What would you do?

Use of skills learned in CBT for fear of flying:

Managing flying anxiety after September 11th

Simon Kim a , Frances Palin

a , Page Anderson

a,*, Shannan Edwards a ,

Gretchen Lindner a , Barbara Olisov Rothbaum

b

a Georgia State University, Atlanta, GA, USA

b Emory University School of Medicine, Atlanta, GA, USA

Received 2 August 2006; received in revised form 12 February 2007; accepted 19 February 2007

Abstract

Although there is evidence that cognitive behavioral therapy (CBT) is effective in the treatment for fear of flying (FOF), there are

no studies that specifically examine which skills taught in treatment are being used by clients after treatment is completed. This

study examines whether participants report using skills taught in treatment for FOF after treatment is completed and whether the

reported use of these skills is associated with reduced flying anxiety in the face of fear-relevant event, the September 11th terrorist

attacks, and over the long-term. One hundred fifteen participants were randomly assigned to and completed eight sessions of

individual CBT treatment for FOF. Fifty-five participants were reassessed in June 2002, an average of 2.3 years after treatment.

Surveys were also collected from 33 individuals who did not receive treatment for FOF. Results indicated that treatment completers

were more likely to report using skills taught in treatment than individuals who had not received treatment. In addition, self-reported

use of skills among previously treated individuals was associated with lower levels of flying anxiety. These findings suggest that use

of skills taught in CBT treatment is associated with reduced flying anxiety in the face of a fear-relevant event and over the long term.

# 2007 Elsevier Ltd. All rights reserved.

Keywords: Use of skills; CBT; Fear of flying

Journal of Anxiety Disorders 22 (2008) 301–309

1. Introduction

Whereas there are several studies demonstrating the

long-term effectiveness of cognitive behavioral therapy

(CBT) for fear of flying (FOF), to our knowledge, there

are no studies that specifically examine which skills

taught in treatment are utilized by clients who

experience FOF. The lack of research linking use of

* Corresponding author at: Georgia State University, Department of

Psychology, P.O. Box 5010, Atlanta, GA 30302-5010, USA.

Tel.: +1 404 651 2850; fax: +1 404 651 1391.

E-mail address: psypxa@langate.gsu.edu (P. Anderson).

0887-6185/$ – see front matter # 2007 Elsevier Ltd. All rights reserved.

doi:10.1016/j.janxdis.2007.02.006

skills to long-term treatment outcome for FOF is an

important gap in the literature given that CBT

emphasizes teaching clients transferable skills (Hollon,

2003). Moreover, competence with such therapy

skills is presumed to contribute to long-term positive

treatment outcomes. The current study examines

whether skills taught in treatment for FOF are used

by participants after treatment is completed in the face

of a fear-relevant event, the September 11th terrorist

attacks, and is associated with reduced flying anxiety

over the long-term.

Cognitive-behavioral therapy is effective in the

treatment for FOF, a common experience estimated to

affect 25 million adults in the United States and nearly

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309302

10–40% of the adults in industrialized countries

(Arnarson, 1987; Ekeberg, 1991; Nordlund, 1983;

Deran & Whitaker, 1982). A variety of CBT methods

(e.g. systematic desensitization, flooding, implosion,

and relaxation) has been found to yield reductions in

flying anxiety after treatment (Beckham, Vrana, May,

Gustafson, & Smith, 1990; Denholtz & Mann, 1975;

Haug et al., 1987; Howard, Murphy, & Clarke, 1983;

Ost, Brandberg, & Alm, 1997; Solyom, Shugar,

Bryntwick, & Solyom, 1973; Van Gerwen, Diekstrra,

Arondeus, & Wolfger, 2004). In general, these studies

utilized cognitive behavioral approaches to treatment,

incorporating a combination of psychoeducation,

cognitive restructuring, and some form of exposure.

More recently, use of virtual reality as a tool in treating

individuals with flying anxiety has been examined and

has demonstrated positive post-treatment outcomes in

case studies (North, North, & Coble, 1997; Rothbaum,

Hodges, Watson, Kessler, & Opdyke, 1996; Smith,

Rothbaum, & Hodges, 1999; Wiederhold, Gevirtz, &

Widerhold, 1998), as well as both uncontrolled (Botella,

Osma, Garcia-Palacios, Quero, & Banos, 2004) and

controlled (Maltby, Kirsch, Mayers, & Allen, 2002;

Rothbaum, Hodges, Smith, Lee, & Price, 2000;

Rothbaum et al., 2006) trials.

