Welcome! Here's where you can obtain accurate Australian-based Airline and Clinic-tested information about Fear of Flying

My name is Les Posen, a Clinical Psychologist in Melbourne, Australia.

A full colour brochure about my work - take it to your GP

Working with a dog phobic - notes from the first session and a surprise discovery 

What should you expect when you make an appointment to seek help and guidance for your anxiety condition? The reality of 21st century treatment might surprise you.

Almost everyone who comes to this blog is seeking help for their fear of flying, or help for someone who is fearful of flying. But because I mention in my blog's introduction that I work with a variety of anxieties, people come here because Google or some other search engine brings them here.

At the same time, referrals come to me from people who don't know this blog exists, referred by friends, family, my professional society, doctors, other psychologists, or from interviews in the media. If it's a flying situation, I'll take down details on the telephone, have the prospective patient send me an email, then write a return email with details of appointments times, as well as forms to fill in prior to the first session. (I also include address details, confidentiality arrangements, as well as payment details.  I also include requests such as bring a USB memory stick or an iPod to record the session. I also ask them to  wander through this blog to see if their situation has been discussed.

This week I saw someone for the first time referred by a friend for her lifelong dog phobia. This is quite a common fear, and in this woman's case, it had become a real intrusion into her quality of life, preventing her from enjoying visiting friends and going for walks. 

She came with her doctor's referral, which allows my fees to be substantially covered by Australia's national medical health insurance scheme called Medicare, and I took a history including how she believed her fear had commenced then worsened since being a young child and seeing her father mauled.

Now, like fearful flyers, there is no one dog phobic type. One has to understand the triggers that produce anxious sensations, and how the patient interprets those sensations. From there, one needs to understand what the patient does about those sensations and the accompanying thoughts, or cognitions.

In my new patient's case, rather than asking her to recount a recent event where she experienced a significant fear, I showed her a selection of pictures of dogs, including me with my German Shepherd Dog, which I'd removed from the premises for this first session.

These pictures ranged from small illustrations of little fluffy puppies, through to dogs playing, a collection of cartoon dogs (which brought a smile), through to larger working dogs doing their special jobs with their handlers.

Rather than just asking how she felt watching these pictures, I hooked my patient up to a heart rate monitor, connected to software which measures a parameter called Heart Rate Variability (HRV). The software analyses the change of heart rate over time, and when exposed to various stressors. Unpleasant events produces a characteristic lowering of HRV, suggesting activity of the Sympathetic Nervous System, bringing on the "flight" or "freeze" response. Please: Forget all the hype about the "flight and fight" phenomenon so beloved of stress management programs. They over-exaggerate the "fight" response, which does occur in animals where the original concept of stress was developed. But for most humans, it's the freeze response that occurs, like a rabbit caught in the headlights, and where our rational thinking seems to get cut off.

In fact this is how my patient described her reactions: If she can she will flee a situation which she predicts will bring on danger (like a dog coming towards her off lead). Or if escape is not possible, or the dog is too close, she will go into a freeze response, closing her eyes, and standing rock still.

These responses are evolutionary in nature, serving to save us from immediate danger, but in modern times, they're overkill. So, while she watched pictures of dogs more and more looking like her fearful situation (i.e., going from easy to difficult to watch) I was monitoring changes to her HRV which clued me in to what she was really experiencing.

At one point, having pointed out to her her stressful physical responses which could be measured ("yes, it's like a lie detector!"), we stopped watching pictures, and I showed her in more depth how the HRV measures could be shifted from low (stressed and wanting to flee) to high, a place we could call "calm energy". By this I meant there was still arousal going on, but it wasn't to be confused with a state of relaxation or leisure, like chilling out or kicking back, as some describe.

No, this is about achieving a better balance between the flight response - the Sympathetic nervous system's getting kicked into high gear - and the freeze reaction, where the Parasympathetic system kicks into high gear. Both systems have evolved to be employed for a brief time only - a minute or so until the danger has passed.

But what the HRV training does is to help people achieve a healthier balance between these two systems, much like a rally driver "dances" between accelerator and brake to negotiate corners. You don't want too much of one or the other except in emergencies, but most of the time you want to achieve a more effective combination.

The training in fact starts with changing breathing patterns from unconsciously using the muscles in the throat, chest and back, to more belly or diaphragmatic breathing. Patients can immediately see the change in heart rate that occurs, with heart rate over time changing from a seemingly random and choppy line, to a more predictable hill-and-dale appearance, like a sine-wave.

For an anxious person, knowing they can control a part of their physiology which is the source of and response to their anxiety, is a major breakthrough. In the first session, this generates much hope and motivation for what's to come later: eventual exposure in person, hands on, to their feared stimulus. But we take this in small steps, building competence and confidence as we go along.

Now, you will read of one-session miracle phobia cures, and be offered DVDs and CDs containing training for quick results. By all means, read the testimonials and evaluate for yourself the reality of the claims you'll read and hear about. Frankly, I hold major scepticism for the application of these techniques for all people, but probably there is a small cluster who can be helped in just one session. It's just that in my evaluations I never get to meet such people. It must be my referral system where I'm referred people who've tried almost everything then see me as last recourse; or, they've read all the miracle cure literature and then come to this blog and decided what they've read here better appeals to their sense of how change is possible even for long-held and seemingly intractable fears. Caveat Emptor.

In the next session for my dog phobic patient, I'm going to show her how a dog develops a phobia, and how it's helped to overcome it. Something a little out of the ordinary, but there is method to this apparent "madness".

Now to the point of this blog entry: At the end of the session, the patient and her accompanying friend left quite buoyant and hopeful, eager to return the same week to continue the work and watch the video. Asked if what occurred in today's session was what they expected or if they surprised by today's session content (a question I often ask new patients), the patient said, "Yes!" Why? Because I thought it would be just talking... I didn't expect so much activity and learning!"

