Why Pilots Don't Get Therapy

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Plane crashes and aviation accidents happen for all kinds of reasons.

The collision between the helicopter and the American Airlines flight near the DC airport.

The Alaska Airlines flight where the door panel flew off shortly after takeoff.

These terrifying incidents that make the news, they stick in our minds.

But there's another, less visible safety issue that doesn't really make the news.

Pilots themselves have been raising the alarm about a different kind of risk to passenger safety and a risk to their own well-being.

It involves a rule that's designed to protect passengers, but it might instead be making flying more dangerous.

I'm Hannah Rosen.

This is Radio Atlantic.

Today, our producer, Jocelyn Frank, is with us with a story.

Hey, Jocelyn.

Hi, Hannah.

Thanks for having me.

Sure.

So you've been talking to pilots, and what have they been telling you?

Yeah.

I recently interviewed quite a number of pilots, and one of them has really got me thinking differently about flight safety.

His name is Chris Finlayson.

He's been a pilot for 13 years.

He's married.

He has two young daughters.

And he's a first officer with one of the major airlines in the U.S.

It's a job that comes with a lot of responsibility.

You know, a few flights every day.

He's probably responsible for a few hundred people every time he shows up for work.

So when he got COVID, he had no hesitation about being grounded.

He immediately stopped flying.

I got a really bad bout of long COVID, memory loss, brain fog, fatigue.

That really tanked my serotonin.

That all of a sudden triggered every anxiety I possibly had.

December 19th, 2021 was my last flight.

Even after most of his COVID symptoms subsided, his anxiety just kept going.

And then he got anxiety about his anxiety.

I remember sitting in my bed after a panic attack and just thinking, I can't do this.

And I remember going into the doctor's office in February of 2022, thinking that, frankly, I was throwing my career away.

For most people in a similar situation, having stress, anxiety, even panic attacks, it would lead them to some behavioral therapy or medication.

And then ideally you just get back to a stable, typical, healthy life.

But Chris Finlayson is a pilot, and for pilots, there's a different calculation.

When pilots do seek out mental health care, they risk derailing their careers, disrupting their livelihoods, and ultimately, sometimes their permission to fly.

And if they don't seek help, they could be putting their lives and the lives of hundreds of passengers at risk.

These haunting images are the first we've seen up close of the twisted metal and shattered debris, all that is left of German Wings Flight 9525.

In 2015, there was a terrible crash, an airline called German Wings,

and it turned out that the co-pilot intentionally crashed the plane.

The plane mysteriously crashed into the rugged French Alps on Tuesday, killing all 150 souls on board.

Even Even though it wasn't a U.S.

airline, basically since then, the FAA has been trying to tighten their approach to mental health.

They want to reduce any risk to passenger safety that's linked to any kind of serious mental health challenge.

I think you have to understand that the FAA is, from their perspective, is interested in helping people fly as long as they're safe for themselves and the public.

And the intent is to get as many people flying as they can safely.

Thomas Jetzer works as a medical consultant for the FAA.

He's a certified AME, which stands for Aviation Medical Examiner.

He's one of hundreds of special doctors across the United States who meet with pilots on a yearly or on a six-month basis to review their medical records and decide if they're fit to fly.

And he thinks it's a pretty good system.

Some of these pilots I've seen for 35, 40 years.

Every six months for that long, yeah.

Right.

And it's kind of like a barbershop.

You really get to get their full records to make sure that things are appropriately reported and assessed and documented for the FAA.

If you have a problem, they want to make sure that you're well enough managed that you're not going to be a safety risk to yourself for the public.

Talking to Dr.

Jetzer, I was trying to learn how the FAA system compares to others because a pilot reporting a mental health concern, even to a doctor they've known for 35 years, could halt their career.

And Dr.

Jesser pointed out that the kind of scrutiny he's responsible for, it's actually not even unique to pilots.

It's similar to other high-responsibility fields, like FBI agents or people who work within the nuclear industry, and even a part of his own field, medicine.

For doctors, I mean, there's a questionnaire you fill out, you know, every year when you reapply for your medical license that you have to determine whether you have any medical conditions.

But if I was a doctor and I went on antidepressants, I wouldn't need to report that I'm on antidepressants unless it was impacting my work, right?

Well,

you're right.

There's not as close an observation review of a doctor's every you know six months or a year

there is for nuclear operators.

You don't have it for police or firefighters.

Okay, so Jocelyn, surgeons, police officers, firefighters, all these are also people responsible for the safety and well-being of hundreds of people.

But they could each theoretically just visit a therapist and keep it to themselves.

They could each theoretically visit a psychiatrist.

They could be prescribed anti-anxiety medication and just keep on with their jobs without having to report anything to a special doctor or to their boss or to take time And this added layer of scrutiny for pilots, I mean, they're responsible for hundreds of people at a time.

