Wednesday, April 01, 2015

Co-Pilot's Troubled Past Was Known

We'll get to co-pilot Andreas Lubitz, who crashed Deutsch Lufthansa AG Germanwings Flight 9525 during a depressive episode. But first, when therapists become aware of dangerous situations, our responsibilities right here in the USA.

(1) Firearm Owner's Identification (FOID) and the Mental Health Reporting System

 I'm not sure when it happened, whether it was after a shooting at a school or maybe the Batman massacre in the movie theater in Colorado, but soon after I opened my office slowmail to find a pamphlet from the State of Illinois that disclosed a mandate for mental health professionals. We are to report individuals who have firearms if they have suicidal or homicidal ideation.

The exact statutes vary, but states regulate the sale and possession of firearms to the mentally ill and developmentally disabled, along with federal regulations, too. The Law Center for Prevention of Gun Violence provides us a map of the United States. We can click on a state before deciding if we want to move there.

In Illinois, for example, the state:

  • Requires that any person obtain a ten-year license (a Firearm Owner’s Identification, or FOID, card) to purchase or possess firearms and ammunition. The licensing process requires a detailed background check on the prospective FOID cardholder;
  • Imposes waiting periods between the purchase and actual transfer of a firearm to a purchaser – 24 hours for long guns and 72 hours for handguns;
  • Has implemented some design safety standards for handguns and has equipped the state attorney general with the authority to adopt detailed standards for handguns;
  • Has a Child Access Prevention law, which prohibits leaving a firearm unlocked and accessible to a minor under the age of 14;  and
  • Requires firearms owners to report lost or stolen firearms to law enforcement.
Caveat: The case descriptions in these blog posts are composites of different cases and different individuals and my imagination.

While I read the pamphlet about FOID regulations, I realized that I was to see a gentleman who had suffered from serious depressive bouts in a few hours, and he probably had a gun. He had a military background and worked security.

We had been working together on his depression for about a year, on and off, and he had made significant progress, was back to work, enjoyed his usual activities. But we still got together about once a month, and neither of us trusted that he wouldn't suffer new episodes. If that were to happen, he would be a clear and present danger unto himself. We both knew that. He also had a psychiatrist and a very involved medical team working with him on this and other medical issues.

So about midway through our session I asked if he had ever seen the FOID pamphlet, and showed it to him. He raised his eyebrows, looked at me carefully. "What does this mean?" he asked.

"Do you have a gun?" I asked gently. "Because I think if you get into serious trouble again, I'll have to report you. I could be wrong, have to look into it. Just saying, it's possible I have to do it even now."

He didn't answer, skipped over the subject to something else, and I let him. We finished up and rescheduled. The next day he called to cancel the next appointment, said he'd call me when he needed me. We had been operating like that for a year, a few months weekly, then a few months off. But he never did call, and I didn't follow up.

(2) Aviation as a Mental Health Specialty

It is likely that Andreas Lubitz saw an aviation mental health specialist. This young pilot suffered suicidal ideation and was told not to fly Tuesday. He somehow circumvented the direction and took down an airliner and 149 people with him.

If you have an insurance based practice it is likely that at some point you will work with flight attendants and pilots, even aviation engineers and the blue-shirts behind the counter who help you when your flight is cancelled. And TSA folk.

It is very stressful, flying for a living, or working in an airport. Having treated a few handfuls, at some point, while filling out a profile on the Psychology Today provider site, I checked aviation specialist. Now I'm thinking of editing that.

Not that the stressors are so unusual or different. But many people who work for an airline have commuter marriages and relationships. They sometimes feel homeless, adrift, sleep deprived. There's guilt not being around to go to normal life events, birthday parties. The kids miss you, you miss the kids. Your spouse or partner bears the brunt of the second shifting.

Relationships are intimate among the crew, or certainly there is plenty of opportunity for that, and that can be stressful, too. It is too intimate in those hotel bars, drugging yourself to sleep with alcohol deciding on the cocaine. That movie Flight, highly recommended, is not off base, scarily enough.

Did you know that one of the airlines is known as the love airline? No, not for me to tell, which one.

And naturally, pilots and flight crew don't have it easy. Passengers can be difficult, unpredictable, demanding. On The Moth, a podcast, a flight attendant tells the story of an older gentleman who passed away mid-flight. What do you do? Where do you put him? It is surreal, but real crises happen thousands of miles above us, on those airplanes we take for granted, those dots of white in the sky.

Flight crew persons are not exempt from run of the mill mental health issues and addictions. Depression is the diagnosis of the century, even for them. Those who are impaired, when they come to therapy, beg us not to use that diagnosis: Major Depression.

"Isn't there a V-code you can use?"

A V-code is about life circumstances, marriage problems, social issues. Most people who go to therapy can easily find one that applies, and it is less stigmatizing than an illness that might sneak up, compromise one's ability to do the job.

So often, yes, we do that, because they are true. We use a V-code. But if it is serious, no, you bet, we can't, even if that pilot will be grounded. He might have issues, and may not necessarily a diagnosis other than a V-code. We really have to be careful, though, examine our motives when we ignore a major threat.

The latest on Andreas Lubitz is that he didn't want anyone to know about his depression because he was afraid he would lose his license if the diagnosis became known. He deliberately put himself in a position in which he might kill himself and many others, rather than be tagged as mentally ill, and lose his license.

To him, losing his license was the big thing, totally irrational.

What should have been discussed in his therapy? Surely the potential for harm, should he keep his license, and how that feels, how thousands are affected, when 150 people die. Witness to excessively irrational thinking is one way we know someone is really sick. When thoughts are far removed from reality, we call it psychotic thinking. In a good therapy, the discussion about his thoughts is the discussion to have. The conversation that has to happen really is about keeping the license, losing the license, staying alive, keeping others alive, the risks in all of that and why he can't take them.

Like my discussion with that security guard, somehow it didn't.


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