Calm is not the cure for anxiety

Many people think learning to be always calm in their feared situations will “cure’ their anxiety. They’re wrong – here’s why.

The pursuit of two human emotions can get people into all sorts of bother.

Hector, a psychiatrist, travels the world seeking the meaning of Happiness
Hector, a psychiatrist, travels the world seeking the meaning of Happiness

The first is happiness, which many people diagnosed with depression or similar mood disorders chase and wish for, as if it’s a permanent state of mind. They may say to themselves: “Once I’m happy, I won’t be depressed.” The chase is then on for the circumstances, situations, people, activities, jobs, possessions and so on which will produce happiness, seemingly on a permanent basis. It’s as if something’s been fixed and put right. And the irony is that it requires a lot of energy to enter this chase, something not always available in someone who’s depressed.

The second is anxiety, where many people diagnosed with any one of a number of anxiety presentations are advised that its cure is through calmness and its variety of sources, such as meditation, exercise, medication, mindfulness, and so on.

My many years of working with anxiety has brought me to another way of thinking how best to help patients (and myself, for that matter) manage anxiety. And it’s not through calmness.

The example of boarding a plane for a flight

Rather than just jumping in and giving you the evidence for my thinking, let me offer an example. (Scroll down the page if you prefer to avoid my examples and story telling. It’s OK – I won’t be offended).

When I fly with a patient after working with them for a number of sessions, one of the crucial times where my level of arousal is quite high is the day of our flights, when I’m at the airport, waiting for them to meet me.

I am vigilant within the waiting area we’ve nominated. I am monitoring the time more than usual; I am making sure my iPhone is switched on and in receiving mode, and of course I am keeping an eye on the expected departure time of our scheduled flight – to make sure it’s on time, and which gate we will be heading to.

To help, on my iPhone I have an app which allows me to keep track of flights, and by knowing which Gate we are leaving from, I will also know which flight will be arriving at that Gate, and so I’ll be able to monitor its on-time performance. (see the iTunes App info, below).

Flightradar24 is an app for iOS and Android devices for live tracking of aircraft movement
Flightradar24 is an app for iOS and Android devices for live tracking of aircraft movement (click to go to iTunes)

If you see me, you might look at me and ask, “Hey Les, you look nervous…” It’s true I would not appear to be relaxed, kicking back reading a book, with a cup of coffee or wine in my hand (if I’m waiting in an airline lounge).

I would appear more vigilant and observing of what’s going on around me compared to my normal demeanour. After all, the set of flights I’m about to take with my patient represent a significant test not just for the patient, but my ability to help them institute change via my special knowledge and experience.

All manner of things could occur in the next little while to upset all the planning and weeks of treatment, with most of it out of my control and only so much I can do to put things right.

Here’s some things I have experienced to give you a flavour:

Example 1. I’ve driven in with patient who is a frequent but fearful flyer and I want them to do their usual routines for arriving at the airport. In one instance, a patient chose to park in a long term parking area, where the pick up bus had to do multiple stops along the way. Not just did we arrive late at the car park, but the bus seemed truly intent on stopping at all the waypoints. Knowing the flight would close 20 minutes before the scheduled departure, I really felt we would miss it, so plan B was to ring the Airline Duty Manager and let him know we were on our way, without luggage. We made the flight, and it offered me the opportunity to inform the patient he really needed to buffer in an extra 30 minutes if he was to choose the same car park again. Arriving on board the plane without being breathless from running would be a good start to his next set of flights!

Example 2. With a different patient, sitting in the airline lounge with plenty of time before departure, we discover the inbound plane is still to leave its origin due to weather there, and we will be delayed at least an hour. When it was also announced an hour later they’d be a further delay of another hour due to a mechanical issue, my patient looking very gloomy indeed. Fortunately, I had booked our return flight with the same airline and with the same aircraft (I know how this airline’s system works) so late out also meant our return flight would also be late out. But would it be too late in the day for my patient? Plan B was to approach the Customer Service Desk, show my ID and ask to transfer the flight to another day without penalty.  Experience has taught me this is not the best option, and so I convinced my patient to wait and fly this day. It was a good learning experience for her, as the situation is not an uncommon one, and is bound to occur sooner or later for most frequent fliers.

