CHAPTER 3

The Collapse

The best four years of her life. That’s what Madison expected. Four years just like high school, except better—because now she’d be living on her own.

Actually, not quite on her own, living with a roommate. At first, the room she shared with Emily in Hill—the Penn dormitory—seemed just fine, cozy even. For the first few days, they both kept the room meticulous, desperately preserving the image of college life they’d carried around for years: pictures of high school friends above desks, shampoo and conditioner tucked neatly into a plastic carrying case, roommates moving easily around the shared space with laughter and smiles, music blaring, preparing for a big party.

This image soon dissolved. In its place appeared something more real: the messiness and claustrophobia of two people who don’t really know each other sharing two hundred square feet, of wet towels left on beds, of books and clothes covering every surface, of neither roommate living up to the expectations of the other, because, well, how could they? This disappointment mattered, of course, but then again so many spaces existed outside that little room in Hill: classrooms, coffee shops, the city, frat parties, restaurants, the track.

… The track.

In high school, track was fun. That was essentially its point: it was a form of cross-training that kept Maddy from burning out on soccer. Track came after school, and she spent much of the time running with Emma, her high school best friend, who competed for Boston College. Pressure eventually arose, once she became one of the best in the state, but she started without any kind of wild expectations. She just enjoyed running. She loved waking up on the weekend and going to the Celery Farm nature preserve, where she could churn through however many miles and whatever thoughts were on her mind.

But track in college was a different beast. For one, it was not just track; it was also cross-country. For another, it was not just one practice after school; it was also scheduled in the morning before classes. It was, like most Division I sports, a job—with time commitments, with demands, with expectations of performance. And nothing turns enjoyment into dread faster than obligation.

Maddy had been recruited to Penn by head coach Steve Dolan. She liked him, clicked with him, and assumed he would coach her. But he didn’t. Robin Martin, an assistant coach, was working with her, and the two didn’t jibe as well, in large part because they didn’t know each other. Thus Maddy was missing a crucial energy source: the inspiration sparked by wanting to make an admired coach proud. At Northern Highlands, she had enjoyed a strong relationship with her soccer and track-and-field coaches. Most high school coaches are also full-time teachers; sports are tangential. And because coaching isn’t their livelihood, that layer of stress and urgency, which coaches often pass on to the athlete, is absent.

For all of Madison’s life, late summer and fall had meant soccer. It meant walking onto a grass field, cleats in hand, laughing with friends she’d known her entire life. The work was hard, but it was collective work, with friends to connect with between sprints with a nod (“We got this”), or a laugh (“Coach is crazy”), or an exhausted grimace (“How many more?”)—each person pulling weight toward a larger goal. Now, late summer and fall meant waking up at dawn in a cramped dormitory room, in a new city, to trudge to practice and run long distances, the person next to you living inside her own head, considering her own times, responsible only for her own motivation. Maddy didn’t have anyone she wanted to show up for.

And practices rolled toward her as if on a speeding assembly line, with barely enough time to handle one before the next was upon her, morning then afternoon, morning then afternoon. Emily and Maddy spent numerous moments in their room, looking at each other, wishing they didn’t have to leave in just a few minutes to go run—again.

Maddy just wasn’t enjoying it. The training was so different. In high school, she had been a middle distance runner. She had wanted to stretch to the mile at Penn, but cross-country included races four times that length. Also, when she ran races in high school, she usually won. There were only eight lanes, just seven opponents, but still, Madison routinely finished first. On the other hand, a college cross-country meet included hundreds of runners, all literally corralled at the starting line, released onto the course in a wave of humanity—dense lines of people jostling for running room, fighting to prove themselves with each stride. And each of these runners was just like Maddy: used to winning.

To stay confident, Madison would need a shift in perspective. The same time that had won a race in high school would put her in the middle of the pack in college. But that needed to be okay; she needed to give herself time. Although Dolan thought she was doing well, Maddy couldn’t accept the abstract idea that she was doing “well”—not when she had a visceral reminder that she definitely was not. Weren’t runners streaming past her on the course?

