A Grounded Theory Exploration of Addictions Treatment Within a Commercial Airline Setting

Subjects

This study was undertaken within a single medium-sized aviation carrier operating in Australasia, following consultation and consent from airline management and unions. The study protocol was approved in advance by the University of Otago Human Ethics Committee (reference number H20/067). Each subject provided written informed consent before participating.

Recruitment started in 2021 and was initially very slow, hindered by the coronavirus pandemic (COVID-19) and stresses this placed on the medical unit within the airline and the industry itself. The initial intention was to interview only current airline employees who had participated in the airline AOD pathway. This was subsequently extended to also include medical practitioners overseeing the program. The approach supported a purposeful sampling strategy as it became apparent following the initial interviews that meeting the aims of the study would require a wider understanding of the program than could be found solely within program participants. Given their unique oversight position of coordinating and engaging with employees participating in the AOD program over many years, the airline medical practitioners could provide their views and describe their experiences of a number of different elements of the program, from both a “behind the scenes” perspective as well as from having engaged with potential participants of the program whose views we would be unable to attain (those no longer employed by the airline, dropouts from the AOD program, and those who did not agree to enter into the AOD program in the first instance).

Eligible participants were initially approached by a member of the airline medical unit, who forwarded written information from the research team and sought the employee’s permission to be contacted. If agreement was forthcoming, the researcher contacted potential research subjects to discuss the project and address any concerns or questions they had, particularly around maintaining their anonymity and confidentiality. Recruitment was discontinued in 2022 after content saturation was reached.

Procedure

All subjects provided written informed consent and were interviewed by one researcher using a semi-structured interview schedule (available on request). Interviews were conducted primarily via Zoom, with one interview conducted in person. Once anonymized transcripts of the interviews had been created, the original audio-visual or audio recordings were deleted. The interviewing researcher also completed field notes immediately after each interview. Only the researcher who conducted the interviews knew the identity of the subjects and the details linking the identity (first and last name initials, date of birth, gender, and ethnicity) of the interviewee and the transcript. These details were stored separately from interview transcripts on a Microsoft Excel spreadsheet.

Analysis

Grounded theory was chosen to guide the analysis of our data. Given the paucity of empirical understanding as to why AOD programs in this industry are successful, the inductive nature of this methodology allowed new insights to come forward from the data with less imposition of our own pre-existing views and expectations.⁷ This approach is well-established and widely used to understand where there are quantitative outcomes for which the question of “why” remains unclear. It aims to clarify meaning in the interaction of people in complex systems,¹³ recognizing that people create this meaning that can have significant outcomes, such as significantly improved rates of abstinence as found in the sample under study. Put another way, grounded theory aims to discover patterns and processes that explain why people define their reality within groups. This understanding may enable other similar groups to take these insights and apply them within their organizations.

Guided by constructivist grounded theory principles,³ a constant comparative method was used to capture the key experiences of the subjects and remain grounded in the data. This meant data collection and data analysis occurred concurrently. Acknowledging the social constructionist view that theory can offer an interpretation rather than an exact picture,¹ our theory in this case can be defined as a conceptual understanding of a social process situated in a particular context, that being a commercial airline.

Transcripts were all coded by two researchers, a primary coder (interviewing researcher) and a secondary coder (one of three other researchers) to enhance trustworthiness of the data through triangulation. NVivo software was used to manage the coding data and a constant comparative analysis was used throughout the analysis. The coders worked independently in their coding before comparing their findings to identify emerging themes and concepts.

The four coding researchers met fortnightly throughout this 2-yr period to discuss the findings and the key developing questions to pursue, as well as to consider how the data was developing. Memos, exploratory diagramming, and tabling formalized the capturing of thoughts, development of ideas, and identification of gaps where more review was needed. As coding and recoding of reflections progressed, theoretical sensitivity began to develop in the researchers. The different backgrounds of the research team enabled a coproduced approach, adding triangulation and reflexivity to the data.

