“I stood holding the phone! I was shaking! What had I done?”
This was the reaction of a lady in her fifties who had just booked a place on a course to overcome her fear of flying. She had steadfastly refused to apply for a passport until this time, as in her words “That meant I was definitely unable to go abroad.” Her difficulties were far more widespread than just being unable to travel by air. “I was unable to drive a car up higher than the third floor of a multi-storey car park. I was unable to go down the escalators in those modern shopping centres. I did not like lifts, and so it continued”.
Though this particular lady had never flown before, she noted that to her surprise, on taking the “terrifying step” of undertaking therapy for her problem, there were other people on the course, and “some of the others had flown many times, and it was amazing to see how at the start of the course they were just as scared as me”. When people pluck up the courage to find out about the help that is available, many do not know either the range of options, or their own preferences. They can also be concerned that seeking psychological therapy in some ways marks them out as being “weak”, or “stupid”, or even “crazy”.
Fear of flying is classified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) American Psychiatric Association (1994), as a specific phobia, characterised by a marked, persistent, excessive fear that is precipitated by the experience or immediate prospect of air travel. Exposure to this phobic stimulus almost invariably provokes an anxiety response – sometimes to the point of a panic attack – which the individual recognises as unreasonable, and which produces significant interference or distress. Treatment for fear of flying has been offered based on various models of psychological therapy, as well as pharmacotherapy, the latter requiring a medical prescription, usually from General Practitioners and Psychiatrists.
Even a cursory glance at the range of vastly different psychological therapy approaches available shows such a breadth that it can make even the experienced clinician wonder whether all of these can indeed be subsumed under the same heading. Of these different forms of psychological therapy, a number have been utilized specifically to enable people to overcome their fear of flying. The nature of the interventions has usually been dictated by the model hypothesised to describe the underlying cause of the fear of flying (Iljon Foreman, 2002). Thus for those who believe in an unconscious cause, psychodynamic therapy would be the treatment of choice. Carr (1978) reported that before 1965, the standard treatment was indeed psychodynamic psychotherapy and the success rate of treatments was on average 18%. After the development of behavioural treatment, however, Carr (1978) reported an increase in the success rate to 77%. In a review of psychological treatment of a fear of flying Bor, Parker and Papadopoulos (2000) confirm that longterm explorative psychoanalytic therapy has not been shown to be effective in the treatment of a fear of flying. More recent results from treatments based on cognitive behavioural principles have however shown success in 70%-98% of cases (Van Gerwen and Diekstra 2000).
Other treatment interventions such as systemic therapy, hypnosis, virtual reality, reattributional training, systematic desensitisation, stress inoculation training, coping self-talk, cognitive preparation, flooding, implosion, in vivo exposure and relaxation training and cognitive behaviour therapy have all been described in the literature (Denholtz and Mann 1975, Roberts 1989, Rothbaum, Hodges and Kooper 1997, Capafons, Sosa and Vina 1999, Beckham et al 1990, Haug et al 1987). Howard (1983) compared systematic desensitisation, flooding, implosive therapy and relaxation training, and found that all were equally effective compared to no treatment control. The most common and successful treatments reported have included various forms of in vivo exposure and cognitive restructuring, (Beckham et al 1990, Roberts, 1989). It is interesting to note that in one of the more recent therapeutic developments, Anderson, Rothbaum and Hodges (2001) carried out a randomized control study, comparing Virtual Reality (VR), a technique which allows individuals to become active participants, interacting through sight, sound and touch, in a computer generated 3-dimensional world, to standard exposure and to a control group. They found that VR and standard exposure were better than controls, with no difference between the two treatment groups at 2 and 6 month follow up.
Even when reviews indicate that of all the differing forms of psychological therapy, cognitive behaviour therapy has proved the most successful (Andrews 1993), a summary by Van Gerwen and Diekstra (2000) highlighted a considerable range in the duration and content of courses specifically designed to enable people to overcome fear of flying. Thus though most of the courses employed many of the principles of cognitive behaviour therapy, each did so in either a slightly, or sometimes quite substantially, different way to the others.
