and Engagement ........................................................................................................... 78
Self-Efficacy, Self-Regulation, and Self-Compassion .......................................................... 80
Mental Toughness, Psychological Flexibility, and Performing through Pressure ................ 82
Optimism ............................................................................................................................... 83
Autonomy .............................................................................................................................. 83
Relatedness and Cohesion ..................................................................................................... 84
Subjective Well-Being ........................................................................................................... 84
Figure 1. ................................................................................................................................. 87
Measures of Mindfulness .......................................................................................................... 88
Appendix B: Overview and Intervention Details for Sport-Adapted MBI ........................... 90
Module 1: Introduction to Mindfulness; Values and Committed Actions ............................ 91
Module 2: Acceptance and Self-Compassion ........................................................................ 92
Module 3: Mind-Body Connection and Sport ....................................................................... 93
Module 4: Lifelong Mindfulness to Thrive ........................................................................... 94
Appendix C – Intervention Materials ....................................................................................... 95
Module 1: Introduction to Mindfulness; Values and Committed Actions ............................ 95
Module 2: Acceptance and Self-Compassion ...................................................................... 101
Mindfulness and Thriving vi
Module 3: Mind-Body Connection and Sport ..................................................................... 103
Module 4: Lifelong Mindfulness ......................................................................................... 108
Session 7-- Continuing to Build Towards Poise and Psychological Flexibility .................. 108
Appendix D: Assessment Battery ............................................................................................ 113
Mindfulness At-Home Practice Log and Mental Health Referral........................................... 128
References ............................................................................................................................... 129
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1
Living Your Best Life: The Mindful Pursuit of Student-Athlete Thriving
The performance and well-being of athletes are foundationally important goals, and the
ultimate aims of sport, exercise, and performance psychology (SEPP) practitioners. Mental
health can be understood across a continuum that spans from mental illness (i.e., diagnosable
symptoms that impede normal functioning) to mental well-being (i.e., positive mental
functioning); well-being is comprised of social (e.g., relationships), psychological (e.g.,
optimism, eudaimonia), and subjective (e.g., happiness) components (Keyes, 2002). Recently,
public disclosures from elite athletes like Simone Biles and Michael Phelps have illuminated
athlete experiences along this continuum. Phelps shared at the Kennedy Mental Health Forum:
“We’re supposed to be this big, macho, physically strong human being, but this is not a
weakness. We are seeking and reaching for help” (Prizont-Cardo, 2018). Biles noted the
connections between mental health, well-being, and performance: “Put mental health first
because if you don’t, then you’re not going to enjoy your sport, and you’re not going to succeed
as much as you want to” (Nardino, 2021).
Coinciding with these anecdotal accounts, researchers have found that a high level of
performance success does not occur without personal and sport-related experiences of adversity
(Sarkar et al., 2015). Although adversity does not cause mental illness, stressors from the high
pressure environment may magnify athlete mental health symptoms. In addition to the mental
illnesses of the general population (e.g., depression, anxiety), athletes may experience sport
specific stress related to overtraining, injury, athletic identity, transition from sport, disordered
eating, substance misuse, sleep disorders, and more (Chang et al., 2020). As athletes transition
from high school to college, they are near the developmental age when mental illness first arises
in young adults (McGorry et al., 2011), Furthermore, collegiate student-athletes report academic
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2
and performance stress and pressure from coaches, teammates, and family unique from non
student-athletes (Brown et al., 2014). With the student-athletes facing a variety of stressors
related to sport and beyond,it is not a surprise that researchers have prioritized well-being and
performance in their approaches with this population (Gross et al., 2018).
Researchers from a variety of fields ranging from industrial organizational psychology to
positive youth development are investigating the intersection of well-being and performance
through the construct of thriving (Brown et al., 2021; Lerner et al., 2011; Sarkar & Fletcher,
2014; Spreitzer et al., 2005). Although definitions slightly vary across fields, thriving is the joint
experience of consistent high-level performance and healthy development and well-being
(Brown et al., 2018). People experiencing this adaptive state often believe they are learning,
growing, and progressing towards goals or values with a sense of passion and vitality (Spreitzer
et al., 2005). Brown and colleagues (2018) qualitatively examined thriving according to the
perspectives of athletes, coaches, and sport psychology practitioners (n = 15) and identified
facilitators (e.g., training environment, self-regulation), characteristics (e.g., focused, sense of
belonging), and outcomes (e.g., optimal performance, personal development) of thriving.
A key characteristic of thriving is basic psychological needs satisfaction (BPNS), which
accounts for the necessity of humans to experience relatedness, competence, and autonomy (Deci
& Ryan, 2012). Researchers have reported a strong, positive relationship between BPNS and
thriving among both adult and youth athlete samples (Brown et al., 2021; Kinoshita et al., 2021).
Athletes emphasize that strong supportive social connections, collective team goals, and
autonomy-focused coaching facilitate thriving (Brown & Arnold, 2019; McHenry et al., 2020).
These contextual factors may foster an environment that is conducive to learning, growing,
performing through pressure, and building a strong sense of competence (Brown et al., 2021).
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Beyond contextual facilitators (e.g., motivational climate) that might influence both
BPNS and thriving, several personal factors also play a role. Goal setting, mental toughness, self
regulation, self-awareness, concentration, and mindfulness have all been identified as possible
facilitators of thriving (Brown et al., 2018; Gucciardi et al., 2017; Özcan & Vural, 2020).
