The Stepped Care Model in Sport Psychology: Evidence-Based Implementation Guide
- Dr Paul McCarthy
- 3 hours ago
- 18 min read
The stepped care model in sport psychology provides a progressive way to help athletes with their mental health needs. Sport psychologists should record client sessions (with consent). These recordings are great tools to develop professionally, and they work really well with this framework. We have a long way to go, but we can build on this progress in applying sport psychology to coaching environments. Research shows that this field helps athletes learn skills better and perform at higher levels.
The stepped care model for mental health creates a clear path where support increases based on what clients need. This approach supports solution-oriented rather than problem-oriented mental health research in sport. The result is a more streamlined support system. This piece breaks down how you can apply the mental health stepped care model in sports - right from the first assessment to intensive interventions. You'll learn how process reports help new practitioners. The cognitive-behavioral paradigm remains the most common psychological model in sport psychology, and you'll see how it fits into this framework.
Understanding the Stepped Care Model in Sport Psychology
Stepped care has become a groundbreaking way to deliver mental health services to athletes and sports professionals of all types. This system matches different levels of support to specific needs.
Definition of the stepped care model for mental health
The stepped care model delivers support based on each client's changing needs and priorities [1]. The model gives people the least intensive treatment they need for their mental health and moves to stronger treatments only when needed [1]. These simple principles guide the model:
Treatment starts with the simplest option
Staff track progress to see what works
People move to higher levels of care only when needed
Resources get used where they're needed most
Clients choose their treatment path
Many people get better with basic treatments, so specialized care stays available for complex cases. Studies from European medical centers show stepped care works just as well as traditional methods and optimizes healthcare delivery [2].
Origins and adaptation for sport psychology
The United Kingdom created this model [2], and it has spread worldwide as a complete mental health system. Sports psychology teams have only recently started using it, with soccer clubs in England leading the way.
In the last few years, professional clubs in England's top leagues have used different versions of stepped care [3]. To cite an instance, Burnley FC Academy, a top-tier program recognized by the English Premier League and Football Association, tests a stepped-care pyramid model [2].
Sports teams use a pyramid structure where the core team handles most mental health support at lower levels [3]. This setup helps solve small problems before they grow and adds prevention to the system [2].
Comparison with traditional care models
Stepped care is different from old-school approaches in key ways. Traditional systems rely on specialists for all mental health issues. Stepped care spreads the work among staff based on their skills and the problem's complexity.
In sports, this means support staff like physiotherapists and nutritionists can point athletes to self-help tools for simple needs. Coaches trained to spot problems give first-level support [2]. Player Care teams look after non-sport wellness, while sports psychologists and medical staff tackle harder cases [3]. Clinical psychologists or psychiatrists step in only for serious issues.
The model also uses resources better. Old systems often get stuck with specialists handling everything. Stepped care saves expert help for tough cases. English league clubs typically bring in outside clinical help just for serious mental health problems [2].
Prevention sets this approach apart too. Traditional care often waits until problems get big. The pyramid structure of stepped care catches issues early. Small concerns get attention before they grow [3].
The stepped care model lets people move between care levels easily. Players with serious mental health needs see clinicians right away. Those with mild concerns work with Player Care staff and sports psychologists [3]. This beats old systems that lack clear paths between different types of help.
Core Principles of the Stepped Care Framework
The original principles of the stepped care model are the life-blood of its effective implementation in sport psychology settings. These principles show practitioners how to structure interventions, allocate resources, and help athletes throughout their mental health trip.
Least restrictive intervention first
The stepped care approach builds on the basic principle that treatment should start with the least intensive, least restrictive intervention possible. This approach will give a better allocation of resources and prevents unnecessary over-treatment. We started with simpler, less resource-intensive options like self-help materials, psychoeducational workshops, or digital tools instead of jumping straight to specialized psychological services for every concern.
This method serves several purposes. Athletes won't feel overwhelmed with complex interventions when simpler ones might be enough. Specialized resources stay available for those who need them more. Mental health support becomes a normal part of athletic development rather than something only for "serious problems."
Practitioners keep checking if the current intervention level meets the athlete's needs or if they need more intensive support.