After nine interviews, content saturation was considered to have occurred and the researchers used the emerging ideas to conceptualize an initial grounded theory, within expected parameters.^6,9 A further five interviews were then coded to explore whether the grounded theory adequately covered the data and to confirm data saturation. It was considered important to review a significant number of additional transcripts due to the novel data collection approach in this area, the lack of clear prior conceptual approaches, and the wide array of possible understandings. In coding the final five interviews, no new data emerged from the interviews and data saturation was confirmed.

The Relationship Between Company and Employee

A pivotal concept that emerged was the profound relationship between employees and the company, fostering a sense of identity, belonging, and pride in their work. These factors were not limited to identification with professional roles or prestige but extended to the broader identity of being a part of the airline. Subjects consistently emphasized their passion for their work and their strong motivation to maintain sobriety for the sake of returning to their roles in the organization. The desire to remain with the company highlighted the positive impact of a supportive culture in the workplace.

“You know for me for me it’s a job that I love doing…I get frustrated if I can’t go to work…it’s always been about flying, it’s a love of flying, that’s why I do the job…I can’t really think of anything else that I’d want to be doing and so those are big motivations for me to keep going, keep sober.” —Subject A

“Working for the organization does seem to become part of their identity, to a certain extent…they call themselves [“airliners”] and have this real sense of pride and community and identify very strongly with working specifically for [the airline].” —Subject F

Subjects identified the threat an AOD disorder brings to their ability to maintain their jobs and, in turn, their professional and personal identity. Some subjects contrasted this with other groups with AOD disorders where identification of this would not present such a personal and professional loss. The pathway to recovery was therefore intertwined with an integral sense of ego-identity, overlaid by the lived experience as an employee of the airline and the importance of this. The need to manage this threat was clearly expressed and is a critical element in the relationship between individuals and the company.

“So for me, my entire career has been inside [airline]…they are an extension of me, in some ways, part of my wider family.” —Subject J

“That’s a livelihood, their passion, who they are, and if you take that away from them, they may not survive as a person.” —Subject C

Subjects described the iterative nature of the personal, professional, and existential development of the individual as a part of the company with increasing esteem, and the company as a collection of these valued individuals. This sense of positive identity and belonging is further reinforced by the company’s culture and time spent within the organization, and is reflected back to staff, leaving them feeling valued and respected. This cultural backdrop encouraged employees to seek support for their AOD issues.

“…particularly for being a pilot with the company it’s taken a lot for us to get to where we are, the company recognized that, they see our value and obviously they want to continue to keep us working…that’s one of the big things I’ve found from this is that they do value our contribution and want us to keep working for them…so they’ve been very helpful and supportive right through the whole thing to get me back flying and to make sure that I stay sober.”—Subject A

“[Airline] is quite good at, at creating positive mind-set inside the company…I think most people are there for the right reasons. And the company is so big but every part of it, I feel like I could go to and get help. Like nobody would ever say no, to anything, from a day to day work experience. So I feel like if I went to the security team or the medical team that they’re there to help, and they were there to help, I was never disappointed.” —Subject J

The supportive company culture is also evident in the approach to the AOD program’s participants marked by care, respect, and a commitment to helping individuals maintain their positions, further reinforcing the value the company has for its employees. As a result, many subjects felt appreciative of the support they received and became advocates for the AOD program among their colleagues.

“The other thing is that there’s been considerable buy in from people who have been brave enough to go through the program. As seems to be the case people in recovery are often very keen, and so grateful because they see the difference is made to them, they’re keen to share that that benefit with others. I think it’s enormously supported by people who are in recovery.” —Subject G

“They [participants in recovery] also become great advocates for helping other people. And there’s so many of them, who have subsequently put their own time and put themselves out there and told their stories and they become the most committed, productive employees who are there to help other people. So there is immense, quite apart from the safety, there is immense cultural and health value added to the organization taking this approach.” —Subject F

Safety Focused Culture

Additionally, shared values between the company, the workers, and the aviation industry around safety play a significant role in the success of the AOD program. The industry’s strong focus on safety, including the “just culture” approach, facilitate the identification and management of AOD-related risks in the workplace.

