What are people really afraid of?
The Anxiety and Phobia Center of White Plains Hospital has been running a “fear of flying” clinic for many years along with programs to treat the other anxiety disorders, including social phobia and health anxiety. It is the only program we run that has a waiting list. There are a great many people who are afraid of flying. In a time when more and more people are flying to more and more places, one would think that fewer and fewer people would be afraid; but that is not so.
Usually, familiarity with a place or a set of circumstances precludes the development of a phobia. Consider these two cases of agoraphobia, which is the fear of being trapped somewhere and unable, therefore, to escape in the event of a panic attack. These uncomfortable places are usually the same for anyone suffering from agoraphobia—but not entirely.
Once upon a time, (actually it was 20 years ago) I was seeing two agoraphobic women patients. I will call them Thelma and Sandy. Thelma and Sandy did not know each other, but they both had panic attacks, and they were both afraid of getting stuck in restaurants, highways, tunnels, elevators and on bridges. Thelma had one overriding fear, however. She was afraid of traveling through Harlem, which in her mind was dangerous and threatening. Consequently, I drove with her to Harlem. During the middle of the day, on a main thoroughfare, we stopped at a red light. When I turned to speak to her, I discovered her cowering on the floor lest someone spot her and start smashing the windshield. Sandy, on the other hand, never expressed a fear of New York City or of Harlem in particular. I asked her, why?
“I grew up in Harlem,” she told me.
“But what about all the drug dealers?”
“Ah,” she said, waving her hands about dismissively, “if you leave them alone, they leave you alone.”
The difference was familiarity. If someone is submerged in a certain experience which may be frightening, but which is actually safe, that person will sooner or later lose that fear. That is the basis of an exposure therapy—and it is common sense. So much is true also for those who are afraid of flying: the more they fly, the less afraid they become—although not immediately and not in direct proportion. A person flying for a third time may not be noticeably less phobic than when he/she first climbed onto an airplane. However, someone who has flown ten times can be expected reliably to be less afraid. Someone who has flown twenty times is unlikely to be frightened at all. (For an interesting exception, see below.)
So, how come there seems to be just as many people now who avoid flying as there ever were? I think they are just more visible—and more inclined to do something about their fear. At one point those who felt uncomfortable flying could get anywhere they wanted to go without flying. They had come to terms with never flying; and the people around them were not likely to put pressure on them to fly. But now people are expected to fly. To put the matter differently, there may not be more people afraid to fly, but they are more likely to come to our attention.
Those who present with a flying phobia have one or both of two distinctly different fears:
- Some phobic patients are afraid the airplane will crash, killing them. Many have been informed that flying is actually ten times safer per mile than driving, but the fact of flying—the machinery of flying—strikes them as inherently unreliable, even unbelievable; and they worry nevertheless. They feel that in an airplane crash they are doomed. They have no chance of survival. A car accident, on the other hand, leaves some possibility of escape and rescue. The fact that car accidents in the aggregate are much more deadly escapes them.
These individuals take note of every report in the media of an airplane crashing; and these accidents seem to them to happen, not just in threes, but all the time—because they are paying attention to them. Those crashes that are nearby make an especially strong impression.
If asked what their chances would be of dying in such a crash, they might say if pressed, “Maybe, only one in a thousand, but I worry that with my luck I might be that one.” Actually, the odds of them dying every time they get into a large jet airplane are currently about one in two million!
Part of the treatment of this condition is an education in just how safe it is to travel by plane. And, also, just what it means when the plane banks, or when turbulence occurs, or when flames come from the engines. In a way their fear stems from being uniformed. Treatment, as it is in every cognitive-behavioral therapy, involves allowing the patient to experience the phobic situation in a way which will allow learning.
Our program involves, among other things, sitting in a grounded airplane and learning to feel comfortable in that setting. An experienced, professional pilot answers questions.
But even among this group of patients who are afraid primarily of dying in a crash, there are differences.