And this is my point. Behaviours can only be changed by behaving differently. Just talking about new behaviours will get you only so far, just like reading a self-help book. What I think is needed is an appropriate plan for any one patient's presenting situation and history, and then the formation of a good working alliance together with proper measurement to show the patient change is possible, and this is how and why it's going to happen.

If you're thinking of seeking help, ask your prospective agent of change how they go about the change process. Is it just talk, do they accompany you into the feared situation, what model of change do they espouse and where can you read up on it before the first session, so you can start the work in a state of expectation and hope for change, as well as knowing what you're in for in terms of your contribution to the change process?

Bottom line: You don't have to live with phobia. Change is possible with the right guidance, therapeutic alliance, measures, and planning.

What to expect when you contemplate contacting me for assistance...

Even if you're not in a position to contact me directly, consider the following as clues to what to seek when you contact a professional in your area.

Ok, so you've read through the blog and decided that - "yes, I'd like to come and chat about my fear of flying (or other anxiety-laden situation), so what do I do next?"

Well, the best step so far is to make the decision that you've read enough to get the feeling that a call to me is the next logical step in what seems a rather illogical exercise!

When you ring that mobile number, I'll personally answer 95% of the time. The other 5% of the time it will be answered by an assistant, or will divert to voicemail. If the latter, leave a message including your name, and number and best time to call back. Simple. If it's an assistant who answers, she'll either ask you to wait until I can come to the phone, or she'll take down details when I can call you back or you can ring later in the day or the next day. 

I usually answer voicemail within an hour or two, or if I'm in a workshop or overseas, it can take several hours.

It's also OK to email me (les at lesposen.com - use the @ symbol instead of "at") and outline for me a summary of your concerns and any deadlines (eg departure dates, presentation timetable) you are working towards. I tend to move people with critical deadlines up in my waitlist schedule although I keep very brief waiting periods. You can also let me know how best to contact you (email or phone), best time of day, and if you've already seen your GP for a referral to me.

If you choose to ring, make sure you have a few minutes to chat, as I don't merely make appointment times. I usually ask some questions about your situation in an effort to gauge if I'm the right person for you to be seeing now or if there's another referral that should occur first (happens in about 5% of phone calls).

I'll also usually ask you to write me an email with your contact details, and I'll then write back with a selection of appointment times, trying as best to fit in with your time demands - somewhere, we'll find a best match for both of us.

After that, you can expect an email from me containing:

1. Time and date of appointment.

2. Location (including nearby streets and public transport, and parking information)

3. Length of session

4. Costs, including means of payment and direct debit banking details.

5. Some attachments, usually pre-session questionnaires relevant to your situation.

6. A notice about recording the session so you can play it back between sessions and recall often overlooked important things said. For that reason, I also encourage patients to bring a USB thumbdrive, and invest in an mp3 player, like Apple's iPod (which start around $70). Patients can also bring their own laptops for me to transfer files of relevance.

7. Final reminder of my contact details, and mention of cancellation notification.

These pre-initial session details I find help to demystify the psychology change process, and help prospective patients feel they've made the correct decision to seek help, and seek it from me.

My task is then ensure that those initial feelings of hope for change remain throughout the sessions.

 Almost all fearful flyers who have done well will experience the odd return of fearful thoughts and feelings in the days before their next flight.

 Here's one patient's story and my guidance for dealing with this challenge.

 Many people who have worked hard to manage their fear of flying learn that the best way to keep their fears at bay is to keep flying, each time practising their learnt skills, behaviour and ideas.

Every so often, a patient will phone me a day or two before a scheduled flight for a brief chat, having noticed a sudden return of their anxious thoughts and feelings.

These calls come out of the blue for me, and I usually have to be quick with some reinforcing words and ideas before moving on with my own tasks for the day.

This happened today when a patient who has now enjoyed much progress rang me, with pre-flight jitters. Because I had flown with her on several occasions and had observed her progress directly, I felt confident in being able to spend a few minutes with her sorting through what needed to be done to prepare her for her next day flight.

In this case, the most important thing is to remind the patient of the normality of the thoughts and thus sensations she was experiencing. That is, because she was accessing memories of previous flights as part of her preparation, the "quick and dirty" part of the brain was also tuning in, and sharing experiences. This part short-circuits the slower thinking, decision-making parts of the brain (the pre-frontal lobes) and is responsible for "act now, ask questions later" behaviours and thoughts.

This meant my patient needed to slow things down, by going through her diaphragmatic breathing exercises (the patient in question has purchased from me a heart rate variability device which allowed her to see if her breathing was of the right kind). Once responding with calm energy, she was instructed to say out a aloud and write down her thoughts about how safe the flight would be, certainly compared to being at home (outer areas of Melbourne are still under bushfire threat) and driving to the airport.

These were well-rehearsed thoughts, practised before a number of previous flights, and she knew they worked for her.

So the message is: It's normal and OK for old ideas to leap in when you're about to do something with which you have "history". The task is to recognise that these ideas are "old brain" ones, designed to get you to act quickly without much thought, and increase arousal levels. Any patient's task is to bring the frontal lobes into the problem solving mix, by better emotional regulation through arousal control (breathing) and appropriate self-talk, focussing on dismissing catastrophic thinking, and rehearsing seeing oneself saying positive sentences approaching various scenes in the flight "envelope", ie. leaving for the airport, arrival, check-in, waiting at the Gate for the flight to be called, boarding, etc.

All these plans can be used to move further and move from being an "automatic" fearful flyer to one who sets achievable goals and moves steadily forward.

Another way of measuring the frequency of fearful flying:  how often is it declared a medical emergency? 

 A journal article in Critical Care published January 20, 2009 gives some clues as to how often fear of flying presents as a situation requiring medical intervention.

If you've been travelling of late and have been a frequent traveller over the last 10 years, you'll know the world of commercial aviation has changed.

