CONTINUING CARE
High quality continuing care is the key to establishing long-term sobriety.
High quality continuing care, also known as 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, most often inpatient or residential, 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 mutual help 12 Step 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 of job loss.
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 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 pilot 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 History of Aftercare
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. The groups actually seem to reduce the risk 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 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 monitoring 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.
Aftercare Components
Individual/Family Counseling
Many pilots who have completed initial chemical dependency treatment also benefit from individual and family therapy. During the course of treatment or after treatment, additional mental health factors may be discovered that are not able to be treated adequately in the short time of initial therapy. Individualized treatment of these issues that may compromise the newly acquire abstinence and recovery is very useful. The counselor should be skilled in both treating the particular condition the pilot has and also be familiar with substance use disorders.
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.
As noted above, chemical dependency is a family disease, as the consequences of the dysfunctional relationships developed during the development of the disease. Marital relations and those with children are strained as learning to cope with the volatile actions of the pilot evolve in to various roles of co-dependency and actions of self-preservation. As the pilot emerges from treatment, these family roles do not instantly revert to a normal, healthy relationship. Rather, they may take years to regain. Counseling can facilitate and accelerate this process and assist in supporting the pilot’s recovery. Family participation in support groups such as Al Anon and Ala Teen are frequently useful.
While this counseling can be extremely helpful in supporting a pilot’s recovery, its primary purpose is not to assist or monitor the pilot’s recovery. It is to help repair the pilot’s various significant relationships. For this reason, the FAA does not consider individual counseling or family therapy an adequate replacement for group aftercare. However, if a pilot in recovery is participating in such care, the FAA requires that periodic reports be provided by the counselor documenting the progress in therapy.
Psychiatric Care/Dual Diagnoses
A small proportion of pilots in recovery will also be diagnosed with a depressive disorder requiring medication. Recall that substance abuse and dependence is a Primary diagnosis that is not the result of a separate mental health or medical condition. A pilot may have a depressed mood as a result of the consequences of drinking or using, but this is not the same as a diagnosis of depression. Depression is a separate phenomenon that should; not be diagnosed until the pilot has 30-60 days of abstinence. It is treated separately.
For those pilots requiring treatment for depression, the FAA has a specific separate protocol for regaining medical certification. Although there are several overlapping components to the FAA requirement for initial certification, several requirements differ. A pilot can regain medical certification with both a diagnosis of substance dependence and a major depressive disorder
Peer Support Groups
Peer support groups focused on an abstinence-based 12 Step recovery such as Alcoholics Anonymous (AA) and other similar groups, for many is considered the cornerstone of long-term recovery for alcoholics. Scientific literature has shown that frequency of participation in 12 Step recovery groups is the best predictor of long-term abstinence. AA has spawned many similar organizations oriented toward specific addictions such as: Narcotics Anonymous (NA), Cocaine Anonymous (CA), Marijuana Anonymous (MA), etc. Other abstinence-based secular peer support groups exist, but are not as widely available as AA.
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.
Birds of a Feather International “is a worldwide network of meetings based on the program of Alcoholics Anonymous*. It was established for pilots and cockpit crewmembers active or inactive in private, commercial or military aviation. We provide AA meetings worldwide (including Zoom meetings), a yearly convention, a newsletter and this website for pilots and cockpit crewmembers in recovery.” Birds meeting groups, termed “Nests” are very helpful in accommodating pilots traveling all over the world, usually located at airline hubs. Some Birds Nests are also located near treatment facilities and assist in bringing a pilot into their fold early in the recovery process. A fellow pilot may serve as a temporary sponsor for a pilot in recovery until establishing a permanent sponsor from a home group.
Relapse Prevention Meetings
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. The meetings are usually hosted by treatment facilities for a group of alumni pilots who may be meeting each other for the first time. The focus of these meetings is relapse prevention rather than treatment and involves strong education seminars and cross-talk opportunities. The primary counselor for the professional’s group frequently leads the program. Opportunities for discussing particular challenges encountered after returning to flying, to families and completing monitoring requirements are plentiful and best practices are discovered. Pilots have reported such visits as helpful in strengthening their recovery program.
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.