“So there’s this really strong safety culture in aviation way stronger, to be honest, than there is a medicine. So safety is just taken as an absolute guiding principle—safety first. And that’s kind of drummed into people right from the beginning when they join the company. That’s not just an [airline] thing, it’s an aviation wide thing, that safety is the ultimate.” —Subject H

“A just culture is no blame…So we’re people, it is expected that people are fallible, that they can make errors, and they can make mistakes. Provided people are acting in good faith and open about mistakes and open to addressing those issues, then an inherent part of just culture and safety culture is to not to act in a punitive way to individuals. I think that helps, I think that helps our program to be able to exist in this organization because it’s an idea and concept that already existed in aviation safety.” —Subject F

The safety culture also enables the more imposing elements of the AOD program, around testing and oversight, to be accepted and tolerated by the employees. AOD disorder assessment and management is clearly linked with risk management and safety, and employees are already accustomed to having such checks and balances in place around their safety-critical work.

“So there is a very high emphasis on safety culture, which I think is paramount when you’re working in the air and that’s something that inherently makes our job easier just because there seems to be an accepted model that aviation safety is of utmost priority. So that does enable us to do our work when engaging with people through alcohol or drug policies a lot easier” —Subject I

Furthermore, the safety culture allows the airline to set higher expectations for recovery compared to community-based programs due to the safety-critical nature of the work. The focus shifts from harm reduction to abstinence, again emphasizing the importance of safety in the aviation industry.

“Because what we’re doing is saying, we are so safety sensitive that we’re not going to adopt the harm reduction model. Here, we enjoy the luxury, if you will, of being able to say, abstinence, or out. Yeah, those are the choices.” —Subject M

Carrot and Stick

The “carrot and stick” model of motivation, a well-established framework for understanding drivers of change in substance use disorders, plays a central role in the success of the AOD program. In this context, the company’s cultural environment means the “carrot” is enhanced, while the “stick” is minimized. This creates a unique clinical situation conducive to positive recovery outcomes.

“With pilots and recovery, we have this big carrot hanging there, which is you want your license back or you want your medical back so it’s pretty strong driver and there are, from what I’ve heard anecdotally, pilots that do slip up or maybe just go back to drinking and they choose drinking over even flying, which to me seems crazy.” —Subject B

The shared recognition of safety and a just approach make the potential “sticks” more acceptable, enabling a focus on recovery, while recognizing the pathway to abstinence will include lapses. The “sticks” are not removed, and there are clear consequences for relapses, such as stand-down periods and increased oversight/monitoring or re-entering treatment. However, a relapse in and of itself is not an overall barrier to returning to work in the longer term. This aligns with the “just” approach to safety for subjects, and it provides a culture of support within which they can function.

“The other thing that I impress on them is that lapses and relapses are part of recovery and all the normal recovery agreement requires them to do is to put their hand up if they have a lapse or relapse, it’s not requiring them to never relapse. It’s just requiring them to share that information if that happens.” —Subject F

“It’s a culture where reporting is encouraged. And if you make errors, and report them, there’s no jeopardy for that. But there is jeopardy for two things. One is willful negligence, deliberately unsafe acts. There’s a grade of behavior, which is unacceptable, because it’s deliberate risk taking. And failure to report is also culpable. But beyond that, everything else recognizes the fact that humans make errors. And aviation has adopted that, from an early stage.” —Subject M

In addition to this, there is a strong focus within the AOD program itself on including peer support, reinforcing and strengthening this model. It assures the participant that they can address their substance use while maintaining their positive work identity. It also fosters a sense of community among participants by bringing together a group of people with a shared sense of identity and experience, creating strong and ongoing interpersonal supports between participants.

“He said the first thing I want to say is, you know if you do what we ask you to do, you’ll be back flying an aeroplane within six months. I can guarantee it. That was the, you know, the best thing you could hear and I kind of knew that because [friend] had sort of alluded to that, he’d told his story at that [peer support] meeting.” —Subject B

“But these people are giving of themselves for themselves. And that’s I think the fundamental reason why it works, because everything you see, hear, and feel in that room is genuine.” —Subject E

Barriers and Challenges

Despite the generally positive reports of the program in the data collected, barriers and challenges were recognized. Many of these barriers are universal to AOD treatment and/or the challenges of occupational medicine. For example, issues with recognizing AOD disorders and seeking support, including denial, normalization of substance use (particularly heavy alcohol use), and stigma. Other challenges may be more specific to this program and cultural context, including the fact that the stigma of a substance use disorder is also linked with the primary fear of job loss.

