THE MIND CRAFT PROJECT – HEALTHY MINDS, HEALTHY PILOTS: A LITERATURE REVIEW ON MINDFULNESS MEDITATION PROGRAMS FOR COMMERCIAL AIRLINES PILOTS

Mindfulness practice originated in Buddhist traditions where it occupies a central place in a system designed to lead to the cessation of mental suffering (Thera, 1992). Mindfulness meditation is a psychological intervention tool that has been shown to be of particular value for people who work in stressful environments who need to excel in their chosen fields. Mindfulness was introduced into secular therapeutic settings through the work of Kabat-Zinn (Kabat-Zinn, 1990) who created mindfulness-based stressed reduction (MBSR) therapies for enhancing well-being and reductions in psychological distress.

Mindfulness meditation has also been considered for prevention of mental illness. This has been examined by the work of Van Der Kolk (Van Der Dolk, 2014). His work explores treatments for post-traumatic stress disorder, childhood trauma and other mental illnesses as a product of trauma. He explores mind-body techniques for people with the severest forms of trauma. Mindfulness meditation is one technique he discusses for prevention and treatment of those individuals with mental illness.

Mindfulness meditation is explored in this literature review will consider both these outcomes – mental wellbeing and prevention of mental illness.

Additional items were identified through hand-searching of reference lists of relevant retrieved articles. Conference proceedings, policies and regulations, meeting abstracts were also searched for relevant mental health management issues.

The following key terms were considered for inclusion for review:

Section 6.1 of the Designated Aviation Medical Examiner’s Handbook issued by the Civil Aviation Safety Authority (CASA) outlines the Psychiatry assessment procedures for pilots, other aircrew members and air traffic controllers (ATC) who suffer or who may suffer from psychological disorders or psychiatric disease. CASA outlines the purpose of these assessments is ‘to ensure that applicants do not suffer from psychological disorders or psychiatric disease … may jeopardise the safety of air navigation. A particular concern is the potential for an affected individual to commit an unsafe act that impairs the safe operation of an aircraft.’

CASA states that ‘the presence of a significant risk at any time during the course of a depressive illness will be disqualifying for pilots and ATCs… Certification may be considered if specialist psychiatric opinion confirms that a pilot or ATC who has attempted or considered suicide represents a low risk to aviation safety. Applicants who have a history of multiple suicide attempts will not usually be granted a medical certificate.’

CASA has provided a fact sheet relating to depression and aviation safety stating that CASA ‘makes decisions on a case by case basis’. Their approach to medical certification is that a well-managed depression is compatible with medical certification. However, any relapse in depressive symptoms and changes to medication must be reported to the Designated Aviation Medical Examiners (DAMEs).

Maintaining mental well-being can be challenging for large organisations, especially for organisations in which an employee’s mental health can impact on safety of the public. Large transport organisations have recognised the importance of ‘safety before schedule’, whereby material risks and safety concerns are addressed through vigorous safety reporting mechanisms and well-defined legislative requirements. However, mental health management proves to be an issue that is hard to assess and manage. The Aerospace Medical Association (Scarpa, 2014) recognises “that there may be barriers affecting a frank discussion of mental health issues between an aeromedical examiner and a pilot”, due to an ingrained culture of fear, in which the pilots fear losing their medical clearance certificate and thus, losing their jobs.

Currently, the Allied Pilots Association (American Airlines Pilots union) has a program called ‘APA Project Wingman’, which aims to provide a confidential “safe zone” of peer Employee Assistance Programs (EAPs) without retribution. The project aims to provide counselling, referral to competent professional authority, public outreach to increase awareness, and de-stigmatization of mental health care. This has resulted in dramatic increase in reporting & counseling for pilots. (Scarpa, 2014)

There are similar programs that exist within airlines around the world to provide assistance to pilots, and sometimes more generally to airline employees, to help in times of personal or emotional distress. In Germany, there is the Mayday Foundation, a program to assist aircrew in handling highly stressful person and professional events and Anti-Skid, a program available for pilots who suffer from alcohol abuse problems.

Similarly, in Australia, QANTAS has a Pilot Assistance Network (PAN) which is a peer support program aimed at mental health promotion, providing counselling and support services for pilots and their families. However, there are no known preventative mental health programs such as mindfulness meditation, yoga or other mind-body practices.

