Clinical Psychology and Psychotherapy, Vol.

3 (1), 62-74 (1996)

Practitioner Understanding
Report Cognitive Change:
a Qualitative Study of
the Impact of
Cognitive-Behavioural
Therapy on Fear of
Flying
Jo Borrill
Thames Valley University, London, UK

Elaine Iljon Foreman

Hillingdon Hospital, UK

A variety of cognitive and behavioural methods have been used in

the treatment of fear of flying. Although successful outcomes have
been reported, the value of specific treatment components in the
process of change has not been established. This study uses clients'
own accounts of treatment to examine their representations of the
mechanisms of cognitive change. Using techniques of qualitative
analysis derived from Grounded Theory, six core categories are
identified which represent key stages in the therapeutic experience.
These are combined to present a model of change, focusing on the
process of achieving control over feelings, cognitions and behaviour.
Some preliminary findings concerning the applications and limita-
tions of the model are also discussed.

INTRODUCTION tive-restructuring), education, group support, and

Successful treatment of fear of flying has been pre-flight exposure. Tortella and Bornas (1993) used
reported in studies using a range of cognitive- six sessions, with four distinct treatment compo-
behavioural techniques, (Roberts, 1989; Doctor et nents: information (about aeronautics and human
al., 1990; Tortella and Bornas, 1993) although the physiological response), rational-emotive therapy,
relaxation, and flight simulator practice. They
nents has not
therapeutic beenofclearly
value established.
different treatment Roberts
compo- identified differences in the degree of fear/ dis-
(1989) used eight 3-hr sessions of group-based comfort reduction following each stage of treat-
therapy focusing on cognitive-behavioural techni- ment, but did not measure the relationship between
ques (relaxation, systematic desensitization, cogni- fear reduction and behaviour change. This makes
interpretation difficult, since Williams (1987) has
'Addressee for correspondence: Jo Borrill, School of Crea- argued that fear reduction may be a weaker
tive, Cultural & Social Studies, Thames Valley University, predictor of positive therapeutic outcome than
Ealing, London W5 5RF, England. increases in self-efficacy.

ССС 1063-3995/96/010062-13
© 1996 by John Wiley & Sons, Ltd.
Understanding Cognitive Change 63

The possible redundancy of certain treatment insights can be gained from verbal reports into the
components is indicated by studies which have process through which a successful therapeutic
used fewer sessions or less elaborate programmes outcome is achieved. The use of clients' accounts
of treatment. Walder et al. (1987) demonstrated would seem to be particularly relevant in an
improved flying after three sessions of treatment, evaluation of cognitive-behavioural therapy where
approximately 9h in total. These three sessions changes in individual cognitions are the central
consisted of information on flight safety and the focus of treatment. Qualitative research may also
physiology of fear, flight simulation, and a return enable comparisons to be made between the
flight in a small group. More strikingly, Beckham et accounts of responders and non-responders, in
al. (1990) obtained successful results through use of terms of the extent to which they have assimilated
a stress-inoculation training manual and minimal the concepts and ideas of the particular treatment
therapist contact. Iljon Foreman and Borrill (1993,
1994) reportedpositive results with clients who Williams and Moorey (1989) stated that the firsi
received only one session of cognitive therapy prior stage of evaluating and developing therapy is to
to an accompanied flight. show that it can work, using case studies and
The contribution of different treatment compo- clinical trials; a second stage involves addressing
nents to therapeutic outcome would ideally be the question how does it work, in conditions or cases
assessed by assigning subjects randomly to alter- where it is known to be successful. Whisman (1993),
native treatments or treatment combinations, reviewing studies of cognitive therapy for depres-
although one study which used this design failed sion, argued that there is a need for further research
to establish any clear differences between treat- into intra-subject variability, especially within-
ments (Howard et al., 1983). However, practitioner- study variations between clients in 'the need for
researchers are acutely aware that in clinical particular treatment components and variations in
settings, random allocation of clients to treatments therapist response to those demands' (Whisman,
may be impractical or unethical. Furthermore, 1993, p. 260). The aim of the present study was
Howard et al. (1994) have argued that the process therefore to examine the extent to which successful
of random assignment 'militates against general- accounts could be used to explore the
isability, as it does not represent the process process of cognitive change during cognitive-
through which patients enter and persevere in behavioural treatment for fear of flying. The focus
treatment' (p. 4). Given the number of possible was on clients' individual responses to the different
uncontrolled variables, including the fact that stages of treatment and on the extent to which their
therapists are rarely randomly allocated, they con- explanations for change matched the theoretical
clude that differences between groups cannot be framework adopted by the therapist.
solely attributed to the independent variables and
suggest that it is self-defeating to espouse a
methodology which cannot be properly implemen-
ted. Howard et al. suggest that an alternative is to
develop more exploratory approaches derived from The methodological approach adopted for this
case-study methodology. These techniques tend to study was that of Grounded Theory (Glaser and
focus on process rather than outcome, including, for Strauss 1967) - a qualitative research method which
example, progress monitoring and patients' uses a systematic set of procedures to develop an
assessments of the therapeutic experience. Rennie inductively derived theory about a phenomenon.
(Strauss and Corbin 1990). Strauss and Corbin
researchers in various forms of psychotherapy argue that through the use of rigorous procedures
showed little interest in using clients' own reports of coding, categorization, abstraction, and further
to help them understand the therapeutic process. data-sampling (see below), the resulting theory
He attributes this to the influences of behaviourism should meet the criteria for 'good science', i.e.
and psychoanalysis which for different reasons theory-observation compatability, generalizability,
'have all contributed to misgivings about the value reproducibility, precision, and verifiability.
of verbal reports of conscious experience (Rennie, Glaser and Strauss's original model discouraged
1994, p. 3). However Rennie's own research into the adoption of any prior theoretical perspective,
counselling (see also McLeod, 1990) has demon- with the aim of allowing theory to emerge from the
strated that through rigorous use of qualitative data. However Silverman (1993) has argued against
methods of data collection and analysis useful the 'romantic impulse' of equating experience with
 64 J. Borrill and E. Iljon Foreman