Progressive intensity based on need
The stepped care model uses a systematic approach to increase support based on continuous monitoring after the original interventions are in place. Athletes who don't show enough progress with lower-intensity interventions move to more intensive options with greater structure, professional involvement, and specialized expertise.
The progression happens across several areas at once:
From self-directed to practitioner-led interventions
From group-based to individual approaches
From generalist to specialist providers
From brief to extended duration
Athletes get support that matches their needs while the system stays efficient. The model lets athletes move in both directions—they can "step down" to less intensive interventions as their condition improves. This creates a dynamic system that adapts to changing needs.
Client autonomy and self-regulation
Athlete autonomy is vital to implement stepped care effectively. Self-Determination Theory (SDT) suggests that encouraging client autonomy through tailored relationship building and better self-management skills can alleviate barriers to desired outcomes [4]. This method introduces four phases: teaching, coaching, supporting, and transitioning. Each phase has specific autonomy-supportive behaviors for rehabilitation professionals [4].
Self-regulation enables athletes to manage emotions, motivation, and performance under pressure [5]. The Integrative Self-Regulation Model has four core components: self-awareness and motivation for change, strategy selection, self-regulatory behaviors, and mental control [5]. This framework highlights the need to monitor and refine strategies continuously.
Recovery self-regulation plays a significant role [4]. It helps athletes identify their current state, desired future state, and actions to minimize gaps during recovery phases. Several self-regulation skills support this process:
Self-regulation lets athletes take control of their mental health trip within the stepped care framework. In spite of that, self-regulation can fail—too much self-awareness leads to over-analysis, poor strategy selection causes maladaptive coping, and overuse of mental control results in cognitive fatigue [5].
The stepped care framework works best when these three principles combine—starting with minimal intervention, progressing based on need, and enabling athletes through autonomy and self-regulation strategies.
Phase 1: Initial Assessment and Triage in Sport Settings
The original assessment acts as a gateway that leads to mental health support within the stepped care model for athletes. This first step determines the right intervention levels and creates clear pathways that show how care should progress.
Screening tools for athlete mental health
The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) is the life-blood screening instrument for elite athletes 16 years and older [1]. This standardized assessment has three most important components:
Triage using the Athlete Psychological Strain Questionnaire (APSQ)
Six disorder-specific screening tools for positive triage cases
Clinical assessment by qualified professionals
The APSQ works as the original screening tool that assesses sport-related psychological distress through 10 items scored on a 5-point scale [1]. Athletes can score between 10 and 50 points. A score of 17 or higher that indicates elevated risk needs further assessment [1].
Athletes with positive triage cases take six disorder-specific questionnaires:
General Anxiety Disorder-7 (GAD-7)
Patient Health Questionnaire-9 (PHQ-9)
Athlete Sleep Screening Questionnaire (ASSQ)
Alcohol Use Disorders Identification Test Consumption (AUDIT-C)
CAGE-AID (substance misuse)
Brief Eating Disorder in Athletes Questionnaire (BEDA-Q) [1]
The IOC suggests these screenings during pre-competition periods, mid-season, end-season, and after major events like injuries, surgeries, or difficult life situations [1]. The SMHAT-1 offers standardized assessment, but qualified professionals must handle the clinical assessment part [1].
Risk stratification and referral pathways
Risk stratification in sports needs a well-laid-out approach [2]. The foundations are accurate diagnosis of why things happen, which experts refine with exercise-specific factors [2]. Several elements shape an athlete's risk profile:
Demographics (male sex and adolescent age may create higher risk)
Sport type (high-intensity interval sports might bring greater risk)
Genetic factors (certain genotypes link to arrhythmic risk)
Exercise intensity and environmental factors [2]
Referral pathways work like a pyramid. Club staff handle most support at lower levels and solve many problems before they grow [2]. Performance staff guide athletes to self-help resources at the pyramid's base [2]. Coaches trained to spot distress signs work at the next level [2]. Player Care teams look after non-sporting parts of athletes' wellbeing [2]. Sports psychologists and medical staff take care of complex cases at higher levels. Clinical psychologists or psychiatrists manage the most severe situations [2].
