We view athletes with eating disorders as a unique subpopulation that requires special approaches to identification, management, treatment and prevention. As a result, we are frequently asked how treating athletes with eating disorders is different than treating their non-athlete counterparts. Treatment per se is not all that different; nonetheless, we believe that treatment efficacy can be increased by including some specific strategies that we will include at the end of this discussion.
In general, the same evidence-based treatments that work well for non-athletes can work well for athletes. The critical issue relates more to the treatment professionals than to particular treatments. Although it is helpful if the treatment providers have experience working with athletes, it is more important if they have the right attitude about working with athletes. Perhaps most important in implementing a program designed to appropriately and effectively identify, manage, treat, and prevent eating disorders in college athletes, the healthcare professionals who will be working with the athletes must have an understanding of, and an appreciation for, the importance of sport in the life of a serious athlete. Along with this, there must be recognition that the sport world as compared to the healthcare world has different goals and concerns. Additionally, the sport world is very conservative and change occurs slowly. In that regard, healthcare workers, especially those in the mental health area, should tread lightly, remembering that we are interlopers in their world.
In working with college athletes, it is important to remember that college athletic programs are run like businesses. Thus, there must be a commitment on the part of the Athletic Director (AD), who holds the purse strings. A program with athletes will need the AD’s approval because the program will require funding. The AD will want to know why the department should fund such a program; that is, what the program will do for his/her athletes. Additionally, the AD is apt to want to know how the program will work; more specifically, the AD will want to know how the athlete gets referred, how long they will have to wait to be seen, and how information regarding the athlete will be handled and exchanged. An informed AD will also be interested in educational and prevention programming.
Coaches have tremendous power and influence with their athletes. In fact, they have so much power and influence with them that programs concerning their athletes cannot succeed without their endorsement and support. Coaches are so powerful that they will be involved whether we as healthcare providers want them to be or not. Thus, it is usually our practice to include coaches whenever such inclusion is permitted by the athlete, is potentially therapeutic, and is accomplished within the reasonable constraints of confidentiality. By including coaches, we may have a little more control over their influence. Our experience is that typically they want to know if the athlete is attending treatment sessions, if they are progressing, if they are allowed to train and compete, and how the coach can help. We try to remember that coaches are people too. Most are genuinely concerned about their athlete’s welfare.
In the college athletic environment, athletic trainers may be the most important people with regard to athletes with eating disorders. They are typically the sport personnel who are charged with managing them. In many ways, they are ideally suited for such responsibility, not only because they spend so much time with athletes; they are often the people athletes confide in first, and they tend to be focused on the athlete’s health rather than their sport performance. Athletic trainers can also be helpful because they serve as liaisons between the coach and the athlete, as well as between the athlete and the healthcare professionals treating them.
In terms of training, coaches and athletic trainers are the sport personnel who can benefit most from training regarding the identification and management for eating disorders in college athletes. Fortunately, most collegiate coaches and athletic trainers have had some training, and hopefully they have at least seen the NCAA Coaches Handbook: Managing the Female Athlete Triad (NCAA, 2005). At minimum, we recommend that coaches and athletic trainers be able to identify common eating disorder symptoms in athletes, but perhaps more important, they need to know how to approach the affected athlete and make an appropriate referral (Thompson & Sherman, 2010). Because coaches often view confidentiality as a stumbling block, it is important that they be informed about not only the constraints associated with psychological treatment, but how best to work within those constraints for the betterment of the athlete.
As mentioned previously, treatment efficacy can be increased with a treatment team with experience and expertise in treating athletes, who also understands and appreciates the importance of sport in the life of the athlete. Additionally, treatment can be enhanced by a therapist who uses sport participation (both allowing and withholding it based on treatment compliance and progress) as a means to motivate the athlete. Also, efficacy can be increased by a therapist who uses the athlete’s “sport family” (i.e., coaches, teammates, etc.) in treatment. Finally, we have written about how the same “good athlete” traits that contribute to good sport performance (mental toughness, commitment to training, pursuit of excellence, coachability, unselfishness, and performance despite pain) may increase the risk of an eating disorder for the athlete (Thompson & Sherman, 1999). Interestingly, treatment efficacy can be increased by a therapist who uses those same “good athlete” traits (Thompson & Sherman, 2010).
Regarding a successful program for college athletes, we have been privileged to work with the Athletic Department at Indiana University—Bloomington for more than 20 years. We use a protocol that requires all athletes with an eating disorder to be in treatment and progressing in order to be considered for training and competition. Our coaches and athletic trainers understand the process and are regularly trained regarding identification and referral.
1). National Collegiate Athletic Association. (2005). NCAA coaches handbook: Managing the female athlete triad. Indianapolis, IN: Author.
2). Thompson, R.A., & Sherman, R. T. (1999). “Good athlete” traits and characteristics of anorexia nervosa: Are they similar? Eating Disorders: The Journal of Treatment and Prevention, 7, 181-190.
3). Thompson, R.A., & Sherman, R.T. (2010). Eating disorders in sport. New York: Routledge.