Nature or Degree

It was the timing and tone of yesterday’s newspaper headlines that crossed the line for me: not any of the discussion about mental health and airline safety.  Of course, occupational health and fitness standards for pilots should be rigorous and we heard yesterday about annual testing, psychological testing, etc., etc..  By now, it may be easy to forget that when papers went to press on Thursday night, we still knew comparatively little about the pilot of the doomed flight.  We certainly did not know that he appears to have ripped up sick notes that were relevant to the day of the crash or what kind of condition they related to – we still don’t, as the German police have not confirmed it.  Whilst we did have suggestion that he had experience of depression and ‘burnout’ – whatever that means – we don’t know the nature or degree of this, do we?

There are other pilots, probably some of them flying as you read this, who have lived experience of depression.  For that matter there are people doing all manner of professional and other private things who have too.  I wonder how many moving cars you walked or drove past today and how many of their drivers have had or do have depression?  And yes, some people do end their own lives in ways that involve the use of vehicles – but we’re not proposing that everyone with any degree of depression, no matter its nature, should be stripped of their driving licence.  “How on EARTH was that man allowed to drive a car?!”  In case anyone is already thinking that the pilots actions cost another 149 lives remember there are almost 2,000 deaths a year on UK roads and that some of those figures will involve lives lost after deliberate actions involving vehicles.

NATURE OR DEGREE

Mental health professionals and mental health law talks about the ‘nature or degree’ of mental disorders. (I still detest that terminology – it is legal language). The Masked AMHP has written about this from his perspective as someone who has to interpret those terms in professional practice, but it essentially boils down to how acutely unwell are you and what is the nature or impact of that condition upon you. To give an example, 1 in 100 people have schizophrenia which can be accompanied by auditory hallucinations of one kind or another. For some patients, this is just another voice to listen to amongst many and causes little particular difficulty against the backdrop of a condition that they can live with an operate a relatively normal life. For others, internal voices are so devastating that it can lead to incredibly self-destructive behaviours and / or substance misuse to ameliorate the impact of them. Two patients such as these would be assessed differently, in terms of the ‘nature or degree’ of their condition.

And my point on this issue is that we still don’t really know what’s going on factually and even if we did, we could not yet understand the ‘nature or degree’ of any depressive condition this pilot may have had.  Certainly not within 72hrs of the crash happening.  This is why the newspaper headlines were premature: maybe that pilot was diagnosed with a terminal condition a week before hand and took an impulsive decision as he struggled to come to terms; maybe he did have a serious depressive condition that he was hiding from his employer and was actively suicidal?  If that latter were true, then of course no-one would question a decision to ensure he didn’t fly a plane into a mountain at 500mph.  But let’s wait and see the full facts – even the German police added on Friday to what the prosecutor in Marseille has said about their working hypothesis and they kept that development vague, so who knows what it means?!

Nevertheless, whatever we end up learning here, we do know that ‘depression’ is not and will not be the sole explanation for the crash, even if it is the most convenient or intuitive one.  Even if we do end up learning that this young co-pilot was acutely unwell and that he had concealed this well from his employer and his colleagues, I will still be more interested in learning that we have reflected on airline safety system for reasons that are far broader than concerns about a pilot’s mental health.  You can only crash a plane deliberately into the French Alps if the broader systems within which pilots are making decisions allows for such a catastrophic choice to be made by one person.  Nuclear missiles cannot be launched from submarines on one person’s say so – it is fairly obvious why things are set up this way.

JUST ONE RISK AMONGST MANY

So absolutely none of this means that we shouldn’t be having a debate about how to mitigate against this happening again – whether for reasons connected to potential mental illness or for any other reason.  I admit to wondering initially whether the crash was caused by some other human factor:  terrorism.  If my instinct had been correct and we weren’t discussing mental illness, we would still be wanting to know why it were possible for one person on a flight deck to islote the other pilot and take the decision to kill 149 other human beings.  You will have noticed that some airlines have already started putting a third qualified pilot onto their flights with a rule that two people must be present on the flight deck at all times.   There are so many other reasons why this could also prove wholly insufficient to stop similar tragedies in the future!