Athletes, coaches, and sport psychology practitioners also reported an optimistic mindset as a
key characteristic of thriving (Brown et al., 2018). Other personal characteristics of thriving, like
vitality, meaning, and purpose, may support thriving outcomes like holistic development and
eudaimonia (Spreitzer et al., 2005; Su et al., 2014). Interventions aimed to improve these
personal factors may help facilitate thriving. For example, positive youth development programs
have been successful in improving thriving outcomes (e.g., holistic development) by focusing on
the intentional application of life skills for young people who have experienced adversity
(Pearson et al., 2021). Positive psychology interventions that guide female university students
towards pursuing intrinsically valued goals have helped increase thriving (Heekerens & Heinitz,
2019). Additionally, researchers have begun to investigate how mindfulness-based interventions
(MBIs) may improve thriving with university students (Özcan & Şahin, 2021).
Mindfulness is defined as an intentional state of accepting, compassionate, and
nonjudgmental awareness within the present moment (Kabat-Zinn, 2003). Mindfulness appears
to influence or have significant associations with several characteristics and outcomes of
thriving, such as relatedness and cohesion (e.g., Baltzell et al., 2014), engagement and flow (e.g.,
Moore et al., 2013), learning (e.g., Zhang et al., 2016), self-efficacy and competence (e.g.,
Blecharz et al., 2014), vitality (e.g., Chang et al., 2022), optimism and mental toughness (e.g.,
Wang et al., 2021). Figure 1 illustrates some of the established and emerging connections
between mindfulness and thriving. In a randomized controlled trial (RCT), Özcan and Şahin’s
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4
(2021) sample of female-identified university students (n = 19) reported significant
improvements in thriving, as measured by the Multidimensional Thriving at Work Scale
[MTWS; Porath et al., 2012], following a 6-session MBI. Seppälä et al. 's (2020) RCT with
university students (n = 131) found that exercises focused on emotional intelligence, self
compassion, gratitude, and self-regulation with breath-based meditations effectively improved
psychological thriving, as measured by a variety of well-being scales, after an 8-week
intervention. Though these studies show promising results, they used different measures of
thriving, did not include follow-up data to examine long-term outcomes, and were not with
student-athletes.
Specific to student-athletes, researchers have identified that MBIs may support the two
key outcomes of thriving: well-being and performance (Gross et al., 2018; Evers et al., 2021).
Gross et al. (2018) compared a 7-week Mindfulness-Acceptance-Commitment (MAC)
intervention group to an active control group who experienced traditional Psychological Skills
Training (PST) with 22 Division III women basketball players. The MAC intervention utilized
psychoeducation and experiential components (e.g., centering exercises, meditations) to teach
mindfulness, cognitive defusion, commitment to values, acceptance, and poise. Relative to the
PST, the MAC intervention was significantly more effective at reducing psychological distress
and generalized anxiety while improving psychological flexibility, emotion regulation, and
performance satisfaction. Using an extended (15-week) yet similar MAC-influenced
intervention, researchers explored the effects with elite female basketball players (n = 40, age M
= 16.3) via a mixed-methods design (Goisbault et al., 2022). Following the intervention, athletes
qualitatively reported benefits related to awareness, attention, and vitality (e.g., commitment
towards values and goals) in addition to significant quantitative improvements with moderate
Mindfulness and Thriving
5
effect sizes for non-judgment, acceptance, interpretations of stress, and performance satisfaction.
Mindfulness might support sport performance indirectly in several ways, including self
regulation and optimism (Wang et al., 2021). Following an 8-week MAC intervention,
participants (n = 60, age M = 19.54) reported significantly higher levels of mental toughness,
endurance, and optimism in relation to running an 800-meter race. Furthermore, when
considering the thriving outcome of holistic development, student-athlete academic performance
is also important and MBIs have also been shown to have positive academic benefits such as
self-regulation and focus (Phan et al., 2022).
Although thriving was not measured directly, these findings suggest MBIs may be useful
in supporting characteristics and outcomes of thriving in student-athlete populations. Student
athletes have reported many qualitative (e.g., vitality, engagement) and quantitative (e.g.,
performance satisfaction) improvements related to thriving, but using instruments specifically
designed to measure thriving (e.g., Comprehensive Inventory of Thriving, Su et al., 2014) could
provide a more comprehensive analysis of these connections. With an emphasis on both
performance success and well-being, the construct of thriving may be a valuable lens through
which to explore optimal athlete experiences in a comprehensive way. The purpose of this
research was to (a) examine the efficacy of a MBI in improving thriving and subjective
performance in collegiate student-athletes as compared to a control and (b) explore the
components of the MBI perceived by collegiate student-athletes to be the most helpful,
beneficial, or challenging. It was hypothesized that participants in the intervention group, relative
to those in the control group, will experience greater improvements in thriving and subjective
performance.
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6
Method
Research Design
A quasi-experimental, longitudinal design was used to gather quantitative and qualitative
data over the course of a 7-week sport-adapted MBI (with five-week follow-up data) to assess
the efficacy of improving student-athlete thriving and mindfulness.
