NFL has been slow to embrace mental health support for players

When Buffalo Bills safety Damar Hamlin suffered cardiac arrest and collapsed on the field in the middle of the "Monday Night Football" game in Cincinnati on Jan. 2, Carrie Hastings, half a continent away, understood what she needed to do — and right away.

"I had a few guys that I sort of immediately knew I should check in on," said Hastings, the Los Angeles Rams' sports psychologist and mental health clinician. "A couple of spouses and significant others, too."

Hastings' familiarity with the Rams' personnel, and with which players might be emotionally traumatized after watching Hamlin's shocking medical emergency, was the product of her having spent six seasons with the club — getting to know the athletes, meeting rookies when they first arrive, and making herself a regular presence at the Rams' facility.

Across the NFL, no such continuity of care exists. The league is working its way toward the kind of mental health support for its players, coaches, and staff in which a range of counseling is standard and readily accessible.

It was just over three years ago, in 2019, that the NFL implemented a formal program to manage its employees' mental health needs. That came as part of a new collective bargaining agreement, after the NFL Players Association pushed hard for its creation. Among other things, the agreement mandates that each team have a licensed behavioral health clinician on staff.

But individual franchises still have great latitude in implementing that directive. Some have full-time sports psychologists; others employ clinicians part time, while a few contract with outside providers and make them available to players, Hastings said. And clinicians aren't required to have any sports background, which some sports psychologists see as a critical flaw.

"This is a very specialized area," said Sam Maniar, a psychologist who consults for the Cleveland Browns and formerly worked as the team's full-time clinician. "The environment of athletics, and especially at the highest level, is something that does require specialization, and not every clinician being brought into the NFL has that."

Hastings was a sprinter and hurdler in her undergraduate years at Notre Dame, has deep professional experience with athletes, and is listed in the U.S. Olympic & Paralympic Committee's registry for sports psychology and mental training. She keeps her private practice a short drive from the Rams' training facility in Agoura Hills, northwest of Los Angeles, and though technically a part-time employee, Hastings said she is at the facility three or four times a week "and basically on call 24/7 during the season."

In that capacity, Hastings has worked to forge a foundation of trust with elite athletes who often think of a sports psychologist only in terms of getting them primed to compete.

"It's often the case that a player comes in for something performance-related, and that opens up the door for conversations in other areas of mental health," she said. "The relationship deepens."

That kind of ingrained presence with teams is crucial, clinicians say, particularly as some athletes have begun to speak more openly about the mental and emotional challenges they face and have indirectly encouraged their peers to be more open to getting help.

Tennis sensation Naomi Osaka, Olympic gold medalists Simone Biles and Michael Phelps, NBA stars Kevin Love and DeMar DeRozan all have publicly discussed their mental health challenges over the past decade, and several have led campaigns to raise awareness. "I credit them for discussing their struggles and the great benefits they received by accessing some care that was available to them," said Maniar, who runs an athletic performance center in Ohio and works with college and high school football teams beyond his relationship with the Browns.

The NFL is a difficult arena for such conversations. Players in the league are accustomed to working through all manner of pain and injury practically as a job condition, and for much of the league's existence, its athletes essentially were trained to show no vulnerability.

The implementation of a leaguewide program, though an important milestone, hasn't radically accelerated the pace of change. "I think the NFL is still a dinosaur in that respect," Green Bay Packers quarterback Aaron Rodgers told The New York Times two seasons ago. "There's a stigma around talking about feelings, struggles, and dealing with stress. There's a lot of vernacular that seems to tag it as weakness."

The players union has become more aggressive in addressing the issue. "NFL players are often seen as the pinnacle of masculinity, and because caring about our own mental well-being and seeking support has not historically been associated with masculinity, too many of us do not prioritize that aspect of our health," union president JC Tretter, an eight-year NFL veteran, wrote in a 2021 blog post to players, urging them to make use of the resources available.

Hamlin's highly unusual emergency, in which he required on-field CPR before being transported to a hospital from the Cincinnati stadium where the Bills and Bengals were playing, "really created anxiety in some players, and it triggered others," Hastings said. In addition to contacting several players individually, she sent out a message across the Rams organization reminding the athletes, coaches, and staff she was available to talk.

"A lot of them were receptive," Hastings said. "The elephant in the room is mortality. The players know they can be hurt, and they've all dealt with injuries, but this included an element over which they had no control."

Players from the Bills and the Cincinnati Bengals stood in stunned silence as Hamlin lay on the field. Days later, Buffalo players still struggled to articulate their feelings. “The scene replays over and over in your head,” quarterback Josh Allen said during a news conference, fighting back tears. "It’s hard to describe how I felt and how my teammates felt in that moment. It’s something we’ll never forget.”

Hamlin's subsequent progress, including his release from hospital care to convalesce at home, "will help alleviate some of the trauma the players have been undergoing," said Dr. Joshua Norman, an Ohio State University sports psychiatrist who often works with athletes on processing emotions. "But even though they try to compartmentalize things, these players have witnessed a serious injury. Some of them will have a strong reaction."

Dr. Claudia Reardon, a University of Wisconsin psychiatrist, said the term "vicarious trauma" applies in this case. "The original traumatic event didn't happen to you personally, but it is experienced as traumatic to have witnessed it or learned about it," Reardon said. Reactions range from fear and helplessness to nightmares and flashbacks, she said, and some athletes will try to avoid "people, places, or things that remind them of the trauma they witnessed."

"I wouldn't be surprised to see a few players retire early," Maniar said. "And a big concern is a player going out there and playing hesitantly or in fear. That is a sure way to get hurt in a sport like football, and this is a league where the contracts are not guaranteed. You've heard the saying 'NFL means not for long.' The players feel that pressure."

The NFL's best chance to make big strides in its mental health coverage, clinicians say, may derive from the simple fact that it is continually drafting and developing new talent. "The younger generation is just more sophisticated about mental health, period," said Norman. "They come to a college campus often already having established some connection with their mental health needs, through counseling or other means. They're more open to the idea of dealing with their mental health."

Within franchise complexes, the work goes on. Both Hastings and Maniar were hired by their NFL teams years before the league made a clinician mandatory, and both made sure they kept an office away from the practice facility for those players who weren't comfortable seeing them at work. But lately, Hastings said, that, too, is changing.

"Players are talking about these kinds of issues with each other more often, and they're doing so very publicly," she said. "In many ways, we've been building out our mental health protocol since I was brought on in 2017." In the NFL, it is proving a slow turn.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.