Aviation Mental Health

Todd Hubbard, Robert Bor, Todd Hubbard, Robert Bor

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317176640
• Edition: 1
• Topic: Tecnologia e ingegneria
• Subtopic: Aviazione

This book provides an authoritative and practical guide to the assessment, management, treatment and care of pilots and other professional groups within aviation; covering a range of relevant topics, for health and human resources practitioners working in the airline industry. Pilot mental health has, hitherto, been regarded as a specialist topic in aviation medicine. Consequently, practitioners and researchers alike have been forced to consult specialist journals or seek out a relevant chapter on this topic in a general textbook to develop or update their understanding of the relevant issues. This book seeks to remedy this situation by gathering together all of the relevant insights into a single authoritative source gathered from the leading specialists in the field. It aims to cover all of the main relevant issues including the assessment, care, management and treatment of mental health problems, as well as the prevention of mental health problems among this occupational group.

Chapter 1

Aviation Mental Health: An Introduction

Robert Bor and Todd Hubbard

A book combining aviation with mental health places one in triple jeopardy. Firstly, in such a highly regulated, safe and successful industry (including both commercial air transportation and military air operations), it would appear from the outside, at least, that mental health issues have little or no relevance. Secondly, many of those employed within commercial and military aviation, and especially pilots, have a deep distrust of psychologists and psychiatrists and are dismissive of anything that hints at “psychobabble.” These negative views may have been formed as a consequence of bad experiences during selection, training, crew licensing or in the course of trying to manage day-to-day personal problems. Thirdly, mental health is not a static or precise science. Much like aviation itself, mental health as a field or specialty keeps evolving. It has long been accepted that definitions of mental illness are culturally relative and have also shifted over the course of time. While this will come as no surprise to most trained physicians, psychologists and psychiatrists, such apparent vagaries do not sit comfortably with those who are used to precision and unequivocal clarity, such as pilots. This book seeks to present a modern, informed, balanced and useful application of mental health issues in aviation and to challenge outdated and negative impressions held by some about what mental health insights can offer to aviation. It is about the mental health of the millions of professionals worldwide responsible for flight. It is not, however, a book about aviation human factors.

As authors we appreciate that some of the negative reactions to mental health issues as well as mental health professionals lies with those responsible for employee mental health, either because the issues have been ignored or because the presence of problems has been used to disadvantage or even terminate the career of an individual. It would seem that mental health issues only appear to have relevance when “things go wrong” with a flight, pilot, air traffic controller, aircraft maintenance engineer, and so on. This perception is regrettable as most crew members accept and appreciate from their human factors courses and crew resource management training that psychological factors have an important role to play in safe and efficient flight. Mental health is also a key area for assessment when crew undergo routine medical checks for licensing and is therefore as much a concern for authorized medical examiners as it should be for crew. Indeed, one could argue that mental health issues are at the heart of challenges to modern air travel and possibly the primary obstacle to coping with the increasing number and length of commercial flights, as well as coping with the unique demands of space tourism and exploration.

There have been numerous psychological and physical challenges to flight for both crew and passengers from the earliest days of controlled and powered flight, just over a century ago. Man has not evolved naturally to fly, as the psychologist, James Reason reminds us (1974). Even though as a species we have evolved over millions of years, our bodies are largely still designed to hunt and gather in small groups in the open plains. We remain a species that is best designed and equipped to be self-propelling at a few miles an hour under the conditions of terrestrial gravity (Reason, 1974). There are several obstacles and “physical evolution barriers” to our position or motion senses, as well as our capacity for processing information, that is apparent to both the novice air traveller and the seasoned pilot. While there have been remarkable achievements in engineering over the past century that have made air travel both possible and highly accessible within the span of a single lifetime, this has not been without its challenges. When evolutionary barriers to motion are exceeded, numerous penalties are exacted, the most common of which are motion sickness, jet lag, fatigue, as well as increased arousal and stress. For flight crew, there may be additional problems relating to judgment, decision-making, perception and concentration, among others. Air travel brings us into close contact with strangers: it also forces us to depend upon and fully trust the input of groups of unseen professionals, and an understanding of the social psychology of behavior within groups and teams is therefore relevant. Air travel also disrupts human relationships: shift-work, short or prolonged absences from home, as well as stress can all exact a toll and demand resilience and unique coping behaviors.

These insights help us to understand that there are five main sources of mental health problems among aviation employees. They include (a) stresses associated with coping, safety and survival, (b) stress that emanates from workload, how work is organized and the organizational climate (e.g. rostering, frequency of flights, jet lag, pensions and financial challenges), (c) personal problems that stem from disruption to personal relationships, which clinical research suggests should act as a buffer to work stress, (d) ever-present concerns about loss of license as a consequence of the onset of a disqualifying medical condition, and (e) normal psychological problems that occur naturally in the everyday life of the population at large. As Jones and his colleagues have pointed out (1997), not only do pilots have to deal with the unique pressures of flying aircraft, but they also have to contend with the normal pressures of daily life as well as job insecurity. At present, there is no published data from longitudinal or cross sectional studies which help us to understand the relative weighting of each of the different causes of mental health problems among aviation personnel and how these may have changed over time. Irrespective of the source of the mental health problems, however, the outcome can be just as serious, if not devastating, for the individual concerned.