So the FAA wants to be as sure as they can that anyone who's in the cockpit is in a really healthy state of mind.

Which totally makes sense that they want that.

Like you should be in a healthy state of mind if you're flying a plane.

I guess my question is, is this invasive amount of scrutiny from your employer or your boss encouraging a healthy state of mind, or is it encouraging you to pretend that you have a healthy state of mind?

Yeah, it's a really good question, a really serious question.

And I looked into the FAA safety systems in some more detail, and it turns out that the processes that they have in place have led to some really terrible unintended consequences.

Like what?

In the fall of 2021, an aviation student who was attending the University of North Dakota, he took his life in a university aircraft.

19-year-old John Hauser, a commercial aviation student from Chicago, died near Buxton.

The National Transportation Safety Board says there were no mechanical problems with the aircraft.

It was later discovered that he actually wrote a note revealing he'd been struggling emotionally, but he felt like he couldn't do anything about it because he feared losing his medical certificate.

His mom actually read some of that letter out loud during a National Transportation Safety Board summit.

In a letter describing the turmoil that John was silently facing, he wrote,

I want to seek help more than anything.

I really do.

I want to get better.

I know I just know if I try, I will have to give up on aviation.

And frankly, I'd rather not be here than to do that.

Even though this was an awful tragedy, thankfully it didn't involve any passengers.

But then there was another event.

Just in a CNN, we are learning that an Alaska Airlines flight was diverted because someone in the cockpit, apparently, tried to shut down the engine mid-flight seen as people.

In the autumn of 2023, an off-duty Alaska Airlines pilot was catching a ride on Horizon Air.

It's a travel trick that's pretty common among pilots called jump seating.

And this pilot, his name is Joseph Emerson.

during that flight, he's accused of trying to activate a fire suppression system that would have cut off fuel to the plane's engines in mid-flight.

We've got the guy that tried to shut the enzyme down out of the cockpit.

Emerson was luckily not successful.

He was escorted to the back of the plane, handcuffed to a seat.

I think he's the dude.

Other than that,

yeah, we won law enforcement as soon as we get on the ground and park.

The plane was rerouted to make an emergency landing.

Emerson later told reporters that he'd been suffering from depression, and he pled not guilty to the charges that were brought against him.

He wasn't piloting that day, but he did have access to the cockpit.

And that means that his position, as technically as a pilot, put the safety of the plane and its passengers at risk.

So these are two pretty high-profile examples where people's lives were at stake.

And in both cases, the pilots were not getting the care they needed.

Those are two scary, terrible situations.

Do we have any idea if they're outliers?

Like, how many pilots are not getting care when they need it?

I talked with William Hoffman.

He's a neurologist and an aviation medical researcher.

And he and his team have been trying to figure out how the FAA's protocols impact the decisions pilots are making about their health.

In 2019, Hoffman and his team launched a survey of over 3,500 pilots across North America, and he found that 56% of pilots reported a history of healthcare avoidance due to fear of losing their flying status.

So that's over half of pilots avoiding care, which is a lot.

I mean, that suggests there's a huge resistance to getting care, which means that Finlessen, who's the guy we were talking about, he's unusual for going through the whole process and seeking care.

Well, at first, Finlesson thought he might not have to go through the full process.

The way the FAA's system works is basically if you go on medication and then you get off of it for 60 days and your treating psychiatrist says, you're good, the FAA can consider this as all just like a little health blip.

You're grounded, you're not flying for that period of time, no regular paycheck.

But after, you can potentially get fairly smoothly back into your job.

So Finlesson was hoping for that when he went to see a nurse practitioner and he started taking a low-dose SSRI for his anxiety.

10 milligrams.

Did that for about six months, tried to go off it, and unfortunately that didn't work.

He knew he couldn't stay off the medication and feel well enough to fly.

If he stayed on medication, he'd have to pursue the longer path for his medical certificate.

It's called requesting a special issuance.

Even with that request, there's no guarantee the FAA would decide he could ever fly again.

And he felt totally stuck.

And that's when my psychiatrist was like, look,

I get all this stuff, but we should really escalate you up to 20 just to see what happens because there's nothing to lose at this point.

And that's when I really gave up, like, okay, I guess I'm just going to be on this rug no matter what.

So I am going to, no matter what, need these special issuance.

And once Finlesson sort of let go of the possibility of that faster path back to his job, the fast path to that medical certificate, his health improved.

When I started that higher dosage of my SSRI,

after about six weeks on that, I was like, oh,

this is clarity.

This is awesome.

This is a good state to be in.

And I've maintained that ever since.

So Finluson achieved this mental recovery, this clarity, but the path back to piloting was still extremely murky.

I didn't know how long it was potentially going to take.

Wasn't sure what exactly that cost was going to be, how I was going to pay for that if I was going to be working, the lack of transparency involved with the FAA's processes, all of those things.

