Podcast: Supporting the Mental Health of Student Athletes

Jeff talks to Cali Werner about her experiences as a student athlete with mental health challenges. They discuss the accessibility of mental health care for student athletes, and where students should turn for help. They also talked about ideas for how coaches and school counselors can better support the mental health of their athletes.

Cali Werner, LCSW, is a clinician and researcher with expertise in OCD and related anxiety disorders and their impact on competitive athletes. She is also a highly successful distance runner and mental health advocate. She received her master’s in social work from Baylor University and credits her own OCD diagnosis with leading her to a career of providing evidence-based care.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for another episode of our educational webinar series.

Our focus today, supporting the mental health of student athletes. And what an important topic this is.

Student athletes are pretty remarkable individuals, right? They train, they compete, they represent their schools and their teams. They inspire us, and they do all this while navigating their academic obligations as well.

But just think about all the pressures that these athletes must feel, whether self-imposed or put on them by others, these pressures can mount, and unfortunately, they can impact mental health.

So today we want to explore some ways to spot the signs and symptoms of mental health challenges in athletes. We also want to look at treatment options for those who are struggling with depression, anxiety, eating disorders, and substance misuse, for example.

Our guest today is someone who knows firsthand about both student athletics and mental health challenges. Cali Werner is a licensed clinical social worker, a clinician, and a researcher.

She has expertise in OCD and related anxiety disorders, and their impact on competitive athletes. She herself is also a highly successful athlete, a distance runner. In fact, as a Division 1 athlete at Rice University, Cali won nine conference championships.

Moreover, she credits her own OCD diagnosis with leading her to a career of providing evidence-based care. Cali, it is so great to have you with us today.

Cali: I am so happy to be here.

Jeff: Well, you and I have a lot in common, and I’m not talking about athletics. I am hardly an elite athlete. What we do share, though, is a passion for mental health advocacy based on our own lived experiences with OCD. And I’m really looking forward to our conversation today. It’s great to finally meet you, at least virtually.

Cali: I am so, so excited, and yeah, I completely agree. I think the OCD advocacy side of things is near and dear to my heart. And so just to be able to tie in personal and clinical experiences is something that I’m really passionate about.

Jeff: Listen, because your background has informed your specialized work so much, I want to start a little bit with your backstory. What are your earliest memories of struggling with anxiety?

Cali: When I was really young, I would go around the house. This is one that I actually don’t even remember, my parents told me this story. But I would go around the house tapping my nose and saying, “Sorry, God, sorry, God, sorry, God.”

Which is, for those listening, a form of scrupulosity, a subtype of OCD where you fear something bad will happen if you do something wrong. And so for me, it was really tied to my faith, and I thought if I could have possibly sinned that God was going to let my nose grow like Pinocchio.

So that was my compulsion of touching my nose at age four. And that’s the earliest that it happened, but of course I remember some different things as I got older.

Jeff: What did your parents think about that at the time? Did they have a framework for understanding what was going on?

Cali: No, so I actually didn’t receive a diagnosis until I was 21, when symptoms got a lot worse. But my parents kind of just, at the time, labeled it as quirky, you know, Cali’s quirky, and did what they needed to do to help me get from one step to the next with as little sticky thoughts as possible.

I even remember a time where my mom had me do an exposure without knowing she was having me do an exposure of tapping a table three times, because I hated the number three, and it caused me a lot of stress.

Jeff: And what do you remember your thoughts about this being as a kid? I mean, do you, do you stop and think to yourself, “This doesn’t make any sense,” or do you think that all kids do this, or what’s going through your mind?

Cali: You know, I think I was definitely less self-aware at the time. I do remember apologizing to my best friend a lot for things, and I was like, “She never apologizes for this kind of stuff,” “why do I feel like I need to?” Which was another anxious tendency that I had.

And so I think I very briefly at times would think back to, “Okay, this isn’t what I should be doing, I hate that I feel this way.”

Jeff: And at what point did you start getting interested in athletics? Were you always a runner?

Cali: I always played sports. So as a little kid, I would say I didn’t play sports well. I was the soccer player that would go pick flowers out in the out fields.

But I went from soccer into basketball and I played volleyball. And I actually thought I wanted to play volleyball competitively. I did some running, and when I was in elementary school, the PE coach was a distance runner. And so I won our local turkey trots there, and surprisingly, he was also the high school coach.

And so when high school came around, I thought I wanted to go to college for volleyball. So I was really going to focus on that and I didn’t sign up for the cross country team, and he actually called my parents’ home phone number and said, “Why isn’t Cali out for cross country?” He remembers me winning these turkey trots as a kid.

And so I ended up doing both, which I’m really grateful for, because definitely didn’t have a chance at a scholarship in volleyball.

Jeff: So you had the early anxiety, you had the early interest in sports. At what point did they merge and what did that look like initially for you? How did the anxiety impact your running?

Cali: I didn’t really notice much OCD tied to my sport until I started getting a lot of success in high school.

So we were 4A at the time, and now it’s 5A, but we would go to state and I was still playing volleyball and doing cross country, and so I think I got third at state and that kind of put me on the map for recruitment and all of those things. And so that pressure became quite a bit.