Participants
Participants were recruited from Division II and III colleges and universities in the
Midwestern and Eastern sections of the US. With the guidance and introductions from a
committee member, the researcher emailed coaches in the region to recruit potential teams. To be
included in this study, participants were at least 18 years of age and current student-athletes on
teams with coaches that agreed to participate in the intervention. Participants or teams that had
previously completed a MBI were excluded. A total of 55 student-athletes from three teams at
two different universities were successfully recruited for the intervention, with a total of 49
participants completing time 2 data collection, and 44 completing time 3 data collection.
Instruments
Background and Demographic Information
Items asked participants to report age, race, sex, sport, years of sport participation, and
current hours per week spent practicing sport. Previous exposure and practice of mindfulness
was also recorded through an item on experiences with mindfulness.
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7
Thriving
The Comprehensive Inventory of Thriving (CIT; Su et al., 2014) was used to assess
thriving. Corresponding with Keyes’ (2002) view of well-being, the 54-item CIT contains 18
subcomponents based on the seven factors of well-being: relationships, engagement, mastery,
autonomy, meaning, optimism and subjective well-being. Participants answered items via a 5
point likert scale (1, Strongly Disagree, to 5, Strongly Agree). Item scores were added for a total
score of positive scales and negative scales, as well as subcomponent scores. Higher scores
indicate greater levels of thriving for positive scales and lower scores indicate better levels of
thriving for negative scales. All subscales of the CIT have shown solid internal consistency
across five validation samples (α ranged from 0.71 - 0.96) and test-retest reliability (0.54 - 0.83).
Internal consistency with the current sample ranged from α = .56 to .87 for subcomponents and
was α = .67 for negative scales and α = .90 for positive scales. One of the validation samples (n =
490, age M = 19.5) was exclusively university students. Convergent and discriminant validity
testing of the CIT shows moderate to strong relationships with several established measures of
well-being and negative correlations with measures of ill-being (Su et al., 2014). Although most
thriving characteristics and outcomes are represented by the CIT, to our knowledge, this is the
first time it has been used to measure thriving within a sport population.
The Multidimensional Thriving at Work Scale (MTWS; Porath et al., 2012) was used to
assess thriving through the participants experiences of learning and vitality in their sport and
academic environment. The MTWS is a 10-item, 5-point Likert scale (1, Strongly Disagree, to 5,
Strongly Agree) inventory in which scores are summed to yield a total score and learning and
vitality subscales, with higher scores indicating higher levels of thriving in the sport or academic
domain. Porath et al.’s (2012) thriving scale has commonly been used in many fields, including
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8
sport (Gucciardi et al., 2017). The construct validity of the MTWS has been supported by
convergent data showing a significant relationship with positive affect (r = .49), learning goal
orientation (r = .37), proactive personality (r = .56), job satisfaction (r = .72), organizational
commitment (r = .41), career initiative (r = .40), and performance (r = .29). Discriminant data
shows a significant inverse relationship between the MTWS and negative affect (r = -.31) and
burnout (r = -.74). Additionally, the MTWS had excellent internal consistency across validation
samples (α ranged from 0.90 - 0.94). Internal consistency with the current sample ranged from α
= .73 to .91 for subscales and composite scales for both academic and sport-adapted versions.
Subjective Performance
Subjective athletic and academic performance were reported on a 1-10 sliding scale in
which participants were asked to “Mark your level of satisfaction with your sport (or academic)
performance over the past month, from 0 (not at all satisfied) to 10 (highly satisfied)”.
Additionally, participants were asked to share two to three factors contributing to their rating.
The 1-10 subjective performance ratings scale has been used by other thriving and sport
researchers (Brown et al., 2017; Arnold et al., 2017; Levy et al., 2011) as an outcome variable in
their interventions.
Mindfulness
The Athlete Mindfulness Questionnaire (AMQ; Zhang et al., 2017) was used to assess
levels of dispositional mindfulness. The AMQ has 16 items that measure three factors; sport
specific present-moment attention, awareness, and acceptance on a 5-point likert scale (1, Never
True, to 5, Always True). Scores are added to yield a total score and subscale scores, with higher
scores indicating greater levels of sport-specific mindfulness. Each of the three factors has been
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9
shown to be internally reliable (αs = 0.64 to 0.75) and to have convergent (rs = 0.21 to 0.46) and
divergent (rs = -0.23 to -0.40) validity with four samples (n = 1302, age Ms = 19.6 to 21.6) of
Chinese athletes (Zhang et al., 2017). Additionally, reliability (αs = 0.75 to 0.77) and validation
with discriminant data (rs = -0.14 to -0.42) of the AMQ has also been supported with US college
athletes (Van Dyke et al., 2021). Internal consistency with the current sample ranged from α =
.77 to .79 for subcscales and was α = .89 for the composite scale.
The Applied Mindfulness Process Scale (AMPS; Li et al., 2016) was used to assess how
participants incorporate mindfulness practices within their lives. The AMPS has 15 items that
measure three factors; negative emotion regulation, positive emotion regulation, and decentering
on a 5-point likert scale (0, Never, to 4, Almost Always). Scores are added to yield a total score
and subscale scores, with higher scores indicating higher application of mindfulness skills. Each
of the three factors has been shown to be internally reliable (α = 0.91) and to have convergent (r
= 0.29 – 0.52) and divergent (r = - 0.48) validity with a large sample of mindfulness practitioners
(Li et al., 2016). Internal consistency with the current sample ranged from α = .74 to .87 for
subcscales and was α = .92 for the composite scale.
