Recommended Practices: Treatment
Treatment for the chemically dependent aviator is a critical decision in the recovery process. The HIMS program was based on the pattern of treatment and continuing care that has proved most effective in dealing with this illness, i.e. extended in-patient treatment and long term continuing care. As the available treatment programs have evolved over the decades resulting in fewer facilities providing in-patient services and more providing residential programs, the HIMS model has been adapted to fit this reality. Today, extended residential treatment consisting of a minimum 28 days is the preferred modality. On occasion, with a diagnosis of a mild or moderate condition, FAA has been willing to accept less comprehensive treatment modes. These modes, however, are determined on a case-by-case basis. For air carrier pilots, the need to ensure the safety of the traveling public generally results in a requirement for the pilot to participate in the 28-day minimum model.
HIMS does not establish certification criteria for pilot treatment. Consequently, there is no list of HIMS’ approved treatment facilities. However, due to the nature of the professional aviator, and the unique requirements of FAA medical re-certification, treatment facilities with a “professionals” program and experience in treating pilots are recommended. Additionally, HIMS and FAA’s experience demonstrates that treatment at facilities with the following characteristics will usually result in better treatment outcomes and fewer delays in medical recertification.
- A full-time certified Physician-Addiction Specialist on staff
- Credentialed and/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 and Psychology Consultants
- A strong family component
- Recovery Program based on the 12-steps of Alcoholics Anonymous
- Endorsement by accreditation or licensure agencies
Addiction is a disease that affects all aspects of one who is afflicted: psychological, physiological, sociological, and spiritual. It is important, therefore, to find a treatment facility that addresses all these areas during treatment. Since treatment is the critical “first step” in a lifetime journey of recovery, it is essential to make that step solid and sure. It is not necessary to pay the highest price available to get this outcome, but one shouldn’t settle for poor treatment that’s provided at bargain basement prices. The quality of treatment is a far more important factor in selecting a treatment program than its cost.
The purpose of treatment is multi-layered. All high quality treatment programs will have a strong disease education component, personal and group therapy to identify personal issues and reconnect the patient with his/her anesthetized feelings, family therapy, support in developing lifetime recovery habits, and assist in creating relapse prevention strategies. Since chemical dependency directly affects all these areas, it is important to address each in order to provide a good foundation for further recovery. One of the most critical items that must be accomplished during treatment is breaking through the patient’s denial.
Pilots are, generally, highly intelligent and skilled at compartmentalizing their emotions. These characteristics are very adaptive to their work environment, so it’s not surprising that they are relatively common in this group. However, these same characteristics often reinforce denial behavior in this population. High intelligence allows for elaborate mental constructs that prevent the perception of alcohol or drug use as the primary cause for an afflicted person’s difficulties. Emotional compartmentalization disconnects dysfunctional behavior from the emotional costs that would normally cause modification. Similarly, these characteristics and the special status afforded professional pilots often results in a sense of uniqueness that is counterproductive to relating to others. So, it is important for a treatment facility to be aware of these characteristics in order to effectively overcome the patient’s denial defenses.
As we previously mentioned, HIMS recommends treatment facilities that have a professional’s program. Programs of this nature make it easier for the pilot to relate to other patients, which is an important part of breaking through his/her denial and creating a sense of “belonging” that will be essential to continued recovery. Programs that aren’t professional in nature may reinforce a patient’s sense of being different and therefore not subject to the same treatment requirements as others. Treatment facilities that provide a professional’s program generally have well educated staff and provide a strong educational component to the treatment process. This environment is quite comfortable for a professional pilot, so it may result in a lower level of resistance to the treatment process.
However, when dealing with relapse cases, the patient has demonstrated an ability to “talk the talk” without being able to “walk the walk.” The relapse is, therefore, a sign that a deeper, more permanent change is needed. In recovery circles it is often said that the longest 12” in the world is that which lies between one’s head and one’s heart. For the relapsed alcoholic or addict, that distance was not successfully traversed by the first treatment experience, so it may be beneficial for a second treatment to take a different approach. In this event, a cognitively oriented professional’s program might not be as good a choice for relapse treatment as a more “down to earth” approach. There are very good treatment facilities that use each approach, but few that can effectively do both.
