- Professionals are mistaken if they assume a treatment that reduces anxiety on the ground will reduce anxiety in the air as well.
- Most methods that effectively treat ordinary anxiety are unhelpful with flight anxiety.
- Expertise in treating fear of flying requires specialized training and extensive in-flight experience with clients.
The most formidable barrier a person faces when trying to overcome fear of flying is the belief that nothing will work. How does this belief develop?
Most profession advice offered to anxious fliers is based on Cognitive Behavioral Therapy (CBT). Though CBT can reduce anxiety triggered "top-down" by irrational thoughts, it is no match for powerful feelings triggered "bottom-up" by the sounds and motions of flight.
It is one thing to understand - intellectually - that planes can handle turbulence. It is another thing to deal with turbulence emotionally. Advice on the web - as well as advice provided by most therapists - doesn't hold up in rough air when a plane feels like it is falling out of the sky.
- Breathing exercises produce physiological benefit only when breathing out. Since there is no physiological benefit when breathing in, the relief breathing exercises provide is largely due to distraction when focused on breathing.
- Distraction, however, is an unreliable strategy. When turbulence begins, distraction ends. This is because downward motions, which feel like falling, release stress hormones and cause a feeling of alarm that pushes its way into awareness in spite of efforts to stay distracted.
- Stress hormones cause an urge to escape. Since escape is not possible, claustrophobia develops. If turbulence continues, inability to escape may cause high-anxiety or panic.
- Mindfulness cannot prevent the in-flight release of stress hormones. Thus it cannot prevent in-flight claustrophobia, high-anxiety, or panic.
- Mantras, statistics, positive thoughts, and affirmations only set unprepared passengers up for failure to board and for claustrophobia, high-anxiety, or panic if they board the flight.
- Cognitive techniques become useless if stress hormones overwhelm cognitive ability.
- Reality testing may disappear when stress hormone levels rise. If so, imagination that the plane is crashing may be experienced as though it were happening.
CBT on the ground vs. in the air
When what an anxious flier believes to be reliable professional advice does not help, it is natural for the person to think they can't be helped. Therapists who treat anxiety with CBT should understand that though it works on the ground, and though it works for some clients in the air, it does not work for clients who get overwhelmed when stress hormones are released by the low-frequency sounds, acceleration during takeoff, and downward motions of the plane in turbulence.
If their parasympathetic nervous system is unable to neutralize the effects of the stress hormones, hyper-arousal causes the collapse of the cognitive abilities (executive function, reflective function, reality-testing) necessary to benefit from cognitive interventions.
Common and fallacious reassurance about fear of flying
When reading a recent article on the web, I was shocked by tips the psychologist being interviewed offered. The psychologist said anxious fliers can "talk themself down" by noting how many planes fly safely. That is not true. The number of planes that land safely - though relevant intellectually - is meaningless emotionally. No matter how safe something is said to be, we still can imagine something slipping through the cracks.
When thoughts about something going wrong on the ground produces anxiety, imagination of escape relieves the anxiety. But, when we think of something going wrong in the air, thoughts of escape do not work because escape is impossible. So when a therapist expects a client to be reassured by statistics, the client has two choices (a.) to incorrectly believe they can't be helped, or (b.) to correctly believe the therapist is clueless.
Many people state that "Fear of flying is not rational." That is not a useful label. Most of my clients are professionals, doctors, lawyers, educators, and more than any other profession, psychologists. A better way to approach fear of flying is to understand how rational the defensive responses built into our brain are. These responses are based on millions of years of evolution. Whether rational, irrational, or neither, these defensive responses kept our ancestors safe long enough to reproduce and pass them on to us.
Evolution has programmed our amygdala to releases stress hormones when something happens that we didn't cause. Evolution has programmed us to maintain a means of escape. It would be irrational not to feel trepidation when placing your life in the hands of people you don't know - pilots, air traffic controllers, mechanics, aircraft designers, government regulators, etc. - in an environment where escape is impossible. It is particularly irrational to trust people we don't know when our experience with people we know has been traumatic.
The problem with exposure therapy and VR
Exposure therapy can be in the form of "flooding" or it can be systematic. In flooding, a person hopefully learns nothing bad happens as the result of full exposure. That may be true on the ground, but the more time a fearful fliers spends in the air, the more the fear is reinforced and the more intense the fear becomes.
In systematic desensitization, initial exposure is mild enough to cause no reaction. Each subsequent exposure is increased slightly. This continues until full exposure does not cause a reaction. Systematic desensitization cannot be adapted to airline flying. The reason is obvious. Exposure cannot be titrated. A passenger is either flying or they are not.
Some tout virtual reality as a means of combatting fear of flying. My experience in the original virtual reality fear of flying research leads me to a different conclusion. In that experiment, the control group and the treatment group were run through a standard fear of flying course ground school. Thereafter, the control group received placebo treatment, which involved sitting on a parked airliner and pretending they were in the air. The treatment group was given virtual reality exposure to flying. Both groups improved, which is to be expected due to the fear of flying course ground school. But virtual exposure accomplished nothing.
The control group that sat on the parked airliner fared better in the long run than the treatment group that received virtual exposure to flying. The reason virtual reality is ineffective for flying is obvious. There is no exposure - and thus no desensitization - to risk. Since the client can discontinue exposure at any moment, there is no desensitization to not being in control. Since the client can leave the office where exposure is taking place, there is no desensitization to being unable to escape. Because it addresses none of the key issues, it is irrational to expect virtual treatment to reduce fear of flying.
Well-meaning mental health professionals may inadvertently compound the individual's problem, or at the very least, fail to adequately address it. No professional should offer advice or treatment for fear of flying unless they have flown dozens of times with clients on actual - not virtual or imaginary - airline flights.
1. Foa E, Kozak M. Emotional processing of fear: exposure to corrective information. Psychological Bulletin. 1986;99:20–35.
2. Barlow, D., (20014) Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic, New York: Guilford.