In early October, Jim went to watch her race cross-country at Lehigh, at the Paul Short Invitational. Penn finished seventeenth as a team, and Maddy came in 104th out of more than 400 runners. That day, she was Penn’s second-fastest runner, despite being the only one who hadn’t run cross-country in high school. After the race, Maddy introduced her dad to her teammates and the other parents. She was still adjusting, trying to understand if she could work through the pressure and the time commitment. “She wasn’t enjoying it like she had in high school,” Jim said. “I could tell, but that was a nice little day for the track team, and she had a good race, so that made things better.”

On November 2, 2013, Stacy drove to Princeton to see Maddy run at Heptagonals, the Ivy League championships. (Stacy and Jim often alternated who attended what, since of their five kids, three were still playing sports.) Madison didn’t say much before the race, because she was too nervous. But Stacy noticed that her daughter seemed different—less radiant, dulled.

The temperature that day was hot, even though it was the first weekend in November, and the course was long, 6,000 meters. Maddy struggled in a way she never had before. She usually had a strong kick on the track and a nonstop motor on the soccer field. She possessed stamina, the result of never cutting corners, of doing all—and often more—of the required work. The way Maddy saw it, people collapsed at the finish line because they hadn’t done enough preparation, not because they’d done too much.

But when she crossed the finish that November day, she collapsed. What was happening to her? The medics at the race guided her to the tent, where they checked her pulse, gave her oxygen, and helped her rehydrate. She had finished forty-fourth out of more than one hundred runners, and fifth on the Penn team. Maddy recovered quickly—physically, at least.

Once she was back on her feet, she found her mom and gave her a hug. The color had drained from Maddy’s face, but how could it not have? She had literally expended all the energy in her body. “Mom, I’m just not happy,” Maddy said that day. “I’m not right—something is not right.”

Stacy assured her daughter that it would be okay, that they would figure it out, but she wasn’t exactly clear about what was happening. Maddy couldn’t articulate precisely what was wrong, only that something was. And Stacy had attended enough of her daughter’s games and meets to know how hard Maddy was on herself, how delicate her self-confidence could be.

A few minutes after the race, mother and daughter took a picture together. The moment the iPhone camera turned on, Maddy transformed: she pulled back her slumping shoulders, wrapped Stacy in a hug, and smiled for the camera.

But the reprieve was momentary. And throughout that fall, Stacy remembers looking at her daughter’s Instagram feed and seeing happiness and excitement. “Maddy, you look so happy at this party,” she recalls once saying.

“Mom,” Madison responded, “it’s just a picture.”

“Post Heps with mama #stacy #Heps #missedya .” (Madison Holleran)

The same night as the race, Madison texted Emma about what had happened.

Madison: THE LEGIT DEATH OF ME

Madison: Never died so hard

Emma: What happened?

Madison: I have no idea

Madison: But I collapsed at the finish line and felt sooooo dizzy I couldn’t walk

Emma: Did you do ok?

Madison: Yeah I finished top five on the team so we ended up doing better than we thought we would actually but it was a horrible feeling

Emma: How are you feeling now?

Madison: Much much better. Finally celebrating Halloween!!!!!! We are gonna be party animals

Madison: Ash and I are cheetahs hahaha

Emma told her mom, Lorraine, about Maddy collapsing at the finish line. Emma thought it was unusual, considering how strong her friend usually was in finishing races, but she wasn’t tremendously concerned. Madison herself seemed to be downplaying the moment, before pivoting to other matters. But as Emma and Lorraine talked more, really deconstructed what collapsing might mean to Maddy, Lorraine mentioned that of all Emma’s friends, Maddy was the least likely to brush off something like this.

Was the collapse only physical? Maddy must be exhausted, but by what, exactly? These questions flashed through Emma’s mind, then quickly evaporated. Running was hard. College was hard. Madison would figure it out, just as Emma was trying to do at Boston College. And, anyway, the collapse could be easily explained: hot weather, too little water, too long a distance.

Of course, what remained hard to understand was the effect this would have on Madison’s psyche. She had never handled failure, even the garden-variety kind, well. During high school, Madison once finished fourth in the 400 hurdles at a county meet—much worse than expected. She started crying and asked to leave the event, even before cooling down. “She had a tremendous work ethic, and she worked hard at everything she did,” Stacy said. “But she just put so much pressure on herself.”

In high school, Madison won constantly, and that steady stream of victories strengthened her fragile psyche. But once she was at Penn, Jim and Stacy, along with her older sister Carli, began to notice the erosion of Madison’s confidence. When Jim saw her at a meet in October, he told her, “I want to see you in the NCAAs in June.”