So anytime I’d have a big race, I would say maybe starting my sophomore year of high school, some magical thinking, superstitious behaviors, and a lot of anticipatory anxiety, to the point where I was crying the night before a big race.

It all kind of started to build and got a little bit worse and a little bit worse until my family and my coach were doing a lot of accommodations just to help me get to the start line.

Jeff: What was the level of awareness, both from your own perspective and from your parents’ and your coach’s perspectives at that point, in terms of whether or not this was a mental health challenge or just some quirks that you were dealing with?

Cali: I think that they all kind of attributed to, “Well, yeah, this is tough for Cali, but it’s what it takes, right?” In their minds, they were like, “It takes this grind, it takes this extra pressure in order for her to be successful,” because I believed that.

I believed, “Well, I have this much success because of how my brain’s wired,” which now I know is not the case at all, and it doesn’t take that, and that’s why I’m a big advocate for the psychoeducation behind it.

But they were all trying to remind me to have fun along the way. My coach’s favorite saying was, “It’s a party out there, don’t forget.” So as I would line up at the starting line, I’d think, “Okay, this is a party.” Because for me, I was already taking it too seriously, and that’s why I think we have more research in how different athletes respond to different coaching styles.

I didn’t need a coach to tell me, “Go out there, grind, give it all you’ve got,” because that would’ve just made me more anxious. I needed someone to remind me, “And also enjoy it.”

Jeff: Cali, give us some specific examples of the way that your compulsions were getting in the way of the running.

Cali: So one thing that got pretty bad was I couldn’t tie my own shoes before races, especially the big ones. So if it was a race, a local meet where there wasn’t as much competition, I could do it on those races, but regionals, state, nationals, I would just redo, and redo, and redo, because I couldn’t get that just right feeling.

And I thought, “If my shoe isn’t just right, I’m going to lose this race or I’m not going to qualify.” And so I would try four or five times, and you put on a different pair of shoes after you warm up in cross country, so you have your regular running shoes and then you put on spikes.

So, when I was putting on the spikes, my coach just knew to stand by, because otherwise I’d be late to the starting line, and then I’d start off flustered.

And so he often would just take over and say, “Okay, let me do it, and then you’re not going to touch it anymore.” And that was one of the big ones. Another one was still tied to that scrupulosity, moral component of OCD where I would feel like I needed to be on good terms with everybody.

Like if somebody was mad at me, that would weigh me down mentally in the race. And so I would go to anybody that came to the race to watch me and I would say, “I’m sorry if I offended you, I’m sorry if I offended you, I’m sorry if I offended you,” just down the line, and they kind of just accepted it as that’s Cali’s thing.

And I was somehow still able to hide it from a lot of the people I went to high school with. This was more like my very best friends knew and my family all knew, or family friends that came to watch, they all knew, but I kept it as hush-hush as I could. And my coach obviously knew, ‘cause he was tying my shoes for me.

Jeff: And that, of course, would be sort of an accommodation that is counterproductive. We’ll talk more about that when we get into the actual approaches for dealing with some of these OCD, and perfectionism, and anxiety issues.

One of the cruel twists of OCD for so many of us is that those of us who battle these obsessions and compulsions are acutely and painfully aware of how nonsensical they were. At what point were you dealing with that sort of self-awareness as you were out there on the field doing what you were doing? Thinking, “This doesn’t make any sense.”

Cali: I think it took a lot longer than it needed to. So there were a couple times here and there in high school where I had a really big trigger, and I remember my family members saying, “Well, you can’t handle doing things like that Cali, because you have too high of anxiety.”

And so at those times, I was like, “Ah, why do I have too high of anxiety?” But it was really in college when I started having a lot of intrusive thoughts, and you know, harm OCD, sexual intrusive thoughts, fear of having another mental illness, that I was debilitated, right?

I felt afraid to kind of just go from one place to the next. I was scared to go into a restroom by myself, because I thought, “Well, what if I harm myself when no one else is there?” And then I was also scared to go in the restroom with someone else, because I was like, “What if I harm them if we’re in that restroom?”

And so I remember doing things like, I mean, as a distance runner, you’re drinking lots of water, right? And so I would hold going to the bathroom until I got home, I lived off campus, from the school day.

And that was a big wake up call of like, “Well, this isn’t normal, I’m a distance runner, why can’t I use the restroom?” So I would say probably my sophomore year at Rice, that’s when I started. I was injured my freshman year, I had a stress fracture, and I think that actually I didn’t have any of the OCD coping skills I needed.

And so the symptoms kind of went down because I didn’t have that pressure of running. But then my sophomore year, started racing, started getting some success, and it came back, I would say, with a vengeance.

Jeff: Was there a particular turning point where you said to yourself, “I need to get help?”

Cali: You know, I was so terrified of being told that there’s something wrong, or for harm OCD, a common fear that individuals have that keeps them from seeking support is like, “What if I go to jail for these thoughts,” right? Even though we know that that’s not the case at all.

And so I kept it to myself quite a bit, but I was terrified. I was thinking like, “I’m going to have to...I don’t know how I’m going to continue on at school.” And so it wasn’t until I went home for Christmas break that my parents saw how much I was struggling, and they said that there’s something...

