One of the principal responsibilities of the Federal Aviation Administration (FAA), through its Office of Aviation Medicine (AAM), is to ensure the medical fitness of more than 600,000 pilots. AAM prescribes and enforces medical standards to ensure safety. With respect to alcoholism, the Federal Aviation Regulations states that the pilot must have “no established medical history or clinical diagnosis of …substance dependence.” A pilot’s livelihood depends upon the absence of disqualifying medical conditions. Therefore, diagnosis means loss of the medical certificate.

Understandably airline pilots have been reluctant to come forward and seek help for this condition because it would end their career. Prior to 1974, the FAA had no practical rehabilitative protocol to accommodate a recovering pilot and return him/her to work with safety. To identify an alcoholic pilot meant suspension or revocation of the medical certification and immediate loss of income.

By the ALPA Code of Ethics, each pilot is enjoined to “keep uppermost in his mind that the safety…of the passengers who entrust their lives to him are his first and greatest responsibility.” Those same codes also state, “A pilot will realize that nothing operates more certainly to create or foster popular prejudices against pilots as a group, and to deprive the profession of that full measure of public esteem and confidence which belongs to the piloting profession, than do breaches of the use of alcohol.” These canons were and are the peer underpinnings of the HIMS prototype.

Regardless of these enjoinders, a pilot’s fear of job loss kept him/her from seeking help and fellow pilots from encouraging him/her to seek help. Prior to 1974, virtually no pilot had been treated for alcoholism and regained their medical certificate.

Understanding The Employee Assistance Program (EAP) concept requires an awareness of the history of occupational alcoholism programming going back to the early 1940’s.

The appearance of industrial alcoholism programs in the early 1940’s as an outgrowth of:

• the successful recoveries effected through Alcoholics Anonymous, founded in 1935, and
• the founding in 1940 of the Section on Alcohol Studies, Laboratory of Applied Physiology at Yale University.

Beginning in the mid-1940’s, tentative programs began to evolve within a handful of major industrial firms, the alcoholism movement had also been gaining strength and allies.

The basic idea at the time was that supervisors could be trained in the symptomatology of alcoholism and look for these symptoms among their subordinates. The most common symptoms mentioned were blood-shot eyes, trembling hands and the smell of alcohol on the breath. The image of the alcoholic employee was not far from the Skid-Row stereotype. The employees identified in these early programs were late alcoholics whose problems were so overt they were obvious to virtually everyone.

Over the years some major problems developed with this approach. To begin with, first line supervisors did the identification and diagnosis and as a result no one above his/her level received help. Consequently, the only people identified were non-supervisory employees even though all evidence indicated that alcoholism affects every occupational and professional level. Furthermore, expecting a supervisor to make medically related diagnoses resulted in legal problems for the supervisor.

A second major problem was that alcoholics were skillful at diverting attention away from their real problem – masters at employing the “Con Game.” With relative ease, the employee convinced the supervisor that the “real problem” was a nagging or spendthrift spouse, an unmanageable child, a physical ailment, money problems, or plain bad luck. Matching a supervisor with a practicing alcoholic was simply no contest – the supervisor lost nearly every time. Termination or early retirement at a reduced income usually became the solution. Everyone lost.

Finally, because of the stigma associated with alcoholism, supervisors wanted to be certain beyond a reasonable doubt that alcoholism really was the problem. Fearing the embarrassment of misidentification, the supervisor waited until the employee evidenced several obvious chronic stage symptoms.

In 1972, the Occupational Programs Branch of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) surveyed existing employer programs countrywide. Out of approximately three hundred companies with a written policy, it was found that only a fraction were working with an acceptable degree of success. Most had started out fast because it was relatively easy to identify chronic or terminal stage alcoholics. After an initial surge, however, many programs slowed and penetration of the population at risk was low. However, there were some distinct elements common to the successful programs and it is from these that the “troubled employee” concept had its genesis and from which the Employee Assistance Programs (EAP) concept had its genesis.

The object of these early EAPs was to avoid the problems experienced in supervisory diagnostic alcoholism programs while successfully identifying and referring those who needed help. A variety of other problems, such as marital, financial, physical, psychological, legal, social, vocational misplacement and job boredom were found to also cause unacceptable job performance.

