Wednesday, May 1, 2013

Cognitive Behaviour Therapy: the gift that keeps on giving

Right after I got home from visiting Italy, I read an online article citing that about 1 in 3 Americans experience some degree of fear about flying.  That didn't surprise me nearly as much as the enormous number of comments following the article, all of which focused on what combination of alcohol and sedatives are most effective in combating it.

That made me sad, especially for the flight-phobic readers who said they have to fly often for work or family, but it did explain why practically everybody I talked with about my fear of flying in the months leading up to my trip said, Oh, just get a prescription, or Oh, have a drink on the flight, you'll be fine.

Neither of these ideas was going to work for me.  I don't drink, and the last thing I ever want while dealing with customs and luggage and crowds and foreign countries is to be sedated.  So today, because everybody I've told gets very interested and wants to want to know more about how it worked for me, I thought I'd talk about what I did instead: cognitive behaviour therapy.

How Cognitive Behaviour Therapy Works

In my experience, the purpose of CBT is to teach you to counter thoughts or ideas that are problematic for you.

I think the easiest way to explain the principle of this is to ask you to imagine that you are standing beside a tree and looking out over an industrial landscape.  For you, from this perspective, the whole world might be black smoke and desolation, anchored by one solitary tree.  (or alternatively, full of lucrative manufacturing opportunity that is all the way down a cliff you can't climb easily.)

Now imagine moving to another side of the tree.  From here, you may still see the industrial area, but also the cheerful, well-functioning town that borders it. Or you may move further still and see that the tree is one of many trees, in which are living a huge range of insect and animal life.

All of these views are valid; they all exist.  But they balance each other, unlike problematic thoughts which may appear to stand alone with nothing else to temper them.

Applying CBT to Fear of Flying

When I began my CBT sessions, my thoughts went something like this:

a/ Turbulence = imminent crashing and death

b/ Getting on the plane = vastly increasing my risk of imminent crashing and death

c/ Sitting tensely gripping the seat and holding the plane up by sheer willpower = possible escape from imminent crashing and death

With help from my doctor, I slowly picked apart all my different fears and examined them.  For homework, I talked to friends who are pilots and watched programs about in-flight mechanical crises and how they were managed.  I also asked almost everybody I know for their thoughts on flying and learned that while some find it uncomfortable for various reasons, others absolutely love it.  I asked the ones who love it why they do and made a list: flying means vacation, it guarantees time to read a book, it's exciting to be up high.

This last one made me stop and think.  Some people love roller coasters and will give up both time and money to be terrified on them.  The feeling that I will do anything to avoid having?  they seek it out.  And yet: those people and I are all human! Bizarre, but true.

So, as I continued with CBT, my thoughts shifted to things like this:

a/ Turbulence is the result of currents of air, moving at different speeds and experiencing different temperatures, shifting into each other and disturbing their positions.  Planes ride on air currents like boats ride on the surface of the water, and even though you can see the water currents more readily than air currents, they are doing the same kinds of familiar things.  Turbulence does not mean the plane is malfunctioning; planes meet with turbulence all the time, especially over the middle of the ocean.  Turbulence is normal.  If it is severe enough to make passengers uncomfortable, the pilot will change position to move away from those air currents.  If s/he doesn't, then either it's not a threat, or the plane - however bumpy the ride - is still in the best possible position at this time.

b/ The plane I am on is very unlikely to crash and kill me.  Many, many mechanical issues can be resolved or accommodated in flight.  The most likely worst case scenario is that we will land where we did not expect to land, and change to another plane.  

b/ Omigosh, you mean I can sit for several hours and read a book, and maybe even doze off over it?  When do I ever get to do that?  Forget holding the plane up with the power of my mind - I'm gonna enjoy the downtime. 

I learned relaxation techniques too, including one that combined deep breathing with the tightening and relaxing of muscles, consecutively, from my toes right up to my eyebrows.  That one triggers your brain to release calming hormones that really help.  Yay!

Writing Off a Fear of Flying

My doctor recognized that I would not be able to fly multiple times just to relieve my fear of it (hello, time and expense?) so she gave me an exercise that worked extremely well for me because I am a writer. 

The assignment was to compose a script that included everything about the flight I knew I had to take, from the time I started packing for it until the time the first flight was over and I had to prepare for the next.   I had to imagine every thought that would be in my head, every sleepless worry-filled night leading up to my departure date, every caught breath as I walked through the airport terminal and checked in (to say nothing of getting on the actual plane.) The more realistic and in-depth I could make it, the more effective it would be in building my confidence.

After I'd written (and/or rewritten) this script, I had to read it out loud, and grade my degree and symptoms of anxiety before, during, and after each reading.  This really helped me to catch where I was still struggling and work harder to adjust my thinking in those areas.

Early Results from My Own Cognitive Behaviour Therapy

I saw a doctor specializing in CBT pretty much every week for nearly seven months to make my Italian holiday happen.