Role of coaches and support staff in triage
Coaches hold a special place in athlete mental health triage because they stay in constant contact with athletes and build strong relationships. Daily interactions help coaches notice subtle mood and energy changes that might show emerging concerns [6]. Coaches often spot behavioral changes like:
Athletes coming late to practice
Less socializing
Missing sessions
Lower energy levels [6]
Coaches should encourage team cultures where athletes talk openly about mental health, feel comfortable seeking help, and support teammates who receive care [7]. They must know their limits and understand at the time to refer athletes to proper resources [6].
Support staff are vital to the triage process too. To name just one example, soccer club physiotherapists and strength conditioning staff often build strong bonds with players. These relationships help them affect players' mental well-being beyond physical care [2]. Regular team meetings help share information and coordinate services effectively [2].
The whole ordeal of triage requires strict athlete confidentiality. Breaking privacy creates a huge barrier that stops athletes from seeking help in the future [7]. The athlete support network needs clear rules about sharing information.
Phase 2: Low-Intensity Interventions for Mild Concerns
The stepped care model's second phase uses low-intensity interventions to help athletes with mild mental health issues. Athletes get support options that work well without using too many resources after their original assessment shows less severe problems.
Psychoeducation and self-help resources
Athletes can learn about mental health conditions and self-management strategies through psychoeducational materials - these are basic tools in stepped care. Mind.org.uk provides a complete self-care library. Athletes can access free wellbeing, grounding, and breathing activities to support their mental health [8]. Their resources have several guides like "Spot. Support. Signpost" which helps identify warning signs. They also offer a mental health and physical activity toolkit with information, tools, and templates [8].
Athletes can benefit from practical guidance documents. These guides cover safe and effective practice, building healthy relationships with physical activity, and supporting young athletes [8]. Sports organizations find resources like "Thriving at Work for the sport and physical activity sector" helpful. This guide shows how to support the core team's mental health. The "CARE resources" help coaches encourage good mental health through their coaching methods [8].
Sporting Wellness partners with trusted providers to give eligible athletes solution-focused, confidential support. Athletes can use counseling services (in-person, phone or video), online CBT tools, and 24/7 helplines [3]. These options are the least restrictive in the stepped care model. Athletes can address their concerns privately before moving to more intensive support.
Digital tools and mobile apps for athletes
Digital mental health tools have become powerful low-intensity options for busy athletes. Apps like MUSE, Heartspace Health, Headspace, Calm, and Smiling Mind help with mindfulness and stress management. Athletes can use guided breathing, meditation, and visualization exercises before competition or during recovery [9].
Some digital platforms help track mood and build resilience. Athletes can record their daily mood, stress levels, and energy with these apps. This helps them spot patterns and early signs of fatigue, burnout, or anxiety [9]. Athletes can monitor their psychological wellbeing with up-to-the-minute data analysis. They can take short rest breaks between training or get alerts about poor recovery [9].
Wearable tech adds another dimension to digital interventions. Devices from Garmin, Polar 360, and Omegawave track sleep quality, heart rate variability, and recovery scores. These metrics help athletes adjust their training and rest periods [9]. Male elite professional athletes in Australian football, cricket, and soccer use the Athlete Psychological Strain Questionnaire (APSQ) as a quick self-report screening tool [10].
Virtual reality applications show state-of-the-art innovation. The University of Derby works with My Energy Game (MEG) on a VR game. Young athletes use a headset to play and understand their self-development better [11]. The game looks at key traits like communication, embracing change, managing disappointment, relationship management, and leadership [11].
Group-based workshops and peer support
Group sessions offer economical ways to provide mental health support while building peer connections. Sporting Chance Clinic runs workshops about lifestyle, problematic behaviors, and addiction. Athletes learn to assess their mental health and connect their behaviors, thoughts, and feelings [12].
These workshops give practical advice on building relationships and understanding emotions [12]. Staff can join different types of workshops - from 60-minute info sessions to 1.5-hour sessions led by therapists. These include group discussions and exercises about handling conversations with struggling athletes [12].