authenticity and has highlighted the need for Clients included those who feared crashing and
researchers to be aware of 'how experience is other external disasters, and clients whose fears
shaped by cultural forms of representation' (Silver- were of internal catastrophe (e.g. panic, negative
man 1993, p. 8). Revisions of grounded theory social evaluation, heart attack). They therefore
encourage researchers to acknowledge their own matched the diagnostic categories of Simple Phobia
theoretical stance as part of the process of subjective and Panic Disorder with Agoraphobia identified in
interpretation involved in all forms of research other studies of fear of flying (McNally and Louro,
(Henwood and Pidgeon, 1995).
In the present study, clients' accounts were All the clients had been treated by the second
viewed within the contextual framework of their author, a clinical psychologist. The treatment pro-
exposure to the concepts and images of Cognitive gramme consisted of one session of cognitive-
Behaviour Therapy. A number of theoretically- behaviour therapy in which the development of
driven questions were formulated at the start of the the fear for each individual was explored and the
research. These questions were not applied in data nature of anxiety was explained. Clients were
collection, which was unstructured, but were encouraged to test out the probability of the
re-visited during the final stage of data analysis as consequences of their fears, for example that they
part of the process of interpretation. The questions would have a panic attack or lose control. The
explored were as follows: second session was an accompanied return flight to
Europe, travelling on a normal scheduled flight.
How do successful clients explain their pro- Measures of assessment included the Spielberger
cess of change? To what extent have they State-Trait Anxiety Scale, the Beck Depression
assimilated the concepts and language of CBT? Inventory, Marks' Fear Survey, and a new measure:
What are the important functions of the FACS (Fear Anxiety Consequences Scale). Data
therapist? How does therapist behaviour relate from the pilot study indicated clear improvement
to clients' confidence in their own ability to in the ability to fly without fear, and reductions in

anxiety and feared consequences (Ilion Foreman

What is the reported relationship between
and Borrill, 1993).
therapist qualities and client self-efficacy? Is
trust in the therapist a necessary or sufficient
condition for change? Data Collection and Analysis
What are the cognitive factors which mediate
The 10 clients chosen to take part in the qualitative
between therapist instructions and behaviour-
al outcomes? Do clients perceive the acquisi- study
first were interviewed
author. in their
Clients were askedown homes by how
to describe the
tion of knowledge as important in the process they had felt about flying before treatment and
of change?
were then asked to describe each stage of the
treatment process. The interviews were unstruc-
Subjects tured but at the end of the interview the interviewer
referred back to any points of relevance to the
Ten people were selected from a pool of successful research questions which had not been covered.
clients who had participated in a pilot study of Clients were not asked directly to evaluate separate
cognitive-behavioural treatment for fear of flying components of the treatment, but the interviewer
(Iljon Foreman and Borrill, 1993). Selection was on focused on each stage chronologically in order to
the basis of location and availability for interview; facilitate spontaneous comments on each part of the
no assumptions were made about their representa- process. Interviews lasted approximately 45 min
tiveness of the group as a whole. The 10 clients and were tape-recorded and transcribed verbatim.
included six women and four men, ranging in age The data was analysed following procedures
from 26 years to 65 years. Five were interviewed outlined by Strauss and Corbin (1990). The first
1-3 months after completion of treatment; the stage of analysis was Open Coding: a detailed line
remaining five had been treated between 13 and by line examination of the text resulting in the
40 months previously. Two clients had never flown production of descriptive codes for units of
before, due to anxiety. The remaining eight had meaning. Using this method, concepts are then
3 getsevere
flown previously but had experienced na compared and grouped under more abstract
symptoms of fear and avoidance which in some categories which are developed in terms of their
cases had led to them avoiding flying altogether, properties or attributes and their dimensions. The
Understanding Cognitive Change

