Authors: Matt Moore1, Keegan Atherton2, and Cindy Miller-Aron3

1Department of Family Science and Social Work, Miami University, Oxford, OH, USA
2School of Education and Human Sciences, Campbell University, Buies Creek, NC, USA
3Ascend Consultation in Healthcare, Chicago, IL, USA

Corresponding Author:

Matt Moore, Ph.D., MSW
501 E. High Street
Oxford, OH 45056

Matt Moore, Ph.D., MSW, is an Associate Professor and Department Chair for the Department of Family Science and Social Work at Miami University in Oxford, OH. His research interests focus on sport social work, sport for development, and positive youth development through sport.

Keegan Atherton is a BSW student at Campbell University in Buies Creek, NC. He has a decorated military career with the United States Air Force.

Cindy Miller-Aron, LCSW, CGP, FAGPA, works for Ascend Consultation in Chicago, IL. She is several decades of clinical social work experience with an emphasis in sport social work and psychiatric care.

Line of Efforts: Unity of Purposes for Professionals Working with Elite Athletics


The purpose of this commentary is to explore how military practices can help provide holistic care for the biopsychosocial well-being of elite athletes. In particular, authors explore how Joint Doctrine related to Lines of Efforts (LOEs) and Human Performance Optimization (HPO) could provide a model of integrated care for elite athletes. The commentary includes an introduction to factors impacting elite athlete mental health, a review of military LOEs, and how these LOEs could support HPO among elite athletes. This includes a discussion on the inter-professional practice and informational diversity needed to support elite athletes both in and away from competition. The authors also discuss the key stakeholders needed to support elite athlete health and well-being, with an emphasis on full collaboration from professionals to transform practice.

Keywords: elite athlete, military, integrated care, health, well-being


Recent studies show elite athletes are susceptible to mental health symptoms and disorders such as depression, anxiety, mood disorders, substance use, and eating disorders (13, 15, 22). Factors impacting elite athlete mental health are both athlete-specific and general risk factors (21). Athlete-specific risk indicators include sport related injuries (16), performance failure or maladaptive perfectionism (22), overtraining (19), and sport type (e.g., team versus individua; 25). General risk factors might include adverse childhood experiences (3, 23) sexual assault and interpersonal violence (17, 26), criminal justice involvement (6, 7), racial and sexual injustice (4, 18), and loneliness and social isolation (8).

With a rise in discussion regarding elite athlete mental and behavioral health, comes an increased need for professionals who can provide a centralization of multiple tasks to support athlete well-being. This centralization requires an integrative approach that encourages inter-professional practice and informational diversity, (15) and draws upon the strengths of athletic trainers, strength and conditioning coaches, sport administrators, sport psychiatrists, sport psychologists, sport social workers, and other members of an integrated care team (14). Developing such an inter-professional model requires an approach that promotes inter-professional collaboration versus inter-professional competition (8, 14). It also encourages a perception of collective change, not only for individual athletes but for systems as a whole. This team must believe in supporting elite athlete well-being both in and away from competition. The team must understand their individual roles within an inter-professional model to ensure elite athletes have access to education and services that are culturally responsive, address stigma, and demonstrate an understanding of athletic identity (8, 11, 14, 28). To promote these outcomes, members of an inter-professional care team must consider existing models of collaboration. One such model, not yet explored in elite athletics, is the armed forces approach to Lines of Efforts (29, 30).


Joint Doctrine defines Lines of Efforts (LOEs) as the unity of purpose that centralizes multiple tasks and missions behind a desired effort (1). From an armed forces perspective, LOEs ensure an increase readiness; demonstrate a competitive edge with discipline and speed; develop a strong team; and foster trusted connections.  These LOEs contain multiple objectives that allow our armed forces to maintain a path to achieving a shared vision.

First, to increase readiness, members of our armed forces execute their outlined mission daily to develop, deliver, support, and sustain efficiency and effectiveness. Through these efforts, members of our armed forces maintain the infrastructure, operational agility, tools, and processes to ensure success in combat readiness. Second, to maintain a competitive edge, members of our armed forces routinely revolutionize their training to maintain cutting-edge approaches. These cutting-edge approaches require a cultural mindset that values clear and consistent lines of communication. This communication should include identified roles, responsibilities, structure, and partnerships.

Third, by creating a culture and climate where individuals can thrive, talent will come and reinvigorate a competitive edge. In addition to an effort to recruit talent, there is also a need to manage talent, provide supervision and mentorship, encourage resiliency, maintain mission awareness, and create an inclusive environment for learning. Fourth, our armed forces garner international respect through their connectedness to the overall mission of protecting the safety and security of others. This common goal strengthens teamwork and communication, creates educational opportunities, and helps to ensure internal and external efforts are working towards a clear vision.


