What would you do?

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C H A P T ER FIVE

Clinical aerospace psychology in the future: a dialogue

Robert Bor in conversation with Brett Kahr

When reflecting on the contents of this book, we felt that many questions remained unanswered about clinical aerospace psychology and mental health issues among passengers and aircrew. The conversations that ensued between us helped to deepen our understanding of some issues and address certain controversies. They also focused our thinking about the provision of mental health care in this field. We hope that readers might enjoy a departure from regular text and "join" some of the discussion we have had on this interest ing topic.

Brett Kahr: Robert, can you speak about how you became in volved in aviation psychology?

Robert Bor: A s a clinical psychologist and family psychothera pist, I have had a long-standing interest in the ways in which individuals manage journeys throughout the life cycle—both external journeys from country to country and internal jour neys from stagnation to growth. On a more concrete level, I have also had an ongoing interest in the realities of air travel

Bor, Robert, and Brett Kahr. <i>Anxiety at 35,000 Feet : An Introduction to Clinical Aerospace Psychology</i>, Routledge, 2004. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=764942. Created from apus on 2019-11-24 20:34:12.

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itself, and during an earlier period in my life I had even contemplated becoming a professional airline pilot. At British Airways, one particular pilot invited me to visit Cranebank, the British Airways training centre at Heathrow Airport. I spent two hours in the flight simulator, and apparently I had performed sufficiently well that the pilot who had invited me to explore the simulator actually wondered whether in fact I had already acquired a pilot's licence! This encouragement prompted me to pursue formal training for what has been an ongoing personal passion, and I obtained my pilot's licence in 1996. My growing interest in the field of clinical aerospace psychology stems from the blending of my clinical training, my lifelong passion for travel, and my experience as a pilot.

My formal work as an clinical aerospace psychologist be gan in the mid-1990s, when I had been invited to develop a counselling service for the flight crew of several international airlines. In this context, I began to become more familiar with the internal world of pilots, and I learned a great deal about their lifestyles, their relationships, and the unique problems that they had to face in their "office at 35,000 feet", for the pilots do indeed refer to the flight deck as "the office".

In the wake of events of 11 September 2001, we subse quently learned that some of the terrorists who flew the planes into the World Trade Center and the Pentagon had attended flight schools. Some people have become concerned about how qualified pilots are trained, whether they undergo selection for the training, and whether anyone can simply walk onto an aeroplane and start flying a plane. Readers will be relieved to know that the training of the qualified pilot is actually a rigorous procedure, and that pilots must submit themselves to continued monitoring in order to ensure that their flying licences remain current. Indeed, almost every time a qualified pilot begins to fly a commercial aeroplane, he or she will have at least one other pilot colleague on the flight deck who will be constantly monitoring the pilot's perform ance every leg of the journey. Physical and mental health checks are part of the on-going licensing requirements for all pilots.

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After having undertaken work as a counsellor to pilots and then subsequently having obtained my pilot's licence, I began to work as a therapist to pilots and crew and to their spouses or other family members, who asked for help with conflicts and disruptions in their personal lives. Subsequently, I have counselled individuals who have had to work with airline employees who have themselves had to support the families of employees involved in incidents, and on rare occasions, disasters. Many of these airline workers found themselves suffering from some of the highly recognizable symptoms of post-traumatic stress disorder, especially secondary traumati zation, in the wake of working with the survivors and be reaved relatives of those affected by airline accidents.

I also began to work with passengers who have suffered from mild, moderate, or extreme varieties of travel phobia or fear of flying. Although most of the work in treating fearful fliers has been of a brief nature, I have found that it has been necessary to explore clients' life histories in greater detail, and here my training in family therapy has been indispensable. People who present at travel phobia clinics generally baulk at the idea of being referred for a lengthy Freudian psycho analysis. Therefore, one must find a way of intervening in a reasonably short space of time but also move beyond the traditional cognitive-behavioural modes of treating the symptom and explore the deeper family and systemic issues that may have contributed to the development and mainte nance of a travel phobia. Some of this clinical work was devel oped at the Royal Free Hospital Travel Health Clinic in London.

In the mid-1990s, while I was serving as Professor of Psy chology at City University in London, the head of the univer sity's School of Engineering invited me to participate in their newly developed M.Sc. degree programme in Air Transport Management, the equivalent of an M.B.A. for pilots and sen ior managers in the airline industry. I became involved in teaching the psychology components of that course as well as those on the Diploma in Travel Medicine at the Royal Free Hospital. These experiences also provided the initial stimulus

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for research in clinical aerospace psychology, both as a super visor of student research projects, and for my own pro gramme of clinical research. I have looked at unruly passenger behaviour or "air rage", which had become a more widely reported phenomenon. This lead to a research project for the International Civil Aviation Organization (ICAO). My colleagues and I surveyed the world's leading airlines, and we examined both their understanding of the problem and their procedures for dealing with air rage. We have also sur veyed the experiences of cabin crew with regard to air rage incidents. We have now turned to examining the recorded incidents of air rage. With the cooperation of senior police colleagues we are examining the histories of the perpetrators of air rage, enquiring whether these individuals "acted out" only on the aeroplane, or whether they had also previously had other chargeable offences while on the ground. It would appear that in some cases, perpetrators have a history of con duct disorder or antisocial personality patterns dating back to their childhood and adolescence. My current research focuses on different aspects of passenger behaviour and the mental health of aircrew.

BK: Robert, can we think about clinical aerospace psychology as a discipline? It seems there are a small number of mental health professionals in the world who are working in this field, or what we are now calling "clinical aerospace psy chology". Do you think that this is a field that has potential for growth? Is this is an area that we should be encouraging more mental health practitioners to become involved in? Maybe each airline should have one psychologist on staff to deal with the few cases of intractable fear of flying. What are your thoughts?

