Aftercare / Monitoring
High quality aftercare and monitoring is the key to establishing long-term sobriety for the newly recovering pilot. Aftercare and monitoring consists of several elements, some mandated by the FAA and some not. The FAA Office of Aviation Medicine uses the term aftercare to mean the specific structured outpatient treatment that occurs after the initial intensive phase. This structured outpatient treatment usually includes periodic meetings with a psychiatrist and weekly group therapy sessions.
In a more general sense, aftercare and monitoring can refer not only to structured outpatient treatment, but also to meetings with peer monitors, meetings with company supervisors and employee assistance personnel, meetings in recovery groups like Alcoholics Anonymous (AA), contact with AA sponsors, relapse prevention visits to the pilot’s treatment facility, and compliance testing. Most airlines with highly effective HIMS programs view aftercare for their pilots from this broader perspective and provide for pilot involvement in most, if not all, of these areas.
Recovery from chemical dependency is sometimes marked by relapse. Aftercare and monitoring is intended to address this issue. Of course, every relapse instance for an alcoholic or addict represents a direct threat to their health and wellbeing, as well as to the health of others. Additionally, a recovering pilot’s relapse represents an operational risk to his company. These risks are often compounded because the pilot involved will usually not voluntarily admit to the re-use of the addictive substance out of shame, a desire to avoid re-treatment, and fear for his job. The shame and fear can then act as an incentive to drink or use again and a vicious cycle may develop. The key to preventing such a cycle is, simply, to ensure it doesn’t begin. The AA “Big Book,” the main text for recovering AA members, says that continuous sobriety for an alcoholic requires a strong defense against the first drink. Effective aftercare and monitoring is the foundation of such a defense for chemically dependent pilots.
Sometimes people refer to the broader view of aftercare and monitoring as “continuing care.” The use of this term, continuing care, is generally intended to indicate the need to address the potential for relapse: to, in essence, treat the patient against relapse. Since all the components of the recovery program act in concert, it is somewhat difficult to isolate one aspect or another as “treatment.” Usually, however, the term “treatment” is reserved for the initial intensive phase of treatment (typically residential treatment for 28 days). Subsequent recovery program components are referred to as aftercare, aftercare and monitoring, or continuing care; and sometimes all three interchangeably. Because of their varying meanings, it is always a good idea to be specific about one’s meaning when using these terms.
The understanding of aftercare and monitoring, and the view of the number and nature of the components that comprise it, has evolved over time. In the early years of the HIMS program, the initial success rate was good by contemporary standards, but not as good as was hoped. After reviewing the instances of relapse, the FAA added structured outpatient treatment with a therapist as a necessary requirement of the HIMS program. This change subsequently resulted in a reduction in the rate of relapse.
When the FAA examined the different varieties of the structured outpatient treatment experience, they quickly discovered that a group experience was by far the most successful. Individual aftercare sessions were not as effective as group sessions at preventing relapse occurrences. Also, less than weekly sessions were not as effective as those held weekly. Additionally, if the therapist was not well acquainted with addiction medicine, or if the therapist had a psychoanalytic perspective, the outcome was less favorable. Ultimately, the FAA determined the ideal picture of aftercare therapy should be a weekly group meeting of an hour and a half’s duration. It should be a group of 8 to 10 recovering people and led by a health care professional familiar with addiction. The group dynamic should be both supportive and confrontational, with an emphasis on issues of life-adjustment as it relates to ongoing sobriety.
The FAA has found through experience with these groups that they are effective in the early identification of relapses. Also, however, the groups actually seem to prevent the occurrence of relapses. Fellow group therapy members, being in recovery themselves, are particularly sensitive to the signs of relapse. It is extremely difficult for a group member who is entertaining the idea of drinking or using not to telegraph that idea to other group members. It is an axiom of AA that a relapse occurs in the mind before it occurs in the body. It seems clear that relapse thinking is identified quickly in the group therapy context, and confrontation and support by group members can actually prevent the physical relapse. Importantly, in safety sensitive commercial aviation, one must maintain a non-punitive environment to encourage a recovering pilot’s peers to openly voice any concerns they might have to program monitors. Such a non-punitive environment should not, however, preclude taking appropriate action should relapse behavior be unreported and ongoing.