second set of procedures, described as Axial Table 1. Core categories and sub-categories
Coding, involved reconstructing the data in new Categories Sub-categories
ways by making connections between categories,
focusing on causal relationships and contextual Establishing the Therapist qualities
therapeutic Legitimizing expression of fear
constraints. In this study connections between
relationship Borrowing belief
categories were analysed first at the individual
level, drawing up process models for individual Tolerance of
clients. Comparisons were then made between anxiety Antiong acessing knowledge
clients in order to identify core categories and
Cognitive re-labelling
develop a general model of change, while noting Rational thinking
and exploring individual differences. Throughout
the analysis there was an emphasis on verifying or Facing up to fear
Making the unknown known.
refuting emerging hypotheses by referring back to
the original data. Sharing fear
Deist rand Learning to trust
Joining the club
RESULTS
from this analysis of the interviews six core
I expected. But I warmed to her straight away
categories were identified, four of which contained
sub-categories (Table 1). These categories are because I thought she was a very open and warm
defined and discussed below, with examples from person and that was quite important. If she'd been
clients' verbatim accounts. formal and cold and clinical then I don't think it
would have had the effects' (client 7).
Informality was associated with warmth. It also
Establishing the Therapeutic Relationship
communicated a relationship based on an equal
This category refers to the clients' initial percep- partnership, perhaps more typical of friendship
tions of the psychologist, and the extent to which than of a professional encounter: 'When she opened
these are seen as contributing to the establishing of the front door she was bubbling and smiling so I
a positive relationship between the psychologist knew it wasn't going to be the suit and tie, very
and client. The factors which contribute to estab- staid or mechanical... It's not a sombre visage that
lishing the relationship include personal qualities you meet; it's come in, we want to tackle this
of the psychologist: warmth, openness and inform- problem, we'll beat it together' (client 1).
ality. The establishing of the initial therapeutic Furthermore, the informality was perceived by
encounter also provides an opportunity for the clients as indicating relaxation. The significance of
psychologist to legitimize the clients' expressions of this was made clear by client 9: 'She comes over as
fear, and enables the clients to take upon them- being very casual and relaxed and enjoying it all
selves the confidence expressed in them by the immensely... it was all terribly laid back. It's just
psychologist. that she doesn't give the impression that there is
anything to worry about (client 9).
Therapist Qualities To summarize, the personal style of the psychol-
Previous research into psychotherapy of various ogist was seen as important by clients in establish-
forms has emphasized the importance of theing a close relationship which was important for the
'working alliance' between client and therapist. Indevelopment of therapy.
cognitive-behaviour therapy the therapist plays a
more active role in challenging cognitions than Legitimizing the Expression of Fear
would be found in client-centred counselling, for Having established a relationship, an important
example, but the data here suggests that establish- function of the first meeting between psychologist
ing a positive relationship between the client and and client was the psychologist's facilitation and
the psychologist was very important. Clients legitimization of the expression of fear. Legitimiz-
referred specifically to warmth and openness, and ing the fear means encouraging the client to express
in particular to the informality of the psychologist's fears through acknowledging the validity of the
approach which in some cases took them by fear however irrational or bizarre. 'Just actually
surprise: 'She was totally different from anything saying to her, "Look I am terrified of this" and her
66 J. Borrill and E. Iljon Foreman

not saying "Oh don't be silly, of course you're not" course you can do it". It's like borrowing someone's
actually helped. That made a heck of a difference belief in you to actually believe in yourself'.
(client 3). In some cases this meant acknowledging The sense of the psychologist being in control did
the possibility of danger. 'She didn't say "it isn't not come from a formal exercising of power but
dangerous". Everyone else has always said it isn't rather from out of the therapeutic relationship
dangerous, and it so obviously is dangerous, described above: 'I liked E; I had total confidence in
potentially, that if someone says black is white her from just that few hours. I felt that she was in
you can't believe it' (client 10). For others, simply control and she was going to look after me and
talking openly about their fear was sufficient to make me better' (client 7). Ironically, empowerment
arouse strong emotions since it meant acknow- comes from being prepared to relinquish power
ledging their decision to take action:'... I was kind and control, to trust the psychologist and follow her
of numb, but seeing her made it real ... it was like
I'd made a decision that was very hard for me...' It should be noted that establishing confidence
(client 5). was not a matter of reassuring the client that all
For several clients legitimizing the expression of would be easy. Indeed, just as client 10 was pleased
fear contrasted with the approach of friends or that she was not told flying was not dangerous, so
relatives whose response was to try to minimize or client 4 commented on the importance to him of
dismiss the fears. For others it was very important being thrown in 'at the deep end': 'It was not the
that the psychologist's attention was focused on approach of "don't worry about it, you'll be OK,
them and not on other people: 'I wanted to speak there, there." ..! "There was no building up
to someone who would be interested in me and towards it, you know, looking at photos. It was—
next week youll be ying. Thus this client has
not a mass of people. I didn't feel my problem
would have been sorted out in being one of a picked up the distinction, which emerges more
crowd because I felt that we would have been strongly below, between treatment oriented to-
talked to as a whole and they would expect that wards anxiety-reduction and treatment, as in this
my problem was the same as everybody else's' case, focused on promoting self-efficacy.

There may be a potential conflict at this stage Tolerance of Anxiety

between the need to acknowledge the clients' fears,
and the need to challenge many of the statements This category is concerned with allowing the
about fear on rational grounds. From the clients' physiological symptoms of anxiety to be experi-
accounts it is apparent that the acknowledgment of enced in order to change cognitions about the
fear was a necessary starting point and that they consequences of anxiety. The rst stage of this
varied in how quickly they were able to proceed to process is for the client to be able to access
testing out and challenging these fears. However knowledge of the underlying physiological mech-
the most important way in which this conflict was anisms of anxiety, which provide a rational
resolved was through separating out the (valid) explanation for the symptoms. The client is then
expression of feelings from the (invalid) cogni- encouraged to experience emotional arousal; when
tions concerning the consequences of participating this is not followed by adverse consequences a
in the feared activity (see below-Tolerating process of cognitive invalidation begins. The final
stage is when the threat is seen as unreal, and the
symptoms become cognitively relabelled, either as
Borrowing Belief discomfort or as excitement. The therapeutic power
This category refers to the process through which of this process lies in its potential for general-
the clients take on for themselves the confidence ization; ie. clients who perceive that through
and optimism communicated by the psychologist.tolerating anxiety symptoms they can exert control
This occurs in two stages: the psychologist demon- over them, can use this in other situations of
strates clear control over the situation, which emotional arousal.
enables the clients to feel confidence in her. This
then empowers them— to accept and internalize her Acquiring and Accessing Knowledge
When clients were asked what they remembered
eared activity of ying cient expressed this the fist session of treatment, ey ey trembend
succinctly: 'What got me through it is this thing of recalled being given explanations of how the
someone having trust in you—her saying "of body responded to threat and the physiological
fi
fl
Understanding Cognitive Change 67