The standard source of mental health diagnoses is the American Psychiatric Association’s Diagnostic and Statistical Manual IV (APA, 1994). However, those familiar with this taxonomy with appreciate the complexity of defining what is and what is not a psychiatric problem. It was devised with the general population in mind and therefore it does not specifically address those problems that are most likely to affect aviation personnel. It does not specify the standards of mental health required among different occupational groups to work in aviation. It is also of limited value to the authorized medical examiner as it does not list approved treatments for disorders or aftercare required and the likely contra indications for work either as a consequence of the diagnosis or whilst treatment is being provided (Jones & Marsh, 2001).

The mental health of employees in all organizations and industries is directly related to standards of safety and productivity. The airline industry is no exception. In the post 9/11 era, it might be argued that in the light of increased pressure in the workplace, greater security risks and threats, the need for tighter and more robust selection and ongoing appraisal methods of staff, more demanding and challenging passengers and the profound and rapid changes within airlines companies and the concomitant impact on employees as well as passengers, mental health issues assume an even higher priority.

As in many work settings, mental health issues are also a matter of some sensitivity due to social stigma as well as practical and legal consequences for both the affected individual and the organization where problems have been detected. This is certainly true in the airline industry and psychological fitness to work is embedded within the practices and rules that operate in all work places and across occupational groups. A key difference among airline and military aircraft crews is the regularity and stringency of health checks and the ever-present threat of loss of license. The exclusions for medical certification are broadly similar across aircrew licensing authorities the world over. However, some psychological problems are transient or reactive and therefore either amenable to treatment or disappear with the passing of time. There have been significant advances recently in the treatment of certain commonly presenting psychological problems, such as depression and anxiety, while psychological counseling for those suffering from stress and relationship difficulties is more effective than was the case several years ago (Roth & Fonagy, 1996). These and related advances in psychological assessment and treatment should be noted for several reasons. Firstly, it may be possible for some crew members to return to work either during the course of or following treatment for certain psychological disorders. Secondly, the stigma associated with mental health problems and the fear of its consequences among air crew clearly deters some who are affected from seeking professional help from the relevant sources. They either conceal their problems or take the problem to a professional outside of the aviation medical context for treatment which may lead to incorrect advice being given, or inappropriate treatment or monitoring being provided, which may threaten safety. Thirdly, emerging problems such as stress (due to extended periods of duty, uncertainty in the aviation economic climate and threats to jobs, the pensions crisis, etc.) and their impact on psychological health, air crew functioning and safety can be more closely studied.

We hope that readers of this book will gain further understanding of a wide range of contemporary mental health issues that affect airline pilots, as well as others who work in the industry. The contents of the book also highlight for those who work in the industry some of the important mental health issues that may affect passengers. We envisage the primary audience of the book to come from those who work professionally with employees in the airline industry. This includes authorized medical examiners, psychologists, psychiatrists, employee assistance counselors, human resources specialists, crew rostering and operations personnel, air accident investigators, managers, trainers, aviation lawyers as well as those personnel worldwide employed by their respective aviation authorities or air forces. A secondary audience includes those employees within the airline industry about whom this book is concerned, including pilots (commercial, military and private), cabin crew, air traffic controllers and aircraft maintenance engineers, among many others, who may have an interest in the issues raised within this book. We envision that researchers as well as behavioral scientists in related fields, including those concerned with human factors, and others, will also have some interest in the contents of this book. It is possible that some airline passengers might also wish to learn more about mental health issues in aviation.

Those with an interest in mental health issues in aviation have, hitherto, had to consult a wide range of specialist books, journals and professional magazines, often in quite dispirit fields and specialties, to learn about many of the issues raised in this book. Academic papers concerning a wide range of the issues raised have been published in specialist medical, aviation, psychology, psychiatry and human factors journals, as will be seen in the list of references at the end of each chapter. A further aim of this book was to bring some of these insights together into a single authoritative text to assist those interested in learning about current knowledge and trends pertaining to these issues.

It is perhaps surprising that, to the best of our knowledge, there are few – if any other – contemporary specialist books available that address this topic. The first comprehensive collection of papers on the topic, entitled Psychiatry in Aerospace Medicine, and edited by Carlos Perry was published more than 35 years ago in 1967. The topic of psychiatry features as a specialist chapter in most of the core texts in aerospace medicine (see for example, Fundamentals of Aerospace Medicine (De Hart, 1996)), whilst the related problem of psychiatric and behavioral problems among airline passengers are dealt with in more recent related texts, including Aviation Medicine and the Airline Passenger (Nicholson & Cummin, 2002), Passenger Behavior (Bor, 2003) and Psychological Perspectives on Fear of Flying (Bor & van Gerwen, 2003). Readers who have an interest in an historical perspective in aviation mental health should consult the fascinating book by H. Graeme Anderson (1919) entitled The Medical and Surgical Aspects of Aviation which offers what are arguably the first authoritative professional insights into crew selection, the psychology of aviation and “aeroneurosis” (akin to a fear of flying among pilots), and was published at around the time of the birth of the aviation industry. It is remarkable how many of the insights offered by the author nearly a century ago, still apply. There is one notable exception: there was slightly greater tolerance (if not encouragement) of alcohol use among pilots in those early days to subjugate anxiety from the great risk of injury or death from accidents, though there was also recognition that excess alcohol use would ultimately ruin the career of the pilot.