Finally, HIMS recommends facilities that allow for interaction between the patient and other recovering pilots in addition to his/her company representatives. In some areas, pilots in treatment are allowed to attend local “Birds of a Feather” recovery meetings. “Birds” is a group of recovering pilots who hold a meeting based on AA principles. Interaction with such a group can have dramatic positive affects on the patient’s willingness to undergo therapeutic change. Additionally, early interaction with one’s company supervisors can provide much needed security related to one’s employment prospects and also helps establish a good “base line” for future interactions. Please consider this accessibility when selecting a pilot’s treatment facility.
One might presume that geographical location is a prime consideration for selecting a treatment facility. Our experience shows that it is not. While it is important that treatment include a family component, this type of therapy is usually conducted in the latter half of the treatment period. In most cases, the partner or other family members come to the facility for one or more days to participate in “family week.” Since contact with others is limited to non-existent outside the treatment facility prior to “family week,” being geographically separated has little consequence. Also, the access to travel benefits for a pilot and his/her family makes a multi-day stay at an out-of-town facility only slightly more inconvenient than what one would experience locally.
Sometimes a pilot in treatment will focus on family separation rather than his/her own situation. If the family is geographically close, this altered focus can be even more pronounced resulting in unneeded distraction from the treatment process. For all patients, damage has indeed been done to the family, and time and attention will need to be focused to repair it. But, the time used for this purpose during the treatment process will be selected by the staff, not by the patient. In any event, repair of the family unit is a multi-year process and a patient’s early efforts should focus more on one’s self than on others.
As in any health care decision, cost of treatment is an important factor. A 28-day residential treatment program is, understandably, quite expensive. But, research has shown that for every dollar spent on treatment and continuing care, companies receive $2 – $11 in return. The return varies widely because of the different training and replacement costs associated with small and large air carriers. But, all carriers receive substantial benefits in improved reliability and performance. For this reason, many carriers pay a substantially higher percentage of treatment costs than in some other areas of health care. Some carriers pay 100% of treatment costs, and in these cases the company has removed any financial barrier to those seeking treatment.
In other situations, the pilot will bear a greater financial burden. Most health care plans will not normally cover 28 days of residential treatment, so certain pilot specific policies should be developed. Generally, a first treatment will receive the highest level of corporate financial support, while subsequent treatment costs are borne more heavily by the pilot. Some corporations will provide no or low cost loans, while others permit non-flying duty following treatment to allow the pilot to earn a pay check while awaiting medical recertification. There are also loans and grants available through many union organizations and some private foundations. And, on occasion, some treatment facilities have been willing to create payment arrangements for their pilot patients. But, regardless of the level of financial support, the cost of treatment is a bargain compared to the cost of an addiction. It is not unusual for a person to spend more in legal fees for one or more DUI’s than one might spend on treatment. So, as someone in AA might say, “It’s cheaper than drinking.” And another adage that might apply is, “You get what you pay for.”
HIMS encourages company supervisor involvement during the treatment process. A supervisor may attend mid-treatment “how goes it” meetings with the pilot and staff members. These meetings provide an opportunity to hear about the pilot’s condition, personal issues, and treatment process directly from the treatment staff. Additionally, this meeting allows the supervisor to establish a supportive relationship with the pilot. The pilot will also understand someone cares about his/her situation and that their job is secure. So, many benefits can arise from this early interaction.
The supervisor may also attend an end of treatment meeting. This meeting will have many of the same benefits as the mid-treatment meeting, but it also provides an opportunity for signing a continued employment agreement. It’s important the pilot understands and agrees to the conditions of his/her continued employment with the company, including continuous abstinence. Some companies choose to have this agreement in the form of a letter, but HIMS recommends an agreement written as a contract. A contract provides for a more explicit listing of the pilot’s post-treatment requirements and it’s language is often more precise than the language used in a letter. And, while both documents have legal status, the contract form conveys this meaning to the patient more clearly than a letter. And, in many cases, the patient is asked to read the contract aloud before signing it to assure clear understanding by all parties.
Company involvement in treatment is not limited to treatment meetings and contract signings, in some cases the company acts as a principle player in the choice of treatment facility. Since companies commonly pay for the majority of the treatment costs, it is not surprising they wish to make sure they receive a good return on their investment. And, in some cases, the company wishes to have its pilots treated close to their headquarters or a particular domicile to allow for easy supervisory involvement. So, before selecting a treatment facility, make sure the company’s wishes are considered. Not doing so can result in unnecessary expense to the pilot or delays in getting re-certified and returning to work.