mechanisms underlying the fear response: 'She was life at all ... It's like having a pain in your foot or
able to tell me what fear was ... and the something; just wait for it to go and carry on with
mechanism of fear within the body, and how things your business.
are triggered off and the feelings and sensations There is however a problem for clients if they are
that you get. And then you can relate ... when not able to experience the conditions which
you're going through this you know normally arouse their anxiety, since they cannot
happening (client 6). learn to tolerate symptoms fully without experien-
For some clients the information was new; for cing them in situ and their catastrophic predictions
others, it was knowledge which they possessed but cannot be disconfirmed if they are not sufficiently
had not accessed when it was needed. The role of tested. For example, client 2 stated that his main
the psychologist was therefore not just to inform source of fear was experiencing turbulence, which
but to help the client use the information at the he traced back to two bad previous flights. As his
relevant moment: 'She reminded me about how we flight with the psychologist was a fairly smooth
can exaggerate anxiety if we're physically tense. All one he did not have to face up to the thing he
those things that you know but you don't bring into feared most. Although he felt that he had benefited
play. But she reminded me in situ (client 7). from the treatment programme he still expressed
some hesitance about his ability to manage very
Emotional Arousal turbulent flights. In contrast, client 4 had been able
Understanding the mechanism of fear is only to experience emotional arousal which he saw as
helpful if clients are sufficiently emotionally important ingaining a sense of control:
aroused to draw on this knowledge. Particularly 'There's no point in doing it if it just sails by
successful experiences were those where the client without any problem, because you want to prove
was able to experience some of their usual symp- to yourself that you can do it feeling absolutely
toms of fear, for example on the outward flight, but
without any adverse consequences. For example,
before treatment, client 6 had experienced terrify- Cognitive Re-labelling
ing panic attacks where 'I just thought I was going For those clients who successfully negotiate the
to die because of these peculiar feelings, as though process of learning to tolerate anxiety the outcome
my head was going to burst open. Following the can be very dramatic. lhe symptoms are no longer
cognitive therapy session she was able to interpret interpreted as indicating a 'real' fear, but some-
the feelings in a more controlled way: It was her thing which can be controlled and conquered: 'She
giving me a way of looking at myself in the plane stripped away the cling-film of fear and shredded
... where I was able to say, I'm going through this it. Because it's not really a barrier at all' (client 7).
fear, now what is happening... So, because of the The outcome is that the symptoms previously
way she expressed what would happen to us in labelled as anxiety of fear acquire a new label,
fear of flight and the chemical reactions in the which is either discomfort or excitement, or both: 'I
body, I've related to it. thought it wildly uncomfortable but I wasn't
Client 7 expressed very clearly the way in which frightened... It was much more a feeling of "this
tolerating symptoms was found up with the new is highly uncomfortable" than "this is scary"'
knowledge that this was a natural bodily response (client 10). 'I feel excited at the idea of flying. It's a
and did not signify that something awful was about pleasant excitement not a frightening excitement
to happen: 'She also said-if you get this feeling, so (client 9). This new label can then be applied to
what! You're not going to turn blue or grow another other contexts where feelings of anxiety arise. This
head, ... just let it happen. And now I think it's seemed to be particularly the case for those clients
perfectly OK to feel anxious and just to let it who had other forms of agoraphobia: 'Since I've
happen, because it's nature's way of coming got over the fear of flying I can do anything that I
through my body. I will have this flight-fright couldn't do; it really is amazing, the change' (client
feeling, but I can control it. Interestingly, client 4 6). 'The most important (thing) is to say that
thought it was important to contribute to have the whatever you feel it's probably only discomfort. I
symptoms of fear so that he could continue to used to get very uptight about not having any air—
tolerate them, without them seeming special or that I couldn't breathe. She said, you're only
threatening: 'Perhaps it's good actually from time feeling uncomfortable, it's not life-threatening.
to time to have an attack of anxiety... I think, oh That was very important to me and I've drawn
it's there again. So either way it doesn't control my on it since . ...
 68 1. Borrill and E. Iljon Foreman