The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) was used to
measure psychological flexibility, which shares common features with components of thriving
(Sarkar & Fletcher, 2014). The AAQ-II assesses levels of psychological inflexibility versus
flexibility and experiential avoidance versus acceptance. The AAQ-II contains 7 items that are
rated on a Likert scale (1, Never True, to 7, Always True) and added to create a composite score,
with lower scores indicating higher levels of psychological flexibility. Bond et al’s (2011)
validation study (n = 2816) included 6 samples from a range of backgrounds (e.g., college
students, financial industry workers, rehabilitation patients). The researchers found the AAQ-II
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to have high test-retest reliability (rs = 0.79 to 0.81) and good predictive (d = 1.12) and
discriminant validity (rs = 0.49 to 0.71). Internal consistency for the current sample was α = .88.
Program evaluation
Sixteen items were used to assess participants’ satisfaction with the sport-adapted MBI,
perceived benefits, perceived challenges or obstacles, likelihood of continuing a daily
mindfulness practice, and likelihood of recommending the program to peers. Nine items were on
a Likert scale (1, Strongly Disagree to 5, Strongly Agree) while seven items prompted open
answer responses. The program evaluation items (e.g., challenges, obstacles) also captured
negative or adverse experiences of the program, which is an important facet of mindfulness
research (Van Dam et al., 2018). At the start of sessions 2-7 and at data collection 3, participants
were asked how many minutes per day they practiced mindfulness on their own to evaluate
between session practice fidelity and transfer of interventions skills into daily life.
Procedures
During the summer of 2022, the primary researcher conducted a pilot version of the
sport-adapted MBI. This allowed the primary researcher to plan, administer, and evaluate session
content, timing, and mode of delivery. Additionally, administration of the assessment battery
helped evaluate item wording, timing, and explore effect sizes for variables to inform power
analysis for sample size. After the pilot, the researchers attained Institutional Review Board
approval for the study. Convenience sampling was used to gain access to potential sport team
participants. Sports with spring championships were favored to ensure an offseason or early
season intervention, limiting extraneous variables and improving feasibility due to increased
availability of practice time. After recruitment, three Division II teams agreed to participate in
the study: a swim team (n = 33) that was randomly assigned to the intervention group and a golf
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11
team (n = 10) and tennis team (n = 12) that were randomly assigned to the control group. Due to
the smaller rosters of tennis and golf, they were combined for random assignment as an attempt
to balance sample size between intervention and controls. Student-athletes were informed of the
potential benefits (e.g., improvements of well-being, performance) and risks (e.g., adverse
reactions to meditation, loss of time) of the intervention and given the choice to participate prior
to the first data collection by a secondary researcher. Data collection occurred at three
timepoints: pre-intervention (T1), nine weeks later at post-intervention (T2), and a five-week
follow-up (T3). Data were collected in-person through an assessment battery administered in
person at the team’s facility by secondary researchers.
Pilot Intervention
Pilot participants were recruited from a team the first researcher had previously provided
consultation. Although the original intervention was planned for eight weeks, due to scheduling
feasibility, modules 3 and 4 were reduced to one week each and the total intervention to six
weeks. Initially, six participants signed up for the pilot intervention. Five participants completed
the first survey and majority of the intervention, while four participants completed both surveys
(survey took between 13 to 18 minutes to complete). There was a 93% adherence rate for the five
who participated, and sessions took on average 54 minutes. Outcome data from RM-ANOVAs
indicated large effect sizes for the AMQ-16 (ηp2
= .43), AAQ-II (ηp2
= .41), AMPS (ηp2
= .27),
CIT (ηp2
= .25), and MTWS (ηp2
= .25). A power analysis using the effect sizes for mindfulness
and thriving from the pilot study (ηp2
= .25 to .43) suggested 42 total participants as adequate for
statistical analysis with these larger effect sizes. Feedback from the participants informed the
research team of considerations regarding survey items (e.g., rewording CIT community items to
be sport-specific), mindfulness exercises (e.g., participants thought box breathing was the least
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12
useful while awareness of breath was the most useful), and modes of delivery (e.g., all preferred
handouts to write on versus slides or prompt questions with open journaling). While participants
reported practicing formal mindfulness on their own for an average of 28 minutes per week
(participants were encouraged to practice 35 minutes per week), they shared that introducing
more informal methods early on and a weekly check-in could have helped reinforce daily
practice.
After the pilot it was determined that the intervention could be adequately experienced in
seven sessions; the researchers decided to keep modules 1-3 at two sessions each, and to reduce
the final module to one session. Sport-related language (e.g., team, teammates) was added to
items 4, 5, 6, 8, 16 on the CIT to help participants clarify item meaning. Pilot participant
feedback also informed changes to modes of delivery and mindfulness exercises provided for
between-session practice. Aligning with their preferences, prepared handouts were used for each
session and awareness of breath exercises was practiced within sessions and encouraged for
between-session practice more frequently than box breathing.
Intervention Details
The intervention was led by the first author. He has ten years of experience coaching
swimming, applied counseling experience through his MEd., and six years of mental
performance consulting experience. His theoretical orientation integrates acceptance and
commitment therapy, cognitive behavioral therapy, and positive psychology. First introduced to
mindfulness in 2016, the first author has progressively embedded mindfulness into his personal
practice and professional work. With the support of the second author, who has over two decades
of mindfulness practice, the first author has instructed college courses on mindfulness.