My mom actually had done some research on her own and she goes, “I think this might be an OCD thing.” And so we finally got me plugged into the right provider, and they just validated a ton of the intrusive thoughts I’d been having and were able to put a name to it, and it was a relief, but also not enough to help. I needed to do the exposure work to get to a better place.

Jeff: We’re going to talk much more in detail about that exposure work, but fast forward the story for us.

At what point, Cali, did you say, “You know, I’m going to take what I’ve been through and give back to others who are going through something similar by becoming a therapist,” and actually doing the same work that basically saved your life and turned things around for you?

Cali: It was pretty soon after I got plugged into the right support, because I think my eyes just opened to how long I had been struggling. I had, since age four, I had been dealing with OCD tendencies and symptoms on and off, and had a lot of times after, I was able to see, “Oh this was OCD, and that was OCD, when I was 10 and I did this, that was OCD.”

So I was able to see how debilitated I was at times a little bit more clearly. And then also was able to recognize that if I would’ve just had some of that help a little earlier, that would’ve saved me a lot of pain along the way.

And so that’s where I became passionate about evidence-based practice. And another really big turning point for me was when I was really suffering, I think I was at my worst with my OCD, I remember telling myself, “If I can just help one person after this, then I’ll know it was worth it.”

And that helped me to hold on and just get to a place where I could keep challenging the exposures, ‘cause exposure work is hard and I know we’ll get into that, but I just held onto the fact if I can just help one person. And so when I started thinking, “Well, I could help a lot of people by doing this work,” I jumped on board pretty quick.

Jeff: Well, it’s so inspiring to hear your story and what you have done with your challenges and what you’ve been through. We’ll talk more about your personal journey and some of your athletic accomplishments as well.

But right now I want to ask you to sort of pull back the curtain for us and help us understand the pressures on student athletes. We talked about anxiety, and OCD, of course, is one particular challenge, but kind of give us the whole spectrum of challenges that a student athlete might face while going through high school and collegiate athletics.

Cali: Yeah, so I think one that we all, athletes or not, know, is the juggling of your schedule, right? So athletes are in high school going to school and practicing their sport. And I think I would argue that in high school, that’s one of the times that adolescents are comparing more than any other point in their life, right?

They care a lot about what others think and now it’s even worse, I would say, with social media and the comparison that happens from that. And so that’s a big piece from the high school component.

And then when you get to college, I think there’s a whole ‘nother can of worms of, “Okay, am I going to be able to keep my scholarship?” And that time management is crucial. And athletes are known for having a lot of resilience, and I think in our world of mental health we still have a lot of stigma to uncover, but a lot of athletes perceive resilience as being able to tough it out.

Like, I don’t need help, I’m not going to get support, I can do this. And so that’s a really big mental barrier that we have to uncover, that actually resilience is getting the appropriate support and working through some of these challenges.

And so yeah, there’s just a lot of stigma with having to be the best, having to make sure you’ve got it all together, fear of what teammates might think if they find out that they have a mental illness. And so just keeping it hush-hush is actually doing a lot more harm than good.

Jeff: How many of these challenges, percentage wise so to speak, are self-imposed versus put on you by others around you?

Cali: I mean I think it’s probably a big combination, right? Because they’re hearing this from somewhere in the environment or from other athletes, but a lot of it is that internal cognitive distortion type of thought, so to speak, where they think of the “what if,” like what if people won’t accept me for this?

But I think there’s been a picture painted somewhere along the way, and we’re repainting the picture now by having a lot of professional athletes actually speak about their Olympic journeys with a mental illness, or celebrities talking about their struggle with a mental illness.

By being able to see that these individuals that everyone looks up to, inspires to be like, also struggle normalizes it a little bit more, but it’s still tough.

Jeff: Let’s ask you to walk us through some of the mental health challenges that develop based on these pressures. I mean, we talked about anxiety and we talked about OCD. What about depression, and substance misuse, and eating disorders?

Cali: Yeah, so I would say that the NCAA identifies the main pressures for athletes or the main mental illnesses as substance abuse, anxiety related disorders, and depression. And so these are very, I mean, you could see how pressure would exasperate any of these symptoms, right?

And athletes are, in my mind, I look at it as like there’s this time that they have to be a little bit more efficient with, and then also this desire to achieve and do well for their school or make their coach proud.

And so all of these pressures can kind of feed that need for, “Well, I just need to have some relief,” or, “I need to have an escape,” which can lead to that substance abuse side of things.

And then when we have anxiety related disorders, a lot of the pressures to perform can become so much because you anticipate or you think about the worst case scenarios and you focus on those, and then eating disorders are another comparison trap.

Where with distance running, we see a lot of eating disorders and actually this I have to be thin in order to run fast, or if one teammate struggles with an eating disorder, it is like a contagion bomb, because that individual might have a little success for a short period of time.

And so then others think, “Oh, well that’s what it takes. That’s what I have to do,” which is so not the case, And we need to have that mindset of stronger, not thinner.

Jeff: Yeah, the good news about these conditions that you’ve listed there is that they’re treatable. I guess the bad news is that there are a lot of barriers for treatment for student athletes.

And let’s talk a little bit about some of those barriers. Based on your experience, just how accessible is mental healthcare for the student athlete in high school and in college, for example?

Cali: So resources, like financial resources, can be a huge barrier, right? A student athlete has enough to live, maybe not enough to get specialized treatment.