Example 3. One one occasion, I flew out with a patient on one airline and was scheduled to do the return on another airline. After a successful flight out, we sat in the lounge of the inbound airline, but didn’t hear the PA for the return flight. Only when I went to the window and saw the plane taxi past did I have that awful feeling I had mucked up the times! And so I had to organise another return flight with the inbound airline with whom I have an association and had to do some fast talking to get a cheap fare, compared to the monstrously expensive same-day walk-up fare, as it’s called. My patient missed an important dinner, and I have never let the situation occur again! My fees for the day went to pay for the return flights, and it was a very expensive lesson.

Example 4. On a flight into Sydney from Melbourne, I was with a patient who knew how long the flight should take and had prepared herself well for the 1hr25min it was scheduled for. I always say to patients that the schedule is somewhat flexible in order to allow for delays, especially those caused by weather or heavy traffic flow. On this occasion, as we were approaching the airport on base leg with about 10 miles or 10 minutes to run (over the Pacific Ocean south-east of Sydney), I made the prediction we would turn left for long finals and have an easy run in for the next ten minutes over water. This did not occur. Instead, we turned right, held altitude and headed east, away from the mainland. Soon enough, it became clear to me there had been a change of runway from 34L (one of the two long north-south runways in use when the wind is from the North), to the single runway 25 used when the wind is from the West. This means that busy Kingsford Smith Airport is down to one runway for all landings and takeoffs, and we were being routed into a queue. Indeed, it was another 25 minutes before we touched down. My patient who had done some very precise planning was thrown momentarily into a spin, and I had to work fast to explain the situation – all was normal – and help her use her self-management techniques to stay on task. We later were allowed into the flight deck (by prior arrangement) to meet the crew who explained what had happened and how they handled it.

[Small aside – prior to the introduction of jets on the very busy Sydney-Melbourne route in the early 1960s, prop jets like the Lockheed Electra or Vickers Viscount took 55 minutes, even though they travelled at only two thirds the speed of today’s modern jets like the 737 or A330]

Example 5. For myself, when I travel on long international flights with the addition on arrival of a domestic connection, e.g., Melbourne to New York via Los Angeles or San Francisco, I need to leave sufficient time to clear Customs and Immigration, grab my luggage, place it on the interline carousel for the onwards flight, and then go through TSA checks and security before heading to the Gate or the airline lounge if there’s a long delay. Usually, one leaves a minimum of two hours between international arrival and departure. But sometimes, if you can be first off the plane, Customs is quick, your priority bag is waiting for you, you might just be able to make an earlier flight. So instead of arriving in NYC at 10pm, you could make it in at 8pm. Which for me means as the flight into, say, LAX is on its final approach, I am planning my moves to see if I can get to the earlier flight. So while fearful flyers are characteristically beginning to experience much less anxiety (“It’s almost over!”), my levels of arousal are increasing as I actively plan for possible contingencies. The most unpleasant dilemma I know I can face is being offered the earlier flight but only in Coach, rather than the Business Class seating I had pre-ordered using miles. Decisions, decisions! But I can tell you after 14 hours flying in Coach, the ability to fly Business and have a comfy snooze for five hours trumps the early arrival!

So here are some real life examples of things which can occur outside one’s control but for which one needs a plan and readiness to act, perhaps even make up a new plan on the spot. Where I want my patients to get to in their work with me – where I add unexpected extra value – is to learn more about commercial aviation so they know what to do when plans go awry, and not see these occurrences as reasons or a rationale to not fly.

I mean to say,  most people don’t avoid driving because they might get a flat tire and be stuck in peak hour traffic, holding up hundreds of cars. Mind you, I once owned a Datsun 1200, a model notorious for its radiator problems.  Having once blown a gasket in peak hour traffic, I became very vigilant of the car’s temperature issues, and did avoid driving in peak hour traffic!

In other words, yes, stuff happens, but we can mitigate these occurrences with contingency plans, much like pilots in the pre-flight briefing room study the weather and airports along their planned route and order appropriate quantities of fuel for holding or diversions. It’s good airmanship, and the monitoring and updating of weather continues inflight with modern communication devices.

