Seeing a Therapist?
"I am a doctor, after all" - Tizi
Most of my articles tend to have a humorous tone. This one is intended to be a little more serious since it considers a very sensitive topic: mental health.
I wish to begin the article by reminding you of 14 CFR 61.53. If you hold a medical certificate and you have or believe to have a condition that would invalidate your medical, you must ground yourself. This act of incredible integrity, maturity, and professionalism is a necessary step to guarantee safety in the skies.
What constitutes a reason to self-ground is not easy to self-determine. A way to find out is to consult with your trusted Aviation Medical Examiner (AME). They will provide you with advice on how to go by your medical problems.
You don't know what you don't know
Not everyone is well-versed in aviation medicine and aviation law. There are many scenarios where a pilot may put themself in medically difficult situations without realizing.
Your family doctor may prescribe you some SSRI (i.e., antidepressants) for even common things like distress during a divorce. This is because physicians don't do psychotherapy; their only tool is medication. So, if your only tool is a hammer, everything looks like a nail. It's important to discuss with your AME (or possibly even a HIMS AME [Human Intervention and Motivation Study]) the ramifications of taking those medications or seeking an opinion from a psychotherapist who may be able to treat you without medication.
Seeing a mental health therapist for something mild?
Mental health is a topic of great relevance in this day and age. In particular, there are lot of discussions on whether pilots can truly be open about their mental health issues without risk to lose their medical (i.e., fear of losing the job). We will discuss the politics in another article some other time; instead, we will discuss what may happen if you go see a psychotherapist for a mild mental health issue (i.e, stressed out at work, going through a divorce, normal things). We'll call it, phase of life type stuff. Say you moved to another state for work, you're away from family and friends, need to start adulting for the first time, and you're a bit overwhelmed. Or maybe, you're stressed out and burnt out in school and need some counseling. These are the types of cases that we will address here.
If you see a therapist, for whatever reason, you may need to disclose that at your next physical. The one that you absolutely don't need to disclose is marital counseling with your partner. If you go individually, you might need to disclose that.
The FAA takes the stance that you need to disclose any therapy where you have received a clinical medical diagnosis (they call this an F-code in the International Classification of Diseases; for example, major depressive disorder, mild, is F32.0 ;Adjustment disorded is F43.2x, and so on).
Whether the AME grants you a medical certificate or defers decision-making to higher authorities, that depends on the documented diagnosis of the clinician.
Challenges with Health Insurance
Here is where it gets complicated. If you go see a therapist using your health insurance, they need to provide a clinical diagnosis in order to be billable (i.e., the F-code diagnoses). The mildest/most common one is "Adjustment Disorder" which can functionally be considered a "mental health cold".
What this means is that in order for health insurance to cover your sessions, the therapist may need to diagnose something that you don't have, just to be paid. These are all conditions that may ground you if a resolution to the issue is not properly documented.
That being said, if you are diagnosed with an F-code disorder like adjustment disorder, the AME will typically be looking for short term therapies (e.g., <6 months) and expect the therapist to document the issue as resolved (there are caveats, like if you have taken medication, you must have been "off the medication" and symptom-free for a specified period of time). In that case, the probability of receiving your medical is pretty high, and the AME may be able to issue your medical immediately. However, there are other F-code diagnoses that will ground you for some time (could be a long time), like bipolar disorder.
The AME guide provides extensive guidance on this topic. Decision trees and pathways aid the AME in determining whether they can issue the medical or not.
The challenge therefore exists if you go see a therapist for something really mild (e.g., phase of life issues, relational issues, or academic issues, to name a few) these are all considered "Z-code" conditions that are not clinical in nature and are not aeromedically significant (i.e., normal behavior). The problem with Z-code diagnoses is that they are not billable by health insurances. Therefore, your therapist may diagnose you with an F-code issue even if you are presenting a Z-code issue, just for the sake of billing your health insurance. According to aviation pyschology medical professionals in the USA, this is a real problem.
If you visit a therapist, you must discuss with them your profession and possible aeromedical consequences.
The FAA has released the Therapy, Psychotherapy and counseling Information: Pilots / ATCS guidance:
To make their life easier, the FAA recommends you bring this document to them (the third bullet in the document above). It's a document containing Information for Psychotherapists Treating Pilots and ATCS (make sure you have the latest version).
If you care very much about this issue, you should consider reaching out to your representative for congress and lobby for a pilot-specific health insurance that would cover all psychological issues, clinical or not clinical.
Private Practice without Health Insurance
If that is your situation, a solution is to seek a private-pay therapist, without using health insurance. At that point, the therapist can appropriately diagnose you with what you really have. If it's a Z-code issue, then you'll be fine (aeromedically and administratively). You may need to report it to your AME at the next physical (it never hurts to report it), but it will be quickly dismissed as a non-issue. But if your therapist identifies an F-code diagnosis (i.e., for real), then you clearly need help.
A great resource for you to consider is Dr. Abigail Powell in Texas. (TheAviationTherapist.com). She comes recommended to me by a close friend at the FAA. She also practices telehealth and is a great resource for pilots all over the country. As she states on her website, “I grew up around pilots. I speak aviation before I speak clinical.”
In Summary...
If you see a psychotherapist,
You may disclose that to your AME at the next physical.
If it's a Z-code condition, it is not aeromedically relevant and you will be fine.
That doesn't mean that you shouldn't self-ground if you feel unsafe to fly (e.g., your concentration is impacted by your current issue).
If it's a F-code diagnosis, this may be aeromedically significant and may result in grounding or temporary grounding.
If you go see a therapist through health insurance, they may need to issue an F-code diagnosis for billing reasons, which can complicate your medical. You have the right to informed treatment, so discuss with them what you are being diagnosed with and be open about your possible career repercussions.
If you go see a private-pay therapist, you will probably get an accurate diagnosis.
Don't forget the IMSAFE acronym. If you think you have anything that would make you unsafe to fly, you must self-ground. Remember to have integrity, be professional, and be mature.
--------------
This article was written with the help of a highly respected medical professional at the Federal Aviation Administration (FAA). Nothing written in this article necessarily reflects the view of the FAA - it is rather a factual observation of issues that exist today in this field.
Comments