Two Treatments for Fear

of Flying Compared
Cognitive Behavioral Therapy Combined With
Systematic Desensitization or Eye Movement
Desensitization and Reprocessing (EMDR)
Maria Teresa Triscari,1 Palmira Faraci,2 Valerio DAngelo,1
Viviana Urso,1 and Dario Catalisano3

Original Article
1
Laboratory for Psychosomatic Disorders, Local Health Trust of Palermo, Italy,
2
Department of Psychology, University of Palermo, Italy, 3Wind Jet Airline, Palermo, Italy

Abstract. This study aimed to test a combined treatment with eye movement desensitization and reprocessing (EMDR) and cognitive behavioral
therapy (CBT), compared with CBT integrated with systematic desensitization, in reducing fear of ying. Participants were patients with
aerophobia, who were randomly assigned to two experimental groups in a before- and after-treatment research design. The Flight Anxiety
Situations Questionnaire (FAS) and the Flight Anxiety Modality Questionnaire (FAM) were used. The efcacy of each program was evaluated
comparing the pre- and post-treatment levels of fear of ying within subjects. A comparison of the post-treatment scores between subjects was
also conducted. Results showed the effectiveness of each model with a signicant improvement in the examined psychological outcomes in both
groups.

Keywords: specic phobias, aerophobia, psychotherapy techniques, symptoms reduction, FAM, FAS

Phobia is the experience of an unreasonable amount of
anxiety about a particular object or situation, leading to
the stimulus being avoided or else endured with intense dis-
tress. Phobias differ from ordinary fears in their impact on
daily functioning. They may lead to impairments, such as
being unable to maintain a job or social relations (Mogotsi,
Kaminer, & Stein, 2000).
The ying phobia appears as a heterogeneous phenome-
non involving several components, not all of which are spe-
cic to ight itself. It accounts for a signicant and rather
common problem, affecting an estimated 1025% of the
general population.
Fear of ying is a serious problem, with growing per-
sonal and nancial repercussions: Avoiding ying may
entail consequences in both work-related and social terms,
including career repercussions, social embarrassment, and
restrictions (Roberts, 1989). As ying has become an essen-
tial part of our society, several treatments (i.e., anxiety man-
agement, providing accurate information regarding airplanes
and ying, and exposure techniques) have been developed
to help overcome this problem. Most treatment protocols
include exposure in vivo or in-ight simulators, stress
inoculation training, systematic desensitization, ooding,
implosion, and relaxation (Beckham, Vrana, May,
Gustafson, & Smith, 1990; Haug et al., 1987; Howard,
Murphy, & Clarke, 1983), as well as data provision, tradi-
tional psychotherapy, cognitive preparation, coping self-talk,
virtual exposure, and relaxation training (Rothbaum, 1997).
Generally, however, fear of ying has been treated with
behavioral and/or cognitive therapies as a basis, that is, so
far the methods of choice.
The effectiveness of cognitive behavioral therapy (CBT)
individual or group programs has been scientically well
established.
Eye movement desensitization and reprocessing (EMDR)
is a widely used rst-line treatment of trauma (American
Psychiatric Association, 2004; Bisson & Andrew, 2007;
CREST, 2003; Foa, Keane, Friedman, & Cohen, 2009;
INSERM, 2004).
Our study will investigate its applicability to reducing
fear of ying.
Developed in the 1980s by psychologist Francine
Shapiro, EMDR is a powerful psychotherapy technique that
is viewed by some as a breakthrough therapy because of its
simplicity and the quick and lasting relief it can bring
for most types of emotional distress. EMDR is based on
the theory that disturbing or distressing experiences and
the associated images with the related negative emotions
are stored in our brain and as such trapped in our body.
The therapist helps to recall events, images, or thoughts,