There are few research studies examining long-term

CBT treatment outcomes for FOF and the results from

such studies are mixed. Several studies of treatments

using in-vivo and virtual reality exposure have reported

maintenance of treatment gains for at least one year

(Doctor, McVarish, & Boone, 1990; Rothbaum,

Hodges, Anderson, Price, & Smith, 2002; Rothbaum

et al., 2006). One study found that treatment gains were

maintained at 3-year follow-up after virtual reality

exposure (VRE) treatment (Wiederhold & Wiederhold,

2003). However, this study had a very small sample size

(N = 28), and participants’ self-report of flying after

treatment was the only outcome measure. In addition, in

a well-controlled study comparing the effects of VRE

and placebo in the treatment of FOF (Maltby et al.,

2002), treatment gains for participants in the VRE

group were not maintained at 6-month follow-up.

Recently, Anderson et al. (2006) examined the long-

term efficacy of CBT for clients with FOF, after Sept

11th. These individuals originally participated in two

well-controlled, randomized clinical trials for the

treatment of FOF (Rothbaum et al., 2000, 2006) that

compared virtual reality exposure to standard exposure

in-vivo treatments. Results from this follow-up study

showed that treatment gains were maintained, or

improved upon, an average of 2.3 years after treatment

for both virtual reality and standard exposure (Anderson

et al., 2006) providing some evidence for the long-term

benefit of CBT for FOF, and sustainability after a

significant fear-relevant event.

What may account for the sustainability of treatment

gains? Although there is clear evidence that CBT

provides short-term gains for FOF and some evidence

that these gains are enduring, the components under-

lying these enduring effects are unclear. Skill acquisi-

tion has been identified as one important component of

CBT treatment, along with changes in cognition,

enhanced coping, and exposure (Prins & Ollendick,

2003). CBT’s emphasis on skill learning is based on

cognitive theories of self-regulation and motivation, and

on the assumption that clients are problem-solvers and

self-motivators (Brewin, 1996). A general assumption

of CBT is that ‘‘prior learning is currently having

maladaptive consequences, and that the purpose of

therapy is to reduce distress or unwanted behavior by

undoing this learning or by providing new, more

adaptive learning experiences’’ (Brewin, 1996, p. 34).

Presumably, the skills learned in treatment contribute to

adaptive learning experiences, as well as the main-

tenance of such adaptive learning.

Thus, CBT therapists deliberately work to build

skills among their clients by emphasizing active

participation and psychoeducation so that clients may

become their own therapist once treatment is terminated

(Beck, 1995; Hollon, 2003). The aim is for clients to

develop transferable skills that can be used to cope with

new problems that arise after the end of therapy

(Westbrook & Hill, 1998), and increase the probability

that they will have effective tools at their disposal when

they are needed in the future in order to manage

emotional responses to stress (Barber & DeRubeis,

1989; Hollon, 2003).

Despite the emphasis CBT places on teaching clients

skills (Westbrook & Hill, 1998), for anxiety disorders

there is a dearth of studies looking at relations between

skills taught in therapy, their use once treatment has

ended, and its association with positive treatment

outcomes. No studies could be identified that specifi-

cally examine the use of skills learned in treatment and

long-term outcomes for FOF. However, research on

social phobia and depression suggests that clients who

systematically apply what they have learned in therapy

are more likely to make progress in treatment (e.g.,

Persons, Burns, & Perloff, 1988), as well as maintain

their treatment gains in the long-term (e.g., Edleman &

Chambless, 1995; Helbig & Fehm, 2004; Young

Weinberger, & Beck, 2001). In addition, research

shows associations between the amount of practice

clients engage in during treatment and the benefits they

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309 303

achieve from exposure therapy (Barlow, O’Brien, &

Last, 1984; Michelson, Mavissakalian, Marchione,

Dancu, & Greenwald, 1986). Finally, a recent study

found that increased coping skills were significant long-

term predictors of treatment outcomes for alcohol

dependence (Litt, Kadden, Cooney, & Kabela, 2003).

