Emeritus Professor David Barlow has long advocated for a transdiagnostic model for the treatment of emotional disorders (Barlow et al., 2018; Laureate Institute for Brain Research, 2019). The transdiagnostic approach, of which cognitive behaviour therapy (CBT) is a part, is particularly useful given the heterogeneity of the presentations for fear of flying. It can be said that working with clients with a fear of flying is analogous to working with other anxiety disorders, given that it covers a range of fear aetiology and responses. While the casual observer might believe that the fear of flying is really about the fear of crashing, the majority of clients attending therapy for fear of flying will acknowledge flying is extremely safe compared to many other daily activities, such as driving, taking public transport, and certain workplace and home activities. It is not often that I need to spend time outlining the probability estimates of meeting one’s doom on a flight as opposed to meeting a premature end in one’s kitchen or car. Commercial flying has become safer and safer over the years. and indeed I will occasionally talk with clients explaining why this is the case. That said, those cases where fear of death in a commercial aircraft is a primary factor in a client’s presentation serve as a reminder that a number of anxiety conditions can render clients fearful of dying, such as anxiety before a surgical procedure or fears of contamination.
A common fear?
In 1980 the Boeing Corporation initiated research on the prevalence and costs of fear of flying in the USA (Bor & van Gerwen, 2003; Dean & Whitaker, 1982; Posen, 2011) and found that one in six Americans were fearful of flying. The report brought a previously ‘undiscussable’ topic into sharp focus, so much so that the airlines were able to acknowledge their bottom line might be affected if people did not fly at all, or more realistically, if people curtailed their flying habits based on fear.
In Australia, both Qantas and Virgin sponsor fear of flying programs, with some measure of psychological input. In 2019, Virgin introduced a program, The Nervous Flyer, in a rare acknowledgment of the prevalence of fear of flying. There is some research suggesting an airline which assists a fearful flyer to fly will receive brand loyalty in return.
Assessment
Like many client presentations, assessment begins with the initial contact, most likely by telephone or email. Referrals often come from GPs, psychiatrists and psychologists (the latter understanding that a knowledge of aviation and a willingness to fly with clients might not be in their toolkit), airlines and airports, aviation crew, and word-of-mouth. I recommend clients read my website (flightwise.com.au), where they identify their current presentation based upon four typical fear scenarios: encountering turbulence, claustrophobia, panic disorder (including agoraphobia and health anxiety) and ‘loss of control’ issues.
I always ask if there is a flight coming up soon, as this guides how soon and frequently clients ought to be seen, and if some commercial flights with me can be squeezed in before their own flights. Rarely nowadays do I see clients who have never flown. This is more relevant to treating children, and their treatment is different and features a higher educational input. The assessment of their sources of fear will take a different course from those who are frequent flyers, or those who may have a previously good relationship with flying.
Clients often explain that, over time, their anxiety has intensified, their dread or anticipation of discomfort commences as soon as a flight is scheduled, or requires fewer onboard events to trigger a negative reaction. These fear responses can result in demonstrable relief once the aircraft starts its descent. For some, taking prescription medication to cope is akin to an admission of weakness. They instead construct a set of ‘safety behaviours’ intended to reduce their physiological discomfort, such as using alcohol and forms of muscle relaxation or breathing practices. Unwittingly, their experience of autonomic relief on landing can often be a reinforcing factor for their belief that flying is dangerous.
In the first face-to-face session, safety behaviours or rituals are explored, but usually gently and in a manner that suggests seeking safety is a reasonable and evolutionary developed mechanism. Safety is predicated on the belief it is unsafe for them to fly, perhaps not by assuming the aircraft is vulnerable, but it is they who are vulnerable to fearful experiences such as panic, loss of control, or embarrassing oneself in front of others.
In this first assessment session, clients often spontaneously offer how and when they believe their fears began; after a very difficult flight, on the way to or from a challenging life event, or as a result of an inflight incident. But often clients also report being confused and even upset that they cannot recall the origins of their fears. They may say “I have always been an anxious person”, or that fear is really out of character for them. For the latter client, this egodystonia can lead to significant loss of self-acceptance, self-compassion or self-empathy as some have described it (Stevens & Woodruf, 2018). For these clients, it is less important to explore the origin of the problem, but rather the problem’s maintaining factors and how they affect other domains, such as public speaking, work and family life, or driving.
These maintaining factors are usually the client’s own set of current anticipatory protocols; how are they expecting to sense, think, feel and behave? Assessment should include how the client has attempted to manage these unpleasant events. What seems to have worked, and have these self-directed efforts (perhaps learned using ‘Dr Google’, friends or their own serendipitous discoveries) worked for more than one flight? Do these efforts require equipment such as noise-cancelling headphones (to reduce engine sounds at take-off), colouring books, an iPad full of entertainment, the wearing of their father’s St. Christopher’s medal, or the superstitious wearing of green underwear? (These are all real examples, the latter coming from the brochure for a fear of flying program run by Air New Zealand).