He was about to begin medical testing, paperwork, research, bureaucratic phone calls, all to get the FAA to decide if he could get back into the air.

And it took him years, years of not flying.

I have to say, that seems amazing to me me that to go on 10 milligrams or even up to 20, which seems reasonable, that taking that amount of medication long term could cost you years of flying.

It just seems like when pilots do decide to pursue mental health care like Finlayson did, they are up against a lot.

Yeah.

It's a complicated system and it can take a lot of time.

Actually, Chris Finlayson had so much time away from piloting and so much time feeling frustrated as he was learning all this different information about the process.

He joined a nonprofit focused on pilot mental health, trying to reform the system.

At the same time, he's in it trying to get his own permission to fly approved.

After the break, we try and get to the heart of it.

Is this system actually keeping passengers safe?

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Jocelyn, Let's say we make the assumption that pilots have more or less the same level of depression and anxiety as the average population.

So that would be like a quarter of all adults in the U.S.

From what you can tell, are a quarter of all pilots seeking mental health care, like applying for those special medical certificates?

Definitely not.

In 2024, out of 150,000 commercial pilots, only about 9,000 applied.

And in the end, only about 3,000 were approved.

So Finlessen was hoping to be one of those 3,000.

He and his doctors decided he needed to take this anti-anxiety medication long term, which meant he was going to have to enter this longer process.

And it became clear it was going to be a really detailed and at times tedious process.

According to the FAA, a lot of people get denied for failing to provide some specific requested information.

It actually accounts for more than 75% of all denials.

And from the start, Chris Finlayson was feeling that potential.

He would think he'd checked a box, only to learn it was the wrong box.

The other requirement is to be evaluated by a board-certified psychiatrist.

The psychiatrist that I was seeing, she was a nurse practitioner that wasn't at the level for which the FA would require.

So I then had to search out a MD.

And that took an additional month.

He had to be on a stable dose for six months before beginning his application.

And that switch in care meant he had to start the six-month six-month count again

and he learned there were additional requirements.

So I had to go through a cognitive screening, a personality screening, as well as an interview by a neuropsychologist.

Each of these tests has a cost and each has to be submitted to this special FAA doctor to review.

I also had to go through neurological testing.

What is that like?

It is boring.

It is paying about four grand out of pocket to play,

oh, what's the app of the phone basically like paying four grand to play luminosity while a doctor stares over your shoulder that's all elective testing none of that is covered by insurance so it's all out of pocket you were use the word elective but it's required for you to come back to flying right so yeah so in the faa world it is absolutely required It is a requirement for me to get a medical.

It is a requirement to have a medical to do my job.

Requirement, requirement, requirement.

Insurance land,

that is,

I do not need to be a pilot because it's not medically necessary for my health.

It is medically necessary for my employment.

So it seems like these medical requirements cost a lot of money, and the pilot is not earning a regular salary.

Right.

Yeah.

The process can cost thousands of dollars, somewhere between $10,000 or $15,000 for most pilots.

And like Finlesson was saying, it's uncommon for insurance to cover these kinds of expenses.

And only a very small percentage of unionized pilots flying with legacy carriers,

which those are some of the biggest ones, they've negotiated for this process to fall under their disability coverage.

And that can offer pilots like Finlessen a partial paycheck, a partial paycheck to support two kids and a wife in grad school.

But that is the best case scenario.

And many other pilots and aspiring pilots who I interviewed for this story have had no stable income and no safety net during their process.

No income?

They're grounded from flying or they haven't received their pilot's license to begin with.

So they're not getting any kind of base level paycheck while they're going through this process.

And aviation is a very expensive field to begin with.

I mean, a lot of pilots take on substantial debt just to get trained.

So this is what they're dealing with while trying to get this special medical certificate.

So that's like a huge disincentive to seek any help.

Absolutely.

Yeah.

It can take years just to gather all of your medical records, get all the paperwork organized and the testing.

And once a pilot and their AME do submit the request, the documents can take months and months for the FAA to actually review.

And that's a lot of time for a pilot to be waiting around on disability at best, more often unemployed.

And I have to say, with recent cuts to federal staffing at the FAA, it's unlikely that this process is going to get any any more efficient.

You know, Jocelyn, listening to you, I'm a little torn.

I fly often enough.

I'm not a particularly nervous flyer.

I'm not sure if I should be worried about my safety.

Like, is there any research that gets at the actual bottom line, the actual outcome of the system they set up?

Does this system, flawed though it may be, result in me, the passenger, being any safer?

It's pretty clear from those terrible suicide-type flights that we do not want a pilot in the pilot seat who is suffering from that kind of intense untreated mental health problem.

It definitely adds risk to passenger safety.

I asked William Hoffman, that researcher, what we know about having mental health problems that you're treating, that you're addressing, or something that was on your record from the past.