Given the lack of research examining whether clients

report using skills learned in therapy after treatment,

and associations between use of skills and positive long-

term outcomes for FOF, the purpose of this study is to

examine whether participants previously treated for

FOF with CBT report using skills learned in treatment

to manage flying anxiety after a fear-relevant event. We

also examine whether self-reported use of skills learned

in treatment is associated with flying anxiety over the

long-term. In the current study, clients were taught three

skills in treatment, namely, breathing retraining, talking

back to negative thoughts, and continuing to fly.

Specific theoretical underpinnings for these skills

include cognitive change as a result of adaptive self-

talk (e.g., Meichenbaum, 1977) and habituation to the

feared stimulus by means of exposure (Foa & Kozak,

1986). We hypothesize that: (1) participants who

received treatment for FOF will more likely report

using skills taught in treatment than a comparison group

of non-anxious individuals who have not received

treatment for FOF, (2) participants treated with CBT for

FOF will be more likely to report using skills learned in

treatment (‘‘taking relaxing breaths,’’ ‘‘talking back to

negative thoughts,’’ and ‘‘continuing to fly’’) than skills

not learned in treatment (‘‘trying to put it out of my

mind/distracting myself,’’ ‘‘talking to friends and

family,’’ ‘‘gathering information about increased secur-

ity measures,’’ and ‘‘listening to the media’’) to manage

flying anxiety after September 11th and (3) among

treatment completers, those who report using skills

taught in treatment will show lower levels of flying

anxiety after September 11th than those who reported

not using skills taught in treatment.

2. Methods

2.1. Participants

All individuals who completed treatment for the fear

of flying across two studies (n = 115) were contacted by

mail in June, 2002. In order to attempt to recruit a

demographically matched convenience comparison

group, treatment completers were sent two copies of

the surveys with two postage-paid return envelopes and

were asked to complete one survey and to give the

second survey to a friend who had never had treatment

for the fear of flying (comparison group). Potential

participants were asked not to complete the ques-

tionnaires together. Participation by comparison group

participants was anonymous, as no identifying informa-

tion beyond basic demographics (current age, sex, race,

martial status, income level) was collected.

To have participated in the original treatment studies,

individuals met current DSM-IV criteria for either

specific phobia, situational type (i.e., FOF), panic

disorder with agoraphobia in which flying was the

feared stimulus, or agoraphobia without a history of

panic disorder, in which flying was the feared stimulus,

as measured by the Structured Clinical Interview for the

DSM-IV (SCID; First, Spitzer, Gibbon, & Williams,

1995). All assessments were conducted by a licensed

psychologist, who was blind to the type of treatment

received. A subset of interviews was rated by another

licensed psychologist, achieving a kappa coefficient of

.94, indicating excellent inter-rater reliability (Roth-

baum et al., 2006).

Of the 115 potential participants who completed

treatment across the two trials, 7 participants’ packets

were returned unopened, and current addresses were

unable to be located. Of the 108 potential treatment

respondents, 55 individuals completed the question-

naires (51% retention). The majority of these respon-

dents received a primary diagnosis of specific phobia,

situational type (flying; 87%, n = 48). The remaining

respondents received a primary diagnosis of panic

disorder with agoraphobia (11%, n = 6) and agorapho-

bia (2%, n = 1). With regard to co-morbidity, sixty

percent received one current diagnosis (n = 33), 26%

(n = 14) received two diagnoses, 13% (n = 7) received

three diagnoses, and 2% (n = 1) received four diag-

noses.

Of the 108 potential comparison group respon-

dents, 33 individuals completed the questionnaires

(31% retention). Respondents were excluded if they

reported direct exposure to the September 11th

terrorist attacks. Comparison group participants were

excluded if they had previous treatment for fear

of flying. One comparison group respondent was

excluded due to prior treatment for fear of flying and

one treatment respondent was excluded due to direct

exposure to the September 11th terrorist attacks.

Treatment completers and comparison group partici-

pants did not differ across age, education, marital

status, race, and income. Respondents were on

average 40 years of age, well-educated (on average

17 years of schooling), married (59%), Caucasian

(92%), and middle-to-upper-income (71% reported > $50K/year).