The idea of identifying these safety behaviours is not to have clients stop, but to ask them to become their own scientists and question their validity and usefulness over time. Changing a client’s self-talk and the resultant improved behaviour starts here: “No matter what gets thrown at me on my flights – all factors of safety outside my control considered – I can manage myself. I might not like what I experience, it may be distressing and unpleasant, but it is not dangerous.” This is often easier learned and said than done in the ‘cold’ setting of the psychologist’s rooms, and requires considerable practice in situ (the ‘hot’ setting) so it becomes their new way to fly.
Each psychologist will do their own form of initial assessment, including current exacerbating factors such as sleep, exercise, nutrition, social relationships, and work/life balance. Because fear of flying can also lead to diminished life enjoyment, mood disorders should also be assessed especially for those with a history of depression.
Target behaviours
As the session moves from assessment to treatment, it is important to ask clients about what ‘better flying’ will look like for them. What desired behaviours, thoughts, feelings and sensations will they likely experience at various stages of what I call ‘the flight envelope’? These are the various stages of a commercial flight; from the booking, to the days before departure, arrival at the airport, moving through security, boarding, and the stages of the inflight experience. In problem-formulation terms, which behaviours, thoughts, feelings and emotions can the client and psychologist agree will change if treatment is successful? And will success also mean an increased tolerance for unpleasant but normal sensations?
Some clients will suggest a return to the way they used to fly; others will say, “if only I can be calm”. I often inform clients that very few people without fear of flying are calm when they fly. They may be excited or a little anxious, but often not calm. To reinforce this message, I ask clients if they look at cabin crew for reassurance – which is another type of safety behaviour. What they observe, especially when they enter the aircraft and meet the cabin manager, is a professional demeanour. However, under that professional demeanour, like an elegant swan gliding on the lake, they are actually paddling fast beneath the surface. In this sense, the crew observe each passenger intensely: Is this passenger well enough to fly? Is that one intoxicated? Is this group of passengers going to be troublesome and therefore a threat to safety?
On the flight deck, the crew also display what appears to be calmness, but indeed they are experiencing high levels of focused arousal, checking and rechecking figures for which there may be last-minute changes affecting the performance of the aircraft. To expect fear of flying clients to be calmer than regular flyers and crew can possibly set them up for failure. What we are seeking for our clients is better self-management and emotional regulation, no matter what occurs in regular commercial flying. Should they experience a sense of calm at some point in the flight it is a bonus.
Historical challenges
In the past, psychologists turned their attention to learning theory (e.g., Skinner, Hebb, Mowrer) to treat phobias and fears, as opposed to a psychodynamic approach. At the forefront was Joseph Wolpe who gave us the term reciprocal inhibition (Wolpe, 1968). The idea was to learn behaviours incompatible with fear, such as relaxation techniques, using muscle tensing and breathing protocols, and ask people to approach their frightening situations with the idea that one cannot be scared and physically relaxed at the same time.
This gave rise to the treatment known as systematic desensitisation. Many psychologists in training developed intricate hierarchies, teaching clients how to assess their fear using SUDS (Subjective Units of Distress). When these treatments were at the peak of their influence, objective means of measuring arousal were extremely expensive and out of the reach of the average practitioner. But as time moved on, and these treatment strategies have been thoroughly assessed and evaluated, the desensitisation model has been found to promise far more than it can deliver. Many clients found a return of distressing symptoms in the months following the end of their treatment.
The dissatisfaction with long-term outcomes of systematic desensitisation led researchers such as David Barlow and his co-worker, Australian psychologist Michelle Craske, to develop a series of manuals for both clients and therapist to work through using a transdiagnostic approach (Barlow et al., 2018). Early CBT therapists like Albert Ellis and Tim Beck developed interventions based on their conception of causal relationships between thoughts, feelings and behaviours.
Each independently developed a list of core beliefs or cognitive distortions which they asserted led to emotional distress. Psychologists-in-training are taught to listen carefully to their clients’ self-talk and note times they engage in exaggeration, mind-reading, fortune-telling, focusing on the negative, et cetera. While it is useful for psychologists to understand the nature of cognitive distortion, it may be asking too much for clients to spend time learning how to differentiate 10 different styles of cognitive distortion.
I prefer the approach of Barlow et al. (2018) and Lisa Feldman Barrett (2017) who see our brains functioning as both prediction devices and pattern-detection devices. Rather than learning 10 styles of cognitive distortions or irrational beliefs, clients are asked to consider how their experience of anxiety is based on two errors of prediction.
The first is an over-prediction, “if I enter or contemplate a certain scenario, I will be in danger”. The second is an under-prediction, namely, underestimating their ability to cope with the discomfort of being in certain situations or even contemplating them. Throughout the rest of treatment, the lens of over- and under-prediction is used to contemplate how safety behaviours come about, and how best to train to approach and then enter the feared situation.