Cognitive behavior therapy proposes the supposition that people’s behaviour and emotions depend to a large extent on what they understand to be happening. What a person thinks and feels can greatly affect their reaction to events and people. Cognitive behaviour therapy involves understanding what one is thinking, acknowledging how this affects one’s feelings and behaviour, and then training oneself to respond in a different way. The new behaviour can lead to a potentially more satisfying way of life and become part of the person’s normal pattern of existence. Cognitive behaviour therapy therefore examines and modifies the relationship between what people think, feel, say and do (Iljon Foreman and Iljon, 1994).
The results of 15 different international courses on overcoming fear of flying all showed high levels of success. However, knowing that something works does not always mean knowing how or why. Thus clinicians and researchers increasingly need to focus their efforts on maximizing effects and minimizing costs, and on specifying variables that facilitate or impede treatment outcome (Foa and Kozak 1986).
At the First International Fear of Flying Conference in Tarrytown, New York (Feb. 1996), research was presented which indicated that people’s fears fell into two categories – those whose fear was of a loss of external control – in other words something happening to the plane, and those who were afraid of a loss of internal control (Iljon Foreman and Borrill 1993). The very worst case for both these scenarios is death. In both groups, the central core of the problem can be summed up by the early adverts for the British National Lottery, “It COULD be YOU!”
Therapy for fear of flying aims to enable the individual to change their perception of risk, such that they then decide that on balance it is more worthwhile to undertake the flight, than to continue with the pattern of overt avoidance (not flying), or covert avoidance (using “props” such as alcohol). The significance of such a change in perception was neatly summarized many years ago by Shakespeare as: “Nothing is either good or bad, but thinking makes it so.” This change in the perception of risk is one of the central aims of cognitive behaviour therapy, (Clark 1999, Salkovskis and Clark 1992, Beck and Emery 1985, Greenberger and Padesky 1995, Wells 1997).
How does this change in perception actually happen? Are there differences between successful clients in what they learn from a course, perhaps as a result of their differing prior experiences? In addition, how can we explain why a small proportion of people fail to overcome their fears?
This chapter began by alluding to the range of people who can be affected by a fear of flying, from those who had never flown before, to frequent flyers, including civilian and even military aircrew (Dyregrov et al 1992, Goorney 1970). The consequences of the fear can be far-reaching. It can limit the person’s professional opportunities, affect leisure options, and even mean that one person may decide to take holidays without their partner on a regular basis, if the partner will not fly. There are implications for long term relationships, and likewise difficulties in family holidays if children refuse to travel. The problem can have a substantial impact on professional life, social life and family life, (Van Gerwen 1988), and can affect marital or relationship satisfaction because fear of flying hampers or restricts either partner’s freedom of movement. When considering the range of the population who suffer from fear of flying, Ekeberg, Seeberg and Ellertsen (1989) propose that individuals affected can be divided into 3 groups – those who avoid all flights, those who restrict flying to an absolute minimum, and experience considerable discomfort prior to and/or during each flight, and those who display continuous mild or moderate apprehension about flying, but do not avoid it, even though it remains an unpleasant experience.
Clinically, it can be challenging to elucidate the detail of people’s fears. Frequently clients will say that they do not know what would happen if they stayed in the feared situation, but they are sure they could not tolerate it, and that it is too much of a risk to try and find out any more. This terror of the unknown is reminiscent of the words of Coleridge, from “The Ancient Mariner” :
“Like one that on a lonesome road,
Doth walk in fear and dread,
And having once turned round, walks on,
And turns no more his head
Because he knows a frightful fiend,
Doth close behind him tread”
(Coleridge 1798)
In order to begin to understand the nature of the cognitive change wrought by therapy, the chapter now describes a model which, it is proposed, underlies the process of cognitive change. The model is presented, and then interrogated regarding whether it can account for the change observed in two clients, both of whom had flown many times prior to treatment. One client had tried several different therapy courses and therapists over a period of years, while for the second, this was a first attempt.
The course that these clients undertook was the “Freedom to Fly” course based in London, U.K. Given the differences between courses outlined by Van Gerwen and Diekstra (2000), the structure of the Freedom to Fly course is worth noting. It consists of three stages: – a telephone assessment, one session in the consulting room, and then a week later, a return flight to Europe on a scheduled plane.