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13
The protocol for the intervention group was influenced by sport-adapted MBIs including
MAC (Gardner & Moore, 2007), Mindful Sport Performance Enhancement (MSPE; Kaufman et
al., 2018), and especially Mindfulness Meditation Training for Sport (MMTS; Baltzell &
Summers, 2017). Specific components from each program align well with conceptual and
correlational connections to thriving and therefore were emphasized. This adaption allowed for
purposeful selection of mindfulness concepts and exercises that may promote thriving.
Participants completed seven sessions within four modules over the course of nine weeks.
Session length will varied from 50-60 minutes and included psychoeducation, didactic
discussions, reflection journal prompts, group and partner reflections, and mindful meditation
exercises with an emphasis on application to performance and well-being in sport and daily life.
Across the course of the four modules, participants were introduced to mindfulness and
acceptance concepts (e.g., present-moment awareness, attention, self-compassion, defusion,
anchoring) and asked to do 5-10 minutes of mindfulness at home each day. The researchers
considered feasibility as well as the previous research highlighting frequency and the potential
impact of brief meditations when deciding dosage recommendations (Karing & Beelmann, 2021;
Edwards et al., 2017). The researchers provided between-session mindful journaling prompts and
meditation resources to support participant at-home practice. An emphasis of the program was to
enhance mindfulness and increase value-driven behaviors by guiding participants towards
intentionally applying skills and concepts towards training, performance, and daily life. Further
details related to intervention design, justifications, and decision-making regarding the
intervention can be found in appendix B. A comprehensive outline of each module is provided in
Table 1.
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Data Analysis
14
Data was analyzed via SPSS. Descriptive analysis via independent sample t-tests and chi
squared analysis was conducted to determine the equivalence of groups at baseline. As an
intervention manipulation check, 2 x 2 ANOVAs were used to assess changes in mindfulness
and psychological flexibility. A series of MANOVAs and ANOVAs was conducted to answer
the first research question and its subsequent parts, while a pragmatic approach with basic
thematic analysis was be used for the second research question (Chen, 2016).
Two 2 x 3 group by time MANOVAs were used to answer examine if those in the MBI
group improved comprehensive thriving (via the CIT), compared to a control group. MANOVAs
allow for a sufficient analysis of complex constructs and questions, making this approach
necessary for the comprehensive definition and measurement of thriving. A 2 x 3 MANOVA
was used for all the positive subcomponents of the CIT and one was used for the negative
subcomponents of the CIT. For each 2 x 3 MANOVA, the researchers tested for multivariate
normality and homogeneity of covariance matrices. Additionally, the researchers conducted 2 x 3
RM-ANOVAs for the subcomponents of the CIT as an exploratory analysis. A series of 2 x 3
group by time RM-ANOVAs were used to assess change for the MBI group relative to the
control, in academic and sport thriving (via the MTWS), as well as subjective performance
satisfaction. For each 2 x 3 RM-ANOVA, the researchers first tested for normality and
sphericity. Post hoc comparisons were made to analyze differences between groups over time.
The second research question focused on participants’ experiences within the intervention
and was analyzed with a pragmatic program evaluation (Chen, 2016). This approach is designed
for the evaluation of real-world programs and incorporates simple quantitative and qualitative
elements to capture participants perceptions and experiences. The 5-point Likert scale items were
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15
averaged across participants so that means and standard deviations could be compared with
similar MBI program evaluations (Worthen & Luiselli, 2016). A post-positivist approach was
used for the program evaluation open response data analysis. With an understanding that while
the true objective reality of the study cannot be fully captured, it is important to allow the
participant’s words to determine themes (Ponterotto, 2005). In alignment with a post-positivist
approach, content analysis was used to determine themes from the open answer items (Wood &
Bloor, 2006). This approach allowed for the efficacy of the intervention to be analyzed directly
from participant perceptions. Consistent with previous researchers, a hybrid approach to coding
was used with questions categorized deductively (e.g., benefits, challenges), and patterns of
responses coded inductively (Fereday & Muir-Cochrane, 2006). Researchers one and three
became acquainted with the data by compiling responses into one source and reading over the
data multiple times. Once familiar with the data, the researchers independently inductively coded
responses to support the rigor and integrity of the analysis. The researchers then met to identify,
debate, and rectify patterns and themes found within the data. Once themes were identified, the
second researcher audited the themes.
Results
Descriptive Statistics and Baseline Characteristics
Independent samples t-tests and chi-squared analysis were conducted at baseline (N = 55)
to examine potential differences between the control and intervention group on DVs. The
intervention group was significantly higher in sport experience (p < .001) and hours per week in
sport (p < .001), but lower in comprehensive positive thriving (p = .02), sport vitality (p = .02),
and sport-specific mindful awareness (p = .02). See Table 2 for full descriptive baseline data.
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16
Intervention Engagement and Effects: Manipulation Check
Attendance for each session was as follows: session one (93.5%), session two (93.5%)
session three (83.8%), session four (90.3%), session five (83.8%), session six (77.4%), and
session seven (96.7%) for an average of 88.4%. Over the course of the program, participants
reported practicing formal mindfulness for 31.95 (SD = 24.89) minutes per week which accounts
for 71% of what was prescribed. At follow-up, participant practice had dropped an additional
20.7% to an average of 25.35 (SD = 21.79) minutes per week, which accounts for 56.3% of what
was prescribed.