According to the American Psychological Association (2), an elite athlete is most often defined as an athlete who competes at a national, international, or professional level, although the term can also refer to accomplished athletes in non-professional contexts. There are often comparisons made between elite athletes and the military personnel who protect our country (9, 12). These comparisons might include advanced physical training, mental preparation, strong leadership skills, self-discipline, teamwork, competitiveness, and resiliency (31, 32). These phrases are intricately woven into the military LOEs and framework for training elite athletes for competition (See Figure 1). The comparisons between elite athletes and military personnel can also provide insight on efforts related to inter-professional collaboration and the connectedness with human performance optimization (HPO; 27). In particular, HPO strategies for developing a team-based approach to providing evidence-based, holistic care to support the health and performance of elite athletes at the individual and team level.

Figure 1. LOE and Elite Athletes


The military publishes a multitude of articles demonstrating their dedication to HPO (5, 10, 27). For many active-duty service members the HPO outlook on holistic healthcare is a refreshing and welcome change (5). Historically military members believed there was an unspoken acknowledgement that if you were unable to perform your job adequately, there was always someone else who could do it better. The HPO outlook changed that mindset and allows service members to talk about their medical concerns, address them head on, and not only become better at their specific military duties, but become better global citizens through a holistic and integrated care approach (10, 27).

HPO supports the lines of efforts discussed above by addressing the various needs of elite athletes to enable them to perform at a high level. There are five pillars used in the military model as Preservations of the Force and Family (POTFF) – physical, psychological, cognitive, social and family, and spiritual (24). These five pillars combined with the four LOEs provide a framework for the transfer of military practices to work with elite athletes. The physical pillar includes sports medicine (e.g., athletic trainers and team physicians), strength and conditioning, and performance nutrition. The psychological pillar breaks into assessment, prevention, and intervention related to mental and behavioral health (e.g., social workers, psychologists, and counselors). The cognitive pillar enhances cognition, monitors head trauma exposure, and protects brain health (e.g., concussion, injury response, and return to play protocols). The social and family pillar enhances relationships, peer mentoring, and bolster social connectedness both in and outside of athletics. The spiritual pillar brings awareness to religious practice (if desired), character ethics, values and beliefs, as well as meaning and purpose. HPO uses two continuous rotating cycles to aid in the diagnosis and treatment of military needs. These cycles also fit within the inter-professional framework desired to promote elite athlete well-being and safety (See Figure 2). These cycles take into consideration therapeutic and rehabilitative efforts, evaluation for safe return to participation, prevention, preparation, education, and recovery efforts.

Figure 2. HPO Cycles

These cycles also provide frameworks for assessing elite athletes prior to sport participation, during active performance, and post-performance (5, 10, 27). Pre-participation screening might include achieving and sustaining functional fitness (e.g., fitness testing), performance nutrition (e.g., diet plans and nutrition education), cognitive readiness (e.g., mental preparation, cognitive techniques, and sleep plans), psychological readiness (e.g., mental and behavioral health screening, relaxation techniques, and cultural awareness), and environmental threats. Active participation focuses on fatigue, alertness, and pain management, situational awareness, stress reduction, and environmental exposures. Post-performance emphasizes returning to functional fitness (e.g., rehabilitation, rest, and recovery), psychological repair (relaxation, mental resetting, and relying on social supports), and recovery nutrition.

Human Performance Optimization requires an integrated healthcare team often made up of team physicians, primary care physicians, athletic trainers, physical therapist, sports dietitians and nutritionists, mental health providers, sport psychiatrist, sport psychologists, sport social workers, strength, and conditioning coaches, amongst others (14, 15). Much like in the armed forces, this team is responsible for considering health management and optimizing performance both during and outside of competition. This might include injury prevention, injury rehabilitation, rest and recovery, food intake, hydration practices, mental health education and treatment, substance use awareness and treatment, medication monitoring, mental performance training, strength and conditioning, etc.

            Military practices outline six levels of HPO integration (5, 10, 20, 27).

  • Level One – Minimal Collaboration
  • Level Two – Basic Collaboration (Distance)
  • Level Three – Basic Collaboration (Onsite)
  • Level Four – Close Collaboration Onsite with Some System Integration
  • Level Five – Close Collaboration Onsite with System Integration
  • Level Six – Full Collaboration Onesite with Transformed Practice

The preferred approach is to reach a level of integration (Level 5 and 6). This ensures professionals are actively working to seek solutions, communicate frequently about client needs, have regular team meetings to discuss holistic care and concerns, and have a shared cultured with supported professional roles (14).


Overall, the HPO and POTFF/LOE guidelines provide a possible model for supporting elite athletes to lead happy, healthy, and rounded lives. This team effort is critical for making the athlete feel “seen” or that their needs are being met. This model also takes into account known challenges facing elite athletes and the level of care needed to ensure success both in competition and other areas of life. Yet, more must be done to evaluate the success of military practices in elite athletes. While there are similarities, elite athletics and military personnel do operate in different systems. For example, military personnel uphold an oath to the constitution of the United States of America and a willingness to give the greatest sacrifice. This message should not be lost in thinking about what we can learn from military operations that could inform other populations.


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