Aftercare / Monitoring Periods
Aftercare and monitoring periods, as required by the FAA, have been extended over time. From the early days of the HIMS program which featured very limited or short monitoring periods, aftercare and monitoring in some cases today extends to the pilot’s retirement age. As the previous discussion indicated, the group aftercare model is the preferred method of providing structured aftercare therapy. Typically, the FAA expects the group therapy to continue for at least two years after the pilot returns to duty. In some cases, it is beneficial to continue the group therapy beyond this initial two-year period. But, the FAA also recognizes that, over time, studies show group therapy loses its effectiveness and that a pilot with a solid recovery will have less need of such treatment. Consequently, the FAA Office of Aviation Medicine has been responsive to initiatives from medical sponsors to reduce the level of group therapy involvement after the initial two-year period on a case-by-case basis.
The Aftercare Group Model
There has been some resistance to the exclusive use of the group model for pilots. Some of the resistance is associated with the difficulty of finding professional, long-term aftercare groups that are geographically convenient. Many aftercare groups are designed to provide a resource for the general treatment population and not for patients with professional licensing and regulatory issues. Some also focus on short-term support. Pilots in short-term oriented groups often become “assistant counselors” and stop benefiting from group participation. Some resistance has also been expressed about the frequency of the group meetings. Weekly meetings are difficult for pilots to attend due to the nature of their occupation. However, scheduling meetings less often than weekly has resulted in pilots making fewer sessions than desired. As a general rule, pilots should be able to attend at least 50% of the scheduled weekly meetings in any significant period. This 50% level is considered to be the minimum frequency that will still result in the accrual of the maximum benefit for the participant.
Some airlines have group meetings at their domiciles. These meetings may include the participation of supervisors, union peer supporters, and members of the employee assistance program (EAP). Such meetings can be effective and useful in assisting the airman and in allowing effective communication and consultation among the various support team members. However, the FAA does not feel these meetings represent the specific aftercare experiences desired from the group therapy context. Therefore, even with the pilot’s participation in such meetings, the FAA requires the additional presence of the preferred out-patient treatment group model.
Other Aftercare Components
As previously mentioned, in addition to FAA mandated aftercare, aftercare or continuing care can also include meetings with peer monitors, meetings with company supervisors and employee assistance personnel, meetings in recovery groups like Alcoholics Anonymous (AA), contact with AA sponsors, and relapse prevention visits to the pilot’s treatment facility. Participation in any or all of these components may be at the discretion of the recovering pilot or may be mandated by the pilot’s company. Usually the pilot’s union, if present, will work in concert with the company to create a strong, effective aftercare program. Preventing a relapse by the recovering pilot is in the best interests of the pilot, the company, and the union’s other members who may require HIMS assistance in the future.
Experience has indicated it is very beneficial to be clear and specific about a pilot’s aftercare requirements. Some companies go so far as creating a specific, legal recovery contract with the pilot. Such contracts explicitly state the pilot’s recovery requirements and the specific consequences for non-compliance with the contract’s provisions. While the HIMS program does not make specific recommendations about the components of a company’s additional aftercare requirements, experience has provided some knowledge of the effectiveness of how some components are executed.
Peer monitoring can be a critical asset in helping identify the early signs of a relapse. Peer monitors often are “graduates” of the HIMS program and have personal experience with the recovery process. Peer monitors are also viewed positively by the program participants, which helps them assist the pilot when he runs into difficulty. Peer meetings should, in our experience, be held at least monthly and face-to-face. Peer monitoring consisting only of telephone contact is seldom effective at identifying relapses or high risk behavior that leads to relapse.
Meetings with company supervisors and EAP personnel, if held, should also be conducted monthly and face-to-face. Such meetings promote confidence in the pilot’s recovery process and allow the pilot to develop a better relationship with his employer. Over time, these meetings help supervisors better understand the threats to a pilot’s recovery and better manage the risks associated with other employees who may be suffering from chemical dependency disease.