Planning and having contingencies ready to go is one of the most important ways to manage panic and anxiety, part of which is the fear of losing the plot, along with all the accompanying unpleasant signs and symptoms.

This is why so many people want you to learn how to be calm so you can always be calm in such situations.

But calmness is not an objective – it’s an outcome of successful planning and rehearsal. I don’t want you to be calm in all situations which bring on discomfort – I want you to be focussed, giving attention to how to carry out the plans we have planned and rehearsed previously.

You will not and cannot be calm for a 14 hour trans-Pacific flight unless you knock yourself out with Valium, hourly doses of Xanax, or large quantities of alcohol. It’s hard for me to recommend such remedies unless for exceptional circumstances, (and they’re a nasty combination, by the way).

How did it get this way?

For a long time, clinical psychologists have believed that pairing “feeling calm” with being in anxiety-provoking situations was the way forward. They invented special terms like “systematic densensitization” and “habituation” and “graded exposure”  and “progressive muscle relaxation” to codify the processes involved in helping anxious patients unlearn their by-now habitual responses to triggering events. Most clinical psychology textbooks devote many pages to these techniques.

Most psychologists still practise this way, even though current evidence suggests there’s another and better way forward. It still consists of exposing patients to their scary situations, but how to do that and what is defined as the “scary situation” has shifted in recent years. “Scary situation” is also considered to be one’s self-talk, as well as the internal sensations of discomfort such as a rapid heart rate, stomach upset, trembling knees, feelings of choking, and so on. It could also be imagery that intrusively “pops” in which might be imagined or a realistic recall of a previous occurrence or something seen on TV or in a movie.

The idea that’s been long held is that one can’t feel anxious and relaxed (think: calm) at the same time, and so teaching patients “relaxation skills” they can employ prior to or in their scary situations was the way to go.

Is it important to be calm in your scary situation?

In a word, no, and indeed aiming for this can set you backwards. Let me return to the airport situation of boarding an aircraft. When I ask patients and indeed my psychologist colleagues what state of mind is preferred for this important situation, the answer invariably is “to be calm”. For the patient, walking on board calmly might be a sign of a shift in self-talk:

“I’m finally over my fear

If I’m calm when boarding, it’s a good sign I can remain calm the entire flight

If I’m calm, it means perhaps my medication has kicked in finally

Boarding calmly is the only way I can do this”

For a treating psychologist, it might be a sign their training in relaxation skills will pay off for the patient, and they’re on the right treatment trajectory.

When I work with patients and ask how they think they should board, more often than not I hear a statement of preference for doing it calmly (for the reasons above). Or if I ask, “When our work is successfully concluded, how should you be able to board?“, once more the answer is “calmly or without worrying”.

Patients are usually rudely shocked (as are psychologist colleagues) when I state that not just is that not my aim, but it’s not likely to happen!  Yet we can achieve a good outcome nonetheless. On the other hand, if you board after being trained to be “calm and relaxed” but discover you’re still highly aroused with all your usual distressing signs, you might infer “I’m not ready to do this…”, and baulk, when in fact it can be done despite the continuing presence of unpleasant feelings.

By now, reading this website entry,  you might be feeling disappointed, less hopeful and somewhat confused, so let me explain.

What I next ask my patient is whether anybody, fearful or not, boards in a calm emotional state. Most will take a moment to contemplate, and respond with: “I suppose not”.

This is an acknowledgement that flying today is not the most chill-out activity you can do! It’s complicated with lots of steps and people to negotiate, unless you happen to be travelling first class and special efforts are made to smooth the way for you. In other words, modern commercial aviation for most passengers is a stressful experience. It’s extremely difficult to board in the sort of calm fashion both patients and psychologists believe (and work toward) is the “right” way. Even for those people who can negotiate all the hurdles airlines and airports put in their way, there are many passengers who might also be excited about their journey, perhaps going on holiday, to a wedding or graduation, or to a job interview. Should these people try not be excited but instead try to be calm when boarding….?

So, I always ask patients and psychologists why we expect them to have so little arousal compared to the average passenger, especially when they’ve started from such a high level. When the patient pauses to contemplate the simplicity of this question, I seize the moment to shift focus from their experience of arousal to that of the airline crew. This is an important part of shifting the meaning of “being calm”.

