What happens in treatment? After I’ve found and read flightwise.com.au, what next?

There are a number of ways people locate my services for fear of flying and related anxiety presentations. Given recent referrals, I thought I’d list a few then write about what happens when a prospective new patient emails, SMSs or telephones (0413040747 – I no longer maintain a landline) to enquire about how I work, perhaps seeking a first appointment.

Prospective patients and consultees can reach me…

  1. Directly from a Google search or similar engine, or link from another website.
  2. Word of Mouth: a friend or colleague has seen me, and is happy to suggest a referral is in order. If you should ring or write to say “Joanne Smith saw you and thought you’d be able to help me too”, I can’t confirm that indeed I saw Joanne. Even if it was a few years ago, it would still represent a breach of confidentiality.
  3. A referral from a GP or psychiatrist under one of the mental health care programs facilitated under the Medicare system. There are a number of programs and so it’s best should you to take this route to find out first how many sessions per calendar year you’re entitled to. If you have already seen another psychologist under a care plan (your rebate under one of the programs, Better Access, is $124.50 per session, higher for visits to the airport, other locations of anxiety or on flights), the clock doesn’t start again, I’m afraid. If you had four sessions previously in the year, you will be eligible for a further six sessions with me, totalling ten for the year.
  4. From another psychologist: This is becoming more frequent as more psychologists understand that at least with fear of flying, it’s quite a specialist area. So while they may continue to work with certain presentations (e.g. relationships, workplace issues) they would prefer more specialist assistance for fear of flying and specific phobias. An appropriate referral from one psychologist to another, with a successful outcome, yields to better “word of mouth” referrals in the future.
  5. From an Employee Assistance Program (EAP): Many large organisations offer their employees and their  families access to brief counselling services.  Usually after six sessions (the usual amount) the psychologist or social worker may choose to refer on, under one of Medicare’s programs.
  6. From an airline, or airport or airline employee: Qantas sponsors two Melbourne-based fear of flying programs (over two weekends including a flight) in May and October. (In Sydney there my be four a year, in other capitals perhaps one). This doesn’t suit some people, or some people prefer not to work within a group program, so they’re often referred to me. I currently have an Aviation Security Identification Card issued via Qantas Melbourne which assists with getting patients on board stationary aircraft and introduced to key airport staff as part of an exposure program.
  7. Sometimes, patients will have heard me speak somewhere or be interviewed in the media and have followed up. It won’t come as a surprise that sometimes those patients are themselves psychologists or medicos, and so are rather cautious in self-referring. It can be a difficult, but ultimately satisfying experience sharing your story of anxiety with a peer.
  8. From my professional society, the Australian Psychological Society who knows of my specialist work, and with whom I’ve achieved Fellowship status, based in part on my bringing new technologies, such as Virtual and Augmented Reality, into the practice of psychology and teaching about them to others. (Of more than 20,000 APS members there are less than 300 Fellows.)

No matter which way it happens, a conversation will usually precede a first face to face or Skype session. Yes, it’s possible to do video conferencing treatments under certain protocols, but unfortunately such psychology consultations are not deemed rebatable at this time. Which is odd because the Australian Federal Government has not just approved this for GPs and psychiatrists but made a special item number and higher rebates and grants for equipment purchase available. This despite the majority of evidence for the efficacy of mental telehealth coming from the research conducted by psychologists. Go figure.

That first conversation may occur after a prospective patient has read this website, or after they’ve been given a treatment plan from their GP who has then asked their patient to call me. Very occasionally, GPs themselves may call, having either known me previously, or Googled me themselves, seeking whether the referral is appropriate. Occasionally, a spouse may seek an appointment for their partner, or a parent for their child, so I don’t necessarily speak with the “Identified Patient” until I meet them face to face.

Even though the system for rebates of psychological services has been in placed for almost a decade in Australia, and private health insurance several decades, more often than not enquiries I receive are from would-be patients who have never visited a psychologist previously. For some, especially lawyers and doctors, obtaining psychological services is a very private matter, and so they avoid all insurers. If their flying or driving or other avoidant situation is part of their working life and their anxiety is intrusive upon it, I suggest they speak with their accountant as to whether my services can be billed as a work expense, thus attracting GST, but may be tax-deductible. This is necessary in preparing tax invoices.

For many prospective patients, most of whom are doing very well in their careers and personal lives, their immediate concerns about their anxiety presentation feel egodystonic: “My fears and concerns seem foreign to me – it’s really odd that I get anxious in these situations compared to those where  I’m achieving and doing well…” (or) “This used to not bother me… I don’t understand why now…”

It becomes important for such patients to spend time here, on this website, to understand both how I work, as well as achieve a better understanding of how their concerns may have developed, and more importantly are being maintained inadvertently.

I say inadvertently because in the first instance it ca very very helpful for patients to understand that some of their automatic routines when confronted with a fear trigger (e.g. gripping the seats when the Captain announces some turbulence might be expected) actually make their predicament worse. The experience becomes subjectively much more intense than it ought to be, and patients “train” themselves to become better at less desirable behaviours, By better I mean faster times to react, stronger reactions the necessary, and reactions to lesser triggers.

Let me share with you a protocol I created some years ago when the original Better Access program, covering 12 sessions, was initiated in 2006. Before that period, it was up to patients and psychologists to agree on treatment meeting frequency. With programs subsidised by the federal government, treatments on these programs are now limited (in April, 2016) to 10 sessions and after that patients either use their private health insurance, pay out of pocket, or find another method. The Better Access program also stipulated the type of intervention it approved. Fortunately, the path I was trained in and continued to evolve meant I was already adhering to the evidence-based model the Government advocated.

