Dr Robert London

Treating Fearful Flyers: The Psychiatrist's Toolbox

Clinical Psychiatry News - Volume 33, Issue 3, Page 27 (March 2005)

Last May, I used this space to describe techniques that have helped me to help patients beat their phobias. As I wrote in that column, 5%-10% of the population suffer from a phobia at some time in their lives (CLINICAL PSYCHIATRY NEWS, May 2004, p. 43).

Time and again, we run across people with phobic responses. A gentleman I know once got himself stuck in a revolving door. Now he no longer uses revolving doors—at least if he has another choice.

Lately I've been intrigued by how little I have been hearing about phobias related to flying. For years, people had been trying hypnosis, behavior modification, group therapy, and airport classes to overcome their fear of flying. After sitting through a 6-, 8-, or 12-week program of education and desensitization, participants in these airport programs often took a trip in an airplane as their final session.

Recently, I asked my psychiatrist friends and some other physician colleagues about what they have been hearing about phobic flyers. The answer I got was simple: “We medicate them.” Some use benzodiazepines, a whole new group swears by Neurontin (gabapentin) as the panacea, and others are convinced that the β-blocker propranolol (Inderal) is a cure-all for the fear of flying. Then there are those, lost in time, who believe that having a few drinks or getting drunk is the way to conquer the fear. Imagine: The frequent flyer equals the frequent drinker.

Medications are not a bad alternative if we understand their ramifications. But I can't imagine wanting a β-blocker or an anticonvulsant in my system as a behavior modification technique. And as for those who support using alcohol as medication, I say, resoundingly, “No!” We don't need to fly with impaired passengers, nor should airline security be further burdened by people who are intoxicated.

In my work with these phobic patients, I have used my Learning, Philosophy, and Action (LPA) technique to give them a lifelong tool to cope with this phobic response. Fear, as we all know, can be generated in many ways. So for me, it's important to get a history of the origin of the fear of air travel, and how it became solidified to the point of incapacitating the patient. This history is a critical part of the patient's learning experience. There is a direct connection between learned experience and the intrapsychic processing that leads to irrational fears, which I believe leads in turn to each individual's intensity in handling the fear. So an individual who has had one poor flying experience, learned to be afraid of flying, and developed a phobia may be easier to treat than a person who has processed fear and anxiety all his or her life. The history process aims to elicit this information. The patient and I develop an understanding of how the patient learned the fear, and—based on that understanding—a strategy of relearning can be rapidly taught. For example, there are five key concepts involved in the fear of flying:

1. Fear of loss of control and a sense of powerlessness.

2. Fear of heights.

3. Fear of enclosed spaces.

4. Fear of falling.

5. Fear of dying.

As these concepts are thought through, the relearning and the strategy of rethinking becomes clearer to the patient.

One of the favorite phrases used by fearful flyers is “it's just my luck [that something bad will happen].” For example, the pilot will have just had a fight with a significant other. Or a bird might fly into the engine. Based on this faulty reasoning, the patient avoids flying, and is relegated to obsessing about it. This material can be factored into the learning phase of the process. In my behavior modification work, I have rarely had to address intrapsychic personality dynamics such as guilt, punishment, or the multitude of psychological issues that can cause anxiety leading to phobias or failures to function well in every day life. Motivated people who wanted and needed to fly made up the population that I treated. They were not “psych” patients in the traditional sense.

I believe that as psychiatry develops and expands, these rapid treatment programs for circumscribed problems—such as a flying phobia—should be part of mainstream psychiatric practice. For these reasons, the learning phase of the LPA technique can be educational and insightful.

The philosophy phase of the technique consisted of an understanding of human development, and how the human species got to the development of air travel. The point of this phase is to introduce a new perspective on air travel, and to dispel the concept that “if God wanted us to fly, we'd have wings,” along with the other rationalizations that some phobic flyers use.

This phase engages patients, welcoming their impressions, additions, and speculations about flight, as well as the learning experiences that have led them to dread the thought of flight. I like to introduce the idea that we humans are part of a long process of development, invention, and innovation that makes progress and striving for excellence part of our history. Beginning with the wheel, we have made one invention after another—including various kinds of aircraft—to improve ourselves and our quality of life.

The action phase of the LPA technique was a combination of reciprocal inhibition and systematic desensitization. Using an imaginary movie screen or big swath of blue sky, I had the patient relax and look at the screen or sky in compartments. The imaginary screen had a line drawn down the middle. On the left side, the patient would visualize a hierarchy of stressors, such as packing; going to the airport; holding a ticket; checking baggage; boarding the plane; sitting down; experiencing the takeoff, the flight, and the landing; and finally arriving where the patient needed to go. Nonflying patients could easily visualize all these stressors based on movies they had seen and experiences they had observed when they accompanied other people to airports.

On the right side of the imaginary screen, the patient can drift into pleasant scenes or experiences from his or her own imagination. Among them, I try to include thoughts and feelings of success on the arrival after a flight. The big blue sky technique resembles the movie screen technique, but allows for a different type of visualization.

If necessary, the action phase is a technique that can be used during an entire flight or just part of the flight. I have devoted three visits, each lasting 1 hour, to this phase. Usually, the learning and philosophy phases were done in one visit.

Today, in place of using in vivo desensitization—which, in fear of flying, would involve going to the airport—we have a great breakthrough in phobia treatment. In a technique called virtual reality, we use goggles, a helmet, and electronic equipment to simulate flight. Hierarchies can be created, and an entire desensitization process can be experienced as if it were real. William Blank, Psy.D., a clinical psychologist at Lutheran Medical Center, New York, who is committed to exploring new technologies to treat anxiety disorders, sees virtual reality as a major breakthrough in the treatment of fearful flyers.

With virtual reality, Dr. Blank explains, turbulence can be simulated, as can air pockets and any normal problems of flight that worry and disturb the fearful flyer. Dr. Blank notes that as these techniques of virtual reality become mainstream treatments, they should be conducted by psychiatrists and psychologists, rather than by a technician. He believes, as I do, that virtual reality used in phobia treatment is a procedure in which physiological changes occur, and professional observation and controls are very important.

As our society becomes more fast-paced, few of us have the luxury of never traveling by air. We can help patients overcome this fear without relying solely on medication.

Let me know about your experiences about treating flying phobias by e-mailing me at cpnews@elsevier.com, and I'll try to pass them along to my readers.

PII: S0270-6644(05)70030-8