Part II – The Right Stuff – Curse of the Modern Pilot?

Why do pilots generally not seek healthcare help for mental health problems?

If you asked most professional pilots that question, you would probably receive an answer along the lines of “because I’m fine, and anyway if I go to my AME they will brand me as a nut job and I’ll lose my licence.” Maybe less so since Germanwings, as there is a greater acceptance that mental health issues cannot and should not be brushed under the carpet, but old habits die hard and we are dealing with decades of historical attitudes here.

Increasing attention, particularly in the US, is being given to the subject of why pilots seem to avoid seeking healthcare for their problems. I will be speaking on behalf of BALPA at a panel at the Aerospace Medical Association (ASMA) Annual Scientific Meeting in New Orleans later this month on this very subject. Levels of alcoholism in the general population vary from 5% to 10% depending on which study you look at. Yet only 1% of the US pilot population is in the HIMS programme at any given time.

When it comes to mental health, numerous studies (e.g. Wittchen et al 2011) show that a significant proportion of the adult population (around a quarter) have suffered or will suffer a major mental trauma in their lives. Yet even the most mature and established Pilot Peer Support programmes in the world show a footfall of no more than 5% annually of the pilot population they serve. Why the gap?

The answer might lie in what can be called the “Virtuous Circle of Professionalism”.

Professionalism is a tricky concept to define. Pinksy et al [1] offer probably the best description of a professional as reliable. In other words, a professional is someone who knows their stuff, looks the part, shows up on time and delivers what is required of them every time. This in turn leads to self–confidence in the individual, which generates the feeling of strength. All of which leads to success, which then feeds back into the reliable. This virtuous circle is the engine of professionalism for most commercial and military pilots (and of course many other professions), and sustains us for most of our careers.

Occasionally, however, life drags down on certain parts of that circle. A nasty divorce can erode the feelings of self-confidence; physical illness can undermine strength; mental illness can affect reliability. Without intervention, the virtuous circle can turn into a vicious spiral of perceived unreliability, under-confidence, and weakness which in the eyes of the pilot inevitably leads to failure, perpetuating the cycle.

Failure is not something pilots deal with easily.

We are recruited as individuals who set high standards for ourselves. We are then trained to high standards, and continually assessed to high standards. Modelling ourselves on The Right Stuff or Top Gun is the humorous tradition and is fine, but it can become a double-edged sword if for whatever reason we fall below what we perceive to be the high personal standards required to be a professional pilot. We are by nature intensely self-critical.

The trouble is that the nature of life dictates that most of us will fall below those very high standards at some stage or other in our careers. It is almost a statistical probability. Taking the concept of stress being the Curse of the Strong, as detailed in the previous blog, we can see how a pilot can relatively easily start to slip from the virtuous circle into the vicious spiral, and the harder they try to climb back up without help, the more they slide down.

In many pilots’ eyes, reaching out for help from healthcare is an admission that they are no longer operating in that virtuous circle but are in a downward spiral and thus have failed. Pilots don’t do failure, and so will keep going trying to fix their problems – whilst pretending that they don’t have any problems – until either they manage to come out of the turbulence intact or things fall apart rapidly and sometimes dramatically.

Suicide is the extreme example of healthcare avoidance for mental health issues.

Of course, this virtuous circle / vicious spiral construct is not one or the other. In reality, it is more of a continuum, where elements of the virtuous circle can get pulled towards their opposite, but the pilot can reverse the process. The key is awareness that there is a deviation from the ideal norm (which can actually be surprisingly difficult and often needs an external perspective to realise it) and then taking positive steps to return back to that ideal.

This is where Peer Support programmes fit in: they represent an interim safe and confidential step of getting help without going initially to healthcare.

Around 15-20% (on average globally) of cases coming to a PPSP will eventually get referred for professional help, but it is striking how many cases get resolved just by long conversations with a skilled and trained Peer. This is the core reason why these programmes are so successful.

Interestingly, if the individual has good resilience (or ‘bouncebackability’), then that return process will be significantly easier. We will look at resilience in more detail in Part III of the blog, but the important point here is that so much of the resilience an individual creates for themselves is as a result of self-help. Whilst the availability of Peers, sympathetic AMEs, GPs, operators and even Regulators are an immensely positive result of the seismic shift in attitudes towards pilot mental health post-Germanwings, for me the biggest positive is the wealth of information, education and tools available for a pilot to get themselves back up to the ideal virtuous circle at an early stage without the need for healthcare.

The internet is personal and private. Pilots are intelligent, used to self-study and are problem solvers. It is the ideal combination for upskilling pilots both to assist with the early stages of life getting difficult (reactive) and also building up resilience so that the individual is better able to cope with slings and arrows in the future (proactive).

Data from PPSPs indicates that pilots are certainly reading the resources put on the websites and keep coming back to find out more. Is this preventing mental health issues sliding into the vicious spiral and requiring healthcare? Impossible to tell at this stage, but my guess is that it is and we won’t see an explosion of pilots seeking healthcare for mental health issues going forwards. There should be a rise, as awareness and acceptance grows, but the aim of the current work being done to give pilots the online tools to help themselves is that they don’t need that professional help as much as perhaps they might have done in the past.

I’ll let you know what the medics in New Orleans think about that idea!

[1]  ‘Psychiatry and Fitness to Fly, American Academy of Psychiatry and the Law, 2019

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This is the second blog in a series by Dave Fielding about pilot mental health. Read the others by clicking below:

Part I – Stress and Self-Awareness

Part III: Resilience and where it fits into Peer Support

The Pilot Advisory Group (PAG) is a peer group of experienced, professional pilots, who are also professionally trained listeners, and are on hand to offer personal assistance to any member in any matter concerning aviation or who is in any sort of difficulty, whether it be of a professional or personal nature. Members can find out more, including how to contact a Pilot Advisory Group volunteer, by clicking here.