They might be able to have their clinical care covered by a school counselor, but that school counselor might not specialize in the type of therapy that they need. Or if they have an eating disorder, that form of cognitive behavioral exposure care is very different than maybe general talk therapy.

And so that’s a huge barrier. Another one is this fear of, “My coach is going to find out.” That’s what a lot of the research shows is, “If my coach finds out, what if?” Or, “If my teammates find out, what if?” That’s another big one.

And then for high school, I think that there’s still this brain development that’s happening. In high school and college, frankly. But where there’s this dismissive side of it of, “Oh, well no, I don’t have a problem, I’m just supposed to be tough, right?”

And I mean, college athletes struggle with that too, but just this power through mentality, or be tougher, or that’s not something that I’m allowed to deal with kind of mentality.

Jeff: Is it your sense that high school and college coach coaches are sufficiently trained to recognize some of these mental health conditions?

Cali: I think it very much depends on the coach and the coach’s background and experience, but yes and no, right?

So I think some coaches do have the knowledge to be able to recognize and send them to the appropriate places, but then there’s others that, for example, even from an elite perspective, I love sports psychology and I’m very passionate about it, but often sports psychologists are not trained clinically, and some are, which is incredible.

But if an athlete is going to their sports psychologist and if they have OCD, that sports psychologist probably isn’t, maybe, going to recognize, “Oh, this is OCD,” and might continue to give them reassurance instead of giving them, “Oh, this is the appropriate care that you need.”

And sports psychologists have to juggle a lot with the whole team, if they are assigned to a team. But yeah, it’s a tricky road but overall, my answer is I think coaches need more education, and I know that a big barrier to that is time, so we have to find an efficient way to do it.

Jeff: You’ve talked a couple times now about stigma around mental health treatment, even, for college and high school students. What does the trend line look like on that? Is it better now than it was when you were going through high school, for example?

Cali: Absolutely, I mean, I think we know, just to use OCD as an example, over the past 30 years we’ve known more about OCD than we had in all of its existence. And I would say that’s kind of the same across the board with mental illness.

We do know more about it, we know more about the specialties that are more beneficial for some diagnoses than others, but we still have a ways to go, right? Like the average length of time for someone to receive appropriate care for OCD is still years and years. And so I think we need to shorten that treatment gap even further.

Jeff: You referenced this earlier as well, I believe, that a number of high profile athletes are starting to speak out about their challenges with mental health. Is that making a difference?

Are we seeing some role models out there opening doors for others to follow in terms of getting treatment?

Cali: Absolutely, and I’ll speak to that on a personal level of working with athletes. When an athlete comes in, a young athlete, when they come in and are struggling, or are shy about opening up.

If they’re a distance runner, being able to just say, “Well, did you know Molly Seidel, she just got third in the Olympics, she just wrote her own story about OCD, and anxiety, and eating disorder struggles.” And they’ll be like, “Oh, she did, really?”

And then there’s just this burden that’s released from their shoulders, like they feel a little bit freer and I think there’s this sense of hope, “Well, she was able to overcome that and I want to be able to do that, so I can do it too.”

So there’s a huge benefit, especially in the younger athletes, being able to see that their superheroes have also struggled and gotten care.

Jeff: Wanted to zero in on your own professional expertise right now, anxiety, OCD, perfectionism with athletes. Talk us through some of the treatment modalities that are used to address anxiety and perfectionism in athletes.

For example, cognitive behavioral therapy, exposure, response prevention. What do you want us to know? Kind of paint the picture for us, if you would.

Cali: Yeah, so if I were speaking to somebody that was newly diagnosed with OCD, I would want them to know, let’s say that, or perfectionism, that they had some tendencies to maybe their pre-performance routine, where they were getting ready, were doing it at 100% perfection, was really hard for them to get out the door on time because they get stuck.

Well, we might talk about how exposure with response prevention is an ease in basis, right? Because if I go into this session with a client and I say, “Well, for the game that you have next week, just put your hair up without using a mirror.”

Because maybe they’re getting really stuck on having their hair look perfect right before a big competition. And if I say that to them, and that’s something that they couldn’t even fathom, well, they would never want to come back into my office again.

So a big way that we try to emphasize is that it’s baby steps, right? So we might start with a small exposure, but what we’re doing in exposure therapy is introducing the individual to that fear and teaching them that their brain can tolerate the uncertainty that for so long it said you can’t tolerate it.

Because most anxiety disorders have a common denominator of feeling like you can’t tolerate the uncertainty, feeling like you have to grasp a sense of control by doing some superstitious behavior or being overly perfectionistic. And we’re trying to, one, see how that road can often lead to burnout, but then, two, find the balance, right, of being able to live freely and enjoy your sport.

And so there’s some acceptance and commitment therapy there too, because we’re trying to get them back in line with their values of, “Well, you can drive and you can try to reach for perfectionism at 100%, but that’s not sustainable. And anytime that you fail, because you will as an athlete, then we don’t want that to crush your world, right? We want you to have this balance.”

And so that was a lot of answers to one question, but you know, teaching them that exposure with response prevention is an ease in approach. We’re doing some smaller exposures over time until they feel that that is easier, and then lo and behold, over time, they get their life back.