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309304

2.2. Treatment

All treatment and follow-up assessments for the

original treatment studies were completed prior to

September 11th, 2001. The treatment was identical for

each of the two trials, which is detailed elsewhere

(Rothbaum et al., 2000, 2006). In brief, participants

were randomly assigned to VRE or SE for eight

individual sessions over 6 weeks. Treatment consisted

of four sessions of anxiety management training (for

both groups), including breathing relaxation, cognitive

restructuring, and thought-stopping, followed either by

exposure to a virtual airplane (VRE) or an actual

airplane at the airport (SE), according to a treatment

manual. VRE was conducted in a therapist’s office

according to a treatment manual (Rothbaum & Hodges,

1999). Patients wore a head-mounted display with

stereo earphones that provided visual and audio cues

consistent with being inside the passenger compartment

of an airplane. During VRE sessions, participants could

taxi, take-off, fly in calm and turbulent weather and land

in the virtual airplane. SE was conducted at the airport

and was spent exposing patients to pre-flight stimuli

(e.g., ticketing), to an elevated coordination center

tower, and to sitting on a stationary airplane.

2.3. Measures

2.3.1. Flying anxiety

The Questionnaire on Attitudes Toward Flying

(QAF, Howard et al., 1983) assesses various aspects

of FOF including: longevity of FOF, treatment history,

and attitudes concerning flying. It includes a 36-item

subsection that asks the participant to rate level of fear

toward different flying situations (e.g., ‘‘The noise of

the engine suddenly increases’’) using a 0–10 scale. The

range of scores is 0–360, with higher scores represent-

ing higher levels of anxiety. Test-retest reliability has

been reported as .92, and split-half reliability as .99. The

QAF-Fear Item (QAF-Fear) is a single item taken from

the QAF, which asks the participant to rate current fear

of flying from 0 (‘‘no fear’’) to 10 (‘‘the most extreme

amount of fear that is possible for you to feel’’). It is

used as a face-valid measure of FOF.

The Fear of Flying Inventory (FFI, Scott, 1987) is a

33-item measure assessing fear of flying intensity, in

which participants rate how much they would be

distressed by various aspects of flying (e.g., ‘‘Take-

off’’) on a scale of 0 (‘‘not at all’’) to 8 (‘‘very severely

disturbing’’). Scores range from 0 to 264. Scott (1987)

has reported test-retest reliability for 15 wait-list

patients as .92, and has demonstrated its sensitivity to

change after treatment. Both the FFI and the QAF are

correlated with clinician-administered measures of

flying anxiety (Rothbaum et al., 2000).

2.3.2. Use of skills

The Fear of Flying after September 11 th

, 2001

questionnaire was developed for the purposes of this

study. This questionnaire asks individuals to indicate

‘‘whether you used any of the following anxiety

management skills after September 11th to deal with

anxiety about airplane travel.’’ The skills specifically

taught during treatment included: ‘‘taking relaxing

breaths’’; ‘‘talking back to negative thoughts’’; and

‘‘continuing to fly.’’ Other skills not taught in treatment

included: ‘‘trying to put it out of my mind/distracting

myself’’; ‘‘talking to friends and family’’; ‘‘gathering

information about increased security measures’’; and

‘‘listening to the media.’’ Individuals were asked to

indicate all that applied.

3. Results

3.1. Treatment and comparison group

In order to address the first hypothesis, multiple

Chi-square analyses were conducted to assess if the

proportion of individuals who endorsed using specific

skills differed in the treatment versus the comparison

group. Of the skills taught in treatment, individuals who

completed CBT were significantly more likely to have

taken ‘‘relaxing breaths’’ (x 2 (1, N = 88) = 10.52,

p < .01) and to have ‘‘talked back to their negative thoughts’’ (x

2 (1, N = 88) = 5.95, p < .05) to deal with

their anxiety than individuals in the comparison group.

No significant differences were found between treat-

ment completers and the comparison group on

‘‘continuing to fly.’’ Of the skills not taught in treatment,

no significant differences were found between treatment

completers and the comparison group on ‘‘trying to put

it out of my mind/distracting myself,’’ ‘‘talking to

friends and family,’’ ‘‘gathering information about

increased security measures,’’ or ‘‘listening to the

media’’ ( p > .05). Table 1 shows the percentage of treatment completers and the comparisons using the

various skills.