Madison responded: “Do you really think I’m going to get there?”

Jim didn’t miss a beat. “Of course,” he said.

“It started to feel like she didn’t see herself as a champion anymore,” Stacy said. “And she wasn’t okay with being good—ever. Good was not good enough.”

“I don’t think she realized how great she was,” Carli said. “Unless she was getting a medal, and then maybe, in that singular moment, she felt it. I would say something like, ‘When you’re rich and famous, don’t forget the little people. I’ll be your assistant.’” And Madison would look at her, actually surprised, and say, “What do you mean?” She didn’t see what everyone else saw. She was too busy fighting for more, for the next victory, in whatever shape it might come—as small as counting the exact number of steps in a flight of stairs, as big as getting into the Ivy League. For a moment, sometimes longer, these victories slowed the treadmill on which her mind churned, the one that made her feel she could never keep up.

When Maddy was in middle school, she would walk to school in the mornings with kids in the neighborhood. As the year went on, she started timing how long the walk took. Once she had that specific number, she needed the next day to be faster, and the day after that, faster still. By the end of the year, she was speed-walking, occasionally breaking into a jog, to beat the previous day’s time. There was something satisfying, calming almost, about controlling time and output in this way. She had created these little tests for herself, ones that she was fairly certain she could pass. That felt good, reassuring: no, nothing was out of her control.

Maddy was addicted to progress, to the idea that her life would move in one vector—always forward, always improving—as opposed to the hills and valleys, the sideways and backward and upside down, that adults eventually learn to accept as more closely resembling reality. Maddy was not unique in feeling this way. Much of young adulthood is presented as a ladder, each rung closer to success, or whatever our society has defined as success. Perhaps climbing the ladder is tiring, but it is not confusing. You are never left wondering if you’ve made the wrong choice, or expended energy in the wrong direction, because there is only the one rung above you. Get good grades. Get better at your sport. Take the SAT. Do volunteer work. Apply to colleges. Choose a college. But then you get to college, and suddenly you’re out of rungs and that ladder has turned into a massive tree with hundreds of sprawling limbs, and progress is no longer a thing you can easily measure, because there are now thousands of paths to millions of destinations. And none are linear.

From second through eighth grade, Kobus Reyneke coached Maddy in soccer. The team practiced three times a week for six years. After a while, he could read her body language, the way her shoulders would sag and her head drop after an imperfect pass or shot. Not necessarily a mistake, just a moment that could have been crisper—the flatness of it often imperceptible to others. When she came over to the sideline, Kobus would stop her, and she would say, “I’m not good.”

“Are you crazy?” he would respond. “You’re the best on the team!” But no matter how adamantly he reassured her, how vehemently he praised her, this interaction, or some variation thereof, played on a loop for all six years he coached the Americans.

Getting Maddy out of her own head was difficult. She was shy; everyone knew that. But there was a depth to her shyness and the wall she built around herself. She had trouble making eye contact with the parents of her friends. They noticed this when she got into their cars after a practice or a game. The other kids would yank open the door, calling everyone Mr. and Mrs.—all kinetic energy. But Maddy would often keep her head down, her answers monosyllabic. During car rides, she almost always spent the time studying, disconnected from the group. Her friends rarely did homework in the car, but whenever seating became crowded, Madison usually pulled out her books. Not always, of course: sometimes a popular song would come on the radio and she’d start singing and bouncing around just like the rest of them. She liked to smile and laugh, but she also possessed an introspective nature unlike that of the other kids.

At Penn, the chipping away at her confidence wasn’t happening only on the track; it was also happening in the classroom. In many of her courses, Maddy was being graded on a curve. She had no experience with curves. She was used to studying for a test, getting most of the answers correct, then seeing a high grade that showed her exactly how she was doing. At Penn, she could study for days, get half the answers correct, and have no clue where that score ranked among those of her classmates. And if she knew only half the answers, wasn’t she probably failing?

School had always been straightforward: collect a specific set of numbers and letters, and receive your desired grade. That was not confusing; that was reassuring. Now, she felt as if she’d been dropped onto a course of unknown length without signs or mile markers.