Cognitive behavioral therapy, we’re reframing distorted thinking patterns. So if an athlete tells themselves, “I’m not going to do well, I’m not going to do well, I’m not going to do well,” well, if they’ve rooted that in their brain, more likely than not, they’re not going to do well.

And so giving them some tools to have some positive reframing of their thoughts so that they can believe in themselves, enhance their confidence, and we know that confidence is tied to positive sport performance, that’s really important.

And then the acceptance and commitment piece is to help them not reach that level of burnout, fall in line with all of their values instead of just the one of being a good athlete.

Jeff: I’m thinking back on your own story, Cali, and you talked about how coaches and others around you, with the best of intentions, essentially accommodated some of your quote unquote quirks.

With the benefit of hindsight, talk about why that’s not productive in the treatment of OCD, for example.

Cali: Yeah, I’ll start off by saying, if someone listening has been accommodating and is just finding out for the first time that that’s not helpful, well, I think anyone would do that, right? When you see your loved one struggling, if you don’t have any knowledge of OCD or an anxiety disorder, you’re going to try to help a person that you care about not suffer in the moment.

But it is counterproductive and there’s appropriate tools to help them, because we really want that individual to be able to have independence for the long term, right? To be able to tie their own shoes, if that’s the appropriate age, they should be tying their own shoes, and feel a sense of confidence instead of fear.

And so yeah, if my coach was tying my shoes, it was just reinforcing that fear in my brain that I couldn’t do it. It was reinforcing, “Well, that’s what has to be done in order for me to have a good race.” And usually when someone has that component of OCD, if you feed it a little, it wants more, right?

So I’ll give an example of my shoes. It was just the shoes that I had an issue with, but then I had a good race, and so I started remembering, “Oh, but I also used this shampoo that night before, and so I better use that shampoo again.”

So it was the shoes and the shampoo, and then I remembered I had four bobby pins in my hair, and so I better make sure I have four bobby pins in my hair. And it just becomes all-consuming, whereas we should target it before it gets to that point.

Jeff: We’ve had several questions come in, let me just kind of sprinkle them in as we go here, Cali. One is from a high school counselor who says that he or she is working with a student who has been diagnosed with OCD.

What general suggestions do you have for providing support in a constructive way?

Cali: Yeah, I think some general tools for them would be to be able to recognize the symptoms, put a label to them, give them some OCD education so that they normalize it. Because often at that high school age, you do feel so out of the norm when you’re struggling with those thoughts.

So, normalizing it, helping them know it’s a lot more common than they think. And then, depending on the severity, getting them plugged into an ERP provider, that’s that exposure with response prevention.

I would say even if they’re noticing some OCD tendencies, it doesn’t hurt to get them plugged in sooner rather than later so that they can get some of those preventative skills, because at the high school level, there’s some stress, and at the college level, there’s more stress, so you would rather have those preventative skills.

We know that stress can lead to an increase in obsession and compulsions. But yeah, the ERP side of things, any way they can get plugged into some of that will be really beneficial.

Jeff: Another audience member wants to know is there a typical age of onset for OCD, and are there particular triggers that can set it off?

Cali: So there can be OCD, I think they’ve found it in as little as two year olds, is what I think the latest research has said. But usually we see it around that 21 age range is a common onset, but it doesn’t have to be.

And then when someone is diagnosed, that gap in time often can be difficult, right? Because like for me, I was diagnosed at 21, but my onset was much earlier, at age 4. And so depending on that. And I think there was a second part to the question that I might need to have repeated.

Jeff: Let’s talk a little bit more about the values aspect of all of this, in terms of act. Can you share from your own experience, for example, how your personal values have factored into your own ability to sit with anxiety and do the hard work of OCD treatment?

Cali: Yeah, this is one of my favorite questions. So I would say with sport, I started to resent it. I hated it. I was still having success in college somehow. I was on the path to go to shambles, very on the edge of that cusp if I had gone any longer without ERP.

But my anxiety, my mental illness made me resent my sport, because I didn’t have the coping skills and it exasperated my symptoms when I had to compete. And so now I’m very passionate about kind of just living that ERP lifestyle, and I’ll get into what that is in a second, but I think any athlete that values a sport should be able to love it again.

And if they don’t, asking themselves, “What is it that’s making me not love it,” right? Is it that I am engaging in obsessions? Am I trying to reach perfection? And if so, it doesn’t have to be that way because you want to be, I mean, not all athletes, but a lot of athletes want to be able to perform in their sport for a long time, right?

Especially at those higher levels. In the college level, they might see themselves still maybe running after college, maybe not competing professionally or anything like that, but if it weren’t for the appropriate support of me learning the balance of, for example, that ERP lifestyle is for me to go on a run now, and if I have a five mile run that day, to every once in a while just test it and say, “I’m going to run 4.9 miles today.”

And see, of course that still makes me feel a little ugh, but it doesn’t cause me debilitating anxiety. And that’s just a reminder that I’m in the driver’s seat and my anxiety disorder isn’t.

And so if we can recognize that balance of, “Yes, I’m an athlete, but I’m also a mom,” or, “I’m also a daughter,” or, “I’m also a best friend,” it shouldn’t all be tied into that, because nobody can handle that much pressure.