A post-9/11 world, changes in economy circumstances, and the development of new aircraft types have seen commercial aviation go from a rather exotic and fun means of getting from A to B, to a much more stressful less pleasant way to go. Fortunately, what hasn't changed is commercial aviation's emphasis on safety, and it remains after elevators and escalators the safest form of mass transport.

What has also changed is the demographic of the flying public. With the advent of no-frills airlines resulting in much cheaper flights, and an aging population, the likelihood of onboard medical incidents has also increased.

To assess this, a group of medical researchers sought information from many of Europe's leading airlines as to incidents on record between 2002 and 2007.

Not all the airlines co-operated unfortunately, but of those who did, more than 10,000 incidents were recorded along with the likely diagnoses.

Here's the title of the article from the actual journal, below:

disorders were responsible for 8.9% of all emergencies (926 cases). The third most common medical emergency was cardiac conditions (509 cases, 4.9%), followed by fear of flying (460 cases, 4.3%), and generalized pain (432 cases, 4.1%)."

What's interesting from an airline's perspective (the cost of diversion is mentioned in the article as being anywhere between $25,000 and $750,000) was that the figures didn't include fear of flying incidents before or during boarding, which can be a "peak experience" time for fearful flyers.

This is when they can baulk and end up being no-shows, requiring time-consuming luggage removal. Or for those feeling overwhelmed by closed doors, can cause the occasional return to the gate after taxiing in order to be let out.

(A former patient who regularly flew domestically and internationally would baulk half the time. So in order not to delay the aircraft he only ever flew with onboard luggage, never checked luggage).

What's also interesting is the total number of incidents - over 10,000 - which were turned over for study by the two out of thirty two airlines who returned data to the researchers, for the five year period under investigation. And that fear of flying was so high up on the list, especially since the conditions labelled as such were serious enough to require medical intervention! Meaning there must have been many many more subclinical cases which did not attract medical attention where the flyer struggled to get through their flight without assistance.

These data suggest airlines need to take onboard medical emergencies seriously, equipping their aircraft with appropriate equipment - particularly oxygen if one carefully reads the report and those of other researchers - and they deserve to reinstall their fear of flying courses, many of which were cut back in cost cutting efforts in recent years.

It may turn out this was a false economy, and airlines might wish to re-instate their courses, not just for the public relations value, for the likely return business it will generate, but because it may well save them money in the long run.

Full report in PDF form here:cc7690.pdf

Thinking about the issue of safety - it's the most basic of shifts in behaving that produces the best results.

 Ideas for you to ponder - and not just for fear of flying, but for most anxiety situations.

 The more I work in the field of anxiety, the more I become convinced that the task of the therapist is to guide his or her clients to feel safe. 

I embolden the two words "feel safe" because I am taking the term "feel" quite literally. To feel safe enables one to take risks. That is, to go into areas or scenarios which may contain elements of risk - that is, possible surprises or unknown elements - yet feel competent in being able to manage whatever novel or unexpected event may occur.

In other words, if you were to only go into situations where the statistics gathered by others or yourself inform you that there is 100% chance of nothing harmful happening, you would find extremely few places on earth to offer that guarantee.

Because of the necessity to go about a world where 100% guarantees don't happen, our brains have become very inventive over millenia to help us ignore risks when they are right under our noses (and in full view). The flip side of this capacity is that we are also inventive when we are able to see danger when statistically risk is very low, or certainly much lower than other things we do with demonstrably higher risks.

Just as us seeing the world is not a property of our eyes (they are just signal detectors) but of our brains - where we make sense of all the lights, and colours and movement and shapes our eyes detect - so do our brains make sense of what seems to be safe from what appears to be dangerous.

The task of fear of flying treatment, no matter what style or methods are undertaken, is to help the patient "feel" safer in the commercial aviation environment. For some that will be a return to previously held feelings of safety before some life changing event took place (which may or may not be aviation related).

For others, who have never felt safe in the aviation environment, a different set of procedures to inculcate a sense of safety needs to be developed. Again, a "one size fits all" treatment strategy disrespects the individual and his or her concerns.

Which is why you can hear very different outcomes from the same treatment program. For instance, at the recent 3rd World Congress on Fear of Flying in Montreal in June 2007 (where I presented too) I heard a number of airlines speak of their programs. Each used their own flight staff as well as psychologists for "relaxation training" and to provide some explanations about anxiety and fear.

Each claimed about the same outcome result: about 95% of people in the course did the graduation flight. What we don't know and I didn't learn was how many people took how many flights in the year after the graduation flight.

What each of the courses had in common was a great deal of information about flying - how planes do it - and the training of crew to make the experience a safe one.

Where most of these courses fall down is the abundance of accurate information about commercial aviation, but a relatively low priority placed on human physiology and psychology. For me, that's where the action is for most patients who come to see me.

When patients know that their bodily sensations are adaptations to certain sensory information such as turbulence, accelerations, changes in engine noise, then they can start the work of normalising these reactions and not having a secondary reaction to them, i.e, being scared of being scared. In other words, both the triggers and the resultant sensations are normal aspects of flying and do not constitute danger. Thus, the alarm bells or panic button can be switched back to standby mode (rather than off).

Many people learn to switch to standby (or low level monitoring mode) using medications or alcohol which can moderate the body's natural ability to reset the alarm bells. The ability is the province of what is called the Parasympathetic Nervous System (PNS), which is one half of the body's automatic response system, known as the Autonomic Nervous System or ANS.

The major nerve which innervates the PNS is the Vagus nerve which both sends and receives information from and to the brain and various parts of the body such as the heart and gut. It is known as the 10th cranial nerve. The other eleven mainly innervate the head, neck and face.

When our alarm bells go off - whether the danger is real or imagined - the PNS decreases its activity so that its opposite number, the Sympathetic Nervous System (or SNS) can recruit many muscles to do the job of acting upon the presence of danger. Think of the PNS and SNS as opposite sides of a see-saw or teeter-totter. As one goes, up the other goes down.

