The NFL’s Latest Approaches to Mental Health
One of the first questions asked was a simple but important one: Where do you put the office of your team’s mental health clinician?
In a conference room with about 100 medical professionals and NFL team employees, one club shared its answer: On the first floor of team headquarters, near the locker room and the cafeteria, where the players spend much of their time. It’s the only office in the building without windows, for privacy.
Another attendee raised his hand and asked about tips for how to connect players with the help they need, while also maintaining their privacy? A different NFL team’s director of player engagement explained that once he shares the cell phone number of the team clinician with a player, he doesn’t ask for or receive any further information, unless the player signs a release form. He also tells players he has a list of several other names, including clinicians of multiple genders and races, so they can talk to whomever they are most comfortable with.
One morning last week, Nyaka NiiLampti—a licensed psychologist hired in December as the NFL’s vice president of wellness clinical services, after three years working for the players union—was leading this discussion about how to address the mental health needs of the NFL’s 2,000 players. The agenda for this day-long Player Health Summit, hosted by the NFL and the NFL Players Association in New York, included hot topics like a 25-minute “CBD Update” and a session on concussion treatments. But the primary focus was implementing the new measures to address behavioral health and pain management that the league and the players agreed to in May.
The summit gathered head team physicians, head athletic trainers and directors of player engagement. Also present were the behavioral health team clinicians and pain management specialists that new joint agreements between the league and the players require each team to retain before the start of the 2019 season. As of last week, Allen Sills, the NFL’s chief medical officer, said “virtually everyone” had filled both positions.
In the context of the ongoing labor negotiations toward a new collective bargaining agreement this summer, the fact that new provisions to protect player health were added to the current CBA in May reflects the two sides’ ability to work together. In introductory remarks at last week’s summit, Sills introduced his counterpart at the players union, Thom Mayer, as “a real partner.” In turn, Mayer pointed to the meeting as a sign of progress over the last few years. “The idea that we would have had this meeting previously,” Mayer told the room, “is inconceivable.”
Solomon Thomas was also in New York last week, spending part of the summer break from the NFL calendar on a media tour along with Christine Moutier, the chief medical officer for the American Foundation for Suicide Prevention. After Thomas’s older sister, Ella, died by suicide in January 2018, the 49ers defensive end began to use his voice to speak about mental health and suicide prevention. About five months after losing Ella, Thomas and his family participated in an overnight walk for the AFSP in Dallas, one of his first steps in becoming a mental health advocate. “I realized what I can say can really help other people, or really help myself, or get a conversation started,” Thomas says.
He’s been part of a growing conversation about mental health beyond the NFL, but also within it. Last season, Vikings defensive end Everson Griffen spent five weeks away from the team to focus on his mental health. Thomas’s 49ers teammate, Marquise Goodwin, sat out for two weeks as he and his wife, Morgan, processed the grief of losing twin baby boys 19 weeks into her pregnancy. And midway through last season, the 49ers helped Thomas address his own mental health in the wake of losing his sister. GM John Lynch, who drafted Thomas and once took a class with him at Stanford, told him that if he needed some help, they could connect him with a therapist.
“He could kind of tell, I was probably putting a mask on in front of my teammates,” Thomas says. “That was really helpful, really powerful for me, to have John reach out to me like that and help me continue to get mentally healthy and to continue my walk through my grief process.”
The increased spotlight on both mental health and the use of painkillers, both inside and outside the NFL, played a role in the new guidelines being adopted for the 2019 season. Over the past several years, the NFL and the Players Association have worked to establish mental health resources for both current and former players, but these have varied team to team and many players have said they aren’t aware of everything that is available. Now with regulations written into the CBA, which could thus be grieved or penalized if they are not met, the bar has been raised.
About 90 percent of teams were already working with a clinician in some capacity, NiiLampti said, but those clinicians were at the clubs an average of three hours per week. The new agreement mandates they must be available to players at the team facility a minimum of twice per week, for at least 8 to 12 hours—a significant increase. And while past education included steps like an hour-long module for rookies or a slide-and-a-half during training camp, clinicians will now conduct at least two mental health education sessions per season. Teams have emergency action plans for other serious health concerns—cardiac emergencies, heat illness and severe neck and spine injuries—and now they will each create a plan for mental health emergencies, to be reviewed and rehearsed annually.
The question about office location is a common one, because teams are trying to work through the best way to fully integrate the presence of the clinician, most of whom have not been listed among the “medical staff” on team websites. One team at the summit in New York said that the clinician is the first meeting rookies take as part of their orientation; another club said that they make sure the clinician is visible, on the practice field, on the team plane and in the lunchroom, to normalize his presence. At an identical summit in Las Vegas—teams picked one of the two to attend—one club said its head coach put his arm around the clinician while meeting with players and said, “I use this person. My family uses this person.” But even with these steps, there are hurdles in getting some players to feel comfortable seeking them out.
“Some guys won’t sit at the same lunch table as our team therapist, because they are like, I don’t want anyone to think something is wrong with me,” Thomas says. “I have heard guys say out loud, ‘Oh, I can’t sit at that table.’ I’m just like, why? There’s a huge stigma about that; people are still afraid of therapists, still afraid of getting help, because they don’t want anyone to know that anything is wrong with them.”
Men overall are less likely to seek out mental health resources than women, studies have shown, but there are specific stressors in the NFL compounding that. Players are taught not to trust fully anyone in the building, because they can be cut or traded at any time.
