Breathing Exercises: Counterproductive for Flight Anxiety

So that this article is not misunderstood, I’m laying out the points at the beginning.

• Breathing exercises are counterproductive as a technique for dealing with flight phobia.
• Breathing exercises relieve anxiety through psychological escape from the outer world to one's inner world.
• Inner world retreat works only when ones inner world is unperturbed and is expected to remain so; otherwise anticipatory anxiety may develop.
• In turbulence, stress hormones are released which force awareness of the flight into the person's inner world.
• If the person has depended on psychological escape, emotional regulation may become impossible.
• Arousal, together with noises and movements of the plane cause the person to believe that what he or she feared would happen is actually happening.
• High anxiety, claustrophobia, panic, and terror may result.
• Breathing exercises are, however, valuable in meditative disciplines that lead to self-discovery.

Almost every article on flight anxiety recommends the use of breathing exercises. Most therapists who treat flight anxiety teach breathing exercises as the primary way to maintain emotional control. Pilot Ron Nielsen runs a fear of flying course based on breathing exercises which he claims are highly effective (specifically 90%) in controlling fear when flying.

What does science say? When we breathe in, the vagus nerve causes the heart to beat faster in order to transport the new supply of oxygen in the lungs. Seconds later, having transported most of the oxygen, we breathe out. As we do, the vagus slows the heart.

Though that is all science tells us, we tell ourselves something different: that deep breathing calms. Well, yes. Deep anything calms. If we focus it, anything repetitious calms. Immersing ones self in needlepoint calms. Listening to music calms.

Why? Stress hormones are released by the amygdala whenever it senses anything unexpected or non-routine. If a person is able to control their environment so as to exclude the unexpected and the non-routine, relaxation will result provided, of course, that imagination does not throw a monkey wrench into the relaxing works. After all, the amygdala can respond – not only to what meets the eye – but also to what we place in the “mind’s eye.” That is where repetitive activities come in. Once the environment has settled down, for the mind to settle down, the contents of the mind must be controlled. If a repetitive activity can occupy the mind enough to exclude troublesome thoughts, the amygdala will produce no stress hormones. It will allow relaxation to take place. The repetitive activity does not have to be breathing. It only needs to be non-threatening, and something the person can stay focused on.

The problem is, when flying, the environment may not settle down. When turbulence begins, relaxation ends. In turbulence, the plane drops again and again. Each drop causes a release of stress hormones which grab hold of the person's attention and sabotage efforts at relaxation.

Just as one drop after another causes stress hormones to build up during turbulence, during takeoff, one thing after another - noises, motions, acceleration, etc. - causes stress hormones to build up. British Airways captain Steve Allright leads course participants in unison breathing during takeoff. He says unison breathing gets them through takeoff. Whether it involves breathing or not, activities done as a group reduce anxiety. But, once the group flight is over, the anxious flier is on his own with no group to help him.

A different approach was used by Captain Truman Cummings, a pioneer in fear of flying treatment who established a course at Pan Am in 1975. Rather than breathing during takeoff, he instructed his students to wiggle their toes during takeoff, slowly at first as the plane started down the runway, and faster as the plane picked up speed. This provided participants with an activity that - instead of avoiding experience of the flight – connected them to the reality of flight.

This brings up a point made by researcher Edna Foa, Ph.D. Foa objects to the use of breathing exercises. She sees escape from reality as anti-therapeutic. Therapy is generally thought of as – not what helps a client avoid reality – but what supports a client to experience reality and adapt to it. By focusing on breathing exercises, a person avoids the very experience they need to learn to deal with.

• "In this study, “taking relaxing breaths” was not significantly associated with . . . positive treatment outcomes."

The only issue in question is whether breathing exercises are counterproductive, as Dr. Foa and Dr. David Barlow believe:

• Schmidt et al: "patients receiving BR exhibited trends toward poorer end state functioning on both self and clinician rated measures . . . "We have suggested that therapists refrain from the use of respiratory-control techniques as a means for coping with or managing anxiety."
• Barlow: ". . . any behavior that . . . enables avoidance of or distraction from the panic sensation is maladaptive . . . because it is an attempt to keep the patient 'safe' from a false threat (i.e., panic symptoms, high anxiety) . . . . use of breathing retraining . . . is discouraged and is maladaptive."

Anticipatory anxiety about an upcoming flight is a different matter. In anticipatory anxiety, the person thinks "what if" this and "what if" that? These "what ifs" cause stress hormone to build up which control the person's attention, and force him to remain focused on imaginary threats.

The 5-4-3-2-1 exercise can break this hold. In the exercise, intense focus on non-threatening objects in the environment ends stress hormone release. During this two minute exercise, previously accumulated stress hormones dissipate, and offer a window of opportunity in which, free of stress hormones, the person can more easily focus on other matters.

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Though breathing exercises have no place in the treatment of flight phobia, they can be of value when used to promote personal growth. Zen training, for example, uses breathing exercises that are complex. The aim is to follow a specified breathing pattern in such a way that the person may happen upon an experience in which, according to Katsuki Sekida “body and mind are fallen off, no thought stirs, the mind is empty.” In this state, the person is aware only of awareness.

In my own experience of this, when my self-concept began to fall away, I was terrified; I thought the disappearance of my self-concept meant I was dying (I suspect losing ones sense of self is what causes terror in panic). But after self-concept disappeared, and awareness remained, I realized that what I thought of as “me” was dispensable. If it could go away, it was not the essential identity I had thought it was. Perhaps my basic identity was what remained: simply awareness. If so, then all of us have the same basic identity. And, if that basic identity, awareness, stops in me, it continues in others; a realization that brought fear of death to its knees.

The bottom line: those who recommend breathing exercises as a means of controlling flight anxiety are grasping at straws. They have nothing effective to offer. But, the news is not all bad. Effective methods do exist which not only control fear of flying but do so automatically. For more information, read "Establishing Automatic Control at http://www.psychologytoday.com/blog/conquer-fear-flying/201210/establishing-automatic-control

Recent breathing exercise research:

• Rapee, R. (1985). A case of panic disorder treated with breathing retraining. Journal of Behavior Therapy and Experimental Psychiatry, 16(1), 63-65.
• Foa E, Kozak M. Emotional processing of fear: exposure to corrective information. Psychological Bulletin. 1986;99:20–35.
• de Ruiter, Corine, et al. (1989). Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia. Behaviour Research and Therapy, 27(6), 647-655.
• Salkovskis, P., Clark, D., Hackmann, A. (1991). Treatment of panic attacks using cognitive therapy without exposure or breathing retraining. Behaviour Research and Therapy, 29(2), 161-166
• Garssen, B., de Ruiter, C. and Van Dyck, R. (1992). Breathing retraining: A rational placebo?. Clinical Psychology Review, 12(2). 141-153
• Craske, M., Rowe, M., Lewin, M., Noriega-Dimitri, R. (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36(1), 85-89
• Schmidt, N., Woolaway-Bickel, K., Trakowski, J. et al. (2000). Dismantling cognitive-behavioural treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424
• Meuret, A., Wilhelm F., Ritz T, et al. (2003) Breathing training for treating panic disorder: useful intervention or impediment? Behavior Modification, 27: 731-754.
• Barlow, D., (20014) Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic, New York: Guilford.
• Kim, S., Palin, F., Anderson, P., Edwards, S., Lindner, G. (2008). Use of skills learned in CBT for fear of flying: Managing flying anxiety after September 11th. Journal of Anxiety Disorders, 22(2): 301-309