My point here is: the newspaper headlines we saw on Friday morning shame us all and make it more likely that such events may occur.  It is perfectly possible to write speculatory headlines as events unfold and as new information comes in without ensuring that other pilots with depression will feel they will be stigmatised for seeking help or support.    And of course if we’re not going to let people with depression fly planes, we’d best have all the driving licences back and start thinking more carefully about our military commanders, amongst other things.  The reality is we all rely upon people with a range of mental health problems to do a wide variety of things:  you have police officers and paramedics out there who have mental health problems – some have even been ‘sectioned’ under the MHA whilst very unwell and are perfectly professional people who are helping keep you alive and well after recovering.  There are other 999 emergency services personnel who have medically retired from service because the nature and degree of their condition meant it was appropriate for them to do so.  All cases on their indiviudal merits.

This post, in the end, is merely a protest against premature generalisation – we should see individuals in their specific context and if it is the case that this event looks predictable in hindsight, then let’s talk about safety systems that aren’t just targetted at pilots’ mental health problems but also those other issues that have caused even more deaths over the years.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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11 thoughts on “Nature or Degree

  1. Good post 🙂 The media frenzy has been scary. So easy to jump and make a knee jerk reaction and further stigmatise people with mental health issues. I am sickened by many comments I am hearing and reading on line and in real life.

  2. Great post – I have referenced you in my own blog post on the issue – for reference on Burnout:

    Burnout is a syndrome of emotional exhaustion. Burnout has been defined by Maslach as a syndrome consisting of emotional exhaustion, depersonalization, negative thinking towards others and a reduced sense of personal accomplishment (Maslach, 1986, Maslach, 1996).

    Maslach C, Jackson SE. Maslach Burnout Inventory Manual, 2nd edn. Palo Alto (CA): Consulting Psychologists Press Inc; 1986.

    Maslach, C Jackson, S Leiter, M, Schaufeli, W, Schwab, R (1996) MBI: The Maslach Burnout Inventory: Manual. Consulting Psychologists Press, Palo Alto (1996)

  3. If noone with experience of mental ill health were allowed to be in positions of responsibility, according to World Health Organisation lifetime prevalence statistics in some countries that would now be approaching* 50% of the population (1 in 4 people in any one year).

    I work in a notifiable profession, in a position of responsibility, which has potential impacts for public safety. I’ve had severe and enduring mental health problems throughout my career, I’ve had time out, when suggested by psychiatrists, and made it back to work too. Some of the most well respected and talented people in my profession have experience of mental ill health. Without their contribution, the profession and society would be worse off. Sure, professional safety systems recognising and responding to impediments to safe practice are a good thing, but those include physical as well as mental ill health.

    It’s a strange contradiction that some media demonise those with mental ill health who cannot work as ‘scroungers’, but a day later suggest that depression should exclude people from work and positions of responsibility. What exactly do they want depressed people to do?

    * http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174588/

  4. People fear the things they cannot explain, understand or control. What probably frightens people more is the often hidden nature of mental ill health. How can society control what they cannot understand? Introducing legislation, procedures or systems reassures the population that they have control of the situation and that this could never happen again. People’s fear is managed, trust restored and business kept going? Would people choose to board a plane knowing their pilot had any degree of mental ill health? Are there particular professions where there should be a legal obligation on medical professionals to contact employers with their concerns? Unfortunately we have a long way to go to ensure employers understand mental ill health, what their employees need and avoid practices which stigmatize people. Of course the real shock for society will be when they get the news that there is no such thing as ‘normal’ and we are all touched at some point in our lives by mental ill health.

  5. We simply don’t know what illness Lubitz was being treated for. The news media speculated, ad nauseum, that he was suffering from depression, but there’s no confirmation of this. But let’s say he was depressed. What are we supposed to do about this? Screening seemed to be the demand of the news media. As a mental health professional, I can tell you that such screening is likely to result in many false positives as well as many false negatives.