Jeff: It’s interesting, there’s sort of a paradoxical aspect of this whole OCD treatment isn’t there? In that the goal is not to get rid of the anxiety, it’s to embrace it, to understand that you can live with it.

Cali: Absolutely, yeah, so that’s another really hard thing for people to accept, right? When they start doing their work with an anxiety disorder, they measure success often by, “Well, I’m still feeling anxious, and so therefore I don’t have success.”

And that’s not the case at all, right? We have to change the behavior first, by engaging in an exposure, by reframing that side. And over time that anxiety does go down, but we can’t live life trying to make it go away, right?

Because when we try to push it away, or make sure it doesn’t happen, that’s like saying, “Well, don’t think of a pink elephant, don’t think of a pink elephant, don’t think of a pink elephant.” And so it just comes back even stronger.

So instead, what we do is we let that anxiety be there, but we don’t let it consume us. And that takes practice, right? So I always say don’t let the anxiety be an elephant in the brain, let it be like a little gnat. Just in the back trying not to pay as much attention to it.

And it gets quieter when we’re able to do that, when we’re able to engage in our day. And if someone’s debilitated, starting off with a goal of just being able to laugh once in the day where they’re having anxiety, and even that one laugh of, “Oh my gosh, did I have five seconds where I was able to enjoy it?” That should be a success. And then trying to build off of that.

Jeff: So Cali, you work with a lot of athletes. Some of them are going to have a clearly defined challenge, like OCD, which is identifiable, and diagnosable, and so forth.

Are there athletes that you work with that are not necessarily dealing with a diagnosable challenge, but are still dealing with anxiety and perfectionism?

And if so, how is that approach different from what you do with someone with OCD, for example?

Cali: Great question. Yeah, I would say the most common that I see is some performance anxiety. And when an athlete has performance anxiety, maybe they just get really in their head around the time of a competition, but when athletes struggle with just some of these anxious tendencies, there’s still a lot of cognitive distortions going on.

And so I would argue that every athlete would benefit from some CBT of recognizing cognitive distortions and then reframing them, because that does have an impact on the confidence.

And even if an athlete doesn’t have a diagnosable mental illness, what we’re doing is we’re building that confidence that they can trust some of their natural ability as an athlete, instead of trying to write their story by overthinking when they go into a game or performance.

And so there’s some freedom there in being able to accept and trust that natural ability. And when we build confidence, we build a more positive performance.

Jeff: I have to ask you out of fascination, I think, as much as anything else, you’re working with both athletes and non-athletes. How is your approach different?

I mean, are are there certain things that athletes bring to the table when they come into your office that are positive, for example, that you can work with?

Cali: Well, one is I feel like I can relate on that level, because I know what it’s like to really, really care about your sport. And so the component that would be a little bit different is... And I mean, there’s non-athletes that have this same mentality with other aspects of their life, right?

Like if they’re a writer and they want to be the best writer that they can be. So I think we can kind of categorize it as that, but oftentimes seeing that drive being over the top is the piece that makes an athlete or a performer stand out, right?

Of when we have a drive that’s over the top, maybe you can be successful for the short term, but it’s not a long term way to live life. And so getting that individual to see, again, through some act that there are other values that are equally as important, and if you can put some of that attention on those other values, it’s actually going to enhance your performance anyways.

Jeff: Great question came in from an audience member. Do you have any suggestions for college counseling centers to form more connections and normalize mental health with coaches and athletic staff?

Cali: Yes. I think that would probably take about an hour and a half to answer, but I’ll give a short blurb of absolutely. I mean, finding out about the local specializations in their area and making connections with them so that you have good referrals for each diagnosis is so crucial.

So, I’m in Houston. Finding somebody that specializes in dialectical behavior therapy for an athlete that’s really struggling with emotion dysregulation for OCD anxiety, finding someone that does that CBT ERP so that they feel confident that they can help an athlete get to that appropriate level of support when it’s needed.

So just making connections in the community so that they can refer out. And if you’re in an area where there’s not a lot of support in the immediate area, even virtual therapy within the state is always an option too, and it’s better to have specialized care than no care.

Jeff: I want to ask you some practical questions, or ask you for some practical tips in dealing with student athletes and mental health challenges. Let’s start with parents who are supporting a student athlete.

What do you most want them to know about their children’s mental health considerations as they are out running, or playing soccer, or swimming, or whatever the case might be?

Cali: I think if they are struggling, like if the parent sees some behaviors that they’re worried about for the long term for that student, sometimes parents can live in fear, and I think having the parent, one, be be proud that they’re even aware of some of those symptoms.

Like that they’re starting to pay attention to it, because that level of self-awareness wasn’t always there and it’s come such a long way.

But then, two, if their child ends up struggling, there is appropriate support, and individuals that have these diagnoses can be just as successful as individuals without them. So I think that can be something that’s helpful to just help take the fear away.

Jeff: What about messaging around winning? How do parents kind of offer a balanced message about the value of doing your best out there, but at the same time taking care of yourself mentally and so forth?

Cali: Well, I think this is where we see the different coaching styles being beneficial, right? So an athlete that’s already hard on themselves doesn’t need the reminder that they have what it takes to win first place, they actually need the opposite.