The telephone assessment enables assessment of suitability- there may be some people for whom it seems that the treatment is unlikely to be of benefit. It is clearly best that they do not join the course in the first place – for their sake – for that of the therapist, and for the others in the group! Once accepted onto the course, people are seen either individually, or as a maximum of four per group. The first session involves taking a detailed history. An explanation for the development of the fear for each individual is explored, and the nature of anxiety explained. The maintaining factors are considered, and clients are encouraged to test out their fears regarding the consequences of their anxiety. The second session involves meeting at the airport and taking a scheduled return flight to Continental Europe. Technical information provided is minimal. The rationale is that one does not necessarily need to understand how something works in order to be comfortable in using it. Many people who have a fear of flying will nevertheless happily use other forms of travel that have equal disaster potential, which they have neither any idea of how it works, nor any control over it, and yet not feel at risk. This view is supported in the conclusion of Wilhelm and Roth (1997), who suggest that informational aspects of a technical nature may be unnecessary.
Trying to understand how therapy can change this perception of risk led Borrill and Iljon Foreman to carry out in-depth interviews of patients, to ascertain what had changed, and to try and understand the process. This paper, “Understanding Cognitive Change: a Qualitative Study of the Impact of Cognitive-Behavioural Therapy on Fear of Flying”, (1996) proposed a model to describe the process of achieving control and overcoming fear.
The model was developed following in-depth interviews with ten people who had successfully completed the “Freedom to Fly” course. The interviews were taped and transcribed, and then analysed using the method of grounded theory (Glaser and Strauss 1967). Common themes regarding the process of change were extracted from the interviews and led to the development of the model. Though it appears quite complex, essentially it can be broken down into four stages, each with their component parts:
(i) Relinquish Control,(ii)Accept Control, (iii) Experience Control and (iv) Achieve Self Control.
(i) The Relinquish Control Phase:
For this to successfully take place, the person needs to establish a relationship with the therapist, and to have their experience legitimized. They then move towards trusting that the therapist is in control. This has been described by some as “borrowing the belief of the therapist that they can do it” – one client said “it’s like borrowing someone’s belief in you to actually believe in yourself, and also learning to leave the flying itself to the pilot!” The trust and establishment of the “therapeutic relationship” appears central to the success of the therapy.
Most people appeared to have a good rapport with the therapist, and felt understood, and also said that they felt that they could trust the therapist. Given that the person undertaking therapy is concerned that they may be risking their actual life, plus risking an emotional and social catastrophe should the therapy not succeed, the vital importance of trust and a good rapport is clearly apparent. Acknowledgement of the potential danger which forms the basis of some people’s fear can facilitate the development of a good rapport. As one client said of the therapist, “she didn’t say “It isn’t dangerous”, and it so obviously is dangerous, potentially, that if some one says black is white you can’t believe it.” It is interesting to note that one lady who did not make any progress with the therapy appears to have felt that she was not well understood by the therapist. She felt that the questionnaires she was asked to fill out, rather than being for her own benefit to enable her to understand her difficulties in greater depth, were primarily for the benefit of the therapist and for “research”. Although she described the therapist as “a nice person and very dedicated”, there is no evidence from her account of any sense of trust or confidence, and hence no possibility of her “borrowing belief”.
Whisman (1993) noted that, in comparison with other theoretical models, cognitive therapy has tended to place less emphasis on the therapeutic relationship and more on techniques. Nevertheless, this model suggests that the therapeutic alliance is vital if therapy is to be maximally effective. This view is supported by a recent review of the literature (Waddington 2002). Roth and Fonagy (1996) concluded from the analysis of 100 research reports on the therapeutic alliance that there was a “robust relationship between alliance and outcome”. Further support is found in the work of Castonguay et al (1996) and Muran et al (1995). It is interesting to note that the work of Krupnick et al (1996) raises the possibility that the therapy relationship has an impact not only on the outcome of psychological therapies, including cognitive behaviour therapy, but also the outcome of pharmacotherapy. Current thinking by such practitioners as Beck and Freeman (1990), Burns and Auerbach (1996) and Wright and Davis (1994) all support the view of the importance of the therapeutic alliance.
