Preventing catastrophic mental health breakdowns

"Aviation safety is rarely threatened by the deliberate destruction of airplanes by pilots, and when they do occur, events are often shrouded with uncertainty as to the pilot’s motivation… Although mental health within commercial aviation is not a new topic, the ability to identify and help pilots who struggle with mental health problems remains a present-day challenge." 1 While pilot suicide can rarely be identified, with absolute certainty, as the sole reason for an aviation disaster, there are several cases where it has emerged as the probable cause. 2 This possibility should not worry only HR practitioners in airlines. Every HR professional should think of ways to prevent such fatal outcomes since innumerable other military and commercial organisations entrust their functionaries with equipment that can imperil tens, hundreds and even thousands of lives. Space being a constraint (both for stowing cabin and column baggage!), this column will focus only on commercial aviation and leave it to the reader to extrapolate elsewhere. 

Robert Burton made a telling (though not comprehensive) attempt to identify the causes of suicide just over four centuries ago. "… [A] modest man, one that hath grace, a generous spirit, tender of his reputation, will be deeply wounded, and so grievously affected with it, that he had rather give myriads of crowns, lose his life, than suffer the least defamation of honour, or blot in his good name." 3 Modern psychology provides us with more scientific (if less poetically satisfying) explanations than Burton’s. Among the more recent is Rory O’Connor’s Integrated Motivational-Volitional (IMV) model of suicidal behaviour. 4 According to his model, vulnerability factors combined with stressful life events lead to suicidal ideation. Pre-motivational vulnerability factors (e.g., socially prescribed perfectionism) increase the sensitivity to signals of defeat. Defeat/humiliation and entrapment are key drivers for the emergence of suicidal ideation with entrapment forming the bridge between defeat and suicidal ideation. Volitional-phase factors govern the transition from ideation/intent to suicidal behaviour. Individuals with a suicide attempt or self-harm history will exhibit higher levels of motivational and volitional-phase variables. Distress is higher in those who engage in repeated suicidal behaviour, and, over time, intention is translated into behaviour with increasing rapidity.

Employees in General

This column has written on more than one occasion about the causes of poor mental health among employees and managers. Three of these need to be resurfaced in the current context.

In the first place we have the impact of general working conditions, including work hours, the physical environment and toxic (politely called 'highly demanding') work culture. Highly monotonous jobs add to the lethal mix. " … We have come no closer to finding answers to the mental devastation caused by deadening work. Not only have we continued to allot repetitive work to the majority of the operatives in the remaining non-automated shop floors in India, the other jobs we have created in high numbers (e.g., the delivery staff for e-tailers) are no less routine and even more stressful." 5 A previous column has described how these can lead to ailments and death (not only through self-injury) as well as the radical changes needed to prevent these. 6 A subsequent column has described how the pressure of public opinion can be harnessed to force change. 7

The impact of a poor work environment can be worsened multiple times, and even a benign environment can be poisoned by unpleasant supervisors, peers and team members. "WB [workplace bullying] is significantly associated with suicidal ideation, suicidal attempts, and feelings of defeat."8  Assuming the entire organisation is not infected, regular organisational assessment, coupled with a vigilant and active HR should be able to curb such practices or cashier incurable perpetrators. 

The final generic cause lies with the individual, albeit precipitated by organisational and work-group practices that debilitate mental health. " A single word captures the reason mental illness is among the least tractable problems for corporates to solve or even ameliorate. Stigma. Unlike physical ailments and disabilities, which employees rarely expend too much effort in concealing because they are generally received with sympathy and helpfulness from colleagues and supervisors, mental illnesses are hidden away for the justifiable fear of the reactions they elicit in the workplace." 9 The following model can counter such anxieties. " Each organisation would need to provide access to a mental health platform for all employees, regardless of level and type of contract. Under conditions of total anonymity, the platform would provide the following five services:

1. A diagnostics module that would help an employee figure out whether s/he has a mental health issue, how serious it is and its tentative classification.

2. A preliminary guidance module which would provide AI-based suggestions of simple dos and don’ts as well as suggest activities which can give relief to the specific types of disturbance the diagnostic module reveals... 

