Recommended Practices: Continuing Care
Many health care professionals refer to continuing care as all the health related components of a patient’s post-treatment activity. Common examples would be clinical group therapy, individual counseling, family therapy, relapse prevention treatment, AA/NA, and meetings with the treating physician. Other post-treatment activities such as peer and supervisory meetings and sobriety testing are considered to be compliance related and not continuing care. For our purposes, we will accept the healthcare professional’s view of continuing care. But, it is important to note compliance related activities, which we will discuss later as monitoring, also support a patient’s sobriety. Since this support is a major component of “continuing care” there is some overlap in the functioning of continuing care and monitoring. In the following sections we will examine each of the continuing care components as they normally appear in a post-treatment HIMS program.
Clinical Group Therapy
FAA considers clinical group therapy to be a very important part of the continuing care program. Pilots are generally intelligent with strong ego structures. These characteristics can sometimes act as impediments to the changes necessary for long-term recovery. Experience has shown that a clinical therapy group, run by a professional and consisting of peer pilots, can aid a pilot in accepting his/her disease and in making the changes required. If placed in a clinical therapy group that doesn’t contain peer professionals, pilots are often elevated to “junior counselor” status and thereby receive less benefit from the therapy.
Clinical group therapy normally begins shortly after discharge from the residential facility and is usually assigned to be coincident with the period of monitoring stated in the Special Issuance Authorization (SIA). The SIA is sent by FAA and indicates their approval to return the pilot to flight status. It is normal for the SIA to be valid for 3 to 5 years minimum and it may be for a longer period. Since the effectiveness of therapy diminishes over time, the Independent Medical Sponsor may petition for removal of the clinical group therapy requirement on a case-by-case basis.
Since chemical dependency is a family disease, wherein every family relationship has been impacted by the drug or alcohol use, it is often a good idea for the family to receive counseling. This counseling may be individual therapy, couples therapy, and/or involve counseling with adult or minor children. In all these cases, professional therapists can be of great assistance in establishing healthy family relationship structures. However, FAA does not wish to determine the timing or duration of this type of therapy should it be undertaken. So, although HIMS strongly supports the practice of providing support to the family in recovery, this decision is left to the family members themselves
In many cases, other individual issues may arise for the recovering pilot. Such issues include such things as anger management, poor coping skills, depression, anxiety, loneliness, etc. Like family therapy, FAA does not get directly involved in the treatment decision for these issues. Should a pilot wish to undertake individual therapy, he/she is free to begin it and end it as deemed appropriate. On occasion, when a treatment team determines a psychological issue is significant enough to threaten the pilot’s sobriety, individual counseling will be recommended as part of the treatment discharge plan. In these cases, FAA and the pilot’s employer will usually expect the therapy to be conducted.
In some respects, the entire continuing care program is a form of relapse prevention. But, many treatment facilities also offer formal relapse prevention visits. Often these visits are available at low or no cost to the returning patient. It is clear that some people benefit from attending one or more of these sessions, usually held annually. However, in most cases, attendance at these functions is at the discretion of the patient. Neither FAA nor most companies mandate participation.
For many recovering people attendance at AA/NA (Alcoholics Anonymous / Narcotics Anonymous) is the single most important factor in maintaining their sobriety. Medical research confirms the critical nature of peer support in AA as it is a better predictor of sobriety than support of a family member. But, AA and AA-type organizations have been deemed as religious organizations by some court decisions. Given these decisions, FAA does not mandate a pilot participant attend AA. However, 12-step programs have a better success rate than any other type of peer support program. So, AA or other 12-step program participation reflects favorably on the patient and often makes those tasked with monitoring the pilot’s sobriety more comfortable. HIMS suggests its pilot participants attend a 12-step program and take away what they perceive as beneficial.
There are other secular peer support groups that deal with addiction or try to help those who consider themselves to be problem drinkers. Among those groups are Moderation Management and SMART Recovery. Because these groups do not necessarily support a goal of abstinence, they are rarely used as part of a HIMS continuing care program.
Very shortly after discharge from residential treatment, an HIMS pilot should meet with his/her Independent Medical Sponsor (IMS). The IMS is a specially trained FAA Aviation Medical Examiner (AME) who will sponsor the pilot for a Special Issuance Medical certificate. The IMS is central to the entire continuing care program. The IMS will conduct a physical evaluation of the pilot, but they will also receive all the written reports from other caregivers. Ultimately, it’s the IMS’ authority as FAA medical representative that allows the pilot to fly. In other words, should the IMS choose to withdraw their sponsorship, the pilot is immediately grounded.
Because of the IMS’ unique position as manager of all the continuing care reports, the IMS may be aware of disparate pieces of information that indicate potential problems with a pilot’s recovery. However, the IMS will also probably have the least personal contact with the pilot of all the caregivers and monitors. So, the IMS may be both more, and less likely to become aware of problem behavior depending on the source of the information. In general, it is very important to provide comprehensive and accurate information to the IMS, and equally important that the IMS’ experience confirm the information that is reported.
Many IMS’ choose to meet with the pilot frequently early in recovery. These frequent meetings, often monthly, help establish familiarity with the pilot, provide a “base line” to evaluate future behavior, and extend support to the pilot while they are early in sobriety. Six months after treatment discharge, the rate is usually reduced to quarterly until the pilot completes a year of sobriety. Following this year, if the pilot demonstrates good recovery, the rate is often reduced further to once every six months. Of course, this reduction in frequency is dependent on the quality and stability of the pilot’s recovery program and can be influenced by input from other members of the HIMS Team.