Rational Thinking ing one session of cognitive therapy, when in some

These successful clients had clearly assimilated cases they had been exposed to 'logical' arguments
much of the language of a cognitive-behavioural and refutations on previous occasions, for example
from friends or partners, with little effect? It may be
experiences in terms of developing rational or that the confidence established in the psychologist
was critical in enabling them to make their beliefs
logical ways of thinking. Adopting a rational
open to challenge. Another important element was
approach to thinking about flying was referred to
the extent to which they perceived the psychologist
in client descriptions of various stages of the
as empathic. But most important seems to be the
treatment, but it was particularly apparent in their
accounts of the first session (i.e. the cognitive
therapy). From the clients' perspective, a rational
prices of ace sic infarmation a bo ux pennie-
approach involves examining the logical validity of
possibility of bringing feelings as well as
thoughts under rational control. Client 6 described
fears and the probability of feared outcomes. It also
means drawing on the tolerance of anxiety and
is the hafe bear treatein aer one says Sang
cognitive re-labelling discussed above in order to
agree with you but I can't stop what I feel. I feel
construct new 'rational' explanations of feelings.
these things—-I have no control over it'. In contrast,
For example, client 1 found the validity of one she described the psychologist as 'giving me a way
aspect of his fear challenged at the outset: 'I thought of looking at myself in the plane, logically, where I
if God's going to get us the worst he could do to me
was able to say I'm going through this fear, now
(would be) in an aeroplane... And it came out that
what is happening.
that was unreasonable ... she mentioned about all
Understanding symptoms, tolerating and re-
the other people on the plane. So I thought, . . . well labelling them therefore provides a sense of control
that's a stupid thing—to get me to kill all the other over feelings, so that feelings no longer get in the
people on the plane!' Client 10's fears derived from way of logical argument and judgement. Thus when
concerns about how she might behave. She recalled clients describe themselves as being rational they are
how the probability of her 'behaving badly' was saying that they feel in control of their decision-making
questioned: 'She said, "But have you any reason to rather than being overwhelmed by (irrational) feelings.
think why you should (behave badly)?" I thought
logically it made sense, which to me was very
important. Client 7 was also challenged to re- Facing up to Fear
consider the probability of her responding 'cata- Facing up to fear refers to the various ways in
strophically to fear: 'She asked me-"you think which clients engaged in the experience of flying,
you're going to be sick or pass out. But have you with support from the psychologist. For those who
ever done any of these things?" And I said "No" had not flown before, each stage in their first
So she said, "The chances are you never will then". experience of flying was an important part of
But I hadn't actually talked that through with gaining control, through making the 'unknown'
myself. Rational or logical thinking is therefore into the 'known'. For clients who had flown many
seen as a way of exercising control over feelings: 1 times, facing up to fear meant actively engaging in
wouldn't say I'm not tense at all but I can contain it, the experience, rather than using distraction or
I can rationalize it ... I'm more into stepping back disengagement strategies. Active engagement was
and approaching things in a more rational way. achieved most effectively through following the
Whereas I used to live terribly on my emotions and psychologist's instructions, which were designed to
allow that anxious feeling to take me over' (client 7).provide clients with experiences of mastery. Suc-
Another outcome of 'rational thinking' seems to cesstul clients acquired a strong sense of self-
be a more decisive, non-ruminative approach, as efficacy which took them beyond 'coping' and
summarized by client 6: 'Whereas before I would generalized to other feared situations.
think, "am I going to be able to cope?", that attitude
has gone ... Everything I do, I don't think twice Making the Unknown Known
For the two clients who had never flown before, the
In terms of understanding how a more rational need to face up to fear was seen as relatively
approach is developed, the important question is straightforward. For example, client 3 had learnt
why did the clients respond so quickly in relin- from the initial cognitive therapy session that: 'the
quishing irrational or unsubstantiated fears follow- only way you're going to overcome it is to face it...
Understanding Cognitive Change 69

and you're never going to face it unless you do it. and she said "Look again" and she gradually got
Her fear had been of the unknown-both the me to look out of the window' (client 9). For others,
unknown experience and her own unpredictable who did not have specific problems of avoidance,
response: 'I hadn't done it before and I didn't know the emphasis was on looking around and experien-
how I was going to react and if I was going to have cing everything fully: 'Instead of sitting gripping
... panic symptoms... Having a panic attack on your seat and gritting your teeth she's making you
the plane full of people I would imagine is quite look around the aircraft and at the other passengers
embarrassing. ... she's making you take in everything'
Engaging in the experience contrasts with clients'
previous attempts to deal with their fear through
distraction or disengagement. Clients who had
the first step immediately began the process of previously disengaged through taking alcohol or
disconfirming expectations about how they would drugs were advised not to use these, as their
feel; for example client 3 described how her mastery over feared situations could not lead to
anticipatory fear ('shaking like a bag of jelly) self-efficacy if it was attributable to other agencies.
disappeared when she met the psychologist at the Again, this is linked with the idea of making things
airport. Client 8 described his experience as a series known. Client 1, having been forced to look out of
of steps or milestones. At each step he was the window, commented: 'When I looked out of the
surprised to find that he felt calm instead of window I seemed nearer the ground and it seemed
anxious: 'That was another milestone, when it less frightening because I could see real things. I
really sunk into me, because before it felt like it could see the real wing.. so it's not so frightening
wasn't really happening... I wasn't the nervous as fear of the unknown is it?' He went on to
wreck I thought I'd be describe how this became an immensely enjoyable
Some clients who had flown many times still experience: 'I sat and looked at the wing just
experienced fears of the unknown, for example amazed-and looked at the screws on the wing. I
how they would respond in a difficult or dangerous was trying to look down to see the sea, looking into
situation. Since these situations cannot be sum- the horizon and seeing if I could see where the sea
up at will the treatment focused on met the land. Looking for yachts and just trying to
modifying their negative beliefs about these un- see things'. Clients such as this appear to have gone
knowable situations. beyond mere 'coping' with fear to a new state of
confidence.
Guided Mastery
For clients who had flown many times just facing Trusting and Being Trusted
up to the act of flying was insufficient, since they
had done this repeatedly. The treatment therefore Most clients made some reference to the role of
focused on the way in which they flew, and in other people in the treatment experience. These
particular the need to actively engage in activities included fellow clients, pilots, other airline staff,
they had previously avoided, such as walking and passengers. Their accounts differ in the
about, eating, looking out of the window. The role importance attributed to these interpersonal en-
of the psychologist was to guide them through counters, but a general theme emerges of increased
instructions into situations where they couldtrust and a sense of belongingness. As with the
experience mastery. This was described by client 7 initial therapeutic relationship with the psycholo-
as follows: 'Then she said "I want you to walk the gist, trusting others involves sharing feelings,
'. Normally I've got superglue
length of the plane". helping and being helped, and allowing others to
on the bottom of my shoes. I went up there and I take charge.
was so proud that I'd done it ... I just really felt
that she was in control and I just did what she said. Sharing Feelings of Fear
Then when she said — "Look what you've done" —I Although many clients had chosen this particular
thought, oh I did move, I did look out of the treatment programme because they wanted one-to-
window, I've eaten and I'm still here!' (client 7). one attention, nevertheless the presence of one or
For some clients this generated considerable two other clients on the flight was described as
emotional arousal: 'I was crying all the time and I helpful, providing similar functions to the relation-
wouldn't look out of the window. She said "Look
out of the window" and I gave a two-second glance
 70 J. Borrill and E. Iljon Foreman