Some patients are afraid of the process of dying, and some are afraid of being dead. A good example of the former was a woman who imagined that someday she would be in an airplane when a wing would suddenly fall off. She imagined herself spending the next two minutes falling to her death—knowing she was falling to her death. She told me she did not mind being dead, since we all have to die someday; but she shuddered imagining those last few horrible moments when the people around her were screaming and she was terrified.
On the other hand, many imagine the awfulness of being dead, of not being able to fulfill their dreams, or of not being around for their children who need them, or simply, being forever alone in an endless void.
- A second group of people afraid of flying are more numerous and more difficult to treat. They are agoraphobics, and they fear being in an airplane as they fear being stuck in a tunnel or a movie theater or an elevator. They are afraid of having a panic attack and losing control of themselves. They imagine themselves running up and down the aisles in the airplane, screaming or otherwise calling attention to themselves. To overcome their fear of flying, they must overcome their fear of the panic attack. Since they can have these attacks anywhere, they can practice in restaurants or trains, or any of the other places they usually avoid. But since they may focus primarily on their fear of flying, practicing in that setting is reasonable.
In short, certain fears underlie the fear of flying, and these must be addressed in order for that fear to go away. Fears of being helpless, or alone, often underlie a fear of dying; and these can be addressed in the ordinary business of living with family and friends. Superstitious fears can be considered as part of treatment. Conquering the fear of panic attacks is all that is required to be comfortable eventually in all phobic situations.
There are certain difficulties inherent in treating a flying phobia that are not present in most other phobic situations: namely, the difficulty of doing it in stages. In the end, you are either on the airplane or not. It is hard to get on an airplane a little bit at a time, as one might enter a shopping center slowly, or stand in the back of a theater. Often, I ask patients with a flying phobia to go to an airport and simply stand there for a number of hours watching travelers leave and disembark, and watching the planes, one after the other, take off and land. The calm of all those travelers is contagious, just as fear might be.
The following case, although unusual in certain respects (among them being the fact that the phobic woman was rich and could, therefore, practice in airplanes frequently) is more or less representative of a successful treatment:
Tricia was agoraphobic. When I first started working with her, she had trouble driving, sitting in trains and going to New York City. All of these fears were defeated, more or less, over a period of a number of months. She seemed to be over her fear of having a panic attack. Still, she was afraid of getting on an airplane.
Her first flight was with me. We travelled to a nearby city and immediately travelled back home (on the same plane, it turned out, eliciting some curious stares from the stewardesses.) Boarding the plane initially had brought with it the usual difficulties: an upsurge of anxiety at various points such as the check-in, the X-ray screening and the boarding itself. At the last minute she tried, briefly, to talk me into turning back. The trip both ways seemed uneventful to me, although Tricia excused herself on the way back to go to the bathroom. When she returned, she told me she had just had a panic attack, which I had not noticed. It is worth underlining that even an experienced observer, in the process of specifically addressing a panic disorder, did not notice the attack when it occurred.
Tricia then went on a couple of short flights by herself. Then she flew to Italy with her family and back. “It was terrible,” she told me, but not so terrible that she did not immediately schedule another vacation to Europe.
She flew to England and from there to Paris and from there to Egypt, where, she told me, the small plane she was flying in almost crashed. Then she returned to England and New York. She had no anxious times throughout this trip and none in all the times she has flown since. She has apartments in England and Puerto Rico where she visits frequently.
Most phobics who come for treatment have flown rarely or not at all. But over the years I have encountered about a half-dozen patients who were still phobic despite flying frequently, in one case on a weekly basis. All of these persons had something in common: they always sat on an aisle seat. I don’t think it is possible to fully desensitize oneself without sitting on a window seat. Otherwise, it is not apparent that that person is truly flying. He, or she, might just as well be sitting in a bumpy movie theater. (c) Fredric Neuman 2013