Mary Louise*came into therapy because she was terrified of flying. This was a serious problem since she regularly had to travel for work and she lived far from her family, who she liked to visit several times a year.
Fear of flying is an interesting and complex issue from the point of view of a psychoanalytically oriented psychotherapist. On the one hand it often indicates the presence of some sort of hidden or unrecognized psychological conflict, which will benefit from psychodynamic exploration; and on the other, it frequently responds much better to cognitive therapeutic techniques than to deep psychological exploration. (A number of my colleagues on the PT Website have discussed different aspects of flying fears. Click here to see a list of some of their posts.)
I am not trained as and do not practice as a cognitive behavioral therapist. Yet because I believe that no single form of therapy is enough to help most clients find a way through their psychological difficulties, I have taken training in a variety of therapeutic approaches. I have found that techniques aimed at relaxing and self-soothing can help some clients with certain phobias and anxieties manage their discomfort well enough to join me in trying to also understand some of the hidden meanings of their fears. When this integrative method does not work, I refer these clients to someone who can work more specifically on the symptoms. They may or may not remain in therapy with me to try to understand the hidden dynamics fueling their fears.
There are three basic concepts that I learned from cognitive therapy and teach clients with flying phobias: 1) determine whether or not you basically believe that flying is safe (despite the horrors of crashes, most of us do believe that flying is safer than driving in a car); 2) recognize that the fear is your body's healthy reaction to signals from your brain to prepare for danger; and 3) find ways to stop the signal when possible and manage the feelings when you can't stop the signal.
Mary Louise did a great deal of research and found that indeed, she did believe that air travel was safer than automobile travel. (here are 2 of many possible websites if you want to check for yourself). She also accepted that her fear was related to the classic "fight or flight" trigger in our brains - that is, we feel that we are in danger, and our brains release signals to the autonomic nervous system to either freeze (to escape notice) or run (to get away). My colleague Joanne Cantor on the PT website has a terrific post explaining the way the fight or flight phenomenon works on our minds and bodies.
So what could Mary Louise do to overrule this very powerful part of her brain? One step was to remind herself that she was not actually in danger; that is, to have her thinking brain talk to her non-thinking, physical brain. Another was to distract herself, to make herself focus on something that really engaged her, so that her thoughts did not start to trigger anxiety. For Mary Louise this meant reading a detective story (one that did not involve a plane crash). For some clients, it means doing Sudoku or crossword puzzles. For others it means playing cards. (It is important to have something that does not require electronic equipment which will have to be shut off at takeoff and landing.) And a third was to get medication for use when she absolutely could not get her neurons to stop signaling danger to her body. (Like many of my phobic clients, Mary Louise seldom used the meds, but felt reassured that she had them if none of the other techniques worked.)
As we worked on each of these steps, we were also simultaneously exploring the psychological issues that contributed to her fears. I should say here that I believe that phobias are frequently not caused purely by psychological issues. Anxiety was clearly a family trait in Mary Louise's family, and although a case could be made for the possibility that her environment caused her to develop a phobia, it seemed likely that she had a genetic predisposition for it. This is not to say that there were not also emotional and psychological triggers and meanings contributing to her fears. As the psychoanalyst John Gedo (1) once suggested, when it comes to a question of biology vs. environment, the answer is that it is 100% of each.
As a psychodynamically-oriented psychotherapist - that is, as someone who wants to understand what behavior and feelings mean - I know that while working on the practical aspects of any symptom, clients and I are also gathering information about what is going on behind the scenes in their psyche.
These meanings are often related to some sort of internal conflict that a client unconsciously believes cannot be resolved. When we are finally able to put words and feelings together, clients frequently find ways to manage the conflict that was not available to their nonverbal mind. But bringing these unverbalized thoughts or, as the British psychoanalyst Christopher Bollas (2) once called them, "the unthought unknown" into the light of day, is not always a simple task. Often the information builds quietly until an idea begins to reach the surface of the mind. Although these "aha!"moments seem to come suddenly, they are actually the result of months, sometimes even years, of slowly putting together bits and pieces until they crystallize into an explanatory thought.
For Mary Louise, it happened one day when she bought herself a cupcake. "There I was, nibbling at this beautifully frosted little treat," she said, "and I started to cry." She had learned from our work to try to pay attention to what she was thinking about just before such an emotional moment, as part of the process of trying to understand what it might mean. She said, "I was thinking about my mother; and how much I had loved baking with her when I was little. And then I realized that I feel so different from her. I'm not the little girl she wanted me to be." Tears filled her eyes.
It might seem that we were opening up Mary Louise's fear that her mother was disappointed in her, but this was actually not at all the case. She and her mother were very close, and she knew that her mother was very proud of her. What Mary Louise was beginning to put into words now was her own "unthought" conflict between a wish to be a sweet, innocent girl (represented at that moment by her cupcake) and a strong, independent woman (represented by her work and her travel). While it may sound simple, this conflict had many subtle and powerful threads that we were now able to follow in our therapy. In part, it was about Mary Louise's fears that she could not be independent and needy; that she could not be a strong woman and in a loving relationship; and that she could not be powerful, feminine, loving and loved all at the same time.
At the same time that we followed these threads and she began to question her own unspoken ideas, Mary Louise continued to work on the practical techniques she had learned to use when she got on an airplane. And her fear of flying gradually completely disappeared.
*names and identifying information have been changed to protect the privacy of individuals and families
1) John Gedo, 1991, The Biology of Clinical Encounters: Psychoanalysis as a Science of Mind.
2) Christopher Bollas, 1989, The Shadow of the Object:Psychoanalysis of the Unthought Unknown.