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Tuesday, 19 November 2013

Graduated Exposure in Flying Phobia


The usual way of treating fears and phobias is by graduated exposure. For a person afraid of dogs, we might do sequential exposure exercises like this:

  • Gazing at photo of happy dog
  • Gazing at photo of snarling dog
  • Repeated viewing of happy dog video on Youtube
  • Viewing friend’s placid dog in dog carrier 50 feet away
  • Viewing friend’s placid dog in carrier 10 feet away
  • Friend sits with leashed dog 10 feet away
  • Same, 5 feet away.
  • Friend sits with muzzled and leashed dog, place hand on dog’s back

… and so on.

The details vary depending on the specifics of the person’s fear, but the idea is the same: a stepwise approach of the feared object. Once we have a set of tasks, we look for big gaps in the difficulty level and then fill them in, by making an easy task harder or a harder one easier.

This is all very well, but how do you do it with flying phobia? Sure, we can look at photos of airplanes, visit airports, and sit at the ends of runways watching takeoffs and landings. But sooner or later the person has to go from observing aircraft to taking flights. Inevitably, that’s a big step. How do we make it a manageable one?

Answer: By a careful analysis of actual and possible safety behaviours. A safety behaviour is something that makes a feared situation more tolerable.

Someone with a fear of shopping malls, for example, might only go with a trusted friend, take antianxiety medication beforehand, study maps of the mall to find washrooms and escape routes, and carry water, tissues, and cell phone. We can take the same exposure exercise (say, shop for 30 minutes in the housewares department at Sears) and manipulate the difficulty level by altering the safety behaviours (take medication or not, go with someone or alone, carry cell phone or leave it in the car).

We can do the same thing with flights. Here are some common safety behaviours that nervous flyers use:

  • Sitting in certain rows, near front, back, or exits.
  • Sitting by a window or on the aisle.
  • Traveling with a trusted companion.
  • Taking anti-anxiety medication before the flight.
  • Having anti-anxiety medication in carry-on baggage.
  • Drinking alcohol before or during the flight.
  • Having puzzle book or other distractions.

It’s sometimes difficult to create an ideal desensitization hierarchy for flying phobia, because sufferers typically avoid flying frequently. But where circumstances permit, we can create exercises with a range of difficulty using the same basic experience.

Let’s imagine a nervous flyer in London with family in Paris – about an hour’s flight away. We could recommend that he make a point of taking frequent trips during his therapy. After the usual early items on the hierarchy (photos, videos, airport visits), it’s time for actual flights. Here is a set of flights based on an imagined set of his preferences:

  • Fly in the evening (easier) after a light dinner (drowsier), having taking a benzodiazepine tablet, sitting in aisle seat near the front of the plane (sooner to deplane; less visuals of a crowd of strangers) next to spouse (comforting and a distraction), equipped with water, tissues, mystery novel, and over-the-ear headphones.
  • Same, but with half a tablet.
  • Same, no tablet, bottle in carry-on.
  • Same, but seated midway to the back.
  • Same, but seated in the second to last row.
  • Same, but seated in middle seat, spouse on the aisle (still easy to push past if needed).
  • Seated on aisle, spouse directly across aisle.
  • Same, spouse seated directly behind.
  • Same, spouse seated 5 seats behind.
  • Same, but with earbuds, dull nonfiction book, no water.
  • Same, spouse not on board.

With the number of safety behaviours we’ve identified, it would be easy to come up with a dozen more options. We could then rate the difficulty of each, discard some of them as unnecessary, and get started.

The only real trick is defining the features that would make that first flight tolerable. This often involves stocking up on safety behaviours, which goes against the instincts of good behaviour therapists, whose main agenda is helping the client relinquish these behaviours. But in the case of flight phobia, allowing and even enhancing these behaviours temporarily may be what enables the client to get off the ground.

Monday, 4 November 2013

Launch! The Core Program Online Course for Clinicians


For the past number of months we have been developing a 13-hour course for mental health professionals on how to treat depression in a group format.

This course has now launched and is available online here, along with all of the documents required to run a group. Here’s the preview video:



About the Protocol

The Core Program was developed at UBC Hospital in Vancouver Canada. Originally restricted to patients who had previously been hospitalized for major depressive disorder, it was designed to enhance self-care using cognitive behavioural principles.

The contents include:

  • An orientation to the CBT model, including an acceptance-based approach to difficult emotion.
  • Behavioural activation strategies, to be introduced in Session One and forming a major part of every session thereafter.
  • Psychoeducation about the nature of depression and the nature of stress.
  • Lifestyle management strategies, including specific recommendations in areas including diet, sleep hygiene, exercise, and enjoyable activity.
  • Cognitive material, including demonstrations of outside-awareness cognition, common forms of distorted thinking, and cognitive traps associated with both rising and falling moods.
  • Cognitive change strategies, including awareness, cognitive challenging, and a set of worry management strategies.
  • Social life enhancement, including strategies to build and deepen a social network, and core concepts regarding assertive communication.
  • Relapse prevention strategies including planning for future stressful periods, identifying risks for backsliding, and developing strategies for dealing with relapse should it occur.

Growth of the Program 

Our mandate was to implement the program on-site, then enable other mental health agencies to offer it in their own communities. The plan was to have it operating in three other communities in British Columbia. Once it had been instituted in over 50 communities we began to lose count.

The two-day training program has now been offered in communities across Canada and Australia, as well as in Hong Kong. Groups based on the model have been offered in China, the United Kingdom, the United States, and in South America.

The program has been translated into Arabic, Farsi, and Spanish, and an earlier edition is available in Chinese (traditional and simplified character sets).

Much of the material was also simplified and incorporated into a self-guided manual, The Antidepressant Skills Workbook, designed for family physicians to offer to patients newly diagnosed with depression.

Online Course Contents

The online course offers over 50 short lectures, most of them 5 to 20 minutes long to enable users to access the material they need in a brief and accessible format.

As well, a variety of ancillary documents are supplied in three different formats: US spelling on USLetter, Imperial spelling on USLetter (for Canada), and Imperial spelling on A4 (for other countries).

  • A complete set of slide handouts in both 3-per-page and 6-per-page format, totaling over 500 slides in all.
  • The complete 94-page Participant Manual designed to be distributed to clients – manual designed to work also as a set of separate handouts for use in individual therapy. This manual may be printed and reproduced for clients.
  • The 226-page Clinician’s Guide, with complete teaching instructions, in-session exercise ideas, and a Quick Reference composed of “cheat sheets” that the clinician can take into session as reminders.
  • A set of additional documents including goal-setting forms, cognitive challenging sheets, feedback forms, and an attendance form.
  • Free access to the Farsi, Arabic, and Spanish translations of the manual, and to the Antidepressant Skills Workbook (the latter of which is available to anyone online at no charge).

These materials (without the slide handouts) are also available for sale in digital ($55) or print ($90) format from the Changeways Store.

Group Rates

Group practices, employee assistance firms, HMOs, public agencies, and health regions may wish to purchase multiple spaces for their own employees. We are able to arrange discounts for groups of more than 5, with steadily greater discounts for groups of over 10, 25, 50, 100, and 400 employees. To discuss the program or arrange a group discount, simply contact us.

The PsychologySalon Discount

Take 25% off the standard course fee simply for accessing the course through PsychologySalon.  The coupon code for the discount is “core2.” Here’s the link to the course.