Toward the end of the semester, one of Maddy’s high school friends, Justine Moran, drove down to Philly. The two had grown up together. Justine didn’t play sports, and because of that, their relationship did not rely on soccer or running as the common thread. When together, the two often gravitated to discussing other topics, which is what they did that day in Philly. Over Greek food, Maddy told Justine how stressed she felt about school.

“I get tests back, and the teacher says, ‘Don’t worry about this number,’” Madison told her friend. “I have no idea how I’m doing. I think I’m failing.” Justine did her best to reassure Madison that everything was fine, that she was going to be fine. After all, hadn’t Madison always performed well, even when things became difficult? Why would this time be any different? “I just feel like I’m trying so hard and nothing is working,” Maddy said.

Justine could sense her friend’s unease. “In high school, she had the perfect—well, everything,” Justine said. “She always stood out. But now, she wasn’t fully seeing her success, or all of her work paying off. She didn’t stand out there as much as she did at home. She was just another person, and it felt like that was scaring her.”

Maddy often expected the worst. To her, the prospect of failing out of Penn did not feel like hyperbole; it felt like the probable outcome. How could she believe otherwise, when she had no concrete evidence to the contrary? Everything had been flipped on its head, had become abstract. She was finishing behind a hundred other runners and was told that was good. She knew only half the answers on an art history test and was told not to panic.

Freshman year of college, especially for those playing a sport, is like walking through an obstacle course wearing a blindfold. No context exists for how hard the workouts will be, how long they will last, what each class will be like, what events are fun, what should be avoided. There is no yin-yang, either; no understanding that one week might feel grueling, unmanageable, but just hang on, because the following week will be light and easy. For someone who struggles with the unknown, freshman year of college can feel like walking a path lined with land mines—heart racing, disaster around every corner.

Now add another variable: mental health.

 

Mind, Body, Spirit

In the early 2000s, I played college basketball at the University of Colorado. A month into my freshman year at CU, I began to dread practice. This is not an exaggeration; I once swallowed an entire bottle of iron pills in the hopes that I would become violently ill so I could be excused from that afternoon’s session. Apparently, I believed that spending hours hunched over a toilet was more pleasant than being on the court. Every single day was the equivalent of me holding a thermometer next to a lightbulb, desperately trying to convince someone, anyone, not to make me go. I found myself focusing on whatever small aches and pains I had. A bruise on my shin was likely shin splints, a sore knee tendinitis. And if I complained persuasively enough, perhaps our trainer would tell me I needed to take a few days off.

The hours before practice became a mental battle far more torturous than whatever I was hoping to avoid on the court. Anxiety dimmed my every waking moment. (And often my sleeping ones, too.) Every minute was one minute closer to the next practice, even if it was just one minute removed from the last. I convinced myself I hated basketball. Then this thought would send me spiraling: Who was I if not an athlete? I didn’t know. My identity was as a basketball player. The initial fatigue was, at a base level, physical: difficult morning workouts, increased weights in the gym. But previously, physical strain had always been manageable. I’d always had a comfortable emotional foundation. My feet were planted. A workout was challenging, but it existed within my routine: I went home to my bed, in my room, with my family. Once the foundation shifted, and once my support system became a group of people less warm and caring than my parents, every physical act seemed more difficult.

After about three weeks of this, I walked into the office of Kristen Payne, our athletic trainer, sat in the chair opposite her desk, and started crying. I was lucky. We had developed a close relationship from my first day on campus; I trusted her. As I sat crying in her office, she defended me, dismissing each coach who came into the training room looking for me, wondering why I wasn’t yet on the court.

“She’s not practicing today,” Kristen said.

“But why not? Is she hurt?”

“She’s just not practicing today. End of story.”

That day, she connected me with a counselor, one not affiliated with the school. And once a week for about a month, I drove the few miles to his house outside of Boulder, to talk to him and try to unravel what was happening.

I was embarrassed about having to see someone. I told no one I was doing this. I felt weak. The saving grace was that I was spared the discomfort—unfortunately, that’s how it would have felt to me then—of walking across campus and into the building that housed counseling services. Everything I did, except for attending classes, was within the silo of the athletic department: lift, practice, study, train, eat—even worship. This was my safe space, my comfort zone. And guess what? There was no counseling center, no psychologist’s office, within the athletic department building. The clear message: needing a psychologist is abnormal.