Both animals and humans have similar nervous systems in this respect, and for both, the SNS kicks up a notch in the presence of perceived danger or threat, and causes the animal to either flee or prepare to fight. Sometimes, the brain makes a very quick decision that neither option will promote survival, and so the SNS is outranked by the activity of the PNS which engages the body in a freeze reaction, causing immobilization. We sometimes refer to this as frozen with fear.

This has survival properties in the hope that a predator will not notice a non-moving, non-breathing animal which appears to be feigning death. But this can only be sustained for a minute or two at most, before the animal needs to breathe once more. (Some animals use the same mechanism to go deep diving for long periods of time).

It's similar to going to a horror movie and hearing the audience collectively inhale and hold its breath when a scary image or sound is noticed. It's quite automatic and built into us for survival purposes. Only when we feel safe from danger can we return to normal breathing patterns.

People who are chronically stressed have a disturbed balance between the relative strengths of the PNS and SNS. Usually, stressed out individuals have very low PNS tone as it's called and an overactive SNS which leaves them strung out, irritable and tired. It also makes logical thinking and planning more difficult, and creative thoughts are hard to come by. In other words, the see-saw or teeter-totter is seriously out of whack!

Such people need to be taught how to increase their Vagal tone, and this can be achieved through learning breathing techniques combined with emotional shifts, such as feeling what it's like to have achieved something, or having cared for someone in your life. While I have mentioned the survival mechanisms of flight, fight and freeze, we humans have a fourth and that is to flow, which usually means relying on our social bonds and community to get us through difficult times.

In essence, what one is trying to do is teach the brain/body better means via practice to increase the effectiveness of the PNS and decrease the reactivity of the SNS when it's not needed to kick into action. This can be assisted by also changing one's thinking style to better reflect the reality of the presence of danger or its absence.

Unfortunately, too many therapists put all their eggs in one basket and merely try and help people change their thinking ("turbulence might be uncomfortable, but not unsafe") without helping their patients actually feel safe, in the full meaning of the words.

The virtue of going on flights with patients, or using some virtual means, is that patients do get to experience their uncomfortable sensations while being guided in how to modulate their impact via physiological shifts (e.g, don't hold your breath and don't bring in tension by gripping the seats), and changes to thinking, such as "I know what to do... I have a plan to use my new ways of thinking and breathing".

When patients integrate these two modes of danger reduction, they feel safer, and thus more likely to better estimate their chances of surviving a commercial flight. In other words, they feel it's OK to take a "risk" they ordinarily would avoid, knowing they have tools to manage the risk.

This sounds simple, but requires practise, and the hope generated with the therapist that the practise will pay off in the long run.

Unfortunately, from my perspective, too many Google searches on treatments for fear of flying see the promises of fast, easy and guaranteed "cures" which undermines the time and effort required for enduring success.

I wish it were as easy as many of the websites promise, but in my experience many of these changes are short-lived, don't last beyond the next flight, and don't generalise to other feared situations other than flying. 

US Airways 1549 Airbus A320  into/onto the Hudson River, New York City 

 Important lessons to be learnt from this most fortunate outcome.

On January 5, 2009 I flew from Miami International Airport to Charlotte, North Carolina on board a US Airways Airbus A320. For all I know, Captain Sullenberger may have been the captain of that flight. Or some of the flight attendants on board my flight may have been on board US 1549.

Naturally, patients and pilots alike are talking about this flight, each coming to it from their own perspective. Each group will be filtering the information coming to them, principally from mainstream media reports, and later to come from official NTSB sources once flight recorder equipment data is analysed. But there are some thoughts about this incident I want to share with readers.

1. As much as the media has seized on the event's positive outcome - no lives were lost within the aircraft or within the aircraft's flight path - by calling it a "miracle", another view is that years of training and preparation met with quick-witted decision making. All those years of pilot and flight attendant preparation came together to achieve a successful outcome. It's quite possible Captain Sullenberger with his military and gliding experience pulled off the sort of landing other captains might not have been able to achieve. There is evidence for the superiority of some pilots' training and abilities over others, especially in a state of heightened superarousal. When United Airlines UA232 (Denver to Chicago) lost its centre tail engine, it made an emergency landing in Souix City Iowa despite only being able to change direction with engine thrust variations. When other pilots tried to land the aircraft in the flight simulator using all the same flight parameters, even the most senior could not match the performance of UA232's captain, Al Haynes.

2. Apparently, at some point after the aircraft had been rendered powerless via the bird strike, the Captain called out, "My aircraft!" While you might think this was an exclamation of despair, in fact reports published state that his first officer was the pilot flying (PF) at the time. Realising the emergency, the captain took physical control of the aircraft by calling out "My aircraft". Quite possibly, we'll see written reports his first officer responded with "Your  aircraft" to acknowledge who had physical control of the aircraft's flight control systems. This is standard practice.

3. It has been revealed the flight attendants were all women in their mid- to late-fifties. When I fly internationally, I usually fly across the Pacific to the US with United Airlines despite its outdated equipment when compared to rival QANTAS with whom I often fly domestically. UA simply has the better frequent flier scheme for my needs. But also having flown with them for many years and almost 700,000 miles, I know their cabin crew are the airline's most senior. Frankly, if I am to face an emergency give me surly senior flight attendants every time, who will brook no nonsense and evacuate the aircraft if needed swiftly and safely.

4. Many patients with a fear of heights wonder why aircraft must fly so high up rather than cruise much lower (within view of the ground). The answers are simple: aircraft jet engines perform far better in the thin cold air at very high altitudes. Thinner air also leads to less wind resistance, and thus better fuel economy. There is also less traffic at height, and most importantly should an incident occur, the greater the distance between plane and ground, the more time the crew have to figure out emergency procedures. The crew of US Airways performed exceedingly well because they had to make split second decisions knowing they had only minutes to deal with the situation they faced.

