Treating
Aviophobia

Despite aviation’s outstanding safety record, millions of U.S. passengers suffer some form of acute flight anxiety, a phobia that has grown as airlines add seats and reduce legroom. But as mental health experts work to develop innovative therapies, many of their clients are gradually losing their fear of flying.
By Robert Silk

Illustration by Studiostoks/Shutterstock.com

Illustration by Studiostoks/Shutterstock.com

Athens, Ga.-based lawyer Mary McKillip estimates she had flown 30 times without difficulty prior to a trip in the spring of 1995. But on that journey, flying back to Raleigh, N.C., from Seattle, where she had attended the Final Four as a tutor for the University of North Carolina men’s basketball team, McKillip experienced difficulties with pressure in her ears. As a result, she had a panic attack.

“After that experience, it was 10 years before I got on a plane,” said McKillip, who continues to experience flight anxiety to this day.

She’s far from alone.

According to a 2016 paper in the journal Frontiers in Psychology, estimates of the prevalence of flying phobia have ranged from 2.5% of people to a whopping 40%. The disparity, the study comments, is possibly explained by the fact that lower estimates are of people with a clinically diagnosable phobia while higher estimates come from studies describing individuals with a self-identified fear of flying.

Even at the low end of that range, well in excess of 5 million Americans would struggle with a fear of air travel.

The pervasiveness of fear of flying persists despite the extraordinary safety of commercial air travel relative to other modes of transportation.

Plane crashes, such as the Boeing 737 Max crashes in October 2018 and last March, as well as the recent shooting down by Iran of Ukrainian International Airlines Flight 752, garner big headlines.

But in 2018, the latest year for which final data has been published, out of the close to a billion passengers who flew on commercial aircraft serving the U.S., there was only a single death: a Southwest passenger whose window was shattered in-flight by debris from a broken engine fan blade.

That same year, 36,560 people died on U.S. highways, 169 died during rail transit and 26 died on commercial passenger vessels, according to the Bureau of Transportation Statistics.

More broadly, the last fatal plane crash of a U.S. carrier took place in 2009.

As any mental health expert will tell you, however, phobias aren’t rational. And, said Martin Seif, a New York-based psychologist and a leading expert on flying anxiety, being enclosed in a plane high above the clouds is an ideal laboratory for exposing a number of fears.

“The flying experience is perfect for triggering anxieties,” Seif said. “With anything that causes anxiety, it’s ubiquitous that people don’t like feeling out of control. And of course in a plane, you’re out of control. You’re enclosed in this metal tube of toothpaste, and you are flying 7 miles above the ground.”

"The flying experience is perfect for triggering anxieties. With anything that causes anxiety, it’s ubiquitous that people don’t like feeling out of control."
—Martin Seif, Psychologist

Though the term “fear of flying” is used generically, Seif said “fears of flying” would be more accurate. Fewer than 10% of his fear-of-flying clients through the years have suffered from a specific fear of crashing, he said.

Far more common have been clients whose anxiety about flying stems from the worry that they’ll have a panic attack and be stuck. In fact, that’s an issue for approximately two-thirds of people who are afraid to fly, according to Seif.

Other professionals in the field say the mix is more balanced. Barbara Rothbaum, a psychiatrist and the director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine in Atlanta, said the split among her clients between people who fear crashing and those who fear an anxiety attack is about even.

Seif said social anxiety disorders are another trigger for people who are afraid to fly.

The dense confines of an airplane can be wrenching for those who are uncomfortable in crowds or terrified of germs. Similarly, some people worry about being noticed by strangers if they become visibly afraid or, worse, suffer a panic attack.

Seif even recalled one patient who suffered from obsessive-compulsive disorder and worried that she’d yell out on the flight, “I’m a terrorist!”

Many of the triggers that make fear of flying so prevalent, experts say, have only been exacerbated as airlines have added more seats to planes and as the percentage of seats that are occupied has increased. Load factors on flights operated by U.S. carriers rose from 73.5% in 2003 to more than 83% in 2013, and they’ve hovered there since, according to the Bureau of Transportation Statistics.

Ron Nielsen, a former commercial pilot who runs Phoenix-based Fearless Flight, said,“The density of seating definitely affects the people who are triggered by claustrophobia.”

