Encounter on a flight
I found myself already settled in my seat aboard the plane, lost in my own thoughts and eagerly awaiting the completion of the boarding process. The weather outside was perfect, promising a smooth and enjoyable flight. The air was abuzz with chatter and excitement.
Suddenly, a loud commotion erupted from the back of the aircraft, drawing my attention. I watched as a flight attendant escorted a distraught woman down the aisle. As luck would have it, the seat next to me was empty and the woman was directed to sit there.
It quickly became clear to me that she was in the grips of a full-blown panic attack. Right away I assumed that it was brought on by her fear of flying. The flight attendant did her best to soothe and comfort the woman, but to no avail. Desperate, she rummaged through her belongings looking for a solution. She found one in the form of a pill of Xanax. She quickly swallowed it.
As a trained psychiatrist and felt a sudden urge to offer my assistance. I leaned over to the woman and introduced myself, explaining that I might be able to help. After hearing about her family emergency and how her sister had convinced her to board the plane, I suggested she take a few slow breaths and focus on something pleasant hoping that would calm her “nerves.” I could see in her eyes that her mind had lost all grasp of reason. The urgent need to escape consumed her, as she stared at the plane's door. The passengers were instructed by the overhead announcement to take their seats in preparation for takeoff. It seemed that this command served as a signal for the woman to take action. She leaped from her seat and sprinted towards the door, determined to do whatever it took to save herself. No amount of persuasion could change her mind; in her view, the flight for life was far preferable to a flight in the sky.
For a long time afterward, I pondered over this woman's fear and anxiety-driven behavior on the flight. The psychiatrist in me couldn’t help to consider a multitude of possible reasons for her distress. Perhaps the confined space of the airplane cabin was overwhelming for her, particularly if she was claustrophobic about being trapped in the small, enclosed space. Thinking about the altitude of the flight may have been unsettling if she had a fear of heights. The prospect of a severe panic attack or medical emergency could have been on her mind. Finally, the possibility of turbulence or a plane crash may have been a primary source of fear for her.
“Fear of Flying”
As I experienced the terror of this common phobia firsthand, I couldn't help but think of the novel "Fear of Flying" by Erica Jong, written in the 1970s (1). Although the book primarily describes the complex societal norms that surround female sexuality and the expectations and limitations placed on women, my interest in it was not related to its main theme. Rather, it was triggered by the book's title that resonated with my mind's associative memory. Relying on my intuition, I made the decision to revisit this book half a century after its original publication. Excited and curious, I headed to the library with a mindset to search for any references in the book related to the fear of flying as conveyed through the masterful storytelling of the author.
This is what I found. The book centers on Isadora Wing, a poet who is struggling to find her place in the world. The title of the book is a direct reference to Isadora's fear of flying, both literally and metaphorically. She is anxious about getting on a plane to accompany her husband to a conference in Vienna.
Isadora spends a significant amount of time in psychoanalytic therapy, and her sessions with her therapist are a recurring theme throughout the book. With the help of therapy, she explores her life experiences and begins to understand the root of her fears and desires. She realizes that her anxiety is tied to her fear of taking risks and trying new things in her personal and professional life. For Isadora Wing, flying represents a loss of control and a fear of the unknown.
Psychoanalysis at work
Just before the time when this novel was written, psychoanalysis was at its peak in the United States. Therefore, it is not surprising that it finds its place in the book. The psychoanalytic theory suggests that the fear of flying may represent a symbolic fear of leaving one's comfort zone or feeling out of control. It stems from unresolved conflicts from childhood, particularly related to separation anxiety or traumatic experiences. Ultimately, according to psychoanalysts, the fear of flying may be related to deeper unconscious anxieties.
According to psychoanalytic theory, individuals employ defense mechanisms in an automatic and unconscious manner to shield themselves from unpleasant or traumatic experiences. In the case of the fear of flying, displacement is the main defense mechanism in operation. Flying triggers unconscious fears related to loss of control, vulnerability, or even death. Displacement may manifest as a heightened (anxious) focus on specific aspects of the travel experience, such as the safety procedures or the weather, rather than acknowledging the underlying fears. By focusing on these more tangible aspects of the experience, the individual can avoid confronting the deeper, more uncomfortable emotions that the fear of flying may bring up (2).
The many paths to fear of flying
Soon after the publication of the novel, the 1980s came into view. The scholars began to contemplate new ways of explaining the origin of the fear of flying. A notion was formed, rooted in experimental psychology, that the cause lay in classical conditioning - the act of associating an unpleasant event with a certain trigger. Fear, it was said, was a learned response, an adverse emotion attached to a stimulus present during a traumatic occurrence.