3.2. Use of skills and anxiety levels among

treatment completers

To address the second hypothesis, a paired samples t-

test was conducted to assess whether clients treated with

CBT for FOF used anxiety management skills taught in

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309 305

Table 1

Percentage of participants using various skills after September 11th

Anxiety management skills Treatment

completers

(n = 55) (%)

Comparison

group

(n = 33) (%)

Taught in treatment

‘‘Taking relaxing breaths’’ 65 33

‘‘Talking back to negative thoughts’’ 60 36

‘‘Continuing to fly’’ 38 39

Not taught in treatment

‘‘Trying to put it out of mind my

mind/distracting myself’’

51 36

‘‘Talking to friends and family’’ 33 24

‘‘Gathering information about

increased security measures’’

20 10

‘‘Listening to the media’’ 10 15

therapy more than other potential anxiety management

skills that were not taught in therapy. More specifically,

the average number of skills taught in treatment that was

used by the clients was compared to the mean of skills

not taught in treatment. The results indicate that skills

taught in treatment (‘‘taking relaxing breaths,’’ ‘‘talking

back to negative thoughts,’’ and ‘‘continuing to fly’’)

were significantly more utilized than skills not taught in

treatment (‘‘trying to put it out of my mind,’’ ‘‘talking

to friends and family,’’ ‘‘gathering information

about increased security measures,’’ ‘‘listening to the

media’’), t(50) = 5.60, p < .01. Furthermore, among those respondents who previously had completed

treatment in the original treatment outcome studies,

psychiatric comorbidity was not related to self-reported

use of skills taught in treatment F (3,48) = .39, p > .05.

Table 2

Summary statistics for hierarchical multiple regression analyses

Outcome variable Predictor variables Change statistics

F-test R

Talking back to negative thoughts

Sept. 11th FFI 1. Post FFI 12.77 **

.2

2. Talking back 11.88 **

.1

Sept. 11th QAF 1. Post QAF 15.83 **

.2

2. Talking back 12.65 **

.1

Sept. 11th QAF-fear 1. Post QAF-fear 5.42 *

.1

2. Talking back 5.55 *

.1

Continuing to fly

Sept. 11th FFI 1. Post FFI 12.05 **

.2

2. Flying 13.01 **

.1

Sept. 11th QAF 1. Post QAF 15.25 **

.2

2. Flying 20.00 **

.2

Sept. 11th QAF-fear 1. Post QAF-fear 5.09 *

.1

2. Flying 17.76 **

.2

Note. FFI: fear of flying questionnaire. QAF: questionnaire on attitudes abo * alpha < .05. **alpha < .003.

Finally, to address the third hypothesis, separate

hierarchical multiple regression analyses were con-

ducted to assess the relation between potential anxiety

management skills, including those taught and not

taught in treatment, and fear of flying anxiety after

September 11th (FFI, QAF, QAF-fear). ‘‘Gathering

information about increased security measures’’ and

‘‘listening to media’’ not taught in treatment were

excluded from these analyses due to low rates of

endorsement.

Preliminary analyses revealed a significant associa-

tion between post-treatment anxiety scores on the FFI,

QAF, and QAF-fear and post-September 11th anxiety

scores (r = .48, .51, .29, p < .05). As such, post- treatment anxiety scores were statistically controlled in

all subsequent analyses.

For each regression, the post-treatment anxiety score

was entered in Step 1 (e.g., Post FFI) and the anxiety

management skill was entered in Step 2 (e.g., ‘‘relaxing

breaths’’). The post-September 11th anxiety score was

entered as the dependent variable (e.g., September 11th

FFI). Consequently, 15 separate regressions were run.

As such, a Bonferroni correction was conducted to

address the multiple comparisons made, which required

a p-value (alpha = .05) less than .003 for significance.

‘‘Talking back to negative thoughts’’ significantly

predicted FFI (F (1, 48) = 11.88, p < .003), QAF (F (1, 49) = 12.65, p < .003), and QAF-fear (F (1, 47) = 5.55, p < .05) (Table 2). Above the effect of post-treatment anxiety scores, ‘‘talking back to negative thoughts’’

accounted for 16, 16, and 10% of the variance in

FFI, QAF, QAF-fear scores, respectively. Similarly,

Unstandardized coefficient Standardized coefficient

2 b S.E. of b Beta

1 .56 **

.14 .46

6 -37.78 **

10.96 �.40 4 .55

** .13 .48

6 �58.83** 16.54 �.40 0 .43

* .18 .32

0 �1.80* .77 �.31

0 .47 **

.14 .38

7 �39.11** 10.83 �.42 4 .42

** .13 .34

2 �72.05** 16.11 �.49 0 .19

* .17 .14

5 �3.10** .73 �.53

ut flying. QAF-fear: questionnaire on attitudes about flying, fear item.