Ron Nielsen of Fearless Flight conducts a class last March at Air Hollywood, an aviation motion picture studio in Los Angeles. Video via FOX 11 Los Angeles/Youtube

Nielsen, who coaches people to overcome flying fears, estimates that among the thousands of clients he has worked with since 1987, approximately 40% are afraid of a mechanical breakdown versus 60% who are affected by broader anxiety issues that are closely linked to feeling trapped and to the lack of control one has aboard a plane.

Even people who fly regularly are subject to having their anxieties ratchet up by full aircraft, according to Adam Larter, strategic account director at Studio Black Tomato, a brand strategy and content creation agency.

Larter recently co-conducted a qualitative study on the matter by doing interviews with more than 50 Studio Black Tomato employees. A primary finding, he said, is that the entire air travel experience, from home to destination, evokes fears about what could go wrong. People worry about leaving things behind, missing their flights and having the flight schedule changed. Another worry: having their luggage taken from them due to inadequate overhead bin space.

“This anxiety, even if you fly a huge amount of times, doesn’t really go down,” Larter said.

"This anxiety, even if you fly a huge amount of times, doesn’t really go down."
—Adam Larter, Studio Black Tomato

Though millions of Americans suffer from fear of flying, U.S. airlines offer surprisingly little proactive support. But that’s not the case for airlines everywhere. In the U.K., notably, British Airways regularly offers its daylong Flying With Confidence primary course, which features time with pilots, psychologists and at the end, a 45-minute flight. The carrier also offers separate courses geared to young children and teenagers.

Similarly, Virgin Atlantic began offering its one-day Flying Without Fear course in 1997, also featuring psychologists, pilots and cabin crew. The course is currently suspended for logistics reasons, but Virgin Atlantic said it will resume as soon as possible. The carrier declined to say when the classes were suspended.

Program director Richard Conway said that while Flying Without Fear is not itself a big moneymaker, it engenders loyalty among those who take the course.

“There is a huge business advantage, as we help people and then generate incremental business,” Conway said.

Stateside, no airline offers a standing program to combat fear of flying. Some airlines, however, do make facilities or aircraft available for programs run by other parties. For example, the Seattle-based nonprofit the Fear of Flying Clinic, which is offered biannually, includes a tour of an Alaska Airlines maintenance hangar.

JetBlue, meanwhile, has a How to Overcome Fear of Flying page on its website. The site offers some useful tips, such as suggesting seats over the wings where flyers are likely to experience less turbulence. It also has tips that while valid, could be construed as self-serving, such as suggesting that customers buy premium seats, “for a more relaxing flight experience.”

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A Fearless Flight aviophobia course on a Southwest Airlines plane in Phoenix last month. Photo courtesy of Fearless Flight

A Fearless Flight aviophobia course on a Southwest Airlines plane in Phoenix last month. Photo courtesy of Fearless Flight

A Fearless Flight aviophobia course on a Southwest Airlines plane in Phoenix last month. Photo courtesy of Fearless Flight

Other options

Fortunately, those who are afraid to fly can find U.S.-based alternatives to airline-operated programs.

In spring 2018, McKillip, still suffering from the phobia that began after her panic attack on her way home from the Final Four in 1995, flew from Atlanta to San Francisco with her husband. She described her emotions that day as “terror completely disproportionate to what I was doing. I had uncontrollable shaking. I couldn’t talk to anyone. It was overblown anxiety.”

Mary McKillip, left, used audio provided by Fearless Flight to ease her anxieties on a flight from Atlanta to San Francisco last year.

Mary McKillip, left, used audio provided by Fearless Flight to ease her anxieties on a flight from Atlanta to San Francisco last year.

Mary McKillip, left, used audio provided by Fearless Flight to ease her anxieties on a flight from Atlanta to San Francisco last year.

Still, McKillip wanted to take her three children to Northern California and Yosemite. So, before that trip, in March 2019, she turned to Nielsen and his Fearless Flight program for consultation.

McKillip said she asked Nielsen a barrage of technical questions about the structure of the plane, turbulence and more. Nielsen, she said, taught her that she goes into a fight-or-flight response mode while flying. A primary way he helped her was to provide audio recordings in which the former captain talks clients through various stages of the flight. For example, he describes normal sensations one would experience on descent.