How could an athlete with a mental health issue not feel like an outsider when she was literally forced out of the athletic department and pointed toward a building far away from campus and the athletic bubble? But regardless of distance, therapy helped me; things gradually started to feel better. And within a month or two, I could step onto the court without panicking.

My sister, Ryan, ran cross-country and track at Dartmouth during the same years I played at CU. She was often hurt during college, and in the fall of her senior year, her times plummeted. She just could not get her body to do what her heart and mind asked of it. After one meet—it might have been after Heptagonals, the same race after which Maddy collapsed—my parents found her by herself, crying. Nothing they said could make it better.

Parents don’t really know how to help. Some aren’t prepared for this new version of their high-achieving kid: doubting, sad, tired, confused—emotions they may have rarely dealt with in high school. And isn’t college supposed to be even better than high school? When your child is more mature, self-sufficient, and otherwise flourishing just as she always has been, except now at an even higher level?

The relatively early age—sometimes as early as elementary school—at which parents define children as athletes makes it more difficult to cultivate other parts of their identity. Very little else in our society is rewarded as athletics are. And when you’re young, the distinction between an activity that truly satisfies your soul and one that merely brings accolades is difficult to parse. For many, those two things aren’t mutually exclusive. For others, sports are actually not their passion, a realization that doesn’t come until they’re put into the fire of college sports. But admitting ambivalence of this kind can feel like considering filing for divorce the day after a wedding: everyone involved has already invested so much time and money. And hadn’t you convinced yourself you were truly in love?

Ryan was eventually found to have anemia, a diagnosis that took far too long to reach, and she immediately began taking iron. By track season, her times dramatically improved. But for those few months when her body was playing tricks on her mind, which led to her mind playing tricks on itself, she was nearly inconsolable, and it became clear how much self-worth we both had wrapped up in being high-achieving athletes.

Anemia has nothing on mental illness, although with both, people often assume you’re just weak and can’t push through. We have little sympathy for injuries that we can’t see and touch, for whatever is hurting that isn’t bloody or outwardly broken. But that’s where the comparison between the two ends, because with mental illness, unlike anemia, an official diagnosis usually doesn’t end the stigma. And to make matters worse, those with the least empathy are often teammates—peers.

In the spring of 2016, I spent a week at the University of Oregon talking to student-athletes. One evening, I spoke about mental health with the Student Athlete Advisory Committee, and the first question directed at me was, “How can we think differently as athletes, because from the first day we step on campus, we’re taught that champions never quit and perseverance is what makes greatness? I’m worried a teammate might be really hurting and all I see is weakness.”

No good answer exists for this question, which was the response I gave. I told this young woman that I could deliver the most beautiful monologue about compassion and understanding, but no young person has been compelled toward empathy just because someone implored them to be. I then shared my own personal experience: I was too harsh on teammates who, for example, had transferred (we labeled them “traitors”); only years later did I come to see that just because a situation was right for me didn’t mean that it was right for everyone, and sometimes making a life change is fundamentally necessary for another person. Achieving that kind of insight took almost a decade. And what good did it do those scorned teammates I no longer spoke to? Perhaps the only relevant advice I could offer the Oregon athletes was this: Recognize that empathy might be in short supply. Educate yourself about mental health. And consider the idea that not every struggling teammate is weak.

I had this discussion with student-athletes, but the sentiment could have applied to much of the campus population. According to pretty much every study conducted over the past five years, levels of empathy among college-age students is plummeting. The University of Michigan conducted a study in 2014 that found that college kids are 40 percent less empathetic than they were just twenty years before. Researchers at Michigan’s Institute for Social Research shared their thoughts on why: “The ease of having ‘friends’ online might make people more likely to just tune out when they don’t feel like responding to others’ problems, a behavior that could carry over offline. Add in the hypercompetitive atmosphere and inflated expectations of success, born of celebrity ‘reality shows,’ and you have a social environment that works against slowing down and listening to someone who needs a bit of sympathy.”

After I spoke at the University of Oregon, a young woman approached me and shared the following: “Thanks for talking about empathy. Hopefully my teammates were listening. Sometimes it seems like it’s hard for them to focus on anything other than winning. And so then anyone going through something that remotely compromises that pursuit, like I am right now, gets ostracized. I feel like they talk about me behind my back instead of trying to understand.”