(ii) Accepting Control. This stage includes following the instructions regarding identifying and challenging the person’s ‘irrational’ thinking, accessing information about the normal physiological responses to anxiety, and engaging in behaviour which directly challenges their fears. This guided mastery includes undoing the seatbelt, eating the meal, walking about the cabin and going to the toilet. When clients were asked what they remembered from the first session of treatment, they frequently recalled being given explanations of how the body responded to threat and the physiological mechanisms underlying the fear response. “She was able to tell me what fear was… and how things are triggered off, and the feelings and sensations that you get. And then you can relate… when you are going through this you know what’s happening”. The client who did not benefit from therapy had no recollection of the any discussion of the physiology of anxiety, a critical part of the therapy. She also rejected the suggestions which would have lead to guided mastery, “She said I had to walk about, because I never do. But I didn’t…. she can’t force me”. The stage of guided mastery was seen as particularly important by clients who had a range of in-flight avoidance patterns.
(iii) Experience Control. Clients adopt a rational approach to questioning the irrational thoughts, thus discovering a certain control over the thoughts. They learn that they are able to tolerate anxiety and find that they can in this way control their feelings, plus discovering through guided mastery that they can be in charge of their own behaviour.
The fear that one will lose control over one’s behaviour is graphically illustrated by a gentleman who experienced such intense claustrophobia that he would not sit by the emergency exit in case he became overwhelmed by his feelings, and found that against his will, he would somehow be forced to try and open the emergency exit door while in flight. A critical part of this stage is learning that the experience of high anxiety, whilst extremely uncomfortable, is not dangerous and can be tolerated. It is reported that through tolerating anxiety symptoms, people feel that they can exert control over them, and they can use this in other situations of emotional arousal. As one lady put it “through conquering my fear of flying, I conquered everything else that I feared… it’s just the fact that you have to look at everything logically and I’m doing that in my whole life now”.
Once the person has had their catastrophic negative predictions disconfirmed, this leads to the final part of experiencing control, when they begin to employ cognitive re-labeling of the arousal symptoms and of the movements of the plane, and develop Mastery and a belief in self efficacy. The symptoms can be re-labeled as ‘discomfort’, or even ‘excitement’, but are no longer seen as dangerous, and to be feared and avoided. The benefit of re-labeling seems to be particularly apparent for those clients who suffered from agoraphobia, “Since I’ve got over the fear of flying, I can do anything that I couldn’t do; it really is amazing, the change”. Understanding the symptoms, tolerating and re-labeling them therefore provides a sense of control over the feelings, so that they no longer get in the way of logical argument and judgment. Thus when clients describe themselves as being rational, they are saying that they feel in control of their decision-making, rather than being overwhelmed by (irrational) feelings. An important component of this stage is “facing up to the fear”, and actively engaging in the experience, rather than using distraction and disengagement strategies. It is interesting to note that a study by Wilhelm and Roth (1997) compared cognitive behaviour therapy with and without medication, and found that the latter was superior. This study suggests that the medication prevented clients from fully experiencing the anxiety, and so they did not learn that they could tolerate and hence conquer their fear.
(iv) Achieving Self-Control, the final stage, is that of “Joining the Club”. The person now sees themselves as one of those who “can do”. They now can generalize their techniques to other situations, employ the newly learned techniques of self-instruction, and even begin to instruct others! “Joining the Club” of “normal” flyers does not mean experiencing no fear; rather it means experiencing no more fear than anyone else in the circumstances: “I’m probably normal. I find it no worse than anyone else now, whereas before it was something I wouldn’t even contemplate”. “I felt like I was a proper passenger because I behaved like one”. This is also the basis for generalisation to other fears, since clients perceive themselves belonging to the group of people who “can do” whatever they want to do.