Under the EAP umbrella, all troubled employees were offered assistance and supervisors were trained to monitor job performance and refer when normal progressive discipline failed to correct the behavior. The effectiveness of this approach rested in three areas: (1) a reduced stigma to the EAP, (2) earlier identification, and (3) the fact that the employer controlled the paycheck – in the case of addicted employees, the money needed to keep drinking or using drugs. Supervisors/managers were able to successfully intervene with resistant and troubled employees through the threat of job loss.

One of the 1974 initiatives of the NIAAA was funding of the HIMS. It was apparent to the Occupational Programs Branch that traditional intervention methods – referral by supervisors as a result of an employee’s deteriorating performance, – did not work well for top executives, professionals, or safety-sensitive positions like airline pilots.

Executives and professionals had been virtually impossible for EAPs to reach, because slippages in work performance were harder to detect, and there were elaborate cover-ups by peers. By that time, groups such as doctors, lawyers and nurses were beginning to address peer-referral groups, but special EAPs for professionals and executives were virtually non-existent.

Pilots have a high degree of autonomy, strong denial mechanisms, and a great fear of admitting that they may have a substance abuse or emotional problem.

By the early 1970s, the art of identifying and treating employed alcoholics was progressing through a technique known as “constructive confrontation.” While these confrontations were being applied with considerable success, even among other airline workgroups, little help was available for the employed pilot. Strict enforcement of regulations by the FAA continued to create an insurmountable obstacle for the afflicted pilot. Fellow pilots were reluctant to intervene (confront) for fear of threatening a colleague’s livelihood.

In 1974, the Air Line Pilots Association (ALPA) took the initiative through a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). They, in cooperation with the FAA and airline management, developed a prototype occupational alcoholism program for pilots. The project was called the Human Intervention and Motivation Study (HIMS). There was no evidence to suggest that the level of alcohol abuse among pilots was different from any other population, but ALPA, the FAA and airline leaders believed that any level of alcoholism was undesirable and should be identified and treated.

Airline management participated with ALPA in “constructive confrontation” process and provided health benefits and job security. The FAA joined the initiative by developing an evaluation and monitoring procedure that ensured safety while enabling pilots, who achieved adequate recovery, to return to flying sooner than would otherwise have been possible. This cooperative tripartite system completed elements essential to the HIMS alcohol identification, intervention, treatment and medical clearance for return to work prototype.

The HIMS program was founded upon the premise that pilot susceptibility to alcohol dependence was no different from members of other professional groups. However, periodic binges rather than daily drinking were typical pilot drinking patterns. The cockpit was usually the last place for symptoms to manifest themselves.

Like other groups, 8 – 12% of pilots who drink alcohol, would at some point become alcohol dependent. Alcoholism, as manifested in those affected individuals, was characterized by denial which rendered the pilot incapable of voluntarily seeking help.

In the early HIMS experience, almost 80% of pilots who used the program, needed some type of external, work related pressure to motivate them into treatment. For this program, that pressure constructive confrontation was defined as an intervention. In addition to an intervention system, the staff developed an evaluation and treatment component specific to the program and FAA medical certification standards.

This Professional Pilot Assistance Program was a partnership between management, union, and FAA all working together with confidentiality, to identify, assess, treat, and gain medical clearance within FAA standards, for a recovering chemically dependent pilot. A secondary focus was to help any pilot who had a chemically dependent spouse or child. The initial results of the HIMS Program showed:

• By the close of the initial eight (8) year federally funded project, most major U.S. airlines had endorsed the model, and had HIMS trained management and union personnel on their property.
• The 800 recovering alcoholic pilots had achieved an 85% long-term abstinence rate.
• A cost benefit analysis showed a $9 return for every $1 spent on treatment.
• The program enhanced flight safety. When chemical dependency progressed without therapeutic intervention, it could involuntarily manifest itself by on-duty withdrawal seizures, by violation of governmental or company drinking rules regarding alcohol consumption, or by the insidious effects of hangovers while flying. Any of these could make the airline and the pilot culpable.
• When alcoholism progressed to middle or late stages, it often resulted in costly secondary health conditions that escalated sick leave usage and medical plan costs.