When it comes to mental health among athletes, clinical diagnoses are rare. Truth is, it’s unusual for an athlete to be open and honest with a coach or trainer. I was lucky that I had connected with our team’s trainer before my anxiety struck. She knew me on a few different levels: as an athlete, as a student, as someone who enjoyed talking about books, as an eighteen-year-old kid from New York. On some level, I think I understood that even though I felt I was failing at one identity—athlete—she saw my value on other levels and would recognize that I was more than someone who just happened to put on a Colorado jersey. And I needed her to validate my other layers of self-worth, the kind independent of basketball, because I was not yet capable.

During those months at CU, I thought I was alone, the only student-athlete who couldn’t deal with the transition to college, couldn’t deal with the time commitment, the added pressure, the morphing of my sport from something I loved into something I loathed. Everyone was strong. I was weak. Everyone was succeeding. I was failing. Why would I think otherwise? All the signals I had ever received indicated that I was the lucky one. I was living a dream. Being a big-time college athlete? I should relish that—love every minute. So what was wrong with me?

Nothing, actually—turns out I was in good company. In 2014, the American College Health Association surveyed nearly twenty thousand student-athletes. Some 28 percent of female student-athletes and 21 percent of males reported feeling depressed, while 48 percent of female student-athletes and 31 percent of males reported feeling anxious. Approximately 14 percent said they had seriously considered suicide, with 6 percent saying they had attempted it.

Of course, it’s safe to acknowledge feelings of anxiety and depression, even suicidal thoughts, in a survey. A survey is anonymous. Actually telling a coach or trainer about those feelings is another matter entirely. And even more unusual is the coach or trainer who knows precisely what to do.

Talking openly about debilitating thoughts and emotions might seem like a logical and necessary step for an athlete, until you consider that sports are built on the pillars of toughness and perseverance. Picture every Hollywood sports movie, ever. One thing they all have in common: a montage of the lead character pushing through the pain, training to become the best. Our culture celebrates harder, faster, stronger. Vulnerability, it would seem, undermines that pursuit. And within sports culture, continuing to practice or play, no matter what your mind or body says, is romanticized: T-shirts are emblazoned with quotes, inspirational sayings are stenciled on the locker room wall, epic speeches are given. At Colorado, a saying above one doorway read “Pain is weakness leaving the body.”

Imagine, with that sign hanging over you, telling a coach you can’t run that day. Not because your body hurts (and what kind of hurt is bad enough?), but because your brain does. Many coaches believe these moments are forks in the road, and that choosing to push through pain—in whatever form that pain comes—is what creates champions. Athletes often believe this, too. And it’s not entirely wrong. Pushing through pain, clearing hurdles others have crashed into, is how an athlete improves. Knowing the difference between a hurdle and a brick wall is also crucial—yet recognizing that difference is almost impossible when you’re eighteen years old. That’s the coach’s job. And if a coach isn’t sensitive to brick walls, athletes are often left to engage in debilitating mental warfare: one part of the mind says no more; the other part tells them they’re weak for saying no more.

The National Collegiate Athletic Association has recognized how much work must be done to address the mental and emotional well-being of student-athletes, and also admits that for too long, it’s been a vastly less significant priority than promoting their physical health. If the variance in spending weren’t so disconcerting, the difference would be laughable. Consider the state-of-the-art equipment, expansive weight rooms, training rooms, and practice fields at most Division I schools. If a football player pulls a hamstring, nearly half a dozen licensed professionals hover over him, discussing the most innovative ways to rehabilitate his strained muscle. Yet if most athletic departments’ commitment to mental and emotional health were visualized as a weight room, it would more closely resemble this: a few rusted dumbbells, a cracked mirror, cobwebs, and plenty of open space waiting to be filled.

These are the conditions in which many student-athletes train and play. Getting better in such circumstances is almost completely up to the individual.

In 2014, the NCAA deemed the issue of mental health so pressing that it commissioned a paper on the topic that included stories from former athletes, data, and best practices. “In sports like football, toughness is celebrated and weakness is despised,” writes former National Football League lineman Aaron Taylor in this paper. “We do what’s necessary to navigate this ‘manly’ environment, and that means masking our feelings. Players learn to ‘suck it up,’ ‘rub some dirt on it’ and ‘gut it out,’ usually with positive results. We’re so conditioned to do this that we often default to such behavior in our everyday lives. Unfortunately, masking emotional issues doesn’t work as well in the game of life as it does helping us play through a high ankle sprain. It also helps explain why so many emotional and mental health problems go unnoticed. Players become masters at keeping their game faces on all the time, often until it’s too late.”

