Implementing a systematic course of care.
In the HIMS program, the term treatment is commonly used to refer to the initial specific residential or outpatient program given to the pilot. More accurately, treatment is the sum total of all the efforts expended to effect a remedy for the chemical dependency problem. An ideal comprehensive program consists of the following elements: immediate intervention when warranted, rapid evaluation, assignment to the appropriate level of care, uninterrupted therapy, timely return to flying, thorough monitoring, relapse prevention and contingency planning.
Treatment involves accomplishing many goals:
Identifying Core (Personal) Issues
Reconnecting Anesthetized Feelings
Understanding the Disease
Involving the Family
Inculcating Alcoholics/Narcotics Anonymous Into Daily Living
Developing Relapse Prevention Strategies
Two myths persist regarding treatment:
Both are untrue and can be circumvented by a process called Intervention – a compassionate, rehearsed, professionally facilitated, non-judgemental confrontation that essentially raises the bottom through benevolent persuasion.
Rarely does a pilot enter treatment completely voluntarily; most arrive because of some type of “benevolent persuasion!" Many believe their job is threatened. Fear of job loss often endanders their entire sense of being and identity. For most pilots losing their license and their ability to fly shakes the very foundation of their universe. Such circumstances often make the pilot suspicious and reluctant to fully participate in the treatment process.
The design of any treatment program must be congruent with the type of disease involved; that is, one must consider the particular characteristics of the disease and implement strategies to address them.
Chemical Dependency has four characteristics:
First, it is Chronic, meaning it is permanent and prone to relapse. The disease for abnormal drinkers is called alcohol-ism, not alcohol-wasm! This description implies there is never a return to normal “social” drinking or any “recreational” drug use. The HIMS philosophy requires total abstinence from mood-altering chemicals for safety and continued medical certification. Relapse means reactivation of the original disease, not the acquisition of some new disease. To prevent relapse, one must implement a defense against the first drink or drug, and build an ongoing maintenance program strong enough to countermand any alcohol craving or drug hunger.
Secondly, Chemical Dependency is primary, meaning it exists independently and is not secondary to some other underlying mental illness or personality disorder. Therefore, the addiction must be treated directly with measures distinctly different from the kinds of psychotherapy utilized for mental illness in general. These measures are not designed to empower one to return to social drinking, or develop insight into why one drinks. Total abstinence from all addictive chemicals is the core goal central to this approach. If there is a co-existing mental illness, referred to as a “dual diagnosis” situation, then such illness is considered as another primary disease and treated accordingly.
Thirdly, addiction is predictable and progressive. It is most often progressive with four stages: early-middle-late-and too late! The consistency with which the disease manifests offers only three options to its victims: they wind up either locked up (incarcerated), covered up (buried), or they sober up (get into recovery). Successful recovery can stop the progression, but without good recovery, the outcome is unfortunately quite predicable.
Lastly, Chemical Dependency is catching. The insanity is catching. The stress of living with an alcoholic/addict produces dysfunctional coping behavior similar to that seen in Post Traumatic Stress Disorder. Co-dependent family members often remark that they have lived through a “thousand Vietnams.” Addiction is a family affliction, and therefore, any quality treatment program should have a strong family component.
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.
Most treatment programs follow the American Society of Addiction Medicine guidelines for level of treatment. These may indicate a less intense level of treatment required, particularly for the pilot with a significant period of abstinence before entering treatment. Examples include the pilot with multiple DUI’s, a positive DOT drug test or an intervention for on-duty behavior. The FAA certification process generally proceeds much quicker with a residential or inpatient level of treatment.
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.
Therapy involves a tri-dimensional approach because body, mind, and soul are compromised. Detoxification and medical stabilization by the medical team occur first. Emotional balancing and cognitive restructuring follow and are accomplished by the treatment center counseling staff. This is the educational aspect that therapy focuses on.
Finally, spiritual restoration begins with early exposure to 12 Step Programs such as Alcoholics and Narcotics Anonymous, which are mutual-help fellowships that embrace the 12-Step philosophy. This is the recovery aspect of a comprehensive treatment program that occurs primarily after leaving the facility.