• A Mission Statement
• A Policy
• The Procedures

• Identification
• Intervention
• Diagnostic Assessment
• Treatment
• Continuing Care
• Relapse Contingencies

• Rehabilitation Standards
• Pre-Special Issuance Procedures
• Post-Special Issuance Treatment/ Monitoring

• Training Specific Groups
• Educating the Line Pilot
• Promoting the Program

• Periodic Meetings
• System-Wide Review
• Monitoring
• Data Collection

Formulation of a Task Force or leadership group is recommended. In a small airline it may only be several individuals from management and the union who work jointly to organize the effort. In another carrier it may include those, plus representatives from Benefits, Human Resources, Legal, Labor Relations, Communications, EAP and Medical. There are many areas of the company that interrelate with this program and each should have a vested interest.

The mission of the Task Force is not just to initiate a program, but also to integrate it into the fabric of the corporate systems. Without that, the program can wither when its promoters run out of steam, lose interest or advance to a different employer. In organizing the Task Force, there are three (3) key steps involved.

• Select the people
• Select a chair or co-chair (since this is a cooperative joint management/union group, co-chairs may be preferred)
• Train the group

The Task Force should be trained on at least three (3) topics:

1. the denial syndrome and why addicts can’t come forward voluntarily
2. how the core technology of HIMS confronts denial
3. the specifics of a program

This training/briefing should occur before they decide on program type and scope. Early training facilitates program implementation.

The next step involves integrating the program elements into the corporation and its organizational structure. The initial goal should be to decide upon the type and scope of the program. For example, can it begin as a complete program or should it start small and enlarge? The basic objective is to protect safety by helping pilots recover and gain medical clearance for return-to-work.

When comparing the program elements to the corporate ways of doing business, it is important to decide such things as:

• How formal or informal should the program be?
• Who are the relevant players outside the pilot group?
• How can these people be brought into the process? How will those outside the group be educated in the program and its basics?
• Where are the pitfalls?
• How can the pitfalls be overcome?

The Task Force must review and, where necessary, revise the company benefit plans. They should be compatible with the FAA Medical Standards and the mandated Special Issuance procedures which underpin the treatment and return to work systems. Treatment and benefit plan issues are crucial to success because they guide the choice of treatment providers and medical specialists. For example, an intervention often involves a resistant pilot, full of denial, who requires a diagnostic assessment. The process can break down here unless the assessment resource is capable of and willing to work in a manner consistent with core EAP technology and flight safety.

This resource must (not prioritized):

• Be willing and able to accept the collateral workplace data
• Conduct thorough addiction, social, psychological and physical assessments in a short period of time
• Be capable of diagnosing a person who is resistant and/or in strong denial
• Make recommendations consistent with air safety and the public interest
• Interview spouse and/or family, when applicable
• Provide assessment results immediately upon completion
• Make treatment recommendations, which adhere to FAA standards

The diagnostic assessment issues are one healthcare issue. However, a second one is the blending of managed care philosophies with the expectations of the FAA.

The FAA’s impression of medical necessity for treatment is often higher than the health plan administrator’s definition. Additionally, Care Managers seldom have had hands-on chemical dependency treatment experience. Their philosophy is to approve treatment at its lowest common denominator and wait to see if the patient “fails” treatment (returns to drinking) before approving more intense levels of care (inpatient treatment). Such a philosophy is not in the best interest of flight safety, the airline or the pilot. Neither company nor pilot can afford the “luxury” of relapse as a prerequisite to inpatient care. For this reason, the HIMS experience shows that higher than usual levels of care are deemed medically necessary for both FAA alcohol and substance diagnoses: 1) Abuse, and 2) Dependence.

A third health plan dilemma is the FAA standards for monitoring recovery. This includes initial treatment and the FAA minimum requirement of seven years of monitoring. Continuing care groups allowing participation for more than six months are difficult to find and yet provide the essence of quality recovery and sobriety.