5. This event should put pay to the falsehood that an aircraft losing its engines simply falls out of the sky. In this case, there was sufficient forward velocity to allow for a glide ratio which allowed the crew to make their decisions as to where to put the aircraft to minimise risk to those on board and on the ground.

6. Aircraft can be set up to float if it's known a water landing is likely. There are procedures rehearsed for ditching, and aircraft can be controlled such that water invasion of the hull can be minimised leaving enough time available to evacuate all on board. In the case of US 1549, there was extra bouyancy from the wings as they were not full, and jet fuel's properties allow for greater floatation.

7. My experience with Ansett Australia's development of its Passenger and Crew Welfare manual in the late 1990s saw  me train with United, Continental, and other US airlines and be privy to the aftermath of airline incidents such as TWA 800. Expect some surprises when the full story of the events on the Hudson emerge. This is standard when rare and complex events occur, and it can take quite some time, such as months, before the full story emerges. I especially expect to hear stories of the actions of the cabin crew and passengers in effecting the safe evacuation of all those on board.

8. Patients need to be aware of their cognitive bias kicking in, screaming at them "See! It's dangerous to fly!" My cognitive bias is to see this incident as more evidence of their rarity, and how well-trained personnel kick quickly into their well rehearsed simulations. For me, it reinforces that flying remains the safest means for moving large numbers of people large distances.

Some thoughts about claustrophobia on board aircraft

Trapped in an elevator falling 15 floors - or did it? A Melbourne news story showing how easily our senses can be fooled.

Comparing airline crews' approach to fearful patients taking a flight, accompanied by their psychologist

Every so often you get a chance to see how two airlines competing in the same market place for the same customers, truly compare. I did this on the weekend, accompanying a patient to Sydney and return as part of her fear of flying treatment with me. Let's say at the outset that ordinarily, when psychologists write publicly about patients, they usually try to obscure the patient's details so they cannot be identified. Some even go to the extent of writing in a way that the patient themselves cannot identify they are the subject of the story. One can do this by taking an amalgam of patient experiences and conjuring up one story, true in its elements, but not true to it being the sole experience of one person. It's quite an old literary technique to preserve confidentialities and protects informants and useful sources of information.

One of the problems with fear of flying, when using an exposure based model - that is, actually getting on board aircraft with patients - is that there is always a breach of confidentiality when introducing onself and one's patients to crew. For most patients, this is seen as the cost of doing the business of behaviour change. For myself, it's also a part of doing continued business, so that where possible and with the acknowledgement of the patient, I'll let the airline know ahead of time that we are flying with them soon.

I have regularly done this with QANTAS in Melbourne, contacting Duty Managers by phone or fax, especially when I have spoken to staff recently about getting patients on board stationary aircraft as part of the exposure program. (Not all patients need this, but some are clearly advantaged by this in vivo treatment).

I expect nothing from QANTAS - no special service, no upgrades, no special attention. But there have been times in recent months when my good relationship with QANTAS staff at Melbourne has been especially useful in unexpected situations, and so I find it best to maintain good professional relationships where I can.

I have tried in the past to do the same with VirginBlue, based in Brisbane, but have been consistently rebuffed or my emails have gone unanswered. Bear in mind that these dealings have been with VirginBlue management, and not with crew.

This past Sunday, my patient followed my guidance and booked flights to Sydney on QANTAS and return on VirginBlue. This was no accident, as I had suggested that our first flight together, following several sessions using Virtual Reality and elevators (to help work with the claustrophobic aspects of her presentation), would best be served on the largest aircraft we could fly on as inexpensively as possible.

This turned out to be QF73, a 747-400 from Melbourne's International terminal into Sydney's International terminal. This service then continues on to San Francisco, so is a great way for patients to experience international check-in, customs, and the excitement of people travelling overseas. And it's the same price, and often cheaper, than the usual domestic flight. For some it's more of a hassle, since you cannot use the automated check-in facilities and must get to the airport earlier, but for therapeutic purposes, it's very beneficial.

Also, depending on the time of year, the flight can often be half-full, giving the claustrophobic patient a better opportunity to deal with being in "a large tin can" which is not too crowded. You still can't get off, but there is a greater sense of abundance of air to breathe and room to move.

After clearing customs and security, we spent some time in the international waiting area near Gate 8 contemplating the best time to board: wait until most people had boarded, or get on early and wait on board for the flight to commence. Given that anticipation of feeling uncomfortable was a primary concern, it was agreed to board early and spend more time on the plane, dealing with any urges to get off (escape) into "freedom". Which is what we did, with plenty of time before the scheduled departure.

Once we got our seats (we'd been moved from the back of the plane where the computer had put us to just behind business class by the check-in staff who didn't know of our purpose for flying that day), we settled in and I asked about her boarding experience. My patient thought about it and admitted to a mild case of "jelly legs" on boarding, a sign of physiological arousal. So, I suggested she deplane and do it again, and use some of the training we'd done to reduce her arousal and board without the jelly legs. This she did, and reported improvement. But she also reported some quizzical looks and questions from the cabin crew stationed at the door, who didn't know our purpose for being on board. In fact, while the patient had been heading back out, I had located the cabin crew member servicing our area and explained our purpose for flying, and reassured him, together with my business card, that it ought to be smooth sailing, and we needed no special attention.

On her return, he greeted her and explained that if there was any assistance she required, she should let him know.

When I asked her mid-flight about the experience, she said that the cabin crew seemed more apprehensive than she felt! But overall, the impression left was one of professionalism and courtesy.

During the flight, we were checked on once more, and done so quite discreetly.

Disembarking after a rather uneventful flight which took us to the west of Sydney, then landing to the north on the main runway, RW34L (over lots of water of Botany Bay), my patient was able to experience a roll-out where the 747's weight allowed it to roll past RW25 (the east-west runway) towards the terminal without the need for energy using reverse thrust, and with just a dab of brakes, the giant plane was brought off the active runway onto taxiway then tarmac. From there, we disembarked (I left behind my boarding pass which was required to clear Sydney customs, so had to go back and retrieve it) then we caught a bus over to the domestic terminal for the VirginBlue flight to Melbourne in 90 minutes.