3. An interface bridge to an array of telephonic counselling services from which one or two would be recommended for the individual based on the diagnostic outcome… 

4. An interface bridge to a panel of clinical psychologists and psychiatrists…

5. A module for following up therapy sessions and providing on-line exercises for ongoing low-intensity support." 10

Individuals Who Hold Lives in Their Hands (LITH)

Problems that culminate in suicide can also affect lifeguarding individuals, like pilots, who hold lives in their hands. They often face greater torment because of the responsibility they bear and the drastic consequences any admission of mental disturbance can have.

Take working time. Pilots are not superhuman in coping with long hours and the consequential fatigue and mental health challenges." On the flight deck pilots manage complex, cutting-edge technology in the high-risk, high-reliability system called aviation. In the 1980s, professional pilots were rostered for an average of 46 flight hours / month. Today, flight time limitations (FTL) allow up to 100 flight hours / month, and pilots’ fatigue has become a problem for flight safety… 'Pilot Pushing' refers to the implicit pressure on pilots to use airplanes as effectively as possible for maximum productivity... 'Pilot Pushing' could play an important role for accumulated fatigue and burnout. … Fatigue and sleep problems are not isolated problems but are strongly related to stress, mental health, and wellbeing." 11 Continued stress can cause permanent neurological damage. " Pilots, under extreme pressure to perform well while flying in inclement weather conditions, at night, while attempting to overcome the effects of disrupted circadian rhythms, are often consumed by the negative side effects of prolonged performance under the effect of adrenaline. We know that neuronal damage, particularly in the hippocampi, can be caused by these prolonged states of stress." 12 The suggestions made for minimising organisational stress for general employees need to be implemented with even greater punctiliousness in the case of critical categories like pilots. 13 Once again, public opinion might be roped in to help. For instance, each airline could be mandated to publicly declare how far below the 100 flight hours/month FTL it operates and share the trend line along with other aggregated (mental) health parameters about its pilots.

Similarly, tracking and neutralising localised tanks of toxicity in work groups containing LITH employees should be among the critical non-negotiable responsibilities of HR. Of course, they can use sources like 360º feedback and exit interviews, but there is really no substitute for MBTA (Management By Talking Around). 14

Unlike other employees, who may suffer career setbacks, LITHs can lose their livelihoods if they seek mental health support soon after they first notice symptoms. " Currently many pilots struggle with a lack of support when dealing with a mental health issue. … [A] common argument by pilots for not seeking help is the fear of financial repercussions. If a pilot seeks help and is not issued a medical certificate, then he / she is unable to work… This financial burden further reinforces secrecy and mental healthcare avoidance by many airline pilots." 15 Nor is the stigma an inconsequential outcome. " If you tell the truth about your mental health issue, you might lose your job. If you decide to get professional help, you keep it to yourself. If you take disqualifying medication, you keep that to yourself… You especially keep your secret from others with whom you fly. If you decide to share that information, you will suffer the stigma that comes with mental or psychological conditions." 16 The only way out of this seeming Catch-22 situation appears to lie in creating a low-risk observation pool into which LITHs are placed for observation and help while continuing with their normal duties. To appreciate the help that is needed, it is worth understanding suicide from the perspective Joiner brings." [P]eople have strong tendencies toward self-preservation; evolution has seen to that. … Some people develop the ability to beat back this pressing urge toward self-preservation. Once they do… they are at high risk for suicide, but only if certain other conditions apply – namely that they feel real disconnection from others and that they feel ineffective to the point of seeing themselves as a burden on others." 17 The steps then could be:

1. The process of creating a low-risk observation pool for LITHs would follow the first four steps mentioned in the previous section, namely:
      i. An anonymity-guaranteed, online diagnosis of the mental health of the individual.
      ii. Access to an AI-based mental health advisor as well as video-call-based human counselling services.
      iii. Possibility of consulting a clinical psychologist, should the matter remain unresolved. 
   
   

2. Mechanisms for providing 'connection' to others. There is an endless variety of possibilities. 18 Some of these might raise the costs of employment significantly, but this must be balanced against the risks they reduce. They could include subsidising and otherwise facilitating joining:
      i. Clubs and sports fraternities.
      ii. Professional bodies and hobbies that encourage group interactions.
      iii. Subsidised fares and stay to encourage concentrated family time.
   