[Side story: I’m often asked about hypnosis-base treatments. My understanding is that this approach is not an approved approach under Better Access, so if you should wish to respond to a psychologist who advertises hypnosis as their main intervention, ask if those sessions are rebatable under Medicare. A month or so ago from the time of writing, I was on the same speaking panel as another senior psychologist who asked, during a break, how my fear of flying work was going. After hearing my answer, he spoke of his own success with hypnosis in just a few sessions, for which I congratulated him.

My own thoughts are that some people achieve, from anecdotal reports, dramatic success with applied hypnosis. Of course, I don’t see them. I often see patient for whom hypnosis has been one of a number of attempts over the course of many years in some cases. So, when other therapists speak of their hypnosis work, I smile and listen, but remain steadfast in my belief that many who go down this path remain prospective clients. My suggestion if you take this route is to head into your feared situations when told the work has been completed. Don’t wait until you have to take a flight, or use an elevator, or go through a tunnel or over a bridge – head out before it’s necessary and see how you go. Hopefully, you’ll be pleasantly surprised, but if not, head back and ask for some “top up” sessions]

So, let me share with you my original 12 session plan from 2006 which is still the foundation of my work, so if another psychologist, psychiatrist or GP also wants to know what you can expect, you will have your answers:

Sample Mental Health Treatment Plan for Fear of Flying

For MBS item# 2710

Composed by Les Posen, MAPS, 

Member, APS College of Clinical Psychologists

http://www.flightwise.com.au

NB: This is a sample treatment plan employing an averaging of interventions employed with many patients. Any one individual patient will need his or her own specific plan.

Session 1:

Assessment

Is there a flight due soon? When? To where? With whom? Business or Pleasure?

How many flights in the past year?

When did the fear seem to “take off” or become intrusive?

If continuing to fly, is it getting worse?

Is there a part of the flight that seems to elicit the most fear?

How much interference into quality of life (family, social, individual, work)?

What is the patient’s own explanation for what’s happening?

Any other fears, such as heights, bridges, tunnels, animals?

Any history of panic?

Any co-morbid conditions such as depression or other anxieties, like panic?

Any self-medication, like alcohol or drugs?

Any previous treatment, formal (such as airline course) or other mental health professional?

Assessment instruments re fear evaulation (Les Posen to supply if requested)

Preparation for treatment

Explanation of frequency of FoF ( eg 1 in 6 to 1 in 12)

Normalisation of symptoms in terms of evolution of safety, especially if heights is an issue eg., fear of falling can be seen in infants from about 6 months old.

Information about how CBT and Exposure therapy offers effective treatment.

Session 2

Review of info in session 1, provide feedback for any measures offered in Session 1.

Explain how the treatment will unfold over the next 5 sessions, and its evidence base

Explain how exposure therapy is effective but it means confronting fears in small doses, baby steps, and a flight at the end (with therapist) needs to be planned for. Flight undertaken when therapist and patient agree on readiness and how that is to be assessed. Patient only needs to be 80% ready – as 100% will not happen and is unnecessary.

Possibly exposure to videos of flights, starting with boarding. Explain to patient how SUDS works and ask to use when viewing video. Stop at various points and explain noises, and other triggers, seek distress measure.

Show takeoffs and landings, and measure anxiety. Consider using biofeedback (GSR, HR) at this assessment phase. Assess aviation knowledge, and determine if info needed.

Introduce how thoughts about aspects of videos are part of the issue thus commencing CBT approach, and how thoughts are linked to behaviours, physiology and emotional states.

Introduce breathing as an intervention, to be followed up in session 3 with biofeedback.

Session 3 and 4:

Exposure work, using videos and development of index cards to locate distorted thinking for each situation nominated as above 5 on a scale of 10.

What does the patient to do avoid discomfort and elicitation of fears, eg. pray, hope, look at flight attendants, look away from window, hold breath, etc.

Employ biofeedback to formally teach diaphragmatic breathing. Show how BR of 6-8bpm is consistent with relaxed state and calmness while watching trigger videos, e.g boarding, jetway, entering cabin, waiting in aisle, seated, watching flap sequence, hearing door close, call bells, “cabin crew – arm doors, and cross check, taxiing, engine max. thrust, variations in thrust during clim out, etc.

Between session practice of homework: index cards (“automatic thoughts, rational responses), breathing, calming, visit airport and watch activities., etc.)

Session 5: Commence VR if appropriate.

Session 6. More VR with special focus on areas of significance, eg turbulence. Elicit fearful thoughts, and show means to challenge them, repeat flight situation as needed.

Use outcome measures of fears to seek difference between session 1 and 6

Session 7. (where appropriate) Actual flight and debrief on arrivals.

Sessions 8-12: As needed, as determined by GP, patient, Clinical Psychologist.

Copyright 2006 Les Posen.com (Flightwise.com.au)

Medical Practitioners are permitted to use this MHTP as they see fit.

Now this plan has been modified with new audio visual and technologies added, but my approach ten years ago was pretty sound, and indeed ahead of its time in its use of Virtual reality based approaches, which is becoming the “thing” for gamers and trainers in 2016. It’s still got some distance to go for practising psychologists because

  1. Many psychologists aged over 45 missed the “digital clue train” and are not enamoured of technologies, as I am.
  2. Many psychologists do not wish to spend a lot of money and time learning to use new equipment they were not trained to use in their initial graduate training.

I should add that one of the biggest changes I’ve made is to rely less on SUDS and more on objective measures, now that the technologies to do so are easily available, much less expensive and wearable!

So there you have it. Many years of evidence-based treatment which has at its centre, hard work, not magical one-off treatments. When I know such things exist and can be reliably used, you can bet I’ll be amongst the first to employ them!

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