Yet, as time progressed, it became apparent that there were other ways in which this phobia could be obtained. Like a seedling reaching for the sun, two more avenues grew - vicarious and informational acquisition. The former spoke to the act of observing someone else's anxious behavior and subsequently adopting it, like a mirror reflecting back the image it sees. The latter involved consuming news coverage of alarming events, which could plant a seed of worry and grow into full-blown fear.
The portrayal of air travel in popular media, with its vivid depictions of mechanical failures and terrorist threats, may have a hand in the prevalence of flight phobia. Such dramatizations, though sometimes based on real events, can sow seeds of fear and anxiety in the hearts of their viewers, effectively perpetuating a culture of apprehension. Indeed, movies, TV shows, and news reports all too often paint a picture of the skies as a realm of danger, rather than of the soaring wonder and freedom that it can truly be because it is well-known fact that air travel is one of the safest modes of transportation.
So, the explanation evolved, just as the world does, and the sources of this fear became manifold. Yet, the heart of the matter remained the same - a person's mind can become tangled, like the roots of a tree, in associations that can create a fear of soaring through the skies.
Through the captivating novel I just read and in my exploration of psychoanalytic and other theories, I have gained a better understanding of the complex nature of the fear of flying, particularly the significant role of early childhood experiences and learned emotional traumas in shaping an individual's association with air travel. The notion that our early experiences can have a profound and enduring influence on our thoughts, behaviors, and emotions in adulthood is a fundamental tenet of psychoanalysis and attachment theory.
On the other hand, other psychological theories indicate that throughout our existence, from the moment we are born to the time we depart, our minds and brains are constantly absorbing knowledge and experiences through the phenomenon of associative learning. Just as a sponge immersed in the sea absorbs every drop of water that it comes into contact with, we absorb every bit of knowledge that surrounds us. It's a natural process that occurs whether we are aware of it or not, as our brains tirelessly work to create new connections and build upon existing ones. Research that has been published demonstrates that some individuals who experience fear when flying have learned to be afraid of flying through one or more of the learning pathways that have been described above (3).
Exploring the Evolutionary Roots of Fear
As I contemplated this topic further, I couldn't help but wonder if there was a different approach to take. Perhaps I needed to look beyond the individual and enter much deeper into the territory of fear itself. Was there something innate within the human brain that made us afraid of flying, something that didn't depend on personal experiences but was instead hardwired into our very being? Was there a fundamental element that underpinned this particular fear? Could it be something that was imprinted within us from birth, an integral part of our neural makeup?
To achieve my ambitious aim, I had to turn to evolutionary theory, which illuminates the very genesis of our species. As we ruminate on our primordial origins, we glimpse how our ancestors progressed and acclimated to their surroundings, enhancing their odds of survival and procreation, and bequeathing their genetic legacy to the progeny. Thus, certain cognitive faculties were selectively preserved, in the environment of evolutionary adaptation, typically corresponding to the epoch of hunter-gatherer societies.
Within the depths of our brains, certain emotions have become entrenched, particularly fear and anxiety, serving as an ancient adaptation to the environment. The fear of snakes, spiders, darkness, and heights, is etched within our being, easily activated as a primal instinct, a legacy of our ancestors.
However, the fear of air travel does not follow suit, as it was not a part of the world our forebears knew. Nevertheless, air travel possesses features that our very nature is programmed to dread. For instance, the thought of being high above the ground, where one slip could lead to a certain demise, or confined within an enclosed space where escape is unfeasible, reminds us of ancient times when such places were inherently hazardous and shunned.
Furthermore, the helplessness and lack of control that come with air travel can easily stir up anxiety. Though deemed irrational by modern standards, such fears are a reminder of our lineage and the trials our ancestors had to face to survive (4).
Thus, the biological perspective might be the reason behind the widespread prevalence of flight phobia, affecting nearly half of all air travelers. Its reach is all-encompassing, and I have observed its grasp on my own family, as well as in my patients. In my capacity as a healthcare professional, I have witnessed numerous individuals being afflicted by severe panic attacks and associated physical symptoms, while others suffer from an overarching sense of anxiety and dread, even prior to boarding a plane. Regrettably, for many of them, this phobia exerts an immense influence on their daily life, depriving them of the ability to travel for work or recreation and causing them unwarranted stress and concern.
Understanding the Behaviors and Symptoms
The fear of flying can be an overwhelming and distressing experience for many individuals, as it can penetrate the very core of their being. Those who struggle with this fear share a common desire: to avoid taking to the skies altogether and instead opt for alternative modes of transportation, such as cars or trains.