And so being able to let them know, “Hey, we’re here to support you, and you compete with yourself yesterday.” That’s one of my favorite things to say, right? Compete with yourself yesterday, see what you can do.

That’s maybe a drive to get a new personal record or just have a good day. But at the end of the day, I always like to, for these athletes that have this hard drive, this win drive, there’s only a certain aspect that you can obtain with winning, right?

There’s so many components outside of that that are out of your control. And so having a goal or long-term goal to win isn’t really the most effective goal to have. Having a goal to do your best or compete with yourself is a bit of a better approach to take.

Jeff: What about coaches? When you get a chance to chat with them about these issues, what do you like to pass along?

Cali: I think I like for coaches to know some of the signs to look for when an athlete may be struggling. So like if an athlete is, before a race, or before a competition, trying to straighten out their uniform, or they notice a lot of signs and symptoms, being able to ask them about it. I think coaches are sometimes even afraid to bring that up.

They don’t want to throw off their routine. But I think that that’s an indicator that an athlete would benefit from being able to talk about it. So just if they notice or even have a slight inclination, just checking in with the athlete to see where they’re at with things.

And that just helps the athlete know that the coach is in their corner, which also would open the door a little bit more for the athlete to go to the coach if they really did need help.

Jeff: We often get a number of mental healthcare providers in our audiences for these webinars, and I want you to speak to them directly. If they are having some thoughts about how can they best fine tune their practices for athletes when they are seeing a student athlete?

Cali: I think remembering that every athlete is a little bit different, right? So some student athletes maybe already do have that good balance and their anxiety symptoms aren’t really surrounding their sport.

I’ve had athletes before that are thriving in their sport, but they’re taking their schoolwork to an extreme, right, and we were having to do exposures around their schoolwork. And so really just getting to know each athlete and knowing that there isn’t a one size fits all is kind of the best approach.

Jeff: Let me circle back based on an audience question to something we touched on earlier, and that’s athletes misusing substances to help deal with performance anxiety.

I know that’s not something that you treat in particular, but what are your general thoughts in terms of substance misuse in athletics, and where would you point people for more help?

Cali: Yeah, I mean, first, it’s a real deal, and it’s a big problem in collegiate athletics and post-collegiate athletics as well. And so the difficulty with that, it might be some of the denial from the student athlete, depending on what the substance is of, “Well, I don’t have a problem,” or, “This isn’t affecting me in any negative way.”

So being that person that they can trust and open up to is essential, because otherwise, it might have to be like an ultimatum, which isn’t really the way that we want to go of, “You need this appropriate level of care.”

And we know that there’s benefit in cognitive behavioral work with substance abuse, but there’s a lot of different support levels that, depending on the theory or approach, that someone can go to. But getting that rapport enough with them is the first step, and then being able to refer out after you’ve got that rapport.

Jeff: Let me hit you with a big picture philosophical question. When you look back at your own journey with anxiety and athletics, what are some of the lessons that you would apply to non-athletes?

Cali: I’ve been thinking about this one. So I would say that athletes that have their success tied to everything, right? Like the athlete, as myself, my own personal journey, I felt like success was everything, and that I had to, almost like I had to earn the love, or I had to have that wow factor, or else.

And I think what I would say now is that it’s actually so not true, that in order to be a good athlete, in order to have that wow factor is to find your voice in the balance, right? Like, I don’t think I ever turned heads when I was, I mean, in a good way, tying my shoes four times before a race.

I think what happened was when people saw that, “Wow, Cali’s racing and has a healthy mindset about this race,” that’s where we see the benefit. That people are like, “I want some of that.” And more than anything, I think that ties into everyday life, right?

Because yes, for athletes, it’s success in sport, for someone else it’s success in their career, for someone else it’s success as a parent. And so just being able to remember that you’re also still human, and that as humans we have trial and error.

There’s no athlete that has gone onto the field, or court, or course, where they have been 100% every single day. And so remembering that you can apply that to all aspects of life is important.

Jeff: Let’s turn this on its head and talk about some of the real positive aspects of students being involved in athletics. What tops your list on that front?

Cali: I think problem solving would be a really big one. Being able to make decisions, have some independence, and confidence, right?

With problem solving comes more of the confidence, and then the ability to relieve stress, socialize, I could go on and on, but there’s so many positive benefits to sport. But there’s also a lot of vulnerabilities to sport if it’s not approached in the right way.

Jeff: You probably get this question a lot given the arc of your journey, if you will. But if you could go back and talk to young Cali out there on the track field, for example, tying her shoes over and over again, what would you tell her?

Cali: Ugh, I would 100% say it does not need to be this hard. So I think that would be the first step of, “It doesn’t have to be this way,” right? Like I had kind of gone to the acceptance phase of, “This is what it takes,” and I wish I would’ve known that that wasn’t the case at all.

And I’m okay, like, of course, I’m not stuck on the idea of, “Well, if I could just go back.” Because if I went back, I wouldn’t be doing what I’m doing now of helping others along this journey.

And I always say we would never wish the debilitating mental illness on anybody, but if anything, it does build a level of resilience that you can use to help others along the way.

Jeff: Let’s talk resources. I know that you have a number that you’d like to pass along in terms of websites, organizations, books. Where do you want to point us?