another lady who had a similar fear to me….. it flying and say to myself "I've done it". I think of
was great because we could relate to each other myself as somebody who can do it' (client 5).
and express ourselves, because what she was 'Joining the Club' of 'normal' flyers does not
saying I felt. Up until then nobody felt like I did; mean experiencing no fear; rather it means experi-
everyone thought flying was wonderful' (client 6). encing no more fear than anyone else in the
in contrast, the behaviour of non-fearful passen- circumstances: 'I'm probably normal. I find it no
gers is also helpful, through providing a model: worse than anyone else now whereas before it was
'I felt a bit apprehensive at the time, but I thought something I wouldn't even contemplate' (client 8).
well; there's another 100 people on here with me
and they're obviously not worried, so keep calm' ordinary
It way,'doing'
also means without
theany special
flight attention or
in a business-like,
ritual: 'It was just like I have flown since-just get
Several clients described how they had benefited on, take off, go there, land, get off' (client 7). Clients
from taking on a helping role with a more particularly referred to the fact that in this treat-
frightened companion during treatment: 'I was ment programme, unlike some others, the flight
... so busy worrying about her that I actually was'normal': 'It was a scheduled flight so we
forgot about me' (client 3).
didn't get any special treatment; we experienced it
as it happened which I thought was very nice
Learning to Trust Others
(client 3). 'What appealed to me about (this course)
Just as it was necessary to trust the psychologist in was-you're just a normal passenger. And I
order to be empowered to face up to fear, so an thought that's the way to do it. I felt like I was a
important element for many clients was trust in the proper passenger because I behaved like one' (client 8).
pilot and in other professionals. Some stated Joining the Club is therefore a rite of passage from
explicitly their concern about having to relinquish non-flyer to flyer. Having made this transition
control: 'Well roughly speaking, I didn't trust clients were able to act out the role of helper with
anybody else to sort of take charge; even when I other nervous flyers: 'When I went to France with
used to drive I did all the driving(client 1). This Elsie I'm saying to her "don't hold onto the side,
was dealt with by the psychologist in two ways— don't hold on to me that won't stop anything
first by demonstrating that control is never com- happening. That's what E was saying to me'
plete, and second by setting up (client 7). This is also the basis for generalization to
facilitate trust, most notably arranging for clients other fears, since clients perceive themselves as
to go into the cockpit. I went to see the pilot and belonging to the group of people who 'can do
that was great. He was very reassuring and very whatever they want to do.
relaxed. He was in control and he explained things
to me' (client 5). 'And always to this day it relaxes
me because I know what they're doing now in that The Theme of Control
cockpit and they go through their checklist... and Looking across categories and across individual
that helps terrifically' (client 6). Other airline staff accounts, the overriding theme which emerges is
were also described as providing support: 'As we that of CONTROL. Before treatment, clients
took off I looked up and the steward was looking at expressed a number of different fears concerning
me and I found that really reassuring. I think one of loss or lack of control:
my biggest fears was that I'd be sitting there
terrified and nobody would help me' (client 5). lack of control over the plane itself (fear of
crashing, disaster)
lack of control over bodily symptoms of fear
Joining the Club (fear of being overwhelmed by sensations)
One of the outcomes of successful treatment was lack of control over emotional feelings (fear of
the description by clients of a sense of transition, fear, terror)
from non-flyer or anxious flyer to 'normal' flyer. lack of control over thoughts (rumination,
There was a feeling of belonging to a group from irrational cognitions)
which they had previously been excluded: 'I was lack of control over behaviour (panic, exit,
confident as though I'd, you know, passed behaving badly)
you're one of a gang, one of the crowd. I felt as They did not believe that these thoughts or feelings
though I'd joined something' (client 1). 'Even after I could be controlled and felt themselves to be
came back every once in a while I'd think about helpless victims of their experience.
Understanding Cognitive Change 71