Larger programs include mental health education workshops reaching over 300 participants from Swimming, Paralympic Swimming, Triathlon, Sailing, Rowing, Cycling, Paralympic Cycling and Netball [13]. Participants learn techniques and strategies to boost their wellbeing [13].
Young athletes aged 11 to 16 can attend specialized workshops about positive mental health [14]. These sessions explore healthy mental states, mental health in sport, self-care strategies, warning signs, and available support [14].
Phase 3: Moderate-Intensity Interventions for Emerging Issues
Athletes who move beyond self-help approaches in the stepped care model need moderate-intensity interventions. These form the middle layer that addresses complex mental health concerns. Qualified professionals with sports expertise deliver these services that bridge the gap between basic support and specialized clinical care.
Brief psychological interventions (e.g., CBT-lite)
Cognitive-behavioral therapy (CBT) is the life-blood of moderate-intensity psychological interventions for athletes. Sports teams and athletes have used simplified CBT in their training plans with great results for mental skills development [15]. This method helps athletes identify and challenge negative thoughts that affect performance. It also helps them develop ways to handle stress and anxiety during competitions [16].
CBT interventions for athletes with emerging mental health concerns target four key areas: managing arousal levels, improving concentration, building self-confidence, and refining competition routines [15]. Athletes learn to look at challenges differently, solve problems effectively, and control their emotions in high-pressure situations through these well-laid-out sessions [17].
Expressive writing serves as another valuable brief intervention. Athletes write about their thoughts and feelings regarding specific events over several sessions [18]. Research shows that expressive writing tasks based on cognitive restructuring principles helped reduce self-critical thoughts and boosted positive emotions compared to control groups [18]. Athletes find this approach especially helpful when dealing with performance failures or setbacks.
Acceptance and Commitment Therapy (ACT), a newer form of CBT, focuses on psychological flexibility rather than specific diagnostic treatments [19]. A sports-specific ACT group program that ran for six weeks showed moderate improvements in values, present-moment attention, awareness, and mindfulness. The program also led to small reductions in sports-related avoidance behavior [19]. Research indicates that ACT helps reduce anxiety, eating concerns, and psychological distress in athletes [19].
Performance-focused mental skills training
Mental skills training helps athletes learn, maintain, and improve both motor and cognitive skills through a structured preparation program [15]. This training sits between educational resources and clinical interventions in the stepped care framework.
Key mental skills techniques include:
Visualization - Athletes picture their performances mentally before they happen, which builds focus and confidence [20]
Goal setting - Sport psychologists help athletes set realistic short-term and long-term goals that match their skills and ambitions [20]
Attention-concentration training - Athletes learn about different types of attention and how it changes during training and competition [15]
Arousal management - Athletes learn to tell positive and negative arousal apart and understand how these states affect their performance [15]
Mental training helps athletes understand competition psychology, motivation, focus, and stress management at all competitive levels [20]. The primary goal is to boost performance and well-being by developing cognitive and psychological skills. This differs from mental health training, which centers on awareness, support, and education about mental health challenges [21].
Involvement of sport psychologists in delivery
Sport psychologists now play a vital role in delivering moderate-intensity interventions within the stepped care model. Their work goes beyond just improving performance - they help athletes deal with interpersonal issues and mental health problems like anxiety, depression, and eating disorders [22].
Sport psychologists improve communication, build trust, and strengthen team dynamics in team settings [20]. The need for sport psychology services has grown rapidly, even among youth athletes and serious amateurs [22]. Major League Baseball shows this trend - in 2018, 27 of 30 teams hired mental skills coaches to help players handle the game's mental challenges [22].
Sport psychologists fill a strategic role in the stepped care framework. They assess and support players who need more help than coaches or support staff can provide [4]. Many have training in specialized therapies like cognitive therapy and ACT, but they know their limits and don't work beyond their expertise [4].
Working with sport psychologists creates powerful benefits for coaching staff. These professionals join coaches during training sessions and suggest ways to create better learning environments while players practice [23]. Having mental skills experts help with visualization during gym sessions or concentration work during field practice leads to better results [23].
Sport psychologists serve as key middle-tier providers in the stepped care approach. They guide athletes to the right resources and deliver proven interventions that boost performance through confidence building, better concentration, emotional control, and improved communication [4].
