Treatment is implementing a systematic course of care. In the HIMS program, the term treatment is commonly used to refer to the specific residential or outpatient program given to the patient. But, more accurately, treatment is the sum total of all the efforts expended to effect a remedy for the chemical dependency problem. An ideal comprehensive program consists of the following elements: immediate intervention when warranted, rapid evaluation, assignment to the appropriate level of care, uninterrupted therapy, timely return to flying, thorough monitoring, and relapse prevention and contingency planning.
The design of any treatment program must be congruent with the type of disease involved; that is, one must consider the particular characteristics of the disease and implement strategies to address them. Chemical Dependency has four characteristics. First, it is chronic, meaning it is permanent and prone to relapse. The disease for abnormal drinkers is called alcohol-ism, not alcohol- wasm! This description implies there is never a return to normal “social” drinking or any “recreational” drug use. Relapse means reactivation of the original disease, not acquisition of some new disease. To prevent relapse, one must implement a defense against the first drink or drug, and build an ongoing maintenance program strong enough to countermand any alcohol craving or drug hunger.
Secondly, Chemical Dependency is primary, meaning it exists independently and is not secondary to some other underlying mental illness or personality disorder. Therefore, the addiction must be treated directly with measures distinctly different from the kinds of psychotherapy utilized for mental illness in general. These measures are not designed to empower one to return to social drinking, or develop insight into why one drinks. Total abstinence from all addictive chemicals is the core goal central to this approach. If there is a co-existing mental illness, referred to as a “dual diagnosis” situation, then such illness is considered as another primary disease and treated accordingly.
Thirdly, addiction is predictable. It is most often progressive with four stages: early-middle-late-and too late! The consistency with which the disease manifests offers only three options to its victims: they wind up either locked up (incarcerated), covered up (buried), or they sober up (get into recovery).
Lastly, Chemical Dependency is catching. Its insanity is catching. The stress of living with an alcoholic/addict produces dysfunctional coping behavior similar to that seen in Post-Traumatic Stress Syndrome. Co-dependent family members often remark that they have lived through a “thousand Vietnams.” Addiction is a family affliction, and therefore, any quality treatment program should have a strong family component.
The American Medical Association recognized alcohol dependence as a disease over 55 years ago. Aerospace Medicine, through the ALPA Aero-medical Advisor and the FAA Federal Air Surgeon, embraced this concept through the initiation of the HIMS program in 1974. At that time, the most successful programs began with extended in-patient treatment followed by long term aftercare extending over a period of years. HIMS adopted this treatment model and the majority of HIMS program participants attend in-patient or residential treatment for at least 28 days, followed by 3 years or more of weekly aftercare and monitoring.
There is no list of HIMS or FAA approved substance abuse treatment facilities. An initial diagnostic assessment should match the treatment to the severity of the disease, and health care professionals should consider the safety sensitive responsibilities of the professional aviator when recommending a specific level of care. With these considerations in mind, the HIMS program expects treatment programs to have certain components, including, but not limited to:
- A full-time certified Physician-Addictionist
- Credentialed &/or certified Counselors, some of whom are in substantial recovery themselves
- Acceptance of addiction as a primary disease
- Insistence on total abstinence
- Separation of alcoholic/addict patients from primary psychiatric patients
- Psychiatry & Psychology Consultants
- A strong family component
- Recovery based on the 12-Steps of Alcoholics Anonymous
- Endorsement by accreditation or licensure agencies
Therapy involves a tri-dimensional approach because body, mind, and soul are compromised. Detoxification and medical stabilization by the medical team occur first. Emotional balancing and cognitive restructuring follow and are accomplished by the counseling staff.
Finally, spiritual restoration begins with early exposure to Alcoholics and Narcotics Anonymous, which are mutual-help fellowships that embrace 12-Step programs. Initiating abstinence is merely the beginning of recovery, not the end. Making the changes in attitude, belief system, and habits necessary for the maintenance and growth of sobriety creates real struggles. The critical challenge is to make the transition from dry to sober, and from clean to serene!