“Guys are fighting for their job every day,” Thomas adds. “So they don’t want to have anything seen as a disadvantage or a reason to not be the one chosen. ‘Oh, both of them have the same amount of yards and TDs, but he has mental health problems.’ That’s scary to some guys, I guess. But, it’s something that needs to change.”
For these reasons, during the mental health discussion at the summit, NiiLampti described confidentiality as the “lynchpin” to making the program work. One team clinician described how he keeps a case file totally separate from the team for every player he sees, as if they were a patient at his private practice. Another clinician said he has never been asked by management about any interactions with players, which is why he continues to work for his team. It’s customary in clinical medicine for mental health records to be separate from all other medical records, and the joint mental health agreement includes stipulations for that, according to Sills: The only mental health information that should be entered into a player’s electronic medical record is any psychotrophic medicine he is taking, to avoid his being prescribed a drug that could interact.
Teams were also encouraged to have a referral network of multiple mental health professionals, both to address specific topics such as substance abuse or family counseling, and to ensure that players have options beyond the team clinician. One team’s director of player engagement simply posts their names and contact information on a bulletin board outside his office, so players don’t even have to ask him for a referral.
Thomas says he chose to see a therapist who is outsourced by the 49ers, rather than an in-house employee, which made him more comfortable talking about both on- and off-the-field stressors. He started meeting with her once a week in a room at the team’s headquarters in Santa Clara, Calif. Before he started working with her, Thomas says he didn’t know how to talk, who to talk to, or where to start. She worked with him on acknowledging all the emotions he was feeling after losing his sister, how to release his anger and different coping mechanisms and outlets for his grief. By the end of the season, Thomas began to see a difference in his play on the field, too. He began to recognize the player he was watching on film again.
“I honestly felt like I was running in sand sometimes, or running in mud,” he says. “Then just being able to feel that twitchiness again, that explosiveness. … That’s all due to my head clearing up, or being able to freely live, I guess.”
During OTAs this spring, 49ers coach Kyle Shanahan brought in a group of Navy SEALs for a training session focused on the mental side of the game. After a team-wide discussion about how to cope with stress, they opened up to the floor to anyone who wanted to talk. Thomas stood up and talked about how mental health affects physical health, and that he deals with his mental stress through seeing a therapist. If his teammates see him coming back from a session with his therapist or finishing up a phone call with her, he’s open about telling them what he was doing, hoping they can see it as he does—just a normal part of his routine.
“If our brain’s not working, our bodies aren’t going to work. I said one way I dealt with that was through therapy, and so I hope that motivates guys … Just trying to let them know that nothing's wrong with it—it’s a good thing, it’s for help,” Thomas says. “If guys do it more openly, and the culture of mental health changes in the NFL, I think that is going to change a lot. Because we are a very masculine, tough sport. If we start that change, it will echo throughout the whole league and society as well.”
When Sills was hired by the NFL two years ago, he says Roger Goodell asked him for the major health issues he believed needed to be addressed. After concussions, Sills listed behavioral health and pain management. Around the same time, in the spring of 2017, the players union filed a grievance alleging that the NFL and its teams conspired to violate the terms of the CBA regarding the use and dispensation of opioids and other prescription painkillers; it cited a federal lawsuit filed by the widow of former NFL fullback Charles Evans. “We had significant concerns,” Mayer says, “but I truly feel this is a great example of something good coming out of a disagreement.”
What stole the headlines when the health and safety agreements were announced in May is that the NFL and the players union agreed for the first time to work together on studying alternative pain management therapies for players, including marijuana. They’ll do so as part of two new joint medical committees that will make recommendations on policies and practices for pain management and mental health and wellness. A new prescription drug monitoring program will also track all prescriptions issued to players, reviewed by both the league and the union.
At last week’s summit, team employees listened to a 15-minute presentation on alternatives to opioids, followed by the CBD update led by Kevin Hill, an addiction psychiatrist and author of Marijuana: The Unbiased Truth About The World’s Most Popular Weed. (The MMQB was only invited to sit in on the first hour of the summit, including introductory remarks and a session on the behavioral health practices.) Sills said the joint pain management committee has already met with a couple of experts about the current state of research and will explore ways they might be able to further ongoing research into marijuana and its derivatives. Several players have advocated for the NFL to change its policies to permit marijuana use for pain management, but Goodell and medical advisors on both sides continue to indicate that more information is needed.
“My opinion, and there are a lot of us who share it, is that opinions and attitudes are far outstretching the science behind CBD right now,” Mayer said. Added Sills: “We are open-minded to look at every aspect of how we can better treat pain, but it’s from a data-driven perspective. … We will let the science take us where we need to go.”
As players begin reporting to training camps this month, teams will start sharing information on the new mental health and pain management rules. It’s not a coincidence they’ll be addressed together; one affects the other. The goal, NiiLampti said, is to work with players to prevent an emergency or crisis stage, and that these services can help in optimizing player health and performance. Some clubs, like the one that has a “prevention team,” to this end, are farther along. Others are still figuring out the clinician’s office location. “Guys care about that,” Thomas says.
“I think we will have some [situations] … where there’ll be some players who maybe are held out, or missed games or practices for ‘medical reasons,’ That'll just be the end of it,” Sills says. “And we should all be comfortable with that reality.”
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