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309306

Table 3

Mean post-September 11th anxiety scores for treatment completers

Measures Talking back to negative thoughts, mean (S.D.) Continuing to fly mean (S.D.)

Yes No Yes No

FFI 61.39 (34.11) 98.72 (55.37) 49.24 (31.13) 93.97 (46.63)

QAF 99.01 (59.47) 160.74 (77.60) 71.81 (43.05) 157.70 (68.94)

QAF-fear 4.58 (2.26) 6.37 (3.44) 3.30 (1.98) 6.66 (2.64)

Note. FFI: fear of flying questionnaire. QAF: questionnaire on attitudes about flying. QAF-fear: questionnaire on attitudes about flying, fear item.

‘‘continuing to fly’’ significantly predicted FFI (F (1,

47) = 13.04, p < .003), QAF (F (1, 48) = 20.00, p < .003), and QAF-fear (F (1, 46) = 17.76, p < .003) (Table 3). Above and beyond the variance accounted for

by post-treatment anxiety scores, ‘‘continuing to fly’’

accounted for 17, 22, and 25% of the variance in FFI,

QAF, and QAF-fear scores, respectively. For all

measures, ‘‘talking back to negative thoughts’’ and

‘‘continuing to fly’’ were associated with lower levels

of anxiety (Table 3). In contrast, ‘‘taking relaxing

breaths,’’ a skill taught in treatment was not associated

with post September 11th flying anxiety. All skills not

taught in treatment including, ‘‘trying to put it out of my

mind/distracting myself’’ and ‘‘talking to friends and

family’’ were not significantly associated with post-

September 11th anxiety scores on any of the measures

( p > .05).

4. Discussion

Given the lack of research examining whether

clients report using skills learned in therapy, and

associations between use of skills and positive long-

term outcomes for FOF, the purpose of this study was to

examine whether participants previously treated for

FOF with CBT reported using skills learned in

treatment (‘‘talking back to negative thoughts,’’

‘‘taking relaxing breaths,’’ and ‘‘continuing to fly’’)

to manage flying anxiety after a fear-relevant event. We

also examined whether self-reported use of skills

learned in treatment was associated with flying anxiety

over the long-term.

Results suggested that individuals who completed

CBT were significantly more likely to report using

‘‘talking back to negative thoughts’’ and ‘‘taking

relaxing breaths’’ as anxiety management skills than

individuals who had not received treatment. No

differences were found between the groups on whether

they continued to fly. In addition, no significant

differences were found between the two groups for

skills not taught in treatment (‘‘trying to put it out of my

mind/distraction myself,’’ ‘‘talking to friends and

family,’’ ‘‘gathering information about increased secur-

ity measures,’’ and ‘‘listening to media’’).

The results also indicated that clients treated with

CBT were more likely to report using skills taught in

treatment than skills not taught in treatment to manage

flying anxiety. Hierarchical multiple regression ana-

lyses revealed that of the skills taught in treatment,

‘‘talking back to negative thoughts’’ and ‘‘continuing to

fly’’ accounted for significant variance in post-

September 11th flying anxiety levels. However, ‘‘taking

relaxing breaths,’’ and skills not taught in treatment

(‘‘trying to put it out of my mind/distracting myself,’’

‘‘talking to friends and family,’’ and ‘‘gathering

information about increased security measures’’ and

‘‘listening to media’’), did not account for a significant

amount of variance in post-September 11th flying

anxiety levels.

On the whole, these results provide support for the

emphasis that CBT places on educating clients to become

their own therapist by teaching them skills that can be

used once treatment is terminated (Beck, 1995). Indeed,

not only were clients more likely to report using skills

taught in treatment than skills not taught in treatment to

manage flying anxiety, two of the three skills taught in

treatment (‘‘talking back to negative thoughts’’ and

‘‘continuing to fly’’) were associated with lower levels of

flying anxiety after a fear-relevant event and in the long-

term (an average of 2.3 years after treatment).

