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Fear of flying: contemporary approaches to treatment

Robert Bor
DPhil CPsychol AFBPsS UKCPReg FRAeS
Professor
Psychology Team HIV Medicine
Royal Free Hospital
London

Professor Bor is a clinical ­psychologist and a qualified pilot, with a special interest in aviation psychology

E:robert.bor@rfh.nthames.nhs.uk

Some health professionals may dismiss the significance of a patient presenting with a fear of flying and question the appropriateness of the true use of limited resources to treat the problem. A fear of flying affects between 10 and 40% of air travellers1 and, contrary to popular wisdom, wreaks havoc in people's personal and professional lives. It may also signal the presence of related psychological problems (depression, phobias, anxieties, relationship and development problems) that may require further assessment and treatment. Furthermore, in the wake of September 11, it is no longer possible to lightly dismiss a fear of flying as completely irrational.

Air travel
Every year nearly two billion passengers travel on commercial airlines worldwide. In the early days of commercial flight, air travel was considered an adventure; it was accessible mainly to the rich and famous, was considered risky and at times even dangerous, and while quicker than most other forms of transportation was by today's standards a lengthy ordeal. However, the last quarter of the 20th century was characterised by mass jet-powered air travel where almost anywhere on earth could be reached in less than 24 hours. 
Modern air travel is safe, efficient and accessible, although arguably less romantic and adventurous than in the early days. Air travel presents physical and psychological challenges to the passenger, and the first "air stewardesses" all had a background in nursing. However, this is no longer a requirement since the altitudes at which most large commercial jets fly render passengers less susceptible to motion sickness, and pressurised cabins remove much of the discomfort to the inner ears traditionally associated with the early days of air travel.
While air travel has certainly become far safer over the years, fear associated with flying remains one of the most common phobias and anxiety states for which patients seek psychological intervention. For some, the fear is so overwhelming that they avoid seeking professional help and avoid flying altogether, so the problem remains untreated. This is unfortunate, as the success rates for treating flying and most other phobias are high.(2)

Fear of flying
Fear of flying is classified in psychiatric terms in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association as a specific phobia characterised by a marked, persistent, excessive fear that is precipitated by the experience or immediate prospect of air travel.(3) An anxiety response (avoidance, increased heart rate, adrenaline release or even a panic attack) is invariably provoked by exposure to this phobic stimulus. Interestingly, the individual generally recognises that their response is unreasonable or disproportionate, although this understanding may serve only to intensify the distress and add a measure of shame at having the problem. 
Many sufferers report symptoms of anxiety and distress long before they set out for the airport. Indeed, this anticipatory anxiety may be triggered at the time of booking the airline ticket, while planning the journey or while packing. For some travellers this may be their first experience of a phobia, while as many as 46% will have previously experienced phobias that were triggered by other, perhaps related, situations.(4) The most common of these are agoraphobia and claustrophobia.
It is generally agreed among psychologists that a fear of flying is not a single, unitary problem but comprises several underlying fears,(5) including a fear of crashing, heights, confinement, instability and lack of control. For many passengers who are afraid to fly, the perceived loss of control is the first trigger of their symptoms of anxiety or panic, although closer investigation usually reveals more specific fears. It is wrong to assume that a phobia associated with flying is due solely to adverse fears or anticipatory fears associated with air travel. For a proportion of patients who seek treatment, some knowledge of basic aerodynamics and of how planes fly, how air traffic controllers guide aircraft,redundancy in engineering and design, and clear explanations and informed responses to "what if …" questions can significantly reduce anxiety. Some patients also develop a secondary fear associated with flying. This is fear of having a phobia - that this might signal the onset of a more serious and pervasive psychological problem with even more ­worrying consequences.(6)
It is for all of these reasons that a full and detailed assessment of the patient must be made before treatment
commences. Failure to carry out a general mental health assessment, even a brief one,(7,8) could result in the
underlying problem being overlooked.
The essentials of the initial assessment include finding out:

  • When the problem started and what might have triggered it (see Figure 1). Careful attention should be paid to life transitions (eg, shortly after the birth of a child, or following a bereavement),(5) and distressing experiences associated with previous air travel (eg, excessive and enduring turbulence, or "bumpy" landings).
  • How the individual has coped with or reacted to air travel in the past. A fear of flying might have been preceded by many years of stress-free air travel. This foundation may serve as a building block from which to better understand the nature of the person's fears and from which to build up their coping skills and confidence.
  • How the problem affects the individual's life and routines, as well as their relationships and career.(8)
  • Whether cofactors relating to their psychological state (eg, depression, anxiety) may have triggered, exacerbated or caused the fear of flying. It may then be necessary to treat this before addressing the fear of flying.
  • What specific reactions occur, both generally and in terms of anxiety specifically, to different stages of preparing and experiencing air travel. For example, buying an air ticket; packing for the trip; the journey to the airport; check-in formalities; boarding the plane; takeoff, and so on. Responses to each of these stages should be indicated on a 10-point scale (see Stress Free Flying(9) for a more detailed account of this).
  • Whether anyone else in the family has a fear of flying or suffers from other phobias or fears, as a positive family history of similar problems is common.(10) It is also helpful to discover how that individual learned to cope with or even overcome the problem.
  • What steps the individual has taken to cope with or overcome the problem. Some solutions (such as self-medication, reliance on alcohol or avoidance) serve to maintain or even exacerbate the problem. It is generally accepted that attempted solutions can give rise to new problems.(11) This paves the way for introducing alternative solutions being suggested and tried.
  • The extent or severity of the fear of flying. For example, an individual who is totally phobic and refuses to even board an aircraft will probably require more intensive and focused desensitisation and other cognitive and behavioural interventions than the individual not wholly ­incapacitated by their fear who does not avoid flying altogether.
  • The extent of the person's motivation to overcome the problem. Merely seeking treatment may signal some motivation, but it is necessary to determine whether this is sufficient. Motivation is directly related to efficacy and outcome of treatment.
  • What might happen to the person in different areas of their life, or in relation to their self-concept, if psychological treatment proved unsuccessful. It is always necessary to speculate about the implications or possible consequences of failure, as this is a real possibility for a small proportion of those who undergo treatment.