As goal-oriented people, pilots immediately set forth to complete the “checklist,” memorize the “manual,” follow all “procedures,” comply with all “rules,” stay within the “envelope,” pass the counselor’s “check ride,” and maintain the proper “glide path” to recovery. These tendencies in pilots to intellectualize their disease treatment is very counterproductive for recovery.
Initiating abstinence is merely the beginning of recovery, not the end. Making the changes in attitude, belief system and habits necessary for the maintenance and growth of sobriety creates real struggles. The critical challenge is to make the transition from dry to sober, and from clean to serene! Mutual support groups effectively address these struggles and assist in the transition from insanity to serenity.
Communicating on an intimate emotional level and becoming truly engaged in therapy takes an enormous effort. Pilot personalities tend to be emotionally constricted and not expressive or open. Therapy is designed to change this paradigm so that a pilot can seek help in recovery efforts, recognize and verbalize threats to sobriety and perform the ongoing self-assessments about personal thoughts and actions that undermine recovery.
When a behavior is caused by disease, treating the disease changes the behavior! The old “28-day” residential treatment model is an endangered species. Today’s state-of-the-art medical approach matches the intensity of the service to the severity of the illness. This approach applies to any disease. Not all diabetes is the same: there’s mild, moderate, and severe, each requiring different treatment: diet, pills, or insulin replacement. The same is true for chemical dependency: outpatient, in-patient, or extended residential modalities are utilized.
Pilots, like physicians, are often subjected to more strenuous approaches because of their safety-sensitive occupations. Nevertheless, individualized treatment planning is utilized to treat professional pilots. Experience has shown that total immersion in treatment as an inpatient aids the pilot in the recovery process and may reduce the time to FAA certification following treatment.
Do pilots because of their common personality characteristics and unique working environment require specialized treatment? There has been speculation that pilots have “giant egos,” that they are over-controlling and are subjected to some very unique stresses. The skills to operate a jet aircraft over long distances with hundreds of lives at stake requires self-confidence, independence, intelligence and superb problem-solving skills at a minimum. These may all be barriers to treatment goals and recovery.
Pilots often experience irregular and extended hours, intermittent “down-time,” repetitive family disruption, altered physiology from time zone changes, sleep deprivation, and constantly operate with heightened vigilance waiting for some catastrophic disaster.
All recovering alcoholics and addicts are subject to stress, and the role of particular types of stress in reactivating addiction is unclear. The lack of consistent contact with supervisors and fellow employees does create some challenges to effectively monitoring pilots. But, such adaptations to specific circumstances also happen in other professions.
Similar to the impaired medical professionals programs, both of which require licensing, subject to medical qualification to perform job duties, treatment centers familiar with these groups of professionals often are more successful in dealing with these special issues.
FAA documentation requirements for medical recertification are extensive. Most facilities are not familiar or comfortable with releasing complete medical records of treatment due to privacy concerns. Also, many airline HIMS programs ask for weekly updates on a pilot’s progress in treatment. These are very unusual requirements in the non-pilot population but must be accommodated for the HIMS program to survive and pilots to regain medical certification.
Although gaining popularity in the medical community, the current FAA philosophy does not allow medical certification for pilots currently undergoing Medication Assisted Treatment (MAT). Many of the medications used to treat various chemical dependencies are not compatible with aviation safety. A pilot entering treatment frequently requires medication to prevent withdrawal symptoms. Also, medications to reduce cravings and block euphoric responses may be useful in early treatment. However, prior to petitioning the FAA for medical certification, the pilot must demonstrate a significant period, usually several months, of abstinence without the aid of MAT.
Outcome studies show that the highest treatment success rates occur in the professional populations, especially with commercial pilots.
Rehabilitation, rather than termination, should be the ultimate goal, since it is much more cost effective to treat rather than replace a highly skilled pilot. Commercial airline pilots enjoy a significantly higher than average success rate, and in recovery, constitute a valuable asset to their profession and to the flying public. In addition to a usually loyal, grateful and dependable employee, the airline benefits from substantial cost savings and an improvement in the safety of their operations versus those that discourage chemically addicted pilots from seeking help if they face termination.