In summary, the detailed interviews indicated that the ‘trick’ of the therapist lies in convincing clients that it is the therapist who is in control, and that the client is therefore safe, thus giving “permission” for clients to challenge cognitions, engage in experiences, access knowledge, tolerate feelings and achieve mastery. Assuming the person makes the desired choice, and does indeed test out their catastrophic fears, this results in the disconfirmation of uncontrollable outcomes, cognitive re-labeling of uncontrollable symptoms and feelings, and substitution of controlled behaviour for uncontrollable avoidance. Clients no longer feel at the mercy of unknown fears, but in control of known, ordinary and understandable feelings. Client success is consequently attributed to self-control, not to a crutch, and can therefore be generalized to other feared situations. Successful clients were not only able to fly without fear, but also reported such changes as being able to drive, go through tunnels, face crowds, learn to swim and even take up sub aqua diving, assert themselves in business situations, make decisions, and change many habits of a lifetime.
The model described, developed in 1996 and derived entirely from qualitative analysis of detailed individual interviews from a number of patients often elicits the response from clinicians of: “that’s so obvious!” This parallels the experience many a clinician has had with clients, where once something which has taken painstaking refinement is explained to them in a simple and digestible form, say: “that’s so obvious!” In order to establish whether the model really does encompass the core factors within the process of cognitive change, it was decided to put the model to the test using data from other patients, whose experiences had not been part of the development of the original model, in order to check out if the stages did hold, and whether they held for different clients, in different ways.
Case vignettes
The detailed interviews were carried out by Paul De Ponte in the client’s home, using the guided interview protocol developed by Jo Borrill in 1996. Two clients, Mandy and Emma, were interviewed. Mandy was in her mid thirties, and was a bubbly extravert. She had refused to let her fear of four year’s duration stop her from flying. She took Valium, cried throughout, constantly sought reassurance, and had tried two airline run courses, one of them twice, as well having had hypnotherapy and various alternative therapies. The family had recently bought a house abroad, and the prospect of continuing to fly with her level of terror was overwhelming for her. She said of the “Freedom to Fly” course: “this is the last thing I’m doing. I’m not doing anything else because it’s cost me a fortune and I can’t afford any more. I’ll just have to face the fact that I’ll always have to take Valium, and that I’ll always be terrified, and that’s just the way it is”.
Emma was in her mid twenties, and needed to fly for professional reasons, to enable international expansion of her Theatre Company. She had begun to avoid flying altogether, and felt that she could not start limiting her professional and personal life at this stage.
It became apparent that both clients did go through the four stages of the Model:
Relinquish Control, Accept Control, Experience Control and Achieve Self Control
A few quotes illustrate the flavour of the various stages, from forming the relationship with the therapist through the different levels of control.
“I think she’s a mixture of….. a great guru, and then someone you’re just going on a flight with”.
“She talked about us and about how we felt ourselves – It was definitely more about yourself with Elaine”.
“She made me feel really confident that I could do it, really positive that I could definitely do it.”.
“Now I know if I do have an anxiety attack, it’s not so bad. I’m not going to die”.
“So many pilots have said to me “There’s nothing to worry about and I fly all the time. But it’s different if somebody like Elaine is talking to you, isn’t it? She’s just a normal person”.
Looking for the key elements supplied within the “Freedom to Fly” programme which were missing from Mandy’s previous attempts, one can identify a number of omissions:
Beginning with establishing rapport, the previously attempted airline courses had 45 and 250 people respectively, making it impossible for the close connection which Mandy found so helpful to be established. The smaller of the two courses, with forty five people was “more successful” than the larger, in that Mandy felt more able to ask some questions. However, this course did not include a flight. This element is generally agreed to be crucial by those working in the field (Van Gerwen and Diekstra, 2000), and it would seem to be of considerable significance in progressing through the stages of the model.
The technical information, rather than providing reassurance and knowledge, made Mandy feel more anxious by becoming aware in detail of the things that could go wrong. She said “I don’t get in my car in the morning and think ‘how does it work?’ I just get in”. In line with this, Wilhelm and Roth (1997) postulate from their analysis that informational aspects of treatment programmes to do with how a plane flies may be unnecessary.