Alcoholics Anonymous (AA), for many, is considered the cornerstone of long-term recovery for alcoholics. AA has spawned many similar organizations oriented toward specific addictions such as: Narcotics Anonymous (NA), Cocaine Anonymous (CA), Marijuana Anonymous (MA), etc. These groups often have associated support groups for those people in a relationship with the alcoholic or addict, such as Al-Anon. While many recovering pilots consider participation in these groups a core part of their recovery program, the groups are by design, anonymous. Such anonymity makes it very difficult to reliably ascertain the level of participation of any given member. None-the-less, some companies require participation in these, or similar, organizations.
Regular contact with AA sponsors has also been identified as very beneficial for pilots in the early stages of recovery. However, like AA, this relationship is one based on anonymity. Additionally, within the AA community, a sponsor relationship is afforded the same type of communication privileges as are publically extended to doctor/patient and attorney/client relationships. But, some companies still ask their HIMS participants to meet a certain frequency of contact with their recovery group sponsor, although the company has no knowledge of the nature of those communications.
Follow-up relapse prevention visits by the pilot to his treatment center are also sometimes encouraged. Such visits are usually limited to 2 – 3 days and rarely occur more often than once per year. Some pilots have reported such visits as helpful in strengthening their recovery program.
Finally, individual or family counseling is also sometimes recommended following initial treatment, or it may become warranted based on events later in the pilot’s recovery. The removal of the addictive chemical from the pilot’s life can have far reaching effects. In most cases, family dynamics will undergo major changes. The nature of the relationship with the pilot’s spouse will be completely transformed or may end. The pilot may well experience the re-emergence of feelings that were long ago suppressed by the pilot’s drug or alcohol use. In short, the changes to the pilot’s personality and to other aspects of his life are both numerous and profound. The pilot’s ability to cope with these changes can often be assisted by individual or marital counseling. But, in almost every case, neither the company nor the FAA gets directly involved in determining the nature or duration of this voluntary therapy. Of course, it is also the FAA’s position that such individual therapy does not substitute for the group aftercare experience.
Monitoring, like the term aftercare, can have different meanings. Monitoring may mean the ongoing observation of the effectiveness of the various aftercare components. The term monitoring is also used to describe the abstinence testing conducted by the HIMS Independent Medical Sponsor (IMS) or the company.
In the context of monitoring as observation, the FAA sometimes speaks of monitoring the pilot’s progress. When used in this way, the FAA is trying to express their need to observe progress in the pilot’s recovery. Over the length of the monitoring period the pilot is expected to become comfortable with his sobriety and to avail himself of the available help when needed. Once his sobriety has become well established, the FAA may then reduce the pilot’s aftercare requirements or release him from the special issuance program entirely. To assist them in their oversight of the individual pilot, the FAA desires as much specific information as practical. As a minimum, the FAA requires quarterly reports from the group therapist and prefers that those reports include a description of the therapy process, a discussion of the critical issues affecting the pilot’s sobriety, and an immediate report of any adverse change in the pilot’s behavior. Mere statements of attendance at the group are not adequate.
Monitoring can also refer to abstinence testing. All pilots diagnosed with the disease of chemical dependency or abuse must remain abstinent as a condition of their FAA medical certificate. Also, many companies require abstinence as a condition of the pilot’s continued employment. Because of the nature of addictive disease, one cannot rely solely on the testimony of the recovering pilot. This is not to say that some pilots in early recovery aren’t being truthful, it’s just extremely difficult to determine who is telling the truth and who is not. Given this difficulty, it is imperative that an effective testing program be in place. Some HIMS programs leave testing to the individual IMS and, naturally, the testing is as random and thorough as the IMS makes it. In other programs, the company tests the pilot directly or employs a contractor to conduct the testing. Regardless of the method, however, a testing program has limited effectiveness if it doesn’t include off-duty, random testing. Such testing should also be primarily oriented toward the recovering pilot’s drug of choice, but should include testing for other mood altering substances. Finally, improvements in testing technology have provided an increased ability to “look back” over longer periods of time. If available, utilization of such tests discourages program participants from reusing while increasing the likelihood that those who relapse will be identified.