Here's where I'll place some brochures for you to read about my work

I'm asked often why I give away my knowledge for free on this blog - here's why...

Flight Experience - a New Zealand franchise that let's you fly a 737-800 simulator

Boeing 787 Dreamliner roll out - July 8, 2007

Boeing Aircraft corporation's newest commercial jetliner is due to roll out the hangar on 7/8/7 and will be broadcast live.

Boeing's bet on the future of commercial airline travel, its 787 Dreamliner, is due to be rolled out from its hangar for its first public display on July 8, 2007, which using American convention of mm/dd/yr makes it 7.8.7.

You can view the live ceremony here, starting at 3.30pm PDT (8.30am Melbourne time, Monday July 9)

This is one of the most anticipated of launches because unlike Airbus with its huge A380, Boeing has bet the world wants smaller aircraft with very long distance endurance capacities. Boeing has employed a team of psychologists to help with the plane's interior design and systems, to make passenger comfort a top priority.

"Er - what happened to the reverse thrust?"

A couple of patients returned from their journeys, and today came by for a debrief. This is normal procedure where I invite my patients to spend some time understanding the lessons learnt and lessons applied from their work with me and their subsequent journeys.

Today, the patient I want you to learn from returned from time spent in Europe, in particular Italy. Soon after arriving from Australia, this patient went with some of her family to Sicily where her MD-80 jet landed at one of the island's two main airports, Catania-Fontanerossa.

She described the descent as quite rapid, with multiple changes of speed. Apparently, she was able to manage this part by focussing on what we had discussed during our sessions about typical flight let down experiences, and the different ways aircraft negotiate their way to the runway depending on a variety of predictable factors.

What apparently causes her much anguish was the landing. After touching down the aircraft kept rolling down the runway at high speed and she thought it was about to take off again. She heard no reverse thrust and became quite panicky. The plane in fact did eventually slow down and parked safely at the gate at the newly modernised terminal.

It was her report that the other flights in her time away now became more fraught as she now became highly aroused and aware during landings, a time when she had customarily relaxed.

So what happened?

Clearly, her expectations of what was a normal, and thus safe, landing was violated. I'll go more into this when I give a full report about my presentation at the fear of flying congress in Montreal, but when things did not go according to plan, she felt a sense of loss of safety and her old anxiety routines kicked in.

In today's session, I felt she needed some effort to explain what may have happened. Now keep in mind I know nothing about the Catania airport, but I felt I needed to offer some plausible hypothesis as to what had happened when she landed.

So I started with a wikipedia search of the airport to find out about its runway configuration and proximity to various geographical features such as mountains and sea. It's near both, as well as Mt. Etna.

But what was most important to note was that the single east-west runway at the airport is almost 8000 feet in length. That's almost but not quite two miles. The runway length needed to land an MD-80 is about 5000 feet - that's the recommended runway length as designated by the US-based FAA, i.e., it is not permitted to land on runways less than that length.

In all likelihood, in regular commercial flying the MD-80 would need about half the length of Catania's runway to pull up. Now depending on whether my patient's plane came in over water or land, as the picture below shows (found using GoogleEarth) her flight could simply continue down the runway using brakes alone to bring the plane to taxiing speed in order to make its way to
the terminal area, where the plane would be parked.

ICAO Fear of Fying Congress, Montreal, June 4-6, 2007

Fear of Heights - a most common fear, which I'm about test next week at Melbourne's Eureka Towers 88th floor, known as the Edge.

Did you know that one of the commonest most intrusive "irrational fears" is that of heights? Known as acrophobia, in our modern world anyone with a significant fear of height is at a real disadvantage when it comes to daily living.

Whether it be associated with a fear of flying, driving over water on high suspension bridges, visiting friends in high rise apartments, or even climbing up a ladder to clear the leaves from your home's gutters, it can be quite intrusive for sufferers. And that's not to mention those who need to ride elevators to high floors in office buildings for their work.

Here in Melbourne, one of the tallest structures in our CBD is the Rialto Building. It's a popular office complex housing both government and private sector business, and at it apex it has a visitor's centre where behind mesh fencing you can walk around the building's roof and see 360 degree views many miles away. Then you can pop inside and have a beer, cup of tea, or soft drink to recover.

It has special one stop lifts controlled by operator so the lift heads straight for the top floor. The building has other lifts which service offices, and these are the ones I use with patients in a stepwise effort - pardon the pun - to help them get higher and higher. The ultimate aim is for them to ride the visitors' elevator on their own to the viewing area some fifty floors up.

Well, the Rialto's reign as tallest structure for viewing is about to come to an end with the official opening of the Eureka building viewing platform next week.

This is not your usual viewing area like the Rialto, CNN Tower or Empire State Building.

It seems those who run the show have decided to turn the trip to the viewing area into a theme park ride.

My thoughts on the Garuda Airlines GA 200 incident at Yogyakarta, Indonesia, March 7, 2007

This past week saw a tragic loss of life in an airline incident in the Indonesian island of Java, at the international airport that services Yogyakarta (pronounced "Jog-jakarta").

Shown below is a map of Indonesia, with the area of central Java highlighted in bright green. This area is about 500 miles to the north-west of Australia, about an hour's flight away.

Let's magnify the location to show the city of Yogyakarta, where the incident took place.

You can use GoogleEarth to locate the district's airport, known as Adisucipto International Airport. Wikipedia will tell you more about it, and is keeping a current article open on this incident.

In this blog entry I want to discuss some details of the incident as far as is known at the time of writing, knowing also that the cause of the incident has yet to be officially proclaimed, and a number of survivors are still in critical condition, some undergoing life-preserving surgery. I wish them and their families the very best in what will be a long period of recovery. New ways of thinking about what constitutes "normal" will likely occur.