   

3. Participation in activities that create a self-image of contributing to others rather than seeing oneself as a burden on them. For example:
      i. Social service organisations.
      ii. Involvement in community welfare activities.
      iii. Disseminating expertise and help through teaching, coaching and writing.
   
   

4. If all the above do not result in adequate improvement, there is a point beyond which current protocols should be brought to bear. These should include:
      i. Removal from regular duties with closer monitoring of mental health.
      ii. Direction towards therapies that have been found effective. For instance, "…traditional cognitive behavioural treatment (CBT) while integrating work experiences shows promise in faster return to work among those on leave for mental health issues." 19
      iii. Return to regular duties under adequate supervision.

Moderating the Murderous Mind

Unlike the aspects we have covered so far (as well as in my previous column on suicide at work), 20 what makes the cases we are focused on now truly appalling is the number of innocent lives murderer-suicides knowingly take, along with their own.

There are three additional causal factors we need to take on board in these extremely tragic events. In the first place, work stresses are a prime trigger that add murder to suicide. Secondly, murder-suicides successfully hide from themselves the heartbreaking suffering they cause. Lastly, we treat murder-suicides with considerably more sympathy than we do mass murderers. Each of these has a possible cure, though they become progressively deeper blue-ocean in character.

1. Work stress reduction, especially for LITHs, must be a critical HR priority for organisations that employ people in this category. " … [W]hile an individual may experience burnout symptoms derived from the immediate work context, factors from a higher-level context could serve a protective function. For example, Perceived Organisational Support (POS) – defined as employees’ beliefs about the extent to which their organisation values their contributions and cares about their well-being – has been shown to buffer against work-related strains such as burnout and negative affect. … Broader forms of social support – such as that provided by friends and significant others – may buffer the association between negative workplace emotions and the development of violent extremist attitudes [see earlier column on friendship]. 21 … [POS's] buffering effects are likely preventative, occurring before negative affect fully emerges, rather than acting reactively after such emotional states have already developed." 22
   
   

2. Unlike other mass killers, LITH murderer-suicides are more focused on getting out of a situation they consider intolerable: rather than hating the people they kill, they are usually just indifferent to their suffering. Clearly, in such cases, the checks imposed by society on the individual and by the individual on himself (yes, it’s usually a male) have failed. "Self-regulatory mechanisms do not operate unless they are activated, and there are many psychological processes by which moral reactions can be disengaged from inhumane conduct… It is relatively easy to hurt others when their suffering is not visible and when causal actions are physically and temporally remote from their effects… [W]hen people can see and hear the suffering they cause, vicariously aroused distress and self-censure serve as self-restraining influences." 23 Means have to be found of conveying the terror, pain and distress of innocent victims to the perpetrator. Who knows whether at least some murder-suicides by pilots could have been prevented by the simple expedient of a screen in the cockpit that showed views of the passengers under their charge, cowering and terrified? Simplistic? I am sure smarter minds than mine can find more effective means of overcoming blocks to self-deterrence. 
   
   

3. Finally, the glorification of suicide (if any) has to stop well short of extending to murder-suicides. Even their public naming is open to question once we recall one of the sources of their ghoulish impulses. " … Mass killers have imagined themselves as stars in their personal apocalyptic action movies… They would never be forgotten. 24 "We may well be revulsed by the Church’s (and Dante’s) treatment of suicide." In the Middle Ages suicide was beyond literature. It was a mortal sin, a horror, the object of such total moral revulsion that the outrages against the corpse of the suicide were carried out not only with all due ecclesiastical and legal solemnity but also gratefully… Certainly, Dante never questioned the orthodox judgement of the crime. Instead, he sustained it by devoting one of the grimmest cantos of the Inferno to the suicides.… At the Day of Judgement, when bodies and souls are reunited, the bodies of suicides will hang from the branches of these trees, since divine justice will not bestow again on their owners the bodies they have wilfully thrown away." 25 One wonders, however, whether a similar condemnation of murder-suicides by the media and religious figures, as well as the creative and popular arts, together with their anonymisation, would not go some way to dissuading perpetrators by snatching away any vestige of heroism or even humanity from the crime they are thinking of committing. 

"There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy. All the rest … comes afterwards." 26