The process of treatment may therefore be the psychologist, she took a tranquillizer, and her
represented as a set of steps towards exercising description of the flight is of an uneventful
control. According to clients, the 'trick of the controlled but somewhat passive experience, in
therapist lies in convincing them that she is in which she sought reassurance from flight stewards
control, thus giving 'permission for them and the pilot. At interview she described feeling
challenge cognitions, engage in experiences, access more in control than before treatment, and she felt it
knowledge, tolerate feelings, and achieve mastery. was now possible for her to be a normal flyer.
(NB The psychologist does not perceive herself as However her strategies for dealing with fear tended
taking control or giving instructions, but rather as to involve distraction; she seemed to be concerned
facilitating clients' own choice of action.) This with managing fear rather than being able to
results in disconfirmation of uncontrollable out- tolerate and face it. She was also concerned that
comes, cognitive re-labelling of uncontrollable she might 'slip back', although not to her previous
symptoms and feelings and substitution of con- level of fear. For this client therefore, the establish-
trolled behaviour for uncontrollable avoidance. ing of the therapeutic relationship and the chal-
lenge to rational thinking enabled her to fly
but in control
Clients of feel
no longer known,
at theordinary, unknown fears, successfully, but the absence of guided mastery
mercy ofunderstandable
feelings. Client success is consequently attributed and the consequent failure to engage totally with
to self-control, not to a crutch, and can therefore be the feared experience meant that she is at the stage
generalized to other feared situations. Successful of coping rather than enjoyment. Her membership
clients were not only able to fly without fear, but of the normal flyers club would seem to be still on
also reported being able to drive, go through probationary terms.
tunnels, face crowds, assert themselves in business In contrast, client 10 appears to have achieved a
situations, make decisions, and change the habits of state of confident flying despite the absence of
a lifetime.
guided mastery. In this case her fears centred
A general model of the process of relinquishing around irrational thoughts which were successfully
and achieving control is shown in Figure 1. challenged in the first session. Activities which
other clients needed support to achieve (e.g.
walking about in the plane) were not a problem
for this client and the absence of guided mastery in-
DISCUSSION flight does not seem to have reduced the effective-
ness of treatment. Furthermore, in the absence of
Testing the Model of Change the psychologist, client 10 was nevertheless able to
The model shown in Figure 1 represents the follow some of her instructions, for example to
general process which emerges from the inter- arrive early rather than rushing. From these and the
views; individual differences occur in the impor- other interviews it would seem that guided mastery
tance of the various stages of the process. In order is most critical where the client suffers from a range
to test the validity of the model and explore its of claustrophobic symptoms and/or from specific
limitations it is appropriate to consider whether forms of in-flight avoidance.
particular stages are necessary or sufficient for The most important test of a model of therapeutic
change to occur. This may be done initially by change must lie in its power to explain failure as
looking at clients who did not experience as success. The present study focuses on
aspects of the programme. successful clients but future research needs to
Clients 5 and 10 went through the cognitive examine the small minority of clients who do not
therapy session but were unable to fly with the benefit from the programme. Some insight may be
psychologist before having to fly alone. They gained from the account of one additional client
therefore provide an opportunity to explore the who was interviewed (client 11) who felt that she
importance of the guided mastery component. For had not benefited from treatment.
client 5 the lack of guided mastery seems to be Client 11 expressed fears of crashing but had
associated with a more tentative grip on success. continued to fly out of determination not let her life
She benefited from treatment in that having to be restricted through fear. For this client, the first
acknowledge and discuss her fears brought her to session was marred by the need to complete
the point of being able to face the reality of flying assessment questionnaires which she found intru-
which she had not faced for many years. But in sive: 'They were irrelevant, they were impossible to
order to cope with doing the flight, in the absence of answer, and I can't really remember any of the
 J. Borrill and E. Iljon Foreman

Establish relationship with

psychologist.
Therapist qualities
Legitimisation of expression

Relinquish Control She is in Control Pilot

is in control
'Borrow Belief"

Cognition Information Behaviour

Accept Control:
Follow Instructions Accept challenge to Face up to fear
Access information on
irrational thinking physiological response Guided Mastery

Experience Contrel
Rational approach Tolerance of anxiety Engage in feared activities
Control over thoughts Control over feelings Control over behaviour

Negative Predictions
Disconfirmed

Cognitive Mastery/
Re-labelling Self Efficacy

Achieve Self Control Join the Club

"Can do'

Self Instruction Generalise to other situations

Instruct Others

Figure 1. Model of the process of achieving control

Understanding Cognitive Change 73

questions because they were so incomprehensible that combat demoralization by strengthening the
to me. Instead of feeling that the psychologist was therapeutic relationship, inspiring expectations of
focused on helping her, as other clients had felt, help, providing new learning experiences, arousing
client 11 felt that 'the questions missed the mark- the patient emotionally, enhancing sense of mastery
because they're not about me, they're about or self-efficacy, and affording opportunities for
rehearsal and practice (Frank 1982, p. 20). The
res a rice person a she de ribed the psychologist categories which were identified in this study map
evidence from her account of any sense of trust or tairly closely with Frank's variables, but the clients'
confidence, and hence no possibility of her borrow- accounts provide a clearer understanding of the
ing belief'. This client also had no recollection of any perceived relationship between categories and the
discussion of the physiology of fear (a standard cognitive processes involved in achieving mastery
component of session 1); her memory was domi-
nated by the 'endless questions' to which she felt Frank argued that mastery is increased, not only
unable to provide precise answers. The absence of by providing the person with opportunities to
trust and confidence is associated with the inability experience success, but also through giving the
to benefit either from challenges to irrational client a conceptual framework which labels and
thinking (of which she made no mention) or from explains symptoms and supplies the rationale for
guided mastery, which she rejected because she did the treatment programme. In this study the concept
not feel that it was for her benefit: 'She said I had to of 'tolerance of anxiety' was found to be critical in
walk about, because I never do. But I didn't... she providing the mechanism through which clients
can't force me. It's just a situation that I felt, on learnt to access information about symptoms, re-
reflection, is helping her more than it is helping me. label feelings, and develop new predictions.
This case therefore suggests that the establish- Through using knowledge to 'give names' to
ment of a strong therapeutic relationship, focused feelings which had previously seemed inexplicable,
on the needs of the client, may be a necessary a separation is achieved between anxious feelings
precursor to the later processes of cognitive change. and predicted outcomes.
Whisman (1993) has noted that, in comparison with
other theoretical models, cognitive therapy has
tended to place less emphasis on the therapeutic CONCLUSIONS
relationship and more on techniques. Some studies
of cognitive therapy for depression have reported From these client accounts it would appear that
correlations between ratings of the therapeutic establishing a strong therapeutic relationship is a
alliance and clinical improvement, independent of necessary component of treatment but can be
cognitive change (e.g. Persons and Burns, 1985; achieved very quickly given the right combination
Burns and Nolen-Hoeksma, 1991). However these therapist qualities and style. Without this
studies only assessed the contribution of a good relationship the client is unlikely to be able to
therapeutic relationship to outcome, not whether it progress to the later stages identified in the model.
was necessary or even sufficient for change. In the Guided mastery was seen as particularly important
case of client 11, there is some indication that by clients who had a range of in-flight avoidance
establishing the therapeutic relationship may be patterns. For all clients, engaging fully in the
necessary at the first stage of treatment. Her experience of flying (rather than relaxation, dis-
response to the questionnaires was sufficiently traction, or passive exposure) was seen as the
negative to make her feel marginal to the treatment means by which they progressed beyond coping or
process and despite her determination to fly, the managing flying and experienced the transition to a
lack of trust made her unable to engage in either self-concept of 'normal flyer. Whilst it may be
cognitive or behavioural challenge. The case is unwise to over-generalize from this particular
therefore helpful in drawing attention to aspects of sample, the principles identified in the model as
the treatment programme which some clients may mediators of change (e.g. borrowing belief, experi-
find counter-therapeutic. encing control, and cognitive re-labelling) may be
Previous researchers have attempted to identify tested by other practitioner-researchers as part of
common therapeutic variables which may be found their ongoing process of evaluation.
in all or most forms of psychotherapy (Garfield, We believe that the study has demonstrated the
1994). Frank (1982) suggested that 'all therapeutic richness of data which can be collected from
myths and rituals ... have in common functions personal accounts and analysed using appropriate
 74 J. Borrill and E. Iljon Foreman