  6. Excellently put. I’m also saddened by the outpouring of vitriol I have seen; there is more to this than we currently know for sure.
    It has worried me that the progress made in the last few years to reduce stigma about mental distress has been set back a considerable way by this. Few who have not experienced depression or other mental illness seem to grasp that it simply does not mean a person is insane. Psychosis is quite rare and it’s probable that this young man was psychotic when this terrible tragedy happened. But people will not readily differentiate.

  7. Really liked your article – very clear and balanced thoughts.
    Would just of added that there does not necessarily have to be a relationship between depression, and wanting to kill others.
    Thousands of people unfortunately commit suicide every day, but would not even think of “taking” someone else with them.
    I can imagine that this pilot was depressed but that does not make you want to kill over a hundred people with you – if flying a plane by yourself, I accept that someone depressed could easily think I’ve had enough and crash it into a mountain, but not with a plane load of people.
    I know very little about mental illness, but presume that to do what this pilot did would involve some very unfortunate other mental illness.

  8. I understand calls for psychological testing for pilots. If there were a test that would accurately predict which people were likely to be in such psychological distress that they are very likely to harm others then, of course, we should use it.

    BUT… there is, of course, no such test. Any test used would be a screening test. http://www.ganfyd.org/index.php?title=Screening

    In principle, screening tests can have four sorts of results:

    – True positives: a positive result correctly tells you that the person tested has the condition you’re testing for – in this case, they will crash the plane, killing themself and others
    – True negatives – in this case the test correctly identifies that they won’t do this.
    – False positives – it identifies people who would not do so as being likely to crash the plane…, and
    – False negatives – it fails to identify the pilot who goes on to crash the plane…

    There are measures for this: the “sensitivity”, “specificity”, and positive and negative predictive values – see http://www.ganfyd.org/index.php?title=Interpreting_test_results .

    It is very rare for a pilot to do this. So the prior probability of the test being positive is extremely low; and the positive predictive value of the test will therefore be very poor. So any such testing would certainly identify far more pilots as being at risk of crashing the plane than would ever actually do so; and if the outcome of the test is that they are not permitted to fly, then many pilots would lose their livelihood unnecessarily.

    In any case, most psychological tests are not developed or evaluated in the occupational health setting. It’s one thing asking somebody who comes to a clinic saying they’re depressed and want help to complete a depression questionnaire – they’ll probably do so to the best of their abilities. But as soon as you start doing it in an occupational setting, saying “and if you are identified as “depressed” (or whatever) you’ll lose your livelihood and/or be severely stigmatised”… well, even if they try to complete the questionnaire as honestly as they can, they’ll be aware of the consequences, and it will distort what they say. And if they decide to disguise their problem, unless they’re extremely ill (so ill that you probably wouldn’t need a test), they’ll probably be able to give the “correct” answers – the ones that won’t identify them as being a risk.

    Testing is never going to work for this purpose.

  9. I think this story sheds some light on the complexities of mental health presentations and the well meaning ignorance of lay people. Depression is used as a catch all term to describe odd behaviours that people understandably struggle to understand. Very often other more significant factors, particularly the persons personality ( the essence of a person) are ignored as the interplay between the two (if depression/anxiety is present) are complex and can often only be established by a competent MH professional. Of course it is easier/nicer to believe someone has an “illness” that resembles a physical health problem- easy to treat or at least readily understandable

  10. Great point that we rely on people in all manner of different professions (doctors, train drivers, taxi drivers, dentists, teachers, paramedics, cops, nurses etc.) whom some of which will have depression or other mental illnesses. It’s easy for people to see a label and assume, when there is a whole lot more to it than that. I especially think there’s more stigma around these sorts of professions for people with mental illnesses, and it’s easy to forget that 1 in 4 people suffer from mental illness, and that isn’t just ‘non-professionals’, but of the entire population. Great post.

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