“That was wonderful, affirming,” McKillip said. “I’ve got a 20- to 30-year pilot in my ear telling me this is normal.”

Nielsen said that he’s worked with all sorts of clients whose lives are materially affected by their fear of flying. Some are billionaires who must travel to raise venture capital. Others miss out on family reunions or vacations. He said many clients have told him their phobia caused them to miss a parent’s funeral.

In his treatment, Nielsen focuses most prominently on educating clients about the mechanics of flying and on teaching them to practice mindfulness.

“When you couple learning more and actually monitoring your thoughts, that’s how you get over it,” he said.

"When you couple learning more and actually monitoring your thoughts, that’s how you get over it. "
— Ron Nielsen, Fearless Flight

Indeed, teaching mindfulness is a common approach to resolving flying phobia.

Seif said he works with clients on accepting anxiety, positing that “the most effective way to learn to overcome anxiety is to just let it be and not fight it.”

His students are taught to observe themselves being anxious without judgement. Anxiety, Seif said, is always based on what-if thoughts about the future. The antidote is to stay grounded in the present.

Typically, Seif said, in a class of 25 people, more than 20 will succeed in flying. But even for those individuals, it’s important to keep training by flying regularly, at least every three months, Seif suggested.

Emory University School of Medicine psychiatrist Barbara Rothbaum uses virtual reality as a therapy tool. Photo courtesy of Emory University

Emory University School of Medicine psychiatrist Barbara Rothbaum uses virtual reality as a therapy tool. Photo courtesy of Emory University

Emory University School of Medicine psychiatrist Barbara Rothbaum uses virtual reality as a therapy tool. Photo courtesy of Emory University

Other counselors use similar techniques but with variations. Emory’s Rothbaum, for example, was a pioneer in the use of virtual reality to replace actual practice flights in aviophobia therapy. In her therapy sessions, clients are outfitted with a virtual reality headset and are seated on a raised platform with a woofer underneath.

The woofer helps simulate the feel of engine vibration, the landing gear going down and turbulence.

Peer-reviewed studies undertaken by Rothbaum and others have shown that individuals who are counseled for fear of flying using virtual reality experience similar long-term success as those who take actual practice flights. In a 2006 study, more than 70% of subjects who had been counseled using simulated flights were still flying six to 12 months after the completion of therapy. Rothbaum said her success percentage now is approximately 90%.

Using virtual reality, she said, has major cost and time advantages over in-flight training. In addition, it offers more environmental control.

“If I’m treating them in virtual reality, I can guarantee there won’t be turbulence,” she said. “Or if they’re ready for [experiencing turbulence], I can guarantee there will be.”

"If I’m treating them in virtual reality, I can guarantee there won’t be turbulence. Or if they’re ready for [experiencing turbulence], I can guarantee there will be."
— Barbara Rothbaum, Emory University School of Medicine

Tom Bunn, a former commercial pilot and a licensed clinical social worker who founded the Connecticut-based Soar fear of flying course in 1982, focuses his counseling sessions on teaching clients to link being on a plane with someone in their life who is a calming presence. For example, clients are taught to imagine that person’s face, voice and hug while the flight attendant is closing the plane’s door.

The technique, Bunn said, helps stabilize the body’s autonomic nervous system and helps prevent the revving up of the body’s emotional system on the plane.

Beyond their therapy techniques, counselors also recommend some tricks on travel day for people who remain anxious or afraid. Particularly useful, Bunn and Nielsen said, is explaining the situation to a gate agent or flight attendant ahead of the flight and asking to meet the pilot.

Seeing the pilot can reduce one’s sense of loss-of-control and reassure individuals that they are in capable hands.

Another suggestion for reducing stress is to secure early boarding.

McKillip is still working to overcome her fear of flying. She has acquired passports for her family with a goal in mind of going to Europe. But crossing an ocean remains a hurdle. In the meantime, she said, she regularly checks the flight-monitoring app Flight Aware just to remind herself how regularly the Virgin Atlantic service she hopes to someday take from Atlanta safely completes its transatlantic journey.

“My goal is to go to London,” McKillip said. “I would love to go there.”

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