In this study, ‘‘continuing to fly’’ accounted for the

greatest amount of variance in flying anxiety scores

after September 11th (17–25%). However, of the three

skills taught, this skill was endorsed the least by

treatment completers (38%), though it is notable that it

is equal to the rate at which it was endorsed by controls

(39%). These findings highlight the importance of

encouraging clients to engage in continued exposure

after treatment is completed. An important question for

researchers to address is how therapists can encourage

clients to engage in exposure.

Of the three skills taught in treatment, ‘‘taking

relaxing breaths’’ was a not significant predictor of

flying anxiety. This finding is congruent with recent

S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309 307

trends in the anxiety literature questioning the role of

breathing retraining as an effective component of

treatment protocols for anxiety disorders (e.g., Craske,

Rowe, Lewin, & Noriega-Dimitri, 1997; Schmidt et al.,

2000). Some researchers have suggested that breathing

retraining acts as a safety behavior that interferes with

corrective learning experiences, and may result in less

complete recovery from treatment and a greater risk of

relapse (Schmidt et al., 2000) within the emotional

processing views of fear reduction (Foa & Kozak,

1986). In this study, ‘‘taking relaxing breaths’’ was not

significantly associated with neither poorer treatment

outcome, nor positive treatment outcomes. The fact that

participants in this study most often endorse ‘‘taking

relaxing breaths’’ highlights the importance of con-

tinued research on what functions as a safety behavior

that inhibits recovery, versus what functions as an

anxiety management technique that facilitates recovery.

The findings related to ‘‘taking relaxing breaths’’

also raise the question of how to differentiate between

an anxiety management skill and a safety behavior.

Indeed, given that relaxed breathing could interfere with

the benefits of exposure for FOF, is it possible that

cognitive restructuring could serve a similar purpose? It

may be important to consider the function of such skills.

For instance, a person may use ‘‘talking back to

negative thoughts’’ to decrease their flying anxiety

during an exposure or to construct a more realistic

appraisal of the safety of flying apart from the context of

exposure. These questions warrant additional research

to better understand the mechanism by which traditional

cognitive behavioral skills training bring about positive

treatment change.

A major weakness of this study is the low rate of

participant response. Less than half of the potential

participants responded to the post-September 11th

survey. To address similar issues with the same sample

of treatment completers, Anderson et al. (2006), utilized

multiple imputation procedures to address attrition

and differences between survey responders and non-

responders on pretreatment symptomatology. The

pattern of findings prior to using the imputed data

was identical, which suggests generalizability of

findings from this sample. Unfortunately, we were

not able to utilize these statistical procedures with this

research question, as pre-treatment data on use of skills

was not collected. Another limitation of this study is the

reliance on self-report data. Although we agree with

researchers that use of behavioral avoidance tests at

each assessment point is ideal to substantiate self-report

data of skill acquisition and retention over time

(Ost et al., 1997), a behavioral avoidance test was

not feasible at the time these data were collected. Given

this level of attrition and the reliance on self-report data,

potential biases must be considered and the ability to

generalize findings from this sample is limited.

One strength of this study is the methodological rigor

employed in the original treatment studies upon which

this investigation was based. The original treatment

studies included participants with clinically significant

levels of flying phobia, who were randomly assigned to

well-defined treatment groups, completed standardized,

psychometrically sound measures and were assessed by

Independent Assessors.

This study, to our knowledge, is the first to show that

individuals treated for FOF with CBT report that they

continue to use the skills taught in treatment after

treatment is completed. In addition, this study suggests

that use of skills taught in CBT for FOF are associated

with lower levels of flying anxiety in the face of a fear-

relevant event and over the long-term. These are

encouraging results for therapists who utilize short-term

CBT for treatment of flying phobia and the clients with

whom they work. It will be important for future research

to assess whether or not this pattern of findings is true

for short-term CBT for other anxiety disorders.

Disclosure

Dr. Rothbaum receives research funding and is

entitled to sales royalty from Virtually Better, Inc.,

which is developing products related to the research

described in this article. In addition, she serves as

consultant to and owns equity in Virtually Better, Inc.

The terms of this arrangement have been reviewed and

approved by Emory University in accordance with its

conflict of interest policies.

Acknowledgments

This study was supported by NIMH Grant #1-R43-

MH64971-01, NIMH Grant #2-R42-MH58493-02,

which funded the original treatment outcome studies.

This study was also supported by an unrestricted

education grant from Pfizer Pharmaceuticals Group

#NY01 002466348, which funded the post-September

11th follow-up assessment.

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