Cali: So for OCD and anxiety disorders, my go-to for referrals would be the International OCD Foundation, because you can search there within your state to see what providers are in your area that specialize in OCD and anxiety. They also have related disorders that you can search, so like body focused repetitive behaviors, Tourette’s, skin picking, hair pulling, all of those things.

And I think if someone’s just wanting to learn more education on what OCD is, what the different subtypes are, I would point them to Peace of Mind, peaceofmind.com. They really do a great job of going into all the different subtypes, and they have two to three minute videos, if you don’t really like to read, that you can watch and get a pretty good summary to get started.

And then I could keep going. I’ll say the “Freedom from OCD”, or “Freedom from Obsessive Compulsive Disorder” by Jonathan Grayson is a book I really love to give someone struggling. Voices In Sport for female collegiate athletes. That’s a really great resource for all mental health.

Jeff: Well, speaking of books, you’re being very modest. You’re not telling us about the one that you have penned, “Anxious Annie”. Tell us about “Anxious Annie”.

Cali: I felt like maybe this wasn’t the age appropriate range, but yes, I wrote a children’s book, and it was geared towards my own personal journey with anxiety. I keep it a little general, so just talk about anxiety and the pressure to perform and how if you do put too much pressure on yourself, you’re not really doing yourself a favor, and so being able to find that balance.

So Annie starts off racing, has that pressure, and doesn’t like running, dreads it, and then she learns a little bit more about her overall purpose in running and starts to have some of that freedom.

Jeff: I want to ask you about your advocacy in the OCD and mental health worlds. What is your message? What do you want people to know about anxiety disorders? What do you want people to know about mental health in general? Above and beyond what we’ve talked about with athletics per se.

Cali: I think I would want everyone to know that mental illness is debilitating, but it doesn’t have to be, right? So we could argue that one mental illness is worse than another, but we also know that evidence-based care works.

And so being afraid to seek those resources because of the what ifs isn’t giving yourself an opportunity, and we shouldn’t let, for anyone struggling with a mental illness, we shouldn’t let those weights be something that holds us back in life.

Instead, after appropriate treatment, see how that resilience has grown and let it empower you to make a difference or to do something in your life that you know you’re good at. So just that mental illness, it’s not fun. It’s a terrible thing, but at the same time, it doesn’t have to slow you down.

Jeff: As we’re running out of time, I want to go through a couple more of the questions that have come in here for you. A viewer asks, what type of specific stressors do transgender student athletes face, and how might coaches or other counselors support them? Is that something you’ve run across?

Cali: I haven’t personally, but I mean, I know that it’s happening, right? It’s a big topic in the world right now. You know, one of the big challenges is if a transgender student who started off male and then starts competing as a female, there’s a lot of controversy on how to navigate through that.

And regardless, I think that it’s such a difficult thing, mentally, for the individual going through it that they would need support regardless, right? So having a transgender student athlete have that individual that they can talk to. We know that suicide rates of being transgender, they’re at a higher risk for depression and suicide.

And so being able to give them a resource to navigate through the trauma that is candidly associated with it, because there’s a lot of stigma, shame, bullying, still tied to that, unfortunately.

Jeff: Let me squeeze in one more question about seeking help. It’s so important for parents and young adults themselves to self advocate and to ask a lot of questions.

What are some of those questions that you would have families ask of a potential therapist in terms of dealing with mental health challenges, with or without an athletic tie into them?

Cali: I would tell parents that if you’re going to a clinician and you don’t know what your child is struggling with, do not be afraid to share some of the specifics of what you’ve observed. It’s that clinician’s job to help give appropriate diagnosis and point you in the right direction.

And so if you’re kind of struggling with the scratching your head on, “I don’t know if this is an anxiety disorder, or if this is something that we should even be seeking treatment for.” That clinician’s job is to help you navigate through those decisions. So being able to kind of trust them along the way for a good evidence-based clinician is really important too.

Jeff: And Cali, let’s leave everybody with a little hope here. You get to see a lot of lives turned around through the work that you’re doing, and we certainly have seen your life turn around based on what you’ve shared with us as well.

Speak, if you would, about the hope that is afforded through effective treatment for anxiety disorders and other challenges that student athletes might be facing.

Cali: Yeah, there is support and you’re not expected to go through it alone, right? So that is a huge sense of hope. One, you’re not going through it alone. There’s other athletes, there’s other students that are struggling just like you, or that have struggled that you will see are doing so much better because of that evidence-based care.

But then, two, it’s a big, big burden for you to carry all on your own. And so let that loved one help you, right, by giving them a little bit of what’s going on, or help them point you in the right direction to the appropriate evidence-based care.

And then let that clinician take some of that on and help you come up with a treatment plan. Because even as an OCD clinician that is specialized in OCD, I couldn’t treat my own OCD. It’s too close to home. And so having someone walk on that journey with me has been a phenomenal resource.

Jeff: What a perfect place to wrap things up. Cali Werner, thank you so much for making time for us today.

Cali: Thank you, my pleasure. It was wonderful to be here.

Jeff: Such an inspiring journey and such great work that you’re doing, and we’ll look forward to hearing about your future successes.

To all of you who have tuned in on behalf of McLean Hospital, I just want to thank you so much for taking the time to educate yourself. We’ll see you next time around.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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