Phase 4: High-Intensity Interventions for Complex Needs
High-intensity interventions stand at the top of the stepped care model. These interventions help athletes who face severe or complex mental health challenges. This fourth phase offers the most specialized support within the framework and brings in clinical experts when previous interventions don't suffice.
Referral to clinical psychologists or psychiatrists
Clinical experts lead the top tier of the stepped care pyramid. They provide vital support to athletes with serious mental health difficulties. Clinical psychologists and psychiatrists evaluate patients, create treatment plans and deliver specialized therapies. They also guide staff who work at lower levels of the care pathway [4]. Professional sports clubs in English leagues usually contract external clinical help instead of hiring in-house specialists. Athletes get referrals to trusted mental health specialists outside the club or to specialized organizations like Sporting Chance or Cognacity [4]. Some complex cases need residential treatment facilities for longer periods [4].
Integrated care with medical professionals
The success of high-intensity interventions depends on how well the multidisciplinary team works together. Mental health clinicians hold the highest position, yet they must ensure the whole pathway works effectively [4]. The Australian Institute of Sport Mental Health Referral Network (MHRN) shows how integrated care should work. Their network of expert psychologists and clinicians understands the pressures of high-performance sports [24]. These specialists offer services that range from general wellbeing improvements to complete clinical treatment plans. They help with issues like anxiety, depression, and eating disorders [24].
Safeguarding and crisis management protocols
Mental health emergencies need careful preparation and response protocols, even with preventive measures in place. Organizations should create complete emergency action plans that specify:
Crisis situation definitions
Staff members with appropriate expertise
Required notification procedures
Ethical considerations including confidentiality boundaries [25]
Confidentiality presents unique challenges in athletic environments. Research shows direct pressure to break confidentiality rarely happens. However, indirect attempts—sometimes through deception—occur regularly [4]. Staff education about confidentiality's importance helps promote a culture where athletes feel safe seeking help [4].
Athletes face unique vulnerabilities beyond emergencies. These include overtraining, weight/body image pressures, win-at-all-costs mentalities, and intense coach-athlete relationships [5]. Organizations can reduce these risks with reliable codes of conduct, proper staff training, visible welfare officers, and clear reporting procedures [5].
Supervision and Professional Development in Stepped Care
Quality care across all intervention levels depends on professional growth and supervision in sport psychology settings. Practitioners need the right skills and continuous support to deliver stepped care successfully.
Training needs for sport psychology practitioners
Sport psychology practitioners (SPPs) need clear "role identities" to work within the stepped care framework [4]. Player Care (PC) staff should pursue specialized training through MSc/Certificate courses from Premier Sports Network/Global Institute of Sport or certificates via the Player Care Group [4]. These programs should include resilient wellbeing components that cover mental health assessment, screening, counseling skills, ethics, and mental health governance [4].
Sport Psychologists (SPs) need better defined roles and integration within clubs. Feddersen's review points to the need for more organizational-level input [4]. The "Sport Psychology Canvas" outlines ten thematic areas that help practitioners develop, including psychological frameworks and preferred intervention strategies [4].
Use of supervision to support stepped care delivery
Supervision improves professional performance while maintaining quality services and protecting the profession [1]. Weekly mental health supervision helps "surrogate helpers" within the stepped care model. Their input stays aligned with treatment goals [4]. These helpers work best when they collaborate with Sport Psychologists [4].
The stepped care framework needs strong communication between departments. Teams should hold regular multidisciplinary meetings to share information and coordinate services [4]. Client welfare comes first in supervision, while also protecting the profession and society [1].
Reflective practice and process reports
Process reports are great tools for reflection during supervision. They help practitioners learn and develop [26]. New psychologists in advanced-student to novice-professional stages benefit the most from these reports [26]. Reflective practice should continue throughout all career stages whatever the experience level [26].
Best practice guidelines suggest recording client sessions (with consent) to aid professional development [26]. Process reports help practitioners spot areas where they can grow personally and professionally [26]. This ongoing reflection supports learning as practitioners progress from introduction to achievement phases [27].