To test program fidelity, a manipulation check was conducted via 2 x 2 RM-ANOVAs (n
= 49) for each mindfulness scale and subscale, as well as psychological flexibility, comparing the
means for these variables from pre-program to post-program of the intervention group relative to
the control. From this manipulation check, several significant medium to large effects were
found. There were statistically significant interactions of group and time on the AMPS subscale
of negative emotion regulation (ηp2 = 0.17, p = .01), the AMPS (ηp2 = 0.15, p = .007), the AMQ
subscale of awareness (ηp2 = 0.14, p = .008), AMPS subscale of decentering (ηp2 = 0.13, p = .01),
and the AMPS subscale of positive emotion regulation (ηp2 = 0.09, p = .04). As was intended, the
intervention appears to have led to moderate effects on several mindful process variables.
Although medium effects were found, there was no significant interaction of time and
group on AMQ scores between T1 and T2 for the intervention group relative to the control (ηp2 =
0.06, p = .08). Similarly, there were no significant differences in the AMQ subscale of
acceptance (ηp2 = 0.03, p = .27), AAQ scores (ηp2 = 0.02, p = .39), or the AMQ subscale of
attention (ηp2 = 0.0, p = .99). Though these patterns of data were encouraging, except for mindful
awareness which did have a medium effect, the intended effects of the intervention on self
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17
reported mindfulness and psychological flexibility were not observed. See Table 3 for full results
from the manipulation check.
Impact on Thriving: Between-Groups Differences
Two 2 x 3 RM-MANOVAs were used to analyze changes in comprehensive thriving for
the positive and negative scales. Although effects were seen in the hypothesized directions, there
were no significant condition-by-time effects for either positive (ηp2 = .03) or negative thriving
(ηp2
= .02). Due to a lack of power (Range: 0.25 - 0.49), analysis of the MANOVA results was
limited. To gain a better understanding of the changes in comprehensive thriving, a series of 2 x
3 exploratory RM-ANOVAs were used to examine effect sizes for the subscales of
comprehensive thriving. Medium effects were found for optimism (ηp2 = .09) and meaning and
purpose (ηp2
= .08). Specifically, the intervention group showed improvement of scores,
compared to the control group, on these two variables – providing some support for the
intervention effects.
A series of 2 x 3 RM-ANOVAs were used to assess changes in sport thriving, academic
thriving, subjective sport performance, and subjective academic performance across the course
of the intervention. Subjective sport performance was found to show significant group-by-time
effects with medium magnitude (ηp2 = 0.12). This moderate effect shows that the intervention
group reported greater improvements in sport performance satisfaction compared to the control
group. No significant interaction effects were found for sport thriving, academic thriving, nor
academic performance satisfaction. Results for all thriving-related RM-MANOVAs and RM
ANOVAs with estimated marginal means and notes regarding violations of assumptions can be
found in Table 4. The exploratory result details can be found in Table 5.
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Program Evaluation Feedback
As a result of content analysis, a variety of themes were produced related benefits,
facilitators, challenges, and negative experiences within the program. Participants shared that the
program was effective in providing benefits to sport (M = 4.34 out of 5, SD = .54), including
improved self-regulation (20.4%), enhanced focus (15.9%), and positive changes of awareness
and perspective (18.2%). Participants reported using mindfulness to channel the right mindset
(“helped me be calm but competitive”) prior to performance (“helped get me into the zone”), as
well as in response to adversity (“calm and collected when things get hard”). Finding a balanced
perspective (“take the good things even in dark days”) and reigniting intrinsic motivation
(“actually enjoying swimming for swimming”) also resonated with some participants. The
program also appears to have helped participants in their daily lives outside of sport (M = 4.16
out of 5, SD = .72). Participants reported academic benefits (24.2%) such as improved
engagement (“easier to pay attention in class”) and self-regulation (“nerves when test-taking”).
The self-regulation benefits seen in sport also appeared to transfer to daily life (21.2%) as
participants used mindfulness to help themselves “think clearer” and be “able to relax”.
While 87.5% of participants reported no negative or adverse reactions to mindfulness,
6.2% of participants cited an increased awareness of negative thoughts or emotions. Although
23.5% of participants reported no challenges to learning and practicing mindfulness, maintaining
focus did appear to hinder others (23.5%). The large group setting may have further contributed
to challenges with focus while meditating within sessions (M = 2.59 out of 5, SD =
1.24). Participants found the applied portions of sessions (e.g., meditation; 34.5%) and the
autonomy-supportive strategies (e.g., multiple meditation options; 34.5%) to be most engaging
or helpful aspects of the intervention for learning mindfulness. They also reported that reminders
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(18.8%) and more meditation opportunities (e.g., pre-practice; 18.8%) may have increased their
use of mindfulness between sessions. For more program evaluation data, see Table 6.