2011 Hogrefe Publishing Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914
DOI: 10.1027/2192-0923/a00003
 10 M. T. Triscari et al.: Two Treatments for Fear of Flying Compared
and gently couples rapid eye movements to each event by
careful observation, then redirects the eye movements using
a stimulant or distraction such as a light, object, or music.
The theory is that the brain will reprocess the thought with-
out experiencing the negativity that was once associated
with it. Although additional EMDR applications have been
developed in clinical practice (Shapiro, 2001), research is
lacking to validate this method as an effective treatment
for phobias (Fernandez & Faretta, 2007; Gattinara, 2009;
Gauvreau & Bouchard, 2008; Gros & Antony, 2006;
Newgent, Paladino, & Reynolds, 2006; Protinsky, Sparks,
& Flemke, 2001; Schurmans, 2007). Limited results have
been reported on treatment of panic disorder and agorapho-
bia (Goldstein, de Beurs, Chambless, & Wilson, 2000).
In reviewing the efcacy of the different therapeutic
approaches, only a limited number of studies have been con-
ducted so far. Despite the prevalence of fear of ying pro-
grams carried out in large cities, often sponsored by airline
companies, much of this research has been inhibited by the
Original Article
difculties (also in economic terms) of using actual airplanes
and ights for exposure. The efcacy testing methodology
was often itself awed. Most programs, in fact, have been
criticized for not including a post-treatment ight to evaluate
outcome and also for not undergoing rigorous evaluation.
The aim of the present study is to describe procedures
and clinical outcomes of the following treatment methods
for fear of ying: CBT integrated with systematic desensiti-
zation (CBT-SD), the effectiveness of which has been well
established (Van Gerwen, Spinhoven, Diekstra, & Van
Dyck, 2006), and CBT combined with EMDR (CBT-
EMDR).
Methods
Participants
Fifty-seven participants were enrolled in this study. The
sample included a self-selected group of ight phobic
patients, who had asked to participate in a training program
aimed at reducing or eliminating their fear of ying. They all
met Diagnostic and Statistical Manual of Mental Disorders,
4th Edition (DSM-IV) criteria for neurotic diseases, phobia,
anxiety, and panic attack (American Psychiatric Association,
1994). None of the participants presented neurological disor-
ders, posttraumatic stress disorder or acute stress disorder
(not related to fear of ying), severe agoraphobia, or a
comorbid psychiatric diagnosis.
Two experimental groups were used: the CBT-SD
method was used with 34 patients, 33.3% men and 66.7%
women, with a mean age of 44.39 years (SD = 10.41;
range = 2970). They were employers (54.5%), teachers
(9.1%), reporters (3%), freelancers (6.1%), lawyers (6.1%),
small entrepreneurs (3%), unemployed (3%), pensioners
(6.1%), or housewives (6.1%). The most frequent marital
status was married (68.8%), followed by single (21.9%), sin-
gle in a committed relationship (3.1%), divorced (3.1%),
and widower (3.1%). Educational level ranged from low
(3%) to university (39.4%), with 57.6% high school.
Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914
The CBT-EMDR procedure was used with 23 patients,
30.4% men and 69.6% women, with an average age of
42.52 years (SD = 11.62; range = 2464). They were
employers (43.5%), teachers (4.3%), reporters (4.3%), freel-
ancers (13%), unemployed (8.7%), housewives (8.7%),
managers (8.7%), students (4.3%), or hoteliers (4.3%).
The most frequent marital status was married (50%), fol-
lowed by single (40.9%), single in a committed relationship
(4.5%), and widower (4.5%). Educational level ranged from
low (4.3%) to university (65.2%), with 30.4% high school.
Procedure
An information campaign provided information about the
existence of a special service in the Laboratory for Psychoso-
matic Disorders of the Local Health Trust of Palermo for the
treatment of fear of ying. Participants were informed of the
study procedures and the experimental nature of the program.
Data were collected through the Flight Anxiety Situations
Questionnaire (FAS) and the Flight Anxiety Modality Ques-
tionnaire (FAM) in small-group sessions at baseline (pre) and
immediately after the treatment nished (post). Participants
were randomly assigned to one of the two treatment groups.
The rst one received CBT integrated with systematic desen-
sitization (CBT-SD group) and the second one received CBT
combined with EMDR (CBT-EMDR group).
In both groups, the treatment was carried out in 10
weekly sessions, each one lasting 2 hours and run by an
experienced clinical psychotherapist and two psychologists
on the basis of a previously envisaged program. During
the assessment phase, two questionnaires measuring fear
of ying were completed, and an informed consent form
was signed. All the participants were treated in small groups
during the rst three sessions consisting of cognitive tech-
niques, relaxation techniques, psychoeducation, and educa-
tion about ying. From the fourth to the sixth session,
subjects for the CBT-SD and CBT-EMDR were treated indi-
vidually. A simulated departure in a real airplane and a real
ight ended the treatment.
CBT Sessions 13
The rst three sessions were identical for both groups, with
the following content:
(a) psychoeducation: providing information about anxiety;
enhancing a differential analysis of fear, phobia, and
anxiety; teaching how to manage anxiety;
(b) cognitive and behavioral techniques: teaching how to
restructure dysfunctional thoughts; introducing both
in vivo and imaginary exposure;
(c) relaxation techniques: teaching how to practice
Schultzs autogenic training or progressive relaxation;
(d) information: providing data regarding the basic notions
of ight and aviation, including safety issues, objective
risks, turbulence, and accidents.
2011 Hogrefe Publishing
 M. T. Triscari et al.: Two Treatments for Fear of Flying Compared
The goal here was to help patients work on their dysfunc-
tional thoughts about their fear of ying, by teaching them
how to consider such thoughts critically and, rather, think
rationally. The previously provided data about aviation and
the way anxiety and panic work are especially helpful at this
stage.
SD or EMDR Sessions 46
Sessions 4 through 6 were different for each treatment
group. After an initial assessment phase revolving around
the specic EMDR treatment aspects, patients had been
working individually on their rst problematic air ight
(Session 4). In Session 5, the aim of psychotherapy was
to help patients practice what they have learnt in the previ-
ous session by linking it to when they last experienced fear
or when they last heard reports of fears or of actual disasters.
The focus in therapy had been an actual ight from Palermo
to Rome and back, and its processing, through eye stimuli,
into a fairly positive cognition (e.g., I can handle my
emotions).
Finally, the demonstration psychoeducational session at
the airport involved the whole group as well as the staff
of both the local airline company Wind Jet and the National
Air Trafc Management Authority, ENAV.
CBT Finish: Sessions 710
At this stage, psychotherapy was carried out within the
whole group, through Session 10. Regarding the airport
demo portion (Session 7), after visiting the air trafc control
tower, patients could ask their questions of both an airline
pilot and an air trafc controller. Then, a demo ight
allowed them to go through the different phases that precede
a real ight. Further to a group meeting where the emotions
perceived during the demo ight were examined
(Session 8), the patients had their air baptism by actually
ying from Palermo to Rome and back with a Wind Jet-
provided plane ticket (Session 9). Finally, participants com-
pleted the same questionnaires administered during the prior
assessment phase (Session 10).
Instruments
To verify the diagnosis of fear of ying and to assess ther-
apeutic progress and treatment efcacy, participants were
administered two inventories focusing on feelings, attitudes,
and cognitions referring to specic ight-related events:
(1) The Flight Anxiety Situations Questionnaire (FAS;
Van Gerwen, Spinhoven, Van Dyck, & Diekstra,
1999), with 32 items, which measures the level of anx-
iety produced by specic ying situations. It consists
of three subscales: generalized ight anxiety, referring
to anxiety experienced in connection with airplanes in
2011 Hogrefe Publishing
11
general, regardless of personal involvement in a ight
situation (e.g., seeing or hearing planes or taking
someone to the airport); anticipatory ight anxiety,
pertaining to anxiety experienced before the time the
ight actually starts (e.g., planning a trip, boarding
the plane); and in-ight anxiety, concerning anxiety
experienced during ight, from takeoff to landing
(e.g., different situations in ight). Respondents are
asked to circle the number which corresponded to
their level of anxiety in the situations mentioned, using
a scale from 1 (no anxiety) to 5 (overwhelming
anxiety);
(2) The Flight Anxiety Modality Questionnaire (FAM; Van
Gerwen et al., 1999), which focuses on symptom
expressions, such as physiological responses of anxiety
and thoughts related to the danger of ying. It consists of
18 items structured in two subscales: the Somatic
Modality scale, referring to physical symptoms, and
Original Article
the Cognitive Modality scale, pertaining to the presence
of distressing cognitions. Here the respondents are
asked to rate the degree to which each item accurately
describes the intensity of their own reaction using a scale
from 1 (not at all) to 5 (very intensely).
Data Analyses
An experimental group design was used, with measures at
two stages: pre-treatment and post-treatment. One group
received CBT-SD, and the second group received CBT-
EMDR. As dependent variables, data were collected regard-
ing both ight anxiety situations (i.e., generalized ight anx-
iety, anticipatory ight anxiety, and in-ight anxiety) and
ight anxiety modality (i.e., somatic modality and cognitive
modality). Measurements were taken before treatment began
(pre) and immediately after the treatment nished (post).
We used paired t-tests to evaluate the degree of change,
and we calculated Cohens d effect sizes within groups.
A comparison of the post-treatment scores between-groups
was also conducted. Data were analyzed with SPSS 17.0.
Results
An independent t-test was performed to contrast pre-treat-
ment measures between both treatment groups. No mean
differences were found between CBT-SD and CBT-EMDR
groups in the following measures:
Somatic modality (FAM): t55 = 1.5; p = .15
Cognitive modality (FAM): t55 = 0.5; p = .61
Total score for FAM: t55 = 1.3; p = .2
Anticipatory ight anxiety (FAS): t55 = 1; p = .33
In-ight anxiety (FAS): t55 = 0.5; p = .64
Generalized ight anxiety (FAS): t55 = 1.6; p = .12
Total score for FAS: t55 = 0.6; p = .57
Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914
 12 M. T. Triscari et al.: Two Treatments for Fear of Flying Compared