Evaluating Outcomes and Adjusting Care Steps
Regular evaluation is the life-blood of stepped care that works in sports settings. Athletes' responses help determine timely adjustments and guide their movement through different care levels.
Feedback-informed treatment (FIT) in sport settings
Strong communication between departments is a vital part of effective feedback systems that help share information and coordinate services [2]. Athletes need integrated support, but their confidentiality must stay protected even as information sharing remains significant [2]. Creating a psychologically safe environment is crucial since athletes will only seek mental health help when they trust both the people and systems [2]. Support staff see players daily and play a vital role in spotting those who need specialist help early [2].
Monitoring athlete progress and step-up/step-down decisions
The Mental Health Continuum Model helps athletes understand normal changes in mental states better. This awareness lets them recognize shifts in their condition more easily [28]. The model provides a standard way to spot and refer mental health concerns [28]. Clinical trials show specific criteria determine movement to higher intervention levels. Research found all but one of three participants failed to show meaningful clinical improvement after their original intervention phase [29].
Data collection and outcome measures
Several tools give a full picture of outcomes - disease-specific measures, pain severity scales, quality of life surveys, and psychological tests [30]. The Pain Interference subscale, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale are great ways to get complete evaluation [30]. The Patient Acceptable Symptom State helps measure how satisfied patients are by asking if they call their current condition acceptable [30].
Conclusion
The stepped care model provides a revolutionary framework that addresses athlete mental health concerns at every level of severity. This progressive approach efficiently allocates resources and ensures athletes get support tailored to their specific needs. Without doubt, the model's greatest strength comes from its flexibility, which allows practitioners to match intervention intensity with complex mental health challenges.
Athletes benefit substantially from this systematic approach. Early help-seeking behavior gets encouraged by starting with minimal restrictive options first. This reduces stigma around mental health in sporting environments. The well-laid-out pathway helps athletes who need specialized care to get it quickly through clear referral systems.
Screening tools like the SMHAT-1 provide objective criteria to assess athlete psychological well-being and create standardized entry points into the care system. Self-help resources and digital tools enable athletes to take charge of their mental health trip - a significant part of long-term psychological resilience.
Coaches and support staff serve as frontline observers who spot early warning signs of distress. Their involvement creates multiple intervention points before issues escalate. Sport psychologists act as vital bridges between performance enhancement and clinical care. They deliver evidence-based interventions that target both athletic performance and psychological well-being.
The stepped care model needs organizational commitment and teamwork between disciplines, but its benefits reach way beyond individual athlete welfare. Teams using this approach see better communication between departments and use specialist resources more efficiently, which leads to improved performance outcomes.
Regular evaluation and refinement make this framework work. Treatment guided by feedback keeps interventions responsive to athlete needs, while outcome monitoring helps decide when to adjust care levels. Organizations should invest in proper training and supervision for staff who deliver mental health support.
The stepped care model represents an evidence-based approach that balances efficiency with effectiveness. A proper implementation creates sporting environments where mental health concerns become normal topics, help stays available, and athletes receive appropriate support at the right time.
Key Takeaways
The stepped care model revolutionizes athlete mental health support by providing a structured, progressive framework that matches intervention intensity to individual needs while maximizing resource efficiency.
• Start with least intensive interventions first - Begin with self-help resources and digital tools before progressing to specialized clinical care, reducing stigma and preserving resources for complex cases.
• Implement systematic screening and triage - Use validated tools like SMHAT-1 to objectively assess athlete mental health and create clear pathways for appropriate care levels.
• Leverage coaches and support staff as frontline identifiers - Train daily contact personnel to recognize early warning signs and normalize mental health discussions within team culture.
• Ensure continuous monitoring and flexible progression - Regularly evaluate intervention effectiveness and allow bidirectional movement between care levels based on athlete response and changing needs.
• Integrate multidisciplinary teams with clear roles - Establish strong communication between departments while maintaining confidentiality, ensuring coordinated service delivery across all care levels.
This evidence-based approach creates sporting environments where mental health support is normalized, accessible, and tailored to each athlete's specific circumstances, ultimately enhancing both psychological wellbeing and athletic performance outcomes.
References
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