At the beginning of this time, I was having to drive more than usual and in busier areas than I like.  Which isn't saying much because I have never liked driving and had been developing an increasing fear of that as well.  But within a couple of months full of CBT exercises and discussions, I found I was no longer panicking the night before I had to drive.  Soon I wasn't panicking at all.  I still won't drive somewhere new without mapping out a route and testing it with a friend first so I'm not surprised by any fussy lane changes or construction projects, but once that's set I can do everything I need to do without having to think twice about any of it.

At about the four month mark, I did get on a plane, to fly on a small aircraft to Chicago.  I used all the exercises I had learned and by some standards - especially since those small planes have no cushion to dull turbulence - the trip was a resounding success.  Going out, I didn't become anxious until I arrived at the airport, and I did not cause a scene on the flight with a lot of anguished sobbing or hysteria.  (I did cry, but quietly... I don't think anybody even noticed.)  Coming back, I became anxious only a few minutes before the plane boarded, and I cried even less than I had on the first flight.

I also learned a new trick: looking at somebody who is not having any trouble flying at all, and emulating him or her.  In my case it was a flight attendant who was totally mailing it in at the end of a long day, completely blase about the motion of the plane.  It struck me that if flying was really that routine for somebody, it could be for me too - and once I decided it was going to be, I felt a lot better.

For some people, all of this would be enough, but I wanted to ditch my anxiety completely, so I kept on.

Digging Deeper with Cognitive Behaviour Therapy

In the sixth month of my sessions, I finally recognized something that I had been staring at for many, many years without seeing it.  It's so simple, I'm embarrassed even to mention it, but it's such a powerful illustration of how our brains work and it seems to have turned on a lightbulb for so many people I've talked with, I'm just going to lump it.

When my dad died, I was living out of the country, and I had to fly home on my own for his funeral.

I didn't cry or panic on that flight; after racing to the airport I found it had been delayed, which allowed me to  pick up a bunch of funny novels in the bookshop there.  For eight hours I worked through them one after another, wedged into a tiny seat between a lot of much larger, silent people.  I was just fine.  Right?

Wrong.  I might not have noticed in the moment, but that flight was traumatic.  And trauma doesn't always present itself when it first happens.  Sometimes it needs a trigger, which in my case occurred after several other flights and just before a new one.  That's what made it so hard for me to see the connection: all those perfectly fine flights.  But once it was triggered, my brain took that huge lump of emotion, decided I couldn't cope with it, and plunked it into my air travel bucket.

In other words, I had metabolized grief as flight anxiety.

Once I knew that, and probably also because I had been developing some great new skills, it was incredibly simple to separate my sadness about losing my dad from the idea of being on a plane.  And I'm not kidding about the separation - it was as fast and as complete as a space shuttle ditching the part it needs only for takeoff.

When Cognitive Behaviour Therapy Works, Boy Does It Work

I did have very mild anxiety before my initial flights to and from Italy, but it turned out to be anxiety about missing the flights, and dissipated the minute I arrived at the airport.

I did not cry at all.

I enjoyed the down time: read books, watched movies, and met people.

I hugely enjoyed Alitalia's blood-orange juice.

I didn't need to actively pursue any of the tools I'd learned; I'd absorbed them all.

Turbulence, schmurbulence; I read a book, chewed gum, and - when things got super bumpy - I stopped to breathe.

The Gift that Keeps On Giving

Last time I was at the dentist's, he told me that strangely, every time one of his patients takes a vacation in Italy, s/he comes home with a cavity.  Well, I was in his office again earlier this week and guess what: I have two! And he's filling them as soon as possible.

Now, you can probably guess that a girl who fears flying and driving also fears the dentist, and in my case, you are so right.  But I am having zero anxiety about these fillings.  CBT, you are one of the best things that ever happened to me.  Mwah!

And: Done

There you go, that's my Cognitive Behaviour Therapy story.  I hope it is of some value to you or somebody you know.  If you have questions, throw 'em in the comments or e-mail me; I am happy to help out if I can.  Tomorrow I'm back to talking about the joys of knitting.  Hope I see you then!


justmeandtwo said...

Thank you for sharing all that! I've never much liked flying so I'll think of your words next time.

Good for you being able to make that separation! Wow! You're so strong!

Mary Keenan said...

You know, I never feel like I'm strong so much as lazy about having to suffer too much ;^) The work was very hard and painful, but the payoff: HUGE. and delicious, in the form of awesome cavity-causing gelato.

Marianne said...

I am so proud of you!!! I was saying prayers that this trip would be an easy (at least the flying sections of it) for you. I have so enjoyed all of your posts about the trip, especially the pictures!!!
You are an awesome woman and now (pardon the pun) the sky is the limit for you!!! Have fun!!!

Mary Keenan said...

Thanks so much Marianne... I'm hoping for England next :^)