Visualisation and mental rehearsal

Visualisation and mental rehearsal

Nowadays, less than 20% of my patients cite air safety as their major concern which brings them to see me. Most airline-based courses, and certainly most books and websites spend a lot of time repeating the statistics about flight safety. This is necessary, but for many insufficient to help them fly better.

Ironically, most of my patients are very aware of the statistics, having read a good deal of safety related materials, and yet complain that while this is useful, it doesn’t seem to change their fear response very much.

For the 20%, it’s not a difficult task to find solid evidence for commercial airline safety, which despite some outstanding events in 2014, has been the safest it’s ever been. That doesn’t mean it’s more pleasant than ever, and indeed the flying experience is probably at one of its lowest ebbs, unless you happen to fly in business or first class.

The problem with airline-based fear of flying programs

So while airline-based fear of flying courses spend a lot of time discussing what they know best – commercial aviation, its personnel and safety – they often pay lip service to the psychological aspects of this fear. They may have psychologists on faculty, but often they don’t run the show and their input is quite limited. Moreover, general airline staff, whether they be landside crew helping you with check-in and pre-boarding service, or airside crew who work on or near actual aircraft, are not trained to understand fearful flyers and their requirements: it’s simply not core business. This covers both full service and budget airlines.

Many in the airline customer service section are trained to work with difficult customers, especially budget no-frills airlines who attract first time or less experienced flyers. The often imposed surcharges and extra fees (for choosing your own seat or having your luggage overweight) can see cheap fares truly balloon out, causing quite some consternation at the checkin desk the day of the flight. Other staff work exclusively with high value flyers, in private and by-invitation-only lounges, who expect considerable TLC and “special handling”.

These elite flyers expect special treatment. They or their company is paying top dollar, and airlines often compete for major accounts with leading corporations. Their staff are known as CIPs or Commercially Important Passengers. Celebrity fliers are of course known as VIPs.

Visiting the Airport and Confidentiality Issues

One of the concerns I discuss with patients when we fly together or do an exposure session at the airport and perhaps enter a stationary aircraft (I’m fortunate to be able to access these via my relationship with Qantas Melbourne and some international airlines), is that I have no control over what staff may say. Those staff who’ve met me before and listened to how I conduct such an exposure session really enjoy it because they learn a lot of new and useful ways to work with customers. But many times there are new staff who may not have participated in the work I do.

So once it’s agreed that the usual confidentiality arrangements won’t be in place (I’ve yet to have any patient refuse to do an exposure session for fear of such a breach), we can go visit the airport and do some great exposure work. Most times, airline staff express curiosity about the patient’s situation with some mentioning their struggle to understand how someone could be in fear of what staff and crew do each day for a living. This is especially the case with pilots and less so cabin crew. Pilots almost invariably discuss how safe flying is, given this is their own #1 priority. This is reassuring in some respects, but if the patient’s presentation is one of panic, or acrophobia, or claustrophobia, the question of airline safety is inessential.

Some will attempt to be encouraging and say, “You’ve got nothing to worry about – I’ve been doing this for twenty years and it’s safer than it’s ever been.” Should the patient say, “That’s great, but I suffer a fear of heights”, the conversation usually concludes.

The importance of real place rehearsal

One of the reasons for having patients come to the airport is to have them rehearse some of the routines we have practised in the office setting, sometimes using the Virtual Reality setup to enhance arousal (after the first session’s problem history taking and formulation, I usually suggest to patients we stop using “anxiety” as a description, but more focus on their experience of arousal: what they’re thinking, doing, feeling, and sensing).

Being at the airport for many, but not all, heightens the arousal, as it now includes the sights, smells, ambient temperature, sounds and general activities associated with their feared scenarios.

Moving down a jetway towards the aircraft can be quite arousing – the sound of aircraft taxiing just outside is usually quite loud; one can feel the rumble of planes landing and taking off on close-by runways; one can feel and hear the plane’s Auxiliary Power Unit (APU) supplying power to the aircraft when the main engines are not running; and the temperature in the jetway may be quite hot or cold compared to the air-conditioned environment of the terminal. These temperature changes can cause quite an insensitive increase in arousal, as can the smell of either aviation fuel (think kerosene) or that peculiar coffee grounds odour you perceive onboard.

Memories of flying can distort over the years

Quite a few patients I see haven’t flown for many years, and have a distorted memory of what it’s like to be on-board together.  They can possess an unreal image of how big or small an aircraft’s interior can be. It’s important to help do a reality check before they next fly. Others will tell me that they can board during an exposure session without too much difficulty because “I know we’re not travelling this visit”. Very occasionally, a few are suspicious that perhaps like some Reality TV prank show, I’ll close the doors and a crew will magically appear to take us for a test flight! (Mind you, with my fear of driving patients, we do go for test drives either in my or their car).