“I think the fear of loss of job is one of the biggest ones. I think those are the top three, stigma, denial, and fear of loss of job.” —Subject H

Subjects also noted the cultural aspect of substance use both within the aviation industry and more generally within the wider society of the country. Subjects saw these as being elements that enabled the development of a use disorder and as challenges to ongoing recovery.

“I know the airline industry lends itself to substance abuse because of what I’ve since learned the H.A.L.T.S - hungry, angry, lonely, tired, sick and I’d add thirsty to that. Well, a lot of long haul over nights and overnights in general, you’re ticking a lot of those boxes you know.” —Subject E

“Certainly hazardous drinking is quite culturally normal in many, many areas.” —Subject G

Stigma, including internalized stigma, was prominently described as a challenge within this professional setting. The practical consequence of this was identified as a fear of being unable to maintain their job/identity if a substance disorder is acknowledged, which is an obvious barrier to accessing treatment.

“I was frightened because I was irrational, I thought: oh they’re going to come and put me in a straitjacket.” —Subject L

Some of the barriers outside of the treatment of addiction are common to occupational medicine in general, such as clinicians balancing their obligations to both patient and employer, as well as the fact that these kinds of endeavors are time-, labor-, and resource-intensive.

“There’s actually a challenge, a big challenge that we face in occupational medicine and it’s pretty unique to occupational medicine, the fact that we are at times advocating for the employee, but also at times advocating for the employer.” —Subject I

“One thing that people in this program need, it is time intensive, you need to invest the time upfront in the initial assessment and the coordination of getting through that assessment into treatment, and then getting them across the line to agreeing to the requirements that we need to put in place to return them to work. And you need to sit down with them and spend a lot of time talking to them. And then you have to have regular interaction with them quite frequently, typically it’s at least every month.” —Subject F

Beyond these more universal and shared challenges, there were two difficulties important to highlight as pertinent to this airline’s AOD program. Firstly, linked with resource cost, the COVID-19 pandemic impacted the availability of resources as the medical team had to grapple with a constantly changing environment and guidelines.

“[The airline team] has been kept very, very busy just dealing with the business of keeping the airline running in the context of a pandemic. And there’s been a lot less resource to apply to following up people…It’s disrupted that relationship, it’s disrupted the follow-up care for those people. Even the people who have stayed in the organization, it’s disrupted the follow-up care for those people because sometimes they haven’t been able to physically come in, our strong preference is to have face to face meetings, we do have online consultations with people, that can be okay, if you know them well. Our rate of referral has dropped off dramatically as well.” —Subject F

Secondly, alongside this is the difficulty in trying to get the needs of a safety-critical employment regulator and company met by the country’s public system, which has a different model of care/objectives as well as its own resourcing issues. This means that often AOD program participants need to enter the private system at sometimes significant financial cost to themselves.

“So publicly funded services tend to say right you’ve had your treatment now, here’s a little bit of follow-on care, but away you go. And our view is that follow-on care is actually a core part of maintaining that high rate of sustained recovery. And we document that in a very formalized way, we have a very formal set of expectations around that if you’re going to return to work we expect you to proactively engage in maintenance and your recovery and these are the expectations and we’re going to meet with you regularly and make sure you’re jumping through those hoops.” —Subject F

“So it is more challenging when you’re dealing with the public sector. So people that are in CADS [community alcohol and other drug services], for example, because those clinicians don’t necessarily have the same experience of working with someone in aviation. And naturally they’re very careful about confidentiality and that side of things, their focus is very much on their client and their client’s confidentiality and their clients retaining their job. So those external providers are less likely to provide the sort of reports that would be helpful to us. So it’s generally easier to use the private providers that we know because they know what the expectations are.” —Subject H