Table 1. Average scores on the FAM and FAS subscales for both CBT-SD group pre- and post-treatment and CBT-EMDR
group pre- and post-treatment
CBT-SD/
CBT-
EMDR
CBT-SD group CBT-EMDR group group
Pre- Post- Pre-post Pre- Post- Pre-post Post-
treatment treatment treatment treatment treatment treatment treatment
M SD M SD t d M SD M SD t d t p
FAM SM 28.4 9.8 16.0 7.5 6.8*** 0.9 24.6 8.8 15.4 7.0 6.1*** 1.2 0.4 .73
FAM CM 26.1 7.4 14.8 7.1 9.3*** 1.6 25.1 6.6 13.4 6.2 9.4*** 1.8 0.8 .46
FAM TS 54.5 14.7 30.8 13.9 8.7*** 1.7 49.7 11.5 28.7 10.9 8.9*** 1.9 0.6 .55
FAS AFA 46.3 8.6 26.0 12.1 9.6*** 1.9 44.0 8.5 23.5 8.0 10.7*** 2.5 0.9 .40
FAS I-FA 47.0 13.1 27.9 12.4 7.4*** 1.5 48.5 9.1 26.7 10.5 10.4*** 2.2 0.4 .70
FAS GFA 15.0 5.9 9.5 2.9 5.6*** 1.2 12.7 4.4 8.2 1.8 4.5*** 1.3 1.9 .07
FAS TS 108.3 21.4 63.3 24.2 14.1*** 2.0 105.2 17.8 58.4 17.6 11.8*** 2.6 0.8 .41
Notes. AFA = anticipatory ight anxiety; CBT-EMDR = cognitive behavioral therapy combined with eye movement desensitization
Original Article