A fourth and final area of health plan concern is the FAA Special Issuance evaluations. These include neurocognitive and addiction medicine psychiatric evaluations. Although the FAA medical certification procedures mandate them, health plan administrators seldom do. Since most benefit purchasers and plan administrators are unaware of these parameters, interface with and education of a variety of individuals will be important before the program begins. Jointly pre-selecting and educating those who diagnose, treat and provide long-term continuing care, can help to prevent confusion. Insuring that the costs of these FAA-mandated evaluations and monitoring removes some barriers for accepting the HIMS program requirements.

It is important to have a written foundation for the program. It can include a Mission Statement, a Policy and Procedures

How the carrier arrives at these documents is more important than the documents themselves. It is crucial for all interacting parties to jointly develop them without partisanship. Furthermore, developing them in an adversarial or traditional labor negotiation modality, is counter-productive to an atmosphere of trust and cooperation essential for a good pilot EAP.

The document(s) should include statements about: (not prioritized)

• • The program’s purpose
  • Its relationship to the health plan(s) and accrued sick leave
  • Its relationship to the alcohol/drug testing programs confidentiality
  • Its relationship to FAA Medical certification
  • Voluntary versus intervention access to the program
  • Its relationship to discipline and job security
  • FAA/Company return-to-work procedures
  • Its application to family members
  • Expressions of caring and concern for the health and well being of the pilot and his/her family
  • The partnership between FAA/Company/Pilot group
  • Its relationship to the EAP or Medical, where applicable
  • The responsibility of the employee

When starting this new concept it is sometimes advisable for management and union to agree on the basic procedures but to avoid putting them into writing. The objective here is to be adaptable during the formative phase of implementation. Written formalization can follow as experience dictates. Modification of the written agreement should occur following routine reviews of the program elements, successes and challenges.

Since the Task Force has been trained and the basic elements are in place, domicile management/union teams must be trained. Ideally, each pilot domicile should have both management and pilot representatives and where possible, other interrelated personnel. Their minimal role is to 1) screen data; 2) plan and conduct interventions; and 3) guide, support, monitor the pilot throughout his/her Special Issuance (an FAA return-to-work protocol).

Experience has shown that training for this group of people should, at a minimum, include the following topics:

• The physiology of substance use/abuse
• The disease concept of addictions denial and how it manifests itself in pilots pilot identification and intervention systems
• FAA standards of medical certification and recovery
• Procedures for the special issuance and return-to-work
• Confidentiality and how it works
• Assessment/treatment/continuing care/monitoring
• Relapse-identification and disposition

All of this initial education and training may be accomplished at the annual HIMS Basic Training seminar whose primary audience is the pilots and management from airlines across the world. This training affords the management/union team to interact directly with FAA leadership, Aviation Medical Examiners and addiction medicine psychiatrists/neuropsychologists involved with the HIMS program. The networking opportunity with other airline HIMS representatives allows exchange of best practices to further revise and improve individual programs.

Once the pilot and management volunteers are trained, the program should be announced. Each pilot and spouse should receive a copy of the policy covered by a letter jointly signed by the Vice President of Flight Operations, the head of the pilot union, where applicable, the Medical Director.
Several communications should be sent annually, either in printed format or electronically. At the very least, information should be relevant to chemical dependency, the program and its services. If the program is broad enough to include an array of emotional and personal problems, they should be mentioned along with facts on substance abuse. Each communication should include contact names and telephone numbers of persons who can, with confidentiality provide more information. In most cases, pilots feel safer initially contacting a fellow pilot.
Having information about the program on both the union and company web sites is very important. Such visibility not only increases awareness of the program, but validates its endorsement by all parties. The web site should have links to contact key personnel for questions and for pilots and the family members to seek assistance.
One caveat is important here. The educational material is not primarily distributed for the benefit of the chemically dependent pilot because he/she is in denial. The primary audiences are

• social drinker who may drink to excess or have unsafe drinking habits
• friends/family of a person who is in trouble with alcohol. The latter often feel helpless and/or don’t know where to turn

The Task Force and domicile committees should meet periodically to review, evaluate and correct any weaknesses in the system. The leaders should promote constant review and critique. Where there are multiple crew bases and multiple teams, some type of system-wide review will be productive. Monitoring successful and unsuccessful activities is valuable. Data collection, although tedious, can document success and cost-effectiveness. What is working well should be maintained and strengthened. Throughout the review, individual pilot participant’s confidentiality should be maintained.