What do we know about how that impacts risk?

And here's what he told me.

Right now, there is this simple model that using services, mental health services, or having a diagnosis is a marker for risk.

But remarkably, that has never been systematically studied in research.

That's a complete assumption.

So that is a big assumption.

Yeah.

And it's an assumption that's costing Chris Finlessen and thousands of other pilots multiple years away from their careers.

But it's nearly impossible to get pilots to raise their hands and say, hey, I'll participate in your research.

I should probably be seeing a therapist.

Or, hey, I'm secretly taking mental health medication, so study me, check my flight records, and see how well I'm doing, or calculate all the small mistakes I'm making compared to this other pilot so we can figure out if my mental health issues are actually a problem when it comes to flight safety.

No one's volunteering for that kind of scrutiny, partially because doing so would mean admitting they had not been fully honest about their health prior to that kind of study.

It's a catch-22.

We need data to drive progress, but people are afraid to participate in research.

We can't get that data.

Okay, so if they can't get the data and they don't actually know the answer, what can be done about any of this?

So even if we don't know exactly how risky it is to fly with the current system, we do know that the current system is keeping pilots from seeking care.

And that's a part of the system where risk could be reduced.

One of the reasons I wanted to look into this story is because the FAA did recently request recommendations from a panel of experts about how to address that problem.

Hoffman was one of them.

The group delivered 24 suggestions to lower the barriers to mental health access.

And they presented these suggestions to the FAA last year in April of 2024.

And a few were acted on really quickly.

For example, expanding the number of medications that can be used.

So that was almost immediately implemented.

The total is now eight different drugs, but they're conditionally allowed, which means that you would still need to request a special medical certificate, and it might be granted, but it's not guaranteed.

They also narrowed some of the requirements for neuropsychological testing that a pilot might need to undergo if they are on a medication for mood.

So if a pilot like Chris Finlayson were to begin this medical screening again, he might have fewer tests to go through in order to request the special medical certificate.

And the committee recommended a bunch of other aspects of the process be changed too.

They asked the FAA to modernize the system to reduce paperwork, to improve training for doctors who are reviewing all of these medical records for more consistency, wider disability coverage, so pilots maybe could be covered more often.

And Hoffman was excited about another recommendation too.

One of the key recommendations was requiring that pilots have access to peer support services.

Peer support basically allows pilots the opportunity to talk to each other about sensitive issues that are going on in their lives.

So more like an informal counseling setup.

Yeah.

I asked William Hoffman why he was so excited about peer support.

Peer support does not need to be disclosed to an AME.

So

why not just promote therapy?

It seems like dancing around the idea that people actually could benefit from therapy or could benefit from medication, but instead saying, go talk to a peer or, you know, do this other back channel thing and you don't have to report it.

It's a great question.

It's a critical question.

And

while in a perfect world, we could argue, you know, we could say therapy is not reportable and you should talk to a therapist.

I think more realistically where the rubber meets the road is that there's a lot of distrust, and the pilot peer can be that connection between the pilot needing services and the professional support that's required.

Chris Finlayson decided to go through the process of requesting the special medical certificate.

He, like I said, had his last flight December 19th, 2021.

He went through all of these different steps that took him almost two years.

He submitted his paperwork and about eight months after that, in July 2024, he heard back.

The woman just said, yep, you were denied.

I was like, what?

I actually requested my full file from the FA with the application notes and things that they normally don't send you.

They see me as in remission, but I need to check more boxes essentially.

That's probably the most frustrating thing for me right now is the fact that like I've kind of got hosed and now there's no recourse other than to start it all over.

So.

Can you go back as many times as you want?

Like as many times as you can afford slash endure?

Yep.

Basically I'm having to restart the whole process.

So I have to wait on the FA to send them my paperwork.

I have to wait on my other doctors to send them paperwork.

I have to wait on all that stuff for them to compile that.

I'm probably going to have to redo some testing because the FA is not going to want want to see a test that's a year and a half old.

I'm in for the long haul, let's say the least.

Last year, the FAA approved 2,800 special issuance certificates coded for mental health.

As of this April, they've already approved almost that number, 2,400.

But if the system continues as is, it's likely that thousands of pilots will go on flying without getting or reporting the care that they need.

Jocelyn, thank you.

Thank you.

This episode of Radio Atlantic was produced by Jocelyn Frank.

It was edited by Claudina Bade.

We had engineering support from Rob Smersiak, fact-checking by Steph Hayes and Sam Fentris.

Claudina Bade is the the executive producer of Atlantic Audio, and Andrea Valdez is our managing editor.

Listeners, if you like what you hear on Radio Atlantic, you can support our work and the work of all Atlantic journalists when you subscribe to the Atlantic at theatlantic.com/slash listener.

I'm Hannah Rosen, and thank you for being a listener.

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