To those who lost loved ones, family and friends, please accept my sincerest condolences. It is one thing to lose people to premature death, it's another to lose them in such horrendous circumstances.

The purpose of this blog entry is not to minimise what has happened, but to try to provide a psychologist's viewpoint which may bring some understanding to what has happened and what will likely happen. I am hopeful current and past patients will use the information I'm going to provide in an effort to "hold their own" when it comes to their management of their flying behaviours, and not see themselves "slide back."

To prospective patients (of any psychologist or airline's fear of flying program), I hope the information here will help to balance some of the more sensationalistic reports you are likely to see and read before this incident is laid to rest. And my final hope is that media who are seeking some commentary and unique perspectives may learn something as well.

First, let me state that having worked with fearful flyers, both within and independent of an airline setting, I've exposed myself to many of the the more well-known commercial aircraft incidents, ones which frequently are portrayed on television and often come up for discussion in consultations. In addition, my training with airlines such United Airlines and Continental Airlines has contributed to my knowledge of the passenger and crew welfare aftermath, and my studies in Knowledge Management focussed on what happens on the flight deck and larger airline systems wihich can help explain why rare incidents such as the one at Yogyakarta do in fact occur.

Let's start here: While we await more definitive explanations of what happened at Yogyakarta, experience has some lessons to teach:

1. Many theories of what caused the incident will be bandied about within the media. As time goes on, some of the theories will be eliminated and others will emerge as strong candidates. But one thing will become abundantly clear. No one cause of this incident will be found. Airline incidents of this nature rarely occur because of one fateful error or malfunction. If you read my blog entry on "Safety and Swiss Cheese", you will see how events within a system of "check, cross-check and re-check" rarely occur alone, but have a multiplicative set of linked causations. Multiple defensive structures must fail almost simultaneously for the inherent safety in commercial aviation to be overwhelmed.

2. As rare as these incidents are, those that came previously have been studied and their lessons learnt will be applied in quickly understanding what happened at Yogyarkata. Nevertheless, certain media reports from those most of us have come to trust implicitly such as commercial pilots, have already leapt to conclusions based on the same information you are I are reading in newspapers and hearing on the TV or radio news. These have concluded the fault lies at the feet of the pilots.

3. Others have condemned the Indonesian airline safety culture as being too lax, especially after recent incidents such as where a very heavy landing saw a similar aircraft break its back from a heavy landing at Indonesia's second largest city, Surubaya in February 2007. See the pictures below.

Adam Air lost another 737 on New Year's day 2007, and other reported incidents suggest that this airline's safety culture leaves much to be desired. I would have little problem telling my clients to avoid this airline and find alternative means to travel within Indonesia.

4. Australia's Foreign Minister, who was in Indonesia as part of a conference on international terrorism together with the country's Attorney-General, has questioned Indonesia air safety culture, and his concerns are rightly placed, as far as I can tell. Nonetheless, the matter of wind shear has also been implicated in the Yogyakarta incident, and reports since the incident suggest the same aircraft had experienced landing gear issues the day or two before. Other reports, stating that the aircraft's approach speed was much higher than expected, as judged by passengers and observers, might be due to pilot error, wind shear, or faulty mechanicals, such as the trailing edge flaps not being successfully deployed.

These devices, and the ones at the leading edge, extend the wing length from front to back, as well as increase the wing's curvature, allowing the wing to create greater lift at lower speeds. This enables a slower landing (and take-off where flaps are extended to a lesser degree), but also cause greater drag, noise, and "roughness" due to the smooth structure of the wing changing. Engines normally have abundant power to handle the extra drag at slower speeds, and of course the flaps are retracted in sequence after takeoff, as the aircraft accelerates to cruise speed. On the approach, they are extended in sequence according to speed. You can see them on the damaged 737 above right at their fully extended setting, where you can see the triple-slotted panels that make up the flaps. Extending or retracting the aircraft's undercarriage also affects speed, handling, buffeting, noise, and drag, and occurs according to a planned schedule.

What will need to be known with the current incident is whether the pilots had full control over the flaps, whether any failure for them to simultaneously fully extend (on both wings) occurred and the pilots were notified of it by the usual system checks, and if there was a failure, how is it that the pilots continued their approach if they knew their aircraft was unsafely configured.

5. In addition to expecting more information, both accurate and plausible as well as inaccurate and sensationalistic, we can expect more human interest stories to emerge. Those Australians who were killed and injured have become well-known to the Australian public following rather unprecedented media coverage. Some have cynically suggested that had no Australians been on board this would have been just another third-world loss of non-Western life. The incident received very brief coverage in the American press, and what it got was no doubt due to initial thought of terrorism given the number of Australians on board who were in the service of their country.

Since the incident, the local mainstream media have told us the life stories of those Australians, and we hopefully await news of the success of the recovery of those in intense care as I write.

6. Expect more unusual stories to emerge: Those who couldn't get on the flight and gave up their seat for someone who perished, someone who had a premonition and refused to fly, someone for whom this is not their first incident and they appear blessed with good luck (or bad depending on your perspective), and news of the pilots themselves. We'll hear of heroic acts (when either adrenaline or training or both kick in) and perhaps less than heroic acts from those we might expect better from.

7. Expect to hear more of the Swiss Cheese theory and how this incident will turn out to be what seems to be a conspiracy of low-probability events coming together when the usual safety defenses were breached. "Usual" is relative, and what will be exposed is whether "usual" in Indonesian terms matches "usual" in Australian or American or British aviation terms.

8. Against common sense, there will be fewer self-referrals for fear of flying treatment. Psychological assessment and treatment for fear of flying usually includes any patient's concerns about airline safety, but frankly, this is not where the action lies for most patients. Most accept how safe commercial aviation is compared to other forms of mass transport, and interventions lie in other than areas of safety for most people. However, for some patients where safety is the most pressing concern, these incidents confirm for them that their fears are real and necessary, and not at all irrational or out of the norm. Thus, the see themselves as not needing to be "treated", and they go about finding the best ways to construct their lives around not flying. Many people do this, and never seek treatment, and come to terms with travelling by much higher risk activities such as bus or train or car.