and reprocessing; CBT-SD = cognitive behavioral therapy combined with systematic desensitization; CM = cognitive modality;
FAM = Flight Anxiety Modality Questionnaire; FAS = Flight Anxiety Situations Questionnaire; GFA = generalized ight anxiety;
I-FA = in-ight anxiety; SM = somatic modality; TS = total score.
***p < .001.

These results indicate that the two groups did not differ 70

previous to the intervention. 60

Statistical analysis was carried out to contrast pre-post 50

results. Table 1 shows that FAS and FAM scales indicate sen- 40 CBT-SD
sitivity to CBT-SD. On all scales, the difference between pre- CBT-EMDR
30
and post-treatment scores shows a high effect size (Cohens d
20
ranged from 0.93 to 1.97). In the same direction, FAS and
FAM scales indicate sensitivity to CBT-EMDR. On all scales, 10

the difference between pre- and post-treatment scores shows a 0

very high effect size (Cohens d ranged from 1.16 to 2.64).
Based on these results, both CBT-SD and CBT-EMDR
seem effective in reducing fear of ying.
The t-test carried out to compare the CBT-SD group with
the CBT-EMDR group at post-treatment measures yielded no
signicant differences in the improvements of the two groups.
However, due to the size of the group, the effect size (Cohens
d) of these comparisons was calculated. The main effect sizes
were in the CBT-EMDR group post-treatment, but both CBT-
SD and CBT-EMDR treatments seemed effective, without
statistically signicant differences (Figure 1).
In addition, it is worth noting that a very large number of
patients ew at the end of both treatment models: 31 patients
(93.9%) ew at the end of CBT-SD, whereas 21 patients
(91.3%) ew at the end of CBT-EMDR.
Discussion
In this paper we have presented a study of the application of
two combined psychotherapeutic programs for patients with
fear of ying. To our knowledge, this is the rst study in
which CBT integrated with EMDR was directly compared
with CBT integrated with systematic desensitization.
While CBT-SD is considered to be the rst-line therapy
for fear of ying, there are limited data on whether other
FAM SM FAM CM FAM TS FAS AFA FAS I-FA FAS GFA FAS TS
Figure 1. Post-treatment measures for both CBT-SD and
CBT-EMDR groups. AFA = anticipatory ight anxiety;
CBT-EMDR = cognitive behavioral therapy combined
with eye movement desensitization and reprocessing;
CBT-SD = cognitive behavioral therapy combined with
systematic desensitization; CM = cognitive modality;
FAM = Flight Anxiety Modality Questionnaire; FAS-
= Flight Anxiety Situations Questionnaire; GFA = gen-
eralized ight anxiety; I-FA = in-ight anxiety; SM =
somatic modality; TS = total score.
psychotherapeutic techniques could also improve the treat-
ment of fear of ying. At present, EMDR has only been
empirically validated for trauma-related disorders such as
posttraumatic stress disorder.
Overall, our results indicated signicant improvements
for the treated patients using either psychotherapeutic tech-
nique, as shown not only by questionnaire scores but also
by participation in the post-treatment ight. EMDR gives
similar results as SD and did not fail in this application as
a fear-of-ying treatment.
Although these preliminary results showed the efciency
of both the investigated treatment procedures, upcoming

Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914 2011 Hogrefe Publishing
 M. T. Triscari et al.: Two Treatments for Fear of Flying Compared
research is strongly required. First of all, further studies are
needed to increase the validity of the research. With this
aim, a larger group size should be investigated in the long
term whenever possible. Secondly, methodological enhance-
ments should be pursued, such as the incorporation of con-
trol groups in the experimental design.
In summary, we have presented the results of the rst use
of EMDR combined with CBT in the treatment of fear of
ying. The results showed the statistical and clinical effec-
tiveness of this procedure in post-treatment, as similar to
those obtained with CBT integrated with SD. Further
research should dene the best combination of such tech-
niques for reducing the fear of ying.
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Maria Teresa Triscari, CBT and EAAP
member, is head of Laboratory at the
Department of Psychosomatic Diseases,
Local Health Trust of Palermo, Italy, and
head of project management within the
cooperation agreement among the City
Healthcare Bodies and Airport Authority
(GESAP), the Sicilian air company Wind
Jet, and the National Aviation Board
(ENAV), for the project Fear of Flying?
No Problem! Triscari is the contact
person of an Italian Healthcare Ministry
project on fear of ying and is an EMDR practitioner. She
coauthored (with Lucas van Gerwen) the book Fear of Flying?
No Problem! on fear of ying.
Palmira Faraci, PhD, is a psychologist,
fellowship researcher, and contract pro-
fessor of methodology of research at the
University of Palermo. She was a
visiting scholar at the University of
California, Berkeley. She worked as a
researcher at Giunti O.S., Florence, and
as a statistical evaluator at the Labora-
tory for Psychosomatic Disorders, LHT,
Palermo. Her research activity is focused
on psychological testing.
Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914
 14 M. T. Triscari et al.: Two Treatments for Fear of Flying Compared

Valerio DAngelo, CBT and aviation Correspondence Address

psychologist, is a member of the work-
ing group within the Department of Palmira Faraci
Psychosomatic Diseases, Local Health Viale delle Scienze, Ed. 15
Trust of Palermo, Italy. He works in 90128 Palermo
cooperation with Healthcare (ASP Pa- Italy
lermo) on the progam Fear of Flying? Tel. +39 347 646-5399
No Problem! He deals mainly with E-mail palmirafaraci@gmail.com
anxiety disorders and depression. He is
recognized within the project, by the
Ministry of Health, as an experienced
psychologist on fear of ying.

Viviana Urso, psychologist, has special-

ized in cognitive behavioral psychother-
apy and is a member of EAAP. She
works with private and public structures.
She has worked for the Fear of Flying?
No Problem! project and has collabo-
rated with the Sicilian air company Wind
Jet. She specializes in treatment with
EMDR.
Original Article

Dario Catalisano, biologist, started his

career in the Italian Air Force, and is
now a pilot instructor and examiner on
A320s, with a total of 17,000 ight
hours with Wind Jet airlines, where he is
also ight safety and human factor
manager. He is qualied in aviation
incident/accident investigation and a
human factor specialist. A member of
the Italian Flight Safety Committee, he
collaborates with the Laboratory for
Psychosomatic Disorders, Lht, of Paler-
mo, in the common project Fear of Flying? No Problem! for
fear-of-ying therapy.

Aviation Psychology and Applied Human Factors 2011; Vol. 1(1):914 2011 Hogrefe Publishing