qualitative techniques. Since retrospective accounts evaluation of brief cognitive therapy for fear of flying.
are subject to memory distortions (which may of Scottish Medicine, 13(4), 6-8.
course be clinically interesting) it would be useful Iljon Foreman, E. and Borrill, J. (1994). The freedom to
in future to obtain concurrent accounts of change, fly: a long-term follow-up of three cases of fear of
flying. Journal of Travel Medicine, 1(1), 30-35.
which could then be compared with the quantita- McLeod, J. (1990). The client's experience of counselling
tive measures of anxiety, cognition and self-efficacy
and psychotherapy: a review of the research literature.
obtained at different stages of treatment. Most In D. Mearns and W. Dryden (Eds), Experiences of
important, further research should address the Counselling in Action, London: Sage, pp. 1-19.
range of applicability of the model and its limita- McNally, R. J. and Louro, C. E. (1992). Fear of flying in
tions, by extending the sample to include further agoraphobia and simple phobia: distinguishing
features. Journal of Anxiety Disorders, 6, 319-324.
accounts of clients who failed to benefit from Persons, J. B. and Burns, D. D. (1985). Mechanisms of
treatment or who subsequently relapsed.
action of cognitive therapy: The relative contributions
of technical and interpersonal interventions. Cognitive
Therapy and Research, 9, 539-551.
REFERENCES Rennie, D. L. (1994). Clients' deference in psychotherapy.
Special section: Qualitative Research in Counseling
Beckham, J. C., Vrana, S. R., May, J. G., Gustafson, D. J. Process and Outcome. Journal of Counseling Psychology,
and Smith, G. R. (1990). Emotional processing and fear 41(4), 427-437.
measurement synchrony as indicators of treatment Roberts, R. (1989). Passenger fear of flying: behavioural
outcome in fear of flying. Journal of Behaviour Therapy treatment with extensive in-vivo exposure and group
and Experimental Psychiatry, 21(31), 153-162.
support. Aviation Space and Environmental Medicine, 60,
Burns, D. D. and Nolen-Hoeksma, S. (1991). Coping
styles, homework compliance, and the effectiveness of Silverman, D. (1993) Interpreting Qualitative Data: Methods
cognitive behaviour therapy. Journal of Consulting and for Analysing Talk, Text and Interaction. London: Sage.
Clinical Psychology, 59, 305-311.
Strauss, A. and Corbin, J. (1990). Basics of Oualitative
Doctor, R. M., McVarish, C. and Boone, R. P. (1990). Research: Grounded Theory Procedures and Techniques.
Long-term behavioural treatment effects for the fear of Newbury Park: Sage.
flying. Phobia Practice and Research Journal, 3(1), 33-42 Tortella, M. and Bornas, X. (1993). To fear to fly: evalua-
Frank, J. D. (1982). Therapeutic components shared by all tion of a structured multi-component treatment
psychotherapies. In J. Harvey and M. Parks (Eds), program. Unpublished paper presented at the Euro-
Psychotherapy Research and Behaviour Change. The pean Association of Behavioural and Cognitive
Master Lecture Series, Vol 1. Washington DC: APA. Therapy Congress, London, UK.
Garfield, S. L. (1994). Psychotherapy: then and now. Walder, C. P., McCracken, J. S., Herbert, M. James, P. T.
Clinical Psychology and Psychotherapy, 1(2), 63-68.
and Brewitt, N. (1987). Psychological intervention in
Glaser, B. G. and Strauss, A. L. (1967). The Discovery of
civilian flying phobia. British Journal of Psychiatry, 151,
Grounded Theory: Strategies for Qualitative Research. New

Whisman, M. A. (1993). Mediators and moderators of

Henwood, K. and Pidgeon, N. (1995). Grounded theory change in cognitive therapy of depression. Psycho-
and psychological research. The Psychologist, in press. logical Bulletin, 114, 248-265.
Howard, K. I., Orlinsky, D. E. and Lueger, J. (1994) Williams, S. L. (1987). On anxiety and phobia. Journal of
Clinically relevant outcome research in individual Anxiety Disorders, 1, 161-180.
psychotherapy. British Journal of Psychiatry, 165, 4-8.
Williams, J. M. G. and Moorey, S. (1989). In J. Scott,
Howard, W. A., Murphy, S. M. and Clarke, J. C. (1983). J. M. G. Williams and A. T. Beck (Eds), The wider
The nature and treatment of fear of flying: a controlled
investigation. Behaviour Therapy, 14, 557-567.
Iljon Foreman, E. and Borrill, J. (1993). Plane scared: an Practice-an Illustrative Casebook. London: Routledge