7. Incidents such as this do permit or even force us to pause and review our risk management strategies. Whether we like it or not, risk is all about us, and life cannot occur with any. At the moment, governments and concerned populations are reviewing the risks of continuing their activities while changes to world climate are being assessed as potentially life-threatening.

There are a number of people who write extensively about how we humans assess risk, and how we get it wrong. Sometimes, and often with adolescents, they underestimate risk; with older people, especially those of a conservative nature, risk is overassessed, and often conservative politicians play on these excessive fears, excessive because they don't match any replicable data gathering.

Much of our capacity to estimate risk is determined biologically, Here is one person's thoughts about how the brain is involved, using software as a metaphor:

"The brain is a beautifully engineered get-out-of-the-way machine that constantly scans the environment for things out of whose way it should right now get. That’s what brains did for several hundred million years—and then, just a few million years ago, the mammalian brain learned a new trick: to predict the timing and location of dangers before they actually happened.

Our ability to duck that which is not yet coming is one of the brain’s most stunning innovations, and we wouldn’t have dental floss or 401(k) plans without it. But this innovation is in the early stages of development. The application that allows us to respond to visible baseballs is ancient and reliable, but the add-on utility that allows us to respond to threats that loom in an unseen future is still in beta testing." (Daniel Gilbert, “If only gay sex caused global warming,” Los Angeles Times, July 2, 2006.)


Notice the table below, reproduced from a draft report by computer security expert Bruce Schneier, entitled "The Psychology of Security", which you can download here. (I"m already handing it out to select patients.)

Gathered from numerous pieces of research, this table attempts to summarise some of the ways we fallible human beings assess risk without really being aware of how we do it.

With aviation, many people report having a moment of doubt about the flight they are about to take, and then just as quickly dismiss it with a very rapid internal calculation that says the chances of something happening on their flight are extremely low, and haven't changed just because a thought of their mortality popped into their head unbidden. I occasionally have Lotto numbers pop into my head, but so far, I'm not driving around in a Ferrari as a result of taking a bet with them. (Mind you I did win a few thousand dollars a few years ago when I used the frequently occurring mystery numbers in the TV series LOST - which ironically started with an aircraft crash - to play Lotto)

8. That means that just because you have a thought doesn't make it true, but does require you to review it for veracity and utility. The brain has several mechanisms to cause it to go into "flight and fight" mode - the one that produces those uncomfortable sensations associated with anxiety - before you have a chance to think things through. If you're already perceiving strong physical sensations when confronted with a typical scary scenario, your brain is already into high anxiety mode, and trying to think yourself out of it is unlikely to be successful on its own.

You need to send the "calm" centres of the brain a very direct message that says "I'm safe, I'm just perceiving uncomfortable sensations due to (turbulence, thoughts, sights, sounds, unexplained events, etc.). Then you can follow it up with your cognitions once you start your self-calming activities. This is not the same as feeling relaxed but a very direct means to alter your breathing rate and heart rate variability. I will write more about the latter in another blog entry because I am achieving very good success with some new biofeedback equipment which serves to train patients with getting more heart rate variability.

9. If your flight is imminent and you are not travelling in Indonesia or with an Indonesian airline, your risks of being involved have only changed to make it even less risky because your airline's safety culture is likely to have reviewed its systems, and those who will control your flight will be even more vigilant and risk-aversive. Otherwise, best to keep away from unreliable media reports which are only second-guessing official findings which will ultimately assemble the discoverable facts into a meaningful array. That will take some time while the flight recorder equipment is being analysed in Canberra. This included the Cockpit voice recorder (CVR - shown in orange, below) which records the last 30 minutes flight deck audio of the flight (reports have it the pilots spoke with air traffic control (ATC) in Indonesian, and this was likely the language used on the flight deck. This will need careful translation, not just for the expressions used, but to detect emotional status also.) The other equipment will be the flight data recorder (FDR), which keeps a computer record of the flight parameters, such as control surfaces, speeds, engine performance, altitude and attitude (the angle of the aircraft) and other important measures like wind direction and speed, as assessed by the onboard computers. This data is matched with what the pilots and air traffic control said (as compared to what they did), and a picture begins to emerge about which hypotheses can be constructed and then compared with actual damage sustained.

Come fly with me!

The introduction of Medicare rebates for Clinical Psychology services (to the tune of up to 12 sessions and rebate of $110.00 per session) for those whose GPs or Psychiatrists recommend a Mental Health Treatment Plan, has meant referrals have increased substantially in 2007, and ought to continue apace.

Despite continuing teething problems, such as GPs using incorrect forms, or delays in the Medicare item numbers not being received in time for the first psychology session, more GPs and patients are enjoying the opportunity to consult for anxiety-based conditions. Because Fear of Flying is am anxiety condition recognised in the Diagnostic Manuals, Medicare has been rebating my patients.

Fortunately, most treatments require less than than maximum 12 sessions permitted per calendar year, so patients can keep the remaining sessions up their sleeves for "a rainy day".

That said, many people still attend group programs run by airlines such as Qantas and must pay the full fee themselves, unless their company sponsors them. Even though such programs utilise the services of psychologists, the group program usually does not have the psychologist as the main treatment agent, and so they don't qualify for Medicare group rebates.

So, I want to put to Australian flyers who want to see significant change in their fears, that I am considering regularly flying (say monthly) between Melbourne and Sydney (in the first instance) and taking advantage of the 747s and Airbuses QANTAS uses on Saturdays and Sundays. Here, these repositioning flights leave from Melbourne's International terminal, arrive at Sydney's International terminal, where a bus is then taken over to Domestic for the return flight.