Pilots and others employed within commercial and military aviation are in many ways a unique occupational group. Their training is both intense and vigorous, and the tasks performed by many demand good physical health and psychological stability. As individuals, crew have to be proficient in handling complex systems on board aircraft, as well as have an ability to work as part of a small team or crew and usually within an organization. As shift workers, they do not usually follow the same routine, and a pilot’s office is normally a cramped flight deck on board an aircraft at 35,000 feet in the air. Increasing automation on the flight deck over the past decade has altered the role of the modern pilot. He or she must be an efficient and well-organized manager, proficient at communicating with customers and fellow crew and adept at computer programming as much as demonstrating traditional “stick and rudder” skills. When operating as part of a crew, a pilot’s actions are subject to the close monitoring of other crew members, similar to an incessant driving test. Regular simulator and line tests, as well as medical assessments for physical and psychological fitness, a comparatively low retirement age, increased uncertainty in the job market as well disruption to one’s domestic life, all add to the stress of the job. In an era where litigation is increasingly an option where a pilot’s actions have been brought into question, appropriate psychological assessment of pilots within their six monthly medical examination has to be considered.

Psychological factors that are relevant to the selection of pilots have been fairly well documented. The assessment and management of psychological problems among pilots presenting for medical licensing or who have been referred with specific problems is less clearly understood. While severe psychological disturbance among air crew is generally considered rare, air crew may, nonetheless, suffer from the full spectrum of psychiatric disorders ranging from a phobic fear of flying (Medialdea & Tejada, 2005) to acting on suicidal thoughts, even when flying (Bills, Grabowski & Li, 2005). Psychological problems such as mood disorder (Jones & Ireland, 2004), anxiety as a symptom of another psychological problem or from occupational stress (Cooper & Sloane, 1985; Girodo, 1988), relationship problems (Raschmann, Patterson, & Schofield, 1990), sexual dysfunction (Grossman et al., 2004) alcohol misuse (Harris, 2002), and sleep disturbance (Waterhouse, Reilly, & Atkinson, 1997) present with greater frequency and require careful assessment and treatment. After physical disorders, psychiatric disturbance has been reported to be the most common source of attrition and loss of license among pilots (Bennet, 1983; Smith, 1983). In a cohort of 136 members of cabin crew deemed to be medically unfit to fly, 12.5 percent presented with psychiatric disorders while 30.1 percent and 21.3 percent respectively were grounded for otorhinolaryngological and musculoskeletal problems (Pombal et al., 2005).

Many airline and military pilots regard the potential value of psychology as quite risible. This deep skepticism of psychiatry and psychology stems, perhaps, in large measure from the long-standing historical use of psychometric testing in both the initial selection of pilots for training, and later, in job promotion. Some airline workers hold a rather narrow notion of the breadth and scope of the mental health profession, and it is hoped that this book will help to better explain the relevance of mental health issues among pilots. Especially in an industry which privileges physical safety and robustness of pilots, airline workers may be loathe to seek professional help for mental health difficulties or anxieties, and understandably, regard mental health workers with suspicion. In a profit-driven industry, mental health welfare tends to be marginalized and regarded as a luxury, unless a pilot becomes overtly depressed or alcoholic. Airlines have not been particularly knowledgeable about or sensitive to brewing stresses in their employees. For this reason, accessible, proactive and preventive mental health services need to be developed within the industry.

Aviation mental health is concerned with six main tasks: (a) selecting out those found to be psychologically unfit to fly or work within the industry; (b) monitoring the psychological health of those who enter into training and employment; (c) assessing and treating those who develop psychological problems in the course of their work; (d) determining whether and for how long an individual is unfit to fly or work within aviation; (e) emotionally supporting those deemed to be unfit to fly, whether temporarily or in the longer term; and, (f) preventing mental health problems through proactive intervention, health promotion and research.

The field of aviation mental health should not be seen to be limited to the diagnosis and treatment of psychopathology and psychiatric problems. A book of this scope is also concerned with the prevention of psychological problems, especially among crew. For this reason, the book includes chapters on the need for and approaches to crew (pilots, cabin crew and astronaut) selection. It also presents an overview of those aspects of passenger behavior that may adversely affect crewmembers in the course of their duties. As editors, we have sought to include as many areas that are relevant to the topic of aviation mental health as possible. However, this has not been without its limitations. We recognize that there is a paucity of published literature in several key areas. Readers will note, for example, that there are no chapters which specifically concern or address air traffic controllers or aircraft maintenance engineers. Almost all published aviation mental health research pertains ...