Rarely does a pilot enter treatment completely voluntarily; most arrive because of some type of “benevolent persuasion!” Many believe their job is threatened. Fear of job loss often endangers their entire sense of being and identity. For most pilots losing their license and their ability to fly shakes the very foundation of their universe. Such circumstances often make the pilot suspicious and reluctant to fully participate in the treatment process. As goal oriented people, pilots immediately set forth to complete the “check list,” memorize the “manual,” follow all “procedures,” comply with all “rules,” stay within the “envelope,” pass the counselor’s “check ride,” and maintain the proper “glide path” to recovery. However, communicating on an intimate emotional level and becoming truly engaged in therapy takes an enormous effort.
Treatment involves accomplishing many goals:
• Penetrating denial
• Understanding the disease
• Reconnecting anesthetized feelings
• Identifying core (personal) issues
• Involving the family
• Developing relapse prevention strategies
• Inculcating Alcoholics/Narcotics Anonymous into daily living.
When behavior is caused by disease, treating the disease changes the behavior! The old “28-day” residential treatment model is an endangered species. Today’s state- of-the-art medical approach matches the intensity of the service to the severity of the illness. This approach applies to any disease. Not all diabetes is the same: there’s mild, moderate, and severe, each requiring different treatment: diet, pills, or insulin replacement. The same is true for chemical dependency: outpatient, in- patient, or extended residential modalities are utilized. Pilots, like physicians, are often subjected to more strenuous approaches because of their safety-sensitive occupations. Nevertheless, individualized treatment planning is utilized to treat professional pilots.
Do pilots because of their common personality characteristics and unique working environment require specialized treatment? There has been speculation that pilots have “giant egos,” that they are over-controlling, and are subjected to some very unique stresses. They often experience irregular and extended hours, intermittent “down-time,” repetitive family disruption, altered physiology from time zone changes, sleep deprivation, and constantly operate with heightened vigilance waiting for some catastrophic disaster. The answer remains speculative. All recovering alcoholics and addicts are subject to stress, and the role of particular types of stress in reactivating addiction is unclear. The lack of consistent contact with supervisors and fellow employees does create some challenges to effectively monitoring pilots. But, such adaptations to specific circumstances also happen in other professions.
Two myths persist regarding treatment: 1) the alcoholic/addict must want treatment; and, 2) he or she must hit bottom! Both are untrue and can be circumvented by a process called intervention–a compassionate, rehearsed, professionally facilitated, non-judgmental confrontation that essentially raises the bottom through benevolent persuasion.
For a successful recovery from the disease of Chemical Dependency, the following must be changed: attitude, belief system, perceptions, thought patterns, and habits. Treatment is about motivating patients to make these changes. Therapy involves connecting the intellect with emotions. It necessitates abandoning isolation by establishing a sense of community. It requires acquisition of certain management skills, developing an accurate self-awareness, and above all, experiencing ego reduction at depth.
Outcome studies show that the highest treatment success rates occur in the professional population, especially with commercial pilots. Rehabilitation, rather than termination, should be the ultimate goal, since it is much more cost effective to treat rather than replace a highly skilled pilot. Commercial airline pilots enjoy a significantly higher than average success rate, and in recovery, constitute a valuable asset to their profession and to the flying public.
- Lewis, D.C. A Disease Model of Addiction. In N. S. Miller and MC Doot (eds.) Principles of Addiction Medicine (1994). Chevy Chase, Maryland. American Society of Addiction Medicine, Section 1, Chapter 7, Pages 1-8.
- Hankes, LR, and Bissell, L. In Lowinson, Ruiz, Millman, (eds.) Substance Abuse, A Comprehensive Textbook. Baltimore, Maryland: Willams and Wilkins, 1992: 897-908.