Discussion
The purpose of the study was to examine the efficacy of a mindfulness-based intervention
in improving student-athlete thriving while also evaluating their self-reported experiences with
the MBI. Due to lower than desired statistical power, findings will be discussed in order of most
to least important based on effect size and novel findings. The intervention appears to have had
the intended effect on some aspects of mindfulness (i.e., sport-specific awareness) and
mindfulness processes (i.e., emotion regulation, decentering). Inexperienced meditators may
overestimate their levels of trait mindfulness (Grossman, 2011), so the use of instruments to
measure changes in mindfulness processes may further illuminate the impact of MBIs. The use
of the AMPS to measure change and identify which processes may be most impacted within a
sport-MBI provided novel insight into how and why athletes apply mindfulness. Participants
AMPS scores corresponded with their open answers (“easier to manage big workloads”; “less
anxious for school”), indicating the MBI helped increase their use of mindfulness skills (e.g.,
decentering, emotion regulation, self-regulation, self-compassion) to manage stressful moments,
thereby reducing their suffering in their academic and performance environments. General
psychology researchers have used the AMPS to measure mindfulness processes as a resilience
factor and validation studies have shown moderate relationships between the AMPS and
measures of well-being and mindfulness (Galvin et al., 2021; Li et al., 2016). The connections
between mindfulness skills, their daily lives, and their well-being was discussed throughout the
intervention and was the culminating focus of the final session.
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Sport Performance Satisfaction via Mindful Awareness and Self-Regulation
Although the main hypothesis that the MBI would significantly increase thriving was not
fully supported, several thriving-related findings were noteworthy. Consistent with previous
literature, the MBI appears to have improved athlete subjective reports of sport performance with
moderate effects (Goisbault et al., 2022). These improvements are noteworthy when considering
contextual factors surrounding the intervention group. Improvements at T2 were the highest and
this time point coincided with several stressors (i.e., coming off a travel meet with performance
related pressure, entering final exams with academic-related pressure). Academic and sport
stressors have been shown to inhibit athlete coping and negatively impact performance (Hamlin
et al., 2019). Despite these stressors, participants reported improved performance as they were
able to, as one athlete noted, “stay calm and collected when things get hard”. In their open-ended
responses at the end of the program, athletes shared benefits such as self-regulation, poise, focus,
awareness, and self-compassion that may have contributed to their self-reported improvements in
sport performance.
Self-regulation and poise have been linked with thriving as well as sport performance
(Özcan and Vural, 2020; Perry et al., 2017; Brown et al., 2018). Noting the observed increases in
mindful awareness and decentering (e.g., defusion, non-judgement), athletes may have applied
these skills as methods of self-regulation. One of the meditations shared with the athletes, and
commonly used by the coach for pre-practice mindfulness, focused on using the breath to ground
themselves in the moment and then state a value-based intention. Athletes may have used this
awareness of values to self-regulate and direct their focus and energy away from stressors and
into the practice or performance. Consistent with elite basketball players from the Goisbault et al.
(2022) study, being mindful of sport-specific cues appears to help improve focus, which
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indirectly helps improve performance by helping athletes invest more attention and energy in
each practice session. Finally, practicing self-compassion may increase athlete resilience by
helping them move beyond mistakes and refocus (Mosewich et al., 2013). Participants reported
being able to “separate myself from my performance” and improving their “ability to not be so
critical” which might have given them the freedom and poise to perform.
Impact on Thriving: Optimism and Purpose for Sport and Beyond
Although the results should be taken with caution, the exploratory analysis of changes in
measures of comprehensive thriving indicated that a mindfulness intervention may increase
levels of optimism. These findings support the emerging evidence that mindfulness may help
reduce pessimism or increase optimism in sport (Scott-Hamilton and Schutte, 2016; Wang et al.,
2021). Athletes in other studies have previously described having an optimistic outlook as a key
characteristic of thriving (Brown et al., 2018). Furthermore, items related to optimism in the
present study were not sport-specific but generalized to life experiences. Corresponding with
these improvements, some participants reported positive changes in awareness and perspective
(e.g., optimism, gratitude) in both sport and life such as the athlete that stated they learned to
“take the good things even in dark days”. Student-athletes reporting these positive changes in
both domains is encouraging for practitioners to note when considering mindfulness as a method
to promote holistic well-being. These increases in optimism may be influenced by the
intervention’s emphasis on self-compassion and empowerment (see Module 2, Table 1). It is
possible that participants used self-compassion to dwell less on setbacks and reinterpret failure
with a more mentally tough and optimistic perspective, which their increased AMPS emotion
regulation scores would support.
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The exploratory analysis using the CIT also revealed a moderate intervention effect on
participants’ sense of meaning and purpose. A key focus of the intervention was identifying and
fostering commitment to values for both sport and life. Similar to previous MAC research,
participants in the current study may have become more aware of, or connected and committed
to, values and goals important to their sport (Goodman et al., 2014; Goisbault et al., 2022). Yet
the exploratory findings reveal an improved sense of meaning and purpose in life beyond sport.
The DII student-athletes in the sample may share common priorities with their generation (e.g.
mental health support, holistic development), leading to an appreciation for the MBI’s emphasis
on identifying values important to sport and life (Twenge et al., 2019; Gould et al., 2020). Segall
(2021) implored mindfulness researchers to integrate eastern and western approaches to
mindfulness; describing a similar pursuit of eudaimonia that is fostered when awareness and
actions align with virtuous purposes.
While some of the internal CIT scales seemed to be impacted by the MBI, relative to the
control at follow-up, most of the CIT scales and other thriving measures (MTWS) were not.