The stage of mastery and re-labeling requires that the client actually engages in the feared behaviours. Mandy reported that the extra care, attention and ‘molly coddling’ that she received on the trial flight of her previous course meant that she did not do it herself. She described how even after these earlier courses, whenever she flew, she had frequent visits to the cockpit, constant questions from the crew as to how she was feeling, and repeated reassurance that everything was alright. This meant that she could never achieve the stage of Mastery.
Mandy said that the previous focus on learning to relax proved less helpful than learning to experience the anxiety and to deal directly with it by challenging her terrifying thoughts. She felt that the other courses had aimed to protect people from their fears – one trying to treat the anxiety through relaxation, rather than dealing with the causal, catastrophic thoughts, and the other actually encouraging sedatives and alcohol, if she thought it was necessary. Both of these lead to avoidance, and appear to prevent the stages of Mastery, self-efficacy and joining the club being reached. Foa and Kozak (1986) strongly support this view, concluding from both a theoretical and a clinical perspective that successful exposure requires experiencing of substantial anxiety.
With regard to Emma, analysis of her interview showed that she went through all the stages, in the order outlined by the Model. For instance, she was able to re-label symptoms of anxiety as excitement – “It was fun. There was a sense of adventure”. And for the more frightening parts, the re-labelling was still employed: “This is something I don’t like, not something I’m scared of. I’m excited, not scared”. “It was very empowering”. At the stage of Achieving Control: “there are elements of flying that I can actually enjoy. …. I can fly on any airline”. Given that Emma had not undertaken any therapy before this, it is apparent that previous failure is not a prerequisite to the success of the treatment programme. It would also appear that the effectiveness of the Freedom to Fly programme is indeed linked to the four stages of the model of cognitive change.
In a review paper by Van Gerwen and Diekstra (2000), 15 well established courses for overcoming fear of flying were described. While there were certain common elements upon which all clinicians agreed, there were nevertheless notable differences in content, length and professional background of course leaders and tutors. Highly successful outcomes were reported by all the courses. Given the differences between courses, it therefore seems that there are many routes to the ‘top of the mountain’. The therapeutic journey can thus be construed as a way of climbing to the top of the “Mountain of Fear.” It would be valuable if data across clients from different courses could be compared, to test out whether despite the different routes, the Way Stations, those four sequential staging posts described above, are all the same. Likewise, for those clients who do not succeed, perhaps it is because they have missed out on one or more of the Way Stations, and are still scrambling about precariously, somewhere on the Mountain of Fear, looking for a route that will take them through the four staging posts. Another interesting aspect to investigate is whether internationally the Staging Posts are reached in the same order for all clients.
It is exciting to work in the field of the treatment of fear of flying, as the rewards that clients experience can be as great as the limitations from which they previously suffered.
Both Emma and Mandy have flown since the course, and both report highly successful experiences. Emma laconically described it as “no big deal” while Mandy exuberantly declared that she “was brilliant”. Turbulence was encountered on both their flights, and both reported that they dealt extremely well with it. Assessing themselves, Mandy and Emma described their progress as follows:
Firstly Mandy: “I feel now like I used to feel before when we went on holiday. You know, just looking forward to the holiday and looking forward to getting on the plane and to relax, to read, to have a meal that’s done for me, sit and have a nice gin and tonic. You know, and that’s how I used to feel about it. And that’s how I feel now about it!” Emma concluded: “ All feelings of dread have gone and I can fly on any airline. It’s amazing. Loads of places have opened up to me, and I’m finding myself looking at holidays all the time. I do feel like my confidence has been restored. It’s like having my freedom back”.
Some therapists working in different parts of the world are seeking to refine the interventions that are offered to those whose wings have been clipped by their fears, and many people with a fear of flying are either seeking help, or attempting to overcome their difficulties on their own. It is the ultimate aim of all these endeavours that people are enabled to move from fear of flying and to achieve the Freedom to Fly.
As can be seen from the wealth of studies reviewed in this chapter, there are a wide range of clinical interventions available for fear of flying, which are both varied and creative. However, it can be clearly surmised from the literature that the intention of all those working on this fascinating and complex problem is that, with the increasing refinement of the treatment available, in the words of Jonathon Livingston Seagull:
“We can be free. We can learn to fly”.
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