The mere thought of being thousands of feet in the air can trigger a cascade of physical reactions, including trembling, sweating, and an accelerated heart rate. It can also induce breathlessness, nausea, and dizziness, culminating in a tumultuous internal struggle. Unforeseen panic attacks can arise mid-flight, leaving one feeling disoriented and out of place.
To assuage their anxieties, individuals often adopt pre-flight rituals to settle their minds, such as methodical luggage checks and focusing intently on the airline's safety information. They may also conduct extensive research on weather conditions and flight paths to establish a sense of control and alleviate their fears.
Reaching for the Horizon
To guide one lost in the grip of fear toward the vast expanse of the open sky requires an intricate web of approaches. A tangled mesh of underlying reasons, such as past traumas, phobias, or learned responses can ensnare even the bravest of hearts. Thus, a comprehensive approach, weaving together multiple methods, offers the strongest hope of untangling their distress.
The fear of flying can be compared to a turbulent and intimidating ocean. However, much like a competent captain can steer through stormy waters, there are methods to navigate through emotional turbulence and discover peace while flying in the skies.
Like a seasoned chef, a mental health professional may use a delicate mix of therapies to create a recipe for success. Psychotherapy can be like a sturdy anchor, providing a foundation of understanding and support. Cognitive-behavioral therapy can be like a compass, guiding the mind toward healthy thoughts and behaviors. The act of providing the information is a cerebral intervention, one that seeks to empower individuals with the knowledge to challenge their anxious thoughts. Often referred to as "psychoeducation" in literature, this technique draws on the power of accurate and reliable information to create a reality-based alternative to anxious thinking (4).
Exposure therapy can be like a gust of wind, lifting the mind out of its comfort zone and into a newly found state of confidence. To embrace exposure is to step boldly into the realm of aviation, immersing oneself in the pulsing heart of airports. It is a visceral encounter, one that requires courage and fortitude, whether experienced in the tangible realm or through simulation technology (5). Getting on a flight can be almost insurmountable, but they try, nevertheless, when in vivo exposure is used. They journey to airports with their hearts pounding, subjecting themselves to public areas and maintenance facilities. They are even taken to towers to confront their fears and overcome them. In cabin mock-ups and static planes, they confront their anxieties with shaking nerves. In the last 25 years, a new method of exposure using virtual reality has emerged. With head-mounted displays, the person in fear is transported to an aircraft-like setting, where sound and vision surround him. Immersed in this simulated world, it is a breathtaking experience, one that's proven as effective as in vivo exposure.
And just as a sprinkle of salt can enhance the flavor of a dish, medication can be a tool to alleviate anxiety and ease the journey.
For dessert, mindfulness practices can be like a refreshing breeze, calming the mind and restoring a sense of peace. Visualization can be like a beautiful sunset, casting a warm glow of hope and tranquility. And deep breathing exercises can be like a soothing melody, lulling the mind into a state of relaxation and harmony.
Though the journey may be challenging, with the right mix of approaches and support, it is possible to rise above the stormy sea of fear and fly in the sky with confidence and joy. This multi-component program offers a holistic approach to managing the fear and anxiety of flying, weaving together different techniques to form a tapestry of healing.
I shall conclude as a poet who welcomed the vulnerability of exposure as the crucial essence of this feast, savored by a refined palate.
When first we feel the rush of shock,
Our hearts beat fast, our nerves unlock,
Arousal floods both flesh and mind,
But soon habituation we find.
For exposure, the key to growth,
Requires a spark, a jolt, an oath,
To push beyond our comfort zone,
And face the fear we've always known.
Yet as we brave the unknown land,
Our bodies adapt, our hearts expand,
And what once caused us the great alarm,
Now poses little cause for harm.
So let us embrace this vital truth,
That growth requires a daring youth,
To face the fear and take the chance,
And let habituation's calm advance.
1. Fear of Flying, by Erica Jong, Signet, 1974
2. The Love and Fear of Flying, by Douglas Danford Bond, International Universities Press, 1952
3. The psychology of fear of flying (part I): A critical evaluation of current perspectives on approaches to treatment, by Margaret Oakes and Robert Bor, Travel Medicine and Infectious Disease, 8: 339-363, 2010
4. All We Have To Fear, by Allan V. Horowitz and Jerome C. Wakefield, Oxford University Press, 2012
5. The psychology of fear of flying (part II): A critical evaluation of current perspectives on approaches to treatment, by Margaret Oakes and Robert Bor, Travel Medicine and Infectious Disease, 8: 339-363, 2010
6. A controlled study of virtual reality exposure therapy for the fear of flying, by BO Rothbaum et al., J Consulting Clin Psychol, 68(6):1020 – 1026, 2000.
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