Once in the aircraft,  I’ve usually asked patients to use their imagination to practise what we have rehearsed when it comes to take off and turbulence, and I’ll always ask patients to sit in seats they ordinarily avoid, such as window or middle. This is their opportunity to start the recalibration process, so they can see and experience their arousal is due to their thinking and what they do with their automatic reactions (e.g. gripping the seats, holding their breath) and not the aircraft itself. That many say, “well of course I’m OK – we’re not actually flying” is quite alright, because it refocuses on their experiences of flying, not the aircraft itself.

<img src="Voila_Capture2015-07-12_01-25-42_pm.png" alt="Virtual Reality" /
Using a portable Virtual reality setup on board a real aircraft to extend exposure-based work

However, in July 2015 I began using a portable Virtual Reality system which can allow the patient to experience flying in the real aircraft (left). Whether this advances their treatment remains to be measured (I know of no other psychologists doing this), but feedback so far from a small number of patients is that it has been  very worthwhile experience. Mind you, we usually have done some VR in the office setting first to make sure VR is a worthwhile form of exposure of them – that is, it helps generate high levels of arousal.

The special case of Claustrophobia

However, for some who fear their claustrophobic sensations, walking on board and staying on board can be quite daunting and challenging experiences.

The task then is to approach the boarding process in steps: literally and figuratively. The idea is that the patient should approach their difficult situation while monitoring their specific physiological arousal cues which historically have been a significant source of stress in themselves. That is, there are automatic thoughts about these reactions:

“Oh no, I think my heart skipped a beat… I’m getting really hot just standing here… It feels like I’m choking… Look, my hands are trembling, and my knees are like jelly.”

It’s super important these automatic thoughts be recognised and attended to, then challenged – hard and often.

As much as I have great belief that there are a number of books, websites and apps which can help in this process, my strong suggestion is to seek a few sessions with a psychologist well versed in Cognitive-behavioural therapy (CBT) who can help you locate an app or site then help you get started.

He or she should show you how to recognise, challenge and reappraise your thoughts, then show you how to record these in your app of choice. They must insist you work daily on your thoughts, learning how to challenge, reappraise and internalise more useful and provable thoughts. The challenge with CBT is that like the board game Backgammon, it’s easy to learn but can a lifetime to master.

It’s also interesting to note that some airlines are taking the boarding part of the flight envelope quite seriously. Take a look at the video below from British Airways showing a “Mindfulness Consultant” discussing some ideas. I am not giving this wholesale recommendation, but I do believe some will find it very useful.

Coming back to apps, if you have located a psychologist who will work with you and your choice of apps, you will probably want to re-attend every few weeks and have your progress assessed, with perhaps greater challenges set for you. Having to report back to someone is also a great motivator for many people, similar to having a personal gym trainer to get you started on your healthy activities program, or a mentor at work who is only invested in your changes (as compared to a supervisor who usually will have someone they need to report to).

<img src="Applewatch.png" alt="Applewatch" /
Applewatch daily movement tracking will prove very useful

I must say that with my new AppleWatch it’s been interesting to experience, as others have mentioned to me, how motivating it is to get feedback from the watch about my health stats each day: how may times I stood, how many minutes I exercised sufficient to elevate my heart rate, and by extension how much energy I used. It awards “badges” with each successful week I meet my targets.

If you know others with similar anxious presentations, you can form a group who regularly meet and share your progress and mutual discoveries. Every major city likely has some sort of group who come together to confront these challenges and who will lend support to members. Occasionally, these groups (which can also exist entirely online) will host a professional such as a clinical psychologist to provide more feedback and answer questions. This isn’t group therapy, but more a very limited professional consultation.

Returning to the special case of Claustrophobia,

it’s important to ask yourself if it’s only in aircraft and on long hauls you experience the sensations at a very high, intrusive level, or if you experience it in other situations such as theatres, elevators, tunnels or in dark rooms. These other places will offer you areas to practice your exposure exercises before you fly. Indeed, for some patients, elevators themselves are significant source of panic and avoidance, and flying is secondary to that.

Each time you decide to direct yourself into an exposure situation, be sure of what your goals are for this practice session. Here are some things to ask of yourself (you need to record this to share with your psychologist or peer group) in the most objective way. By this I mean consider yourself to be a Reality TV director informing the crew what you wish the audience to see:

1. Which environment am I entering today?

2. What measures will I be taking before I approach the environment? Will it be my breathing? My heart rate? My skin temperature? My thoughts? A subjective measure of discomfort (a rating out of 10)

3. How long will I stand in the elevator (as an example) before I close the door or select the floor? Will I wait to enter a crowded elevator and just go up or down to wherever it goes, sort will I wait for an empty elevator? If I go to a floor with other people entering the car, will I stay in there or get out?

Do you notice how detailed I am making the exposure session to be? You are much better off to plan your session in fine detail, rather than wing it, at this stage of your self-training. Later on, when you note progress, you will accelerate when you add some randomness to the process. There is good evidence that this is a better approach than going up one floor at a time, or adding a minute at a time, because randomness is a better match for real life, and jangling up your fear response is a much better training experience if you are to recalibrate your fear response system.

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