[[NIP10_fig1_75]]

A range of psychological treatment approaches has been used to help people to overcome their fear of flying (see Table 1). Before the late 1960s, the treatment of choice was predominantly traditional, long-term explorative psychodynamic therapy, with a focus on unconscious causes. A fear of flying within this theoretical model was viewed as a symptom of "deeper" problems, such as a fear of less control, hostility towards a parent figure or even a symptom of a fear of attachment. While these and other explanations might appear compelling, psychodynamic therapy and group analytic therapy have a low success rate (approximately 18%) for fear of flying and are no longer regarded as standard treatment approaches for this problem.(12,13) In contrast, CBT (cognitive behavioural
therapy) has proved to be highly effective in treating a sizeable proportion of fearful fliers.(6,14) CBT is most effective when three factors are covered with the patient(15):

  • Information is offered that describes the basics of aerodynamics, principles of flight and safety issues in
  • aviation.
  • The person is helped to identify the signs and symptoms of anxiety and panic, and to cope with them as a first step to ultimately overcoming them.
  • Graded exposure exercises are carried out with the patient to help desensitise him or her to any unpleasant sensations or fears they may have about air travel. These exercises can be carried out on an actual flight or under simulated ­conditions, using virtual reality technology.

[[NIP10_table1_76]]

Brief solution-focused therapy approaches have recently been developed.(7) The fact that these have also met with an acceptable level of effectiveness in treating the problem suggests that therapy should be tailored to the unique circumstances and needs of the individual.

And finally …
A fear of flying is just one reaction where levels of stress are not adequately managed or contained.(16) It is encouraging for sufferers to be made aware that psychological interventions, especially CBT and other brief approaches, have been shown to be effective in many cases.
However, it is important for nurses to be aware that a fear of flying might signal other psychological problems in an individual's life, and therefore a detailed and sensitive assessment of the patient should always be carried out. Increasing awareness of the health risks and psychological stresses associated with air travel, coupled with the large numbers of people who fly, is likely to result in an increase in the number of those who seek professional help to overcome their fear of flying.

References

  1. Van Gerwen L, Diekstra R. Fear of flying treatment programs for ­passengers: an international review. Aviat Space Environ Med 2000;71:430-7.
  2. Roberts R. A cognitive-behavioural approach to fear of flying: behavioural treatment with extensive in-vivo exposure and group support. Aviat Space Environ Med 1989;60:342-8.
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). Washington, DC: APA; 1994.
  4. Greco T. A cognitive-behavioural approach for fear of flying: a ­­practitioner's guide. Phobia Pract Res J 1989;2:3-15.
  5. Wilhelm F, Roth W. Clinical ­characteristics of flight phobia. J Anxiety Disord 1997;11:241-61.
  6. Bor R, Van Gerwen L, editors. Psychological treatment of fear of flying. Aldershot: Ashgate; 2003.
  7. Bor R, et al. Doing therapy briefly: a postmodern approach. London: Macmillan; 2003.
  8. Taylor S. Understanding and treating panic disorder. Chichester: John Wiley; 2000.
  9. Bor R, et al. Stress free flying. Wiltshire: Quay Books; 2000.
  10. Menzies R, Clarke J. The etiology of phobias: a non-associative account. Clin Psychol Rev 1995;15:23-48.
  11. Watzlawick P, et al. Change: principles of problem formation and problem ­resolution. New York: WW Norton;1977.
  12. Carr J. Behaviour therapy and the treatment of flight phobia. Aviat Space Environ Med 1978;49:1115-9.
  13. Solyom L, et al. Treatment of fear of flying. Am J Psychiatry 1973;130:423-7.
  14. Van Gerwen L, et al. Multicomponent standardised ­treatment programs for fear of flying: description and effectiveness. Cognit Behav Pract 2002;9:138-49.
  15. Rothbaum B, et al. Virtual reality exposure therapy in the treatment of fear of flying: a case report. Behav Res Ther 1996;34:477-81.
  16. Bor R, editor. Passenger behaviour. Aldershot: Asghate; 2003.

Resource
Crewcare Psychological Counselling Service
W:www.crewcare.org

Further reading
Bor R, Josse J, Palmer S. Stress free flying. Wiltshire: Quay Books; 2000.
Bor R, Van Gerwen L, editors. Psychological treatment of fear of flying. Aldershot: Ashgate; 2003.