Since the mid-1970s, the union’s pilot assistance programs have helped several thousand pilots suffering mental health issues, however, there has been little research conducted on preventative psychological intervention tools such as mindfulness training.

Whilst some research has been some mindfulness research conducted for military pilots, there has been no research conducted on the efficacy and effectiveness for civilian airline pilots, particularly, those working in the commercial airline sector.

Medland et al¹⁰ conducted research on the impact of mindfulness training on a Norwegian military helicopter unit. The study is one of the first controlled studies of the effects of mindfulness training in a high-performing cohort in the aviation sector. The program found that mindfulness training increased the observation skills, created a relaxed and more flexible mind, and that it can help to reduce stress in high-workload situations where attentiveness to the task is particularly important. The study also found that after 12 months of mindfulness training, the pilots had improved attentional control, and arousal regulation. The study concluded that mindfulness training can be helpful in high-demand contexts such as military and civilian aviation.

Employees who have engaged mind-body interventions in their workplace have showed significantly greater improvements on perceived stress, sleep quality, and the heart rhythm coherence ratio of heart rate variability (Wolever et al, 2012). However, since there is so little research conducted on mind-body programs for pilots, it is important to consider other high-stress work environments to better evaluate if mindfulness interventions will be beneficial to commercial airline pilots.

Klatt et al. (2015) conducted a study to determine the efficacy of mindfulness interventions for staff in Intensive Care Units (ICUs). ICUs represent a high-stress work environment where personnel experience chronic exposure to catastrophic situations as they care for seriously injured/ill patients. The study found that work engagement and resiliency increase significantly in the intervention group, compared to the wait-list control group. The study concluded that mindfulness meditation is feasible, well accepted, and can be effectively implemented in a chronically high-stress work environment. Jha et al. (2015) also found positive results in relation to mindfulness training for increased attention and building resilience for military cohorts.

Similarly, mindfulness meditation showed positive results for in stress management in highly stressed community workers (Nyklìcêk et al., 2013) and patients with chronic illnesses that have prolonged physical stressors. (Cohen et al., 2017).

Mindfulness interventions are a practical solution that many corporations have utilised to improve resilience, reduce stress and general well-being. However, is mindfulness training effective for diagnosable psychiatric illnesses with reoccurring depressive symptoms and suicidal thinking?

The BEA report found that the Germanwings pilot was diagnosed with psychosomatic disorder and an anxiety disorderr. AsMA (Scarpa, 2014) stated that serious mental illness such as acute psychosis was relatively rare, and its onset was difficult to predict. Barnhofer et al (2015) found that patients with a history of suicidal depression, training in mindfulness can help to weaken the association between depressive symptoms and suicidal thinking, and thus reduce an important vulnerability for relapse to suicidal depression.

Whilst there has been some research into the benefits of mindfulness meditation for patients with serious mental health issues, there is little research conducted on how these preventative measures prevent suicidal actions of depressed individuals. These activities are difficult to predict and there is little research conducted on how mindfulness techniques can help with severely depressed individuals with suicidal tendencies in the aviation sector. Van Der Kolk (2014) does discuss the benefits of mindfulness meditation with severe mental illness in relation to past trauma. He notes that mindfulness is a good skill to help people manage unbearable feelings which can lead to suicide. However, more research is needed in this domain, specifically for pilots in the aviation sector.

Following the 2015 Germanwings crash, the BEA investigation concluded the following factors may have contributed to the failures in medical certification and self-reporting process:

Whilst mindfulness training may assist with stress reduction, increased resilience and better pilot well-being, it does not address cultural behaviours within the aviation industry in regards to the pilot’s fear of losing his/her licence due to decreased medical fitness. Hatcher (2010) discusses the importance of a safety culture being the most effective form of risk management in mental health. Hatcher states, commercial aviation has gained an ‘impressive reduction in the rate of major aviation incidents and serious incidents over a long period of time… Those changes often resulted from safety recommendations after thorough investigations.’ However, risk management relies on cultural changes, and whilst, the safety culture for commercial airlines has drastically improved, there is still much work to be done for mental health management.