Discussing Crew behaviour as a model for better emotional regulation

At this point I ask patients to recall the demeanour of the cabin crew as they get ready to board. Most will reply, “they appear to be calm and professional – or at least, that’s how I want them to be”.

To which I add, “In other words, they are professionally calm – this is something they have learnt to bring to the work situation.”

But then I add my assertion that in fact they are not calm or relaxed. Nor should they be. They are on task and vigilant. There are well-rehearsed steps and procedures to follow before the flight may proceed, and this also applies to the flight crew who are busy checking and re-checking flight parameters, while monitoring the boarding process, current weather (both at the origin and destination airports) and other events before push-back can occur.

In some respects, the crew are like the beautiful swans gently cruising along a river, appearing calm while their webbed feet are paddling like crazy, outside of view under the surface. What you get is not what you see. Your cabin crew are professional safety officers, and about 80% of their training is stuff you’ll likely never to notice them perform. You experience the 20% which is devoted to training in direct customer service, and this is how airlines advertise their cabin crew in order to attract customers. Airlines never compete in their advertisements on their safety records.

The point to this story is that crew may appear calm, but that is a professional well-rehearsed and practised ability to help passengers feel confident in the aviation industry, and especially on this flight. Airlines spend millions of dollars on functional and attractive uniforms so you can easily identify your crew and more millions on training so crew know what to do almost reflexively in the case of unlikely (but must be prepared for) safety challenges.*

So while appearing calm, they are in fact vigilant and physiologically “up”, constantly monitoring their work environment so their flight can leave punctually and safely. Equipment lists are checked, certain items checked for correct operation, safety equipment tested where necessary, and a briefing held before passengers board. They work as a team, something known as Cabin Resource Management, helping each other out with the aim of an ontime departure. You can’t do these important activities calmly, but only give the impression of calmness to an observer.

Instead, crew are trained to work according to well-established protocols including how to maintain their composure under duress. Since the events of 9/11, airline crew workloads have increased because of the expectations of increased safety, even though onboard activities have been advanced through new technologies. Additionally, with the competition coming from budget, “no frills” airlines, more activities such as preparation of the cabin between flights are handled by cabin crew, rather than cabin cleaning teams.

I want to suggest that anxious flyers can take a leaf out of the crew manuals, if you’ve been following my drift. If you want to be calm, follow a set of procedures which will allow you to carry out well-rehearsed plans including that of how to maintain composure under duress.

This means accepting that duress will occur, and knowing how to understand, and manage it, is the best way to fly successfully. Should you employ these procedures well, your chances of experiencing calmness during the flight will increase, but again – calmness is an outcome, not the goal. Being calm is not the cure for anxiety.

UPDATE: After I wrote the main body of this blog entry, I learnt that one of the world’s most awarded airlines, Qantas code share partner Emirates, is beginning to employ new technologies in its Crew training centre in Dubai (below).

emirates-training

According to the website, futuretravelexperience.com, Emirates is planning to include new simulator training for cabin crew. Notice how the article describes placing the training crew into real life simulated situations so they can practise carry out their duties under expected duress.

Here’s the article:

“Emirates’ cabin crew will soon be undertaking virtual, immersive, game-based training following a deal between the Dubai-based carrier and Cubic Global Defense, which traditionally provides realistic military training systems.

Emirates will be the first commercial airline to utilise the system, which is said to incorporate “high fidelity visuals with engaging, synthetic environment technologies”. 3D classroom stations and touchscreen interaction will also be key elements of the training programme.

The aim of the game-based learning is to allow cabin crew to acquire and practice the thought processes and skills required to respond appropriately under the pressure of real-world challenges, but in a safe, virtual environment.

Bill Toti, President of Cubic Global Defense, said: “Cubic continues to expand our innovative training technologies into adjacent industries such as commercial aviation. The EK cabin crew will be educated using the latest advances in instructional design, coupled with the engagement of video game technology allowing an immersive form of on-the-job learning.

“We look forward to helping define a new industry standard in aviation training that cost-effectively focuses on safety while incorporating emerging virtual technology.”

In a soon to be published entry, I’ll write how visiting an Apple store can increase your understanding of focus under duress, and can form a good model of how to change your own behaviour.

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