Interestingly, the means for all but one thriving scale moved in the hypothesized direction from
T1 to T2, but most experienced drop-offs at T3. This pattern may be reflective of the time of
season the swimmers in the intervention group were experiencing; while T1 and T2 were at
moderate training load periods, T3 was during the heaviest training load of the season, when
student-athletes were on a near empty campus during a holiday break. These contextual factors –
the timing of in-season assessments – are important to note for future researchers who study
thriving longitudinally with student-athletes experiencing heavy training loads. Internal factors
like participant’s mood, engagement, and sense of vitality might have been impacted by the
physical exhaustion that accompanies heavy training loads (Alfonso & Capdevila, 2022; Issurin,
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2019). Though the self-report instruments did not reveal significant findings, vitality-related
improvements (i.e. energy, intentional action, flow) were reported by some participants at post
intervention as they shared they were “less tired” and more able to “pinpoint daily goals”, “be
intentional” and “get into the zone”. Ensuring less drop-off in mindfulness practice between T2
and T3 might have further supported their recovery and sense of vitality through this training
period as mindfulness has been shown to aid stress-recovery balance (Holguín-Ramírez et al.,
2020).
While there were some self-reports of improved interpersonal skills, contrary to previous
findings, specific effects on social well-being or team cohesion were not observed over time or
self-reported in the current study (Piasecki et al., 2021). It is possible that athletes from a co
acting sport like swimming may not prioritize social factors and team cohesion as much as
athletes from co-dependent sports like soccer or volleyball (Worthen & Luiselli, 2016). The T3
contextual factors of experiencing the most intense period of training on an isolated campus may
have also limited social interactions and inhibited external factors of thriving (i.e., belonging,
community, trust, respect, autonomy, loneliness) that relate to team cohesion. Similarly, although
the researcher witnessed anecdotal accounts of autonomy-supportive coaching between T1 and
T2 (e.g., allowing the seniors to select events), athletes may have felt less autonomy from T2 to
T3 due to having their holiday break involve intense training on an isolated campus. It is possible
that the coach choosing the team to do the MBI, versus student-athletes signing up at their own
volition, also inhibited autonomy, limited engagement, and acted as barrier to thriving at a
comprehensive level. A lack of autonomy through controlling coach behaviors has been seen to
prevent thriving for female netballers (Gucciardi et al., 2017). An extended MBI like Milligan et
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al.’s (2017) 20-week program may have further guided participants to make value-based
decisions that promote self-autonomy and cohesion despite their circumstances.
When considering the academic domain, although trending in the hypothesized
directions, there were no significant changes in academic thriving or academic performance
satisfaction. While reports of academic vitality did increase over time (ηp2 = .05) relative to the
control group, the effect was not as large as has been seen in previous research using the same
instrument (Augustus & Zizzi, 2022). Participants in the Augustus and Zizzi (2022) study
watched the Headspace Guide to Meditation series (Grosso, 2021) in their health class which
may have promoted transfer of skills to the academic setting. Nevertheless, in the current study
program evaluation, approximately 1 in 4 responses about the daily life benefits of mindfulness
highlighted academic performance. Some student-athletes reported improved focus, time
management, and self-regulation of test anxiety which would correspond with previous academic
research (Milligan et al., 2017; Phan et al., 2022).
Practical Implications
The actual practice of meditation was valued over learning mindfulness concepts as 38%
of participants found the meditations to be the most engaging aspect of the MBI compared to
14% reporting psychoeducation. Facilitative factors like autonomy-supportive strategies (i.e.,
provided multiple options of meditations, discussion-based activities) were also appreciated by
participants (34.5%) which supports research from a self-determination theory perspective
(McHenry et al., 2020). Additional challenges reported included maintaining focus (35.3%),
specifically for longer meditations and in the group format. Practitioners may weigh out the costs
and benefits of dividing teams for MBIs to provide an environment more conducive to
meditation. The use of engaging games (12%) as well as more sessions and interactions (9%)
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were suggested as possible solutions by current participants, highlighting the importance of
building rapport.
From an accountability standpoint, participants somewhat agreed that at-home practice
was challenging (M = 2.88 out of 5) but some also reported the logs as being helpful in
reminding them to practice. At-home practice adherence numbers were similar to Minkler (2023)
and practice dropped-off between the end of the MBI (71% of desired dosage) and follow-up
(56% of desired dosage). A central focus of the final session was to help student-athletes identify
mindfulness resources and plan daily practices for after the MBI ended. Participants in the
current study reported higher intentions of continuing to practice mindfulness in their sport (M =
4.34 out of 5) relative to participants in other sport-based MBIs (M = 3.89 out of 5; Worthen &
Luiselli, 2016). A steeper drop-off in practice post-MBI may have been prevented by the
emphasis on continued daily application. Athletes noted that reminders would have helped them
increase consistency in at-home practice. Practitioners should consider, and future researchers
may explore, the most acceptable and effective ways of using reminders via text, email, or
physical cues in the athletes’ environment. Although the coach did implement some pre-practice
meditations, athletes suggested more meditation opportunities and easier access would have
increased their practice.
While most (88%) of the participants reported no negative experiences while practicing
mindfulness, 2 participants did state they became of aware of negative thoughts or memories.
Although the research is limited regarding adverse or negative experiences with MBIs (Van Dam
et al., 2018), this percentage of negative or adverse experiences (6% or 2 of 33 athletes) is
consistent with estimates in previous literature (Farias et al., 2020), and reinforces the
importance of having referral processes embedded in MBI protocols. While no one requested
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referral for mental health services, multiple participants responded that they already were
supported by the university counselor. Even with adverse experiences being low, having a
referral system in place when conducting MBI