Models for exposure
Asking clients to enter a feared situation, either in real life or in their imagination, is a form of exposure which may lead to improved adaptation or habituation. This has been a dominant model based on learning and extinction theory. The trouble for many fearful flyers is that they either leave their scary situations before this natural reduction occurs, or they engage in safety behaviours to shut down the triggers they experience (such as wearing noise-cancelling headphones or choosing to be away from the window-seat view). Although these distractions appear useful at the time, many clients find the effectiveness diminishes over time.
Habituation is seen by researchers such as Michelle Craske as insufficient for the task, leaving the client’s sense of overcoming their fear in a fragile state. Instead, what is preferable is not just habituation, but knowing the right thing to do in the feared situation. Craske refers to this as either new learning or inhibitory learning. This means if one is to be rid of a well-rehearsed habit of being aroused unnecessarily or too intrusively, it is best to replace it with another set of behaviours more consistent with accurate predictions of what will occur.
Indeed, Craske’s research shows that the violation of expectations while in the midst of feared situations is when the most long-term learning occurs and is consolidated (BABCPtv, 2018; Craske, 2015; Society for a Science of Clinical Psychology, 2014). In other words, if we are going to recalibrate the threat response mechanism, for which the amygdala is central, we must outline expectations including over- and under-predictions, and test them realistically.
Rather than working through a systematic hierarchy, the Craske model randomises the hierarchy in the belief that this bears more verisimilitude to what occurs outside the psychologist’s office. Once more the idea when it comes to flying is, “whatever gets thrown at me I can manage, whether it be turbulence, a change of plane from a wide body to a narrow body, delays on the tarmac prior to take-off or on arrival, circling, a missed approach, or even (the dreaded) lost luggage”.
Traditional CBT proposes that clients engage in acknowledging and challenging their thoughts prior to entering the feared situation, something Barlow has called cognitive reappraisal. Conversely, Craske (2015) asks clients to stay with their fearful signs and symptoms, and notice not just that their fears are not realised, but they can actually tolerate the discomfort of their sensations, whether due to aircraft noises and movements, or their own involuntary sympathetic arousal. The latter is often induced, for example, by reflexive gripping of seats, tightening of seatbelts, or holding one’s breath and restricted breathing.
Indeed, Craske advocates the doubling up or intensifying of the sensations in the therapy room, such as wearing a winter jacket on a hot summer’s day in an elevator, designed to demonstrate to clients that their expectation that uncomfortable moments are intolerable and will last forever is misleading. Essentially, cognitive restructuring occurs after exposure, not before, in order to construct new ways of thinking and behaving for which evidence is at first-hand. Immediate fear reduction is not the aim.
This is only a part of the work for which Craske’s (2015) research leads to applied practice. The other consideration is affect labelling where broadening the client’s lexicon of symptom description to something more granular can be a highly effective treatment technique. As an example, the client who experiences overwhelming claustrophobia as they contemplate boarding, might possess the following self-talk: “I feel really bad when I walk down the tunnel and onto the plane. I feel trapped.” This instigates an automatic threat response. Affect labelling would reframe this as “I can feel my heart pounding and my chest tightening going down the aerobridge and onto the plane. It’s better to think of myself as cocooned, not trapped, even though my arousal would probably be at about six. I think I can identify quite a few triggers for my loss of composure in these kind of situations.” If this sounds like Meichenbaum’s Stress Inoculation model of the ‘70s and ‘80s, you are not wrong. Many anxious clients, at the first sign of arousal, feel themselves going straight from 0 to 10, and the task here is to allow them to be more granular and knowledgeable about these feelings and sensations.
A virtual future?
In 2001 I began exploring virtual reality which allows therapist and client to accurately set and perform repeated exposure experiences and correct behaviours. This is compatible with learning breathing/focusing protocols measured by heart-rate variability and accompanying self-talk. Sometimes, I ask the client to intensify their own sensations. To shorten their breath by breathing through a straw, tighten the seatbelt so it is really uncomfortable, and even allow a more intensive application of their worrying thoughts. Then I show them what I believe to be alternative ways to experience the same computer-generated scenario. This is a path to new or inhibitory learning.
Virtual reality is finding its way into a multitude of settings. From anxiety management, acute and chronic pain management and training for challenging medical procedures, to improving empathic awareness and becoming more aware of how others perceive the world. It is not a treatment in itself, but an extension of what psychologists are already doing but may find difficult to do other than in virtual worlds; such as multiple take-offs in a one-hour session, practising entering an MRI machine, taking an elevator to a basement or entering a room as the walls move closer together. These new ways of experiencing anxiety offer exciting potential methods for the treatment of fear of flying into the future.
The author can be contacted at [email protected]