According to the NCAA, suicide ranks as the third most frequent cause of death among student-athletes—behind accidents and cardiac failure. Colleges and universities do have policies and procedures in place to respond to a student-athlete’s mental health issues. The concern is that the quality of the response, and the intrinsic understanding of the issues, is often subpar, especially when compared to everything we know and study, and discuss at length, about an athlete’s body.

Athletic departments more often than not have numerous staff members fully certified to treat physical injuries, yet most don’t have a single licensed mental health professional on the full-time payroll. For some departments, this isn’t a conscious omission; they’ve simply never considered the necessity. For others, it’s about cost, about where their money will have the most impact. And quantifying the productivity of a training staff—in ankles taped and injuries rehabbed—is much easier than gauging that of a mental health professional.

According to a 2014 article on ESPN, fewer than twenty-five Division I athletic departments employed a psychologist on staff. The importance of a psychologist is this: she may be the only staff member whose job is not related to winning. Even the most compassionate coaches and trainers are dependent on the physical performance of their athletes. It’s a nice bonus if they graduate healthy human beings, but that’s not specifically why they’re drawing a paycheck.

The NCAA is playing catch-up, trying to patch the holes. “One in every four or five young adults has mental health issues,” Timothy Neal, assistant athletics director for sports medicine at Syracuse University, told ESPN. “But what is unique about the student-athlete is they have stressors and expectations of them unlike the other students that could either trigger a psychological concern or exacerbate an existing mental health issue.”

Some of the stressors and expectations are tangible; others are not. Though it defies logic, many young athletes, on signing a college letter of intent, convince themselves that the hardest work is behind them. They understand there will be practices and training once they get to campus, but this may be seen as maintenance. The toughest work—the development of skill through thousands of hours of practice—has already been completed. Now it’s payoff time, an opportunity to be celebrated on a bigger stage. Also, most college scholarships (of the nonathletic kind) reward prior achievement; once a student arrives on campus, there are no daily expectations, though many academic scholarships do require the maintenance of a specified grade-point level. The time commitment for a student-athlete often ranges to twenty-five-plus hours a week. And it’s grueling, exhausting work that tests your character and resilience during a time—freshman year of college—when those attributes are often at their lowest levels.

Until recently, the majority of athletic departments weren’t proactive or preventive; they simply reacted as best they could if an athlete had a mental health issue. Now some schools are trying to equip kids with the tools to strengthen their minds, to handle their emotions. At Texas Christian University, the athletic department administers a mental health baseline assessment for each athlete before the beginning of the season. A number of universities are doing the same. This way, if an athlete’s behavior changes, the trainer has a way of evaluating whether it’s significantly different than it used to be. “Most of college athletics is: ‘Can he run, can he jump, can he shoot?’” says TCU athletic director Chris Del Conte. “And the whole part of the kid is lost. What do you do with the whole of the kid, with those with eating disorders, with the cutters? It’s amazing that coaches are not prepared to deal with this stuff. So a lot of times you have to help them help themselves. ‘Let me take this off your hands,’ or, ‘This is how you have to deal with this. I know performance is the greatest thing you’re looking for, but here’s what we need to do to get there.’ Some of our coaches get it already. Other coaches, it’s foreign to them.”

Molly McNamara ran cross-country and track for Stanford while also struggling with depression. She wrote a piece for the NCAA touching on issues of perfection, injury, toughness, depression, and empathy. At first Molly felt she was unique in her struggle, until she looked around and realized that a number of other athletes at Stanford were dealing with stressors—all coping in various ways. She told herself, “I am not imagining this… this is actually a big issue.” And as Molly recognized, runners, like Madison, often battled their minds in a distinctive way:

“How do you survive those less-than-perfect situations when discipline isn’t enough? When grittiness gets you through the workouts but can’t seem to get you through the rest of the day? As a runner, you’re highly in tune with your body, and you know its highs and lows; you know your normal aches and pains, and you know when you should probably see the athletic trainer. Learning the highs and lows of your mind is much harder.”