RB: I think a large part of mental health practice, particularly in the latter part of the twentieth century, but obviously at the start of the twenty-first century, has been to psychologize different areas of professional practice, ranging from within the legal profession, to medicine, to what we are talking about here, which is the application of psychological ideas and in-

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terventions to aerospace. I think the aerospace field is ripe for participation and intervention. I am not sure that we are yet in a position to talk about a whole sub-speciality of clinical aero space psychology. But it is certainly an area in which mental health practitioners can become more involved.

A question that comes to mind is whether one needs spe cialized aerospace psychologists, psychiatrists, psychothera pists, counsellors, or clinical social workers who can work in this particular field. We certainly need specialists who will advance research practice and collaborate with pilots, with people within the airline industry, and those people are obvi ously going to need more specialist knowledge and give more time and develop good working relationships within that particular field. There are also the interests and problems of passengers, a group who are more likely to seek specialist help, particularly with overcoming a fear of flying.

It would be wrong to suggest that there is extensive psy chopathology in the aerospace industry, particularly among pilots, air traffic controllers, maintenance personnel, airport managers and so on. . . . I don't think that that is at all the case, and there is no hard evidence to suggest that. I think that there are two areas in which mental health practitioners can play a particular role. One is in preventative mental health work, and that is —as we have seen from the research summa rized in this book—a fairly wide range of standard psycho logical problems that may present, either with passengers or airline employees. Many of these are normal, everyday prob lems that one would expect to see in most other organiza tional settings. However, because of the apparent stigma attached to consulting mental health practitioners, some may avoid or delay seeking support. Small problems may inten sify and either never be treated or become deeper. The second is in those areas where specific interventions can be intro duced. The two areas that I would most have in mind would be to do with assisting qualified medical examiners who as sess pilots for their physical and psychological health. That could be in one of two ways: either in direct interventions with the pilots or by offering training to the doctors so as to

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acquire advanced skills in their mental health assessments. There is another area, and that is to consult to airlines and offer training in mental health issues in aerospace. There are so many areas of interest and relevance, including shift-work patterns, coping with fatigue, managing stress, dealing with angry passengers, and team-work, to name but a few. I was wondering what your views would be about this?

BK: Well, I think that it might be helpful and enlightening for us to try to create an imaginary job description for what the first specialist clinical aerospace psychologist might look like. You made a crucial differentiation between two types of interven tions: one dealing with pilots or passengers who have overt mental health difficulties already, and the other in prophylac tic or preventative work, to see whether mental health profes sionals can consult to airlines, pilots, passengers, and medical examiners of pilots at an early stage, to help bring more psy chological knowledge, more elucidation, to this field. So I think that we can conceptualize the role of the clinical aero space psychologist as helping to plan interventions when there are already existing mental health problems and to help prevent mental health problems from developing in the first place. These could be two general arenas for the aerospace psychologist.

RB: There is already a European Association for Aviation Psychology and a similar organization in the United States. Many psychologists in these associations have an occupa- tional/ergonomics interest rather than a clinical one. I'm not convinced that there is such an abundance of work that war rants a whole sub-speciality, so I think it would be helpful to have mental health practitioners who have some specialist knowledge of the presenting problems within the aerospace industry. To talk of a whole sub-speciality might be prema ture at this point.

BK: If we think in terms of clinical aerospace psychologists pro viding interventions where there is a suspected problem or a known mental health problem, it seems to me there are sev eral arenas, some of which have been covered in the book.

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One would be during the assessment or diagnosis of mental health problems in pilots; the other would be in providing psychological counselling or psychotherapy for pilots, cabin crew, or ground staff, either because of their own private life difficulties or because they have been involved in some trau matic work-related incident. We have a diagnostic function and we have a treatment function, and those would be two of the roles that clinicians might play, as well as providing treat ment for passengers who suffer from overt fear of flying or who experience episodes of air rage.

RB: I would add to that very comprehensive list two other categories. One would be extending the same interventions to those people who work in the industry who are often "left out of the loop" when it comes to providing medical care, such as air traffic controllers, who have a stressful job, as well as ground maintenance engineers, many of whom have enor mous responsibilities when it comes to repairing and main taining aircraft. A high proportion of them work antisocial hours, which increases risk of dislocation from their own family and support network and also of poor work perform ance, which could, in turn, lead to incidents and accidents. The second group would be the family and/or care-givers of all the groups we've already spoken about. As we know, many mental health interventions are focused on the indi viduals, and although I think we would all accept that a good clinician would take a detailed family history and would want to assess the impact of a problem or symptom on a wider social or kin network, we are not as good at offering family, couples', or group sessions.

BK: What you said is really striking, especially when you ex tended our list. The different types of people who might be recipients of clinical aerospace psychology interventions now include pilots, cabin crew, air traffic controllers, ground maintenance staff, passengers, as well as the families of all the above. That is potentially a very broad group of people. And yet I have never had anyone from any of these groups come to see me in either private practice or in the public sector. I think

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that many in the airline industry may not be familiar with mental health settings. One might speculate —although it is only speculation—that people who are attracted to spending a lot of their time in the air might be people who have some wish to engage in flight activities: "flight" not only from the ground but "flight" from their own problems. I have never heard any colleague's presentation about treatment of a pilot or treatment of an air traffic controller: perhaps this is a group we do not get to see in the same proportion that we do, for example, businessmen, artists, musicians, or students. It seems to me that we have a fertile population of people who may be experiencing psychological difficulties and yet who do not know how to access that treatment or may not even recognize that the treatment might be h elp fu l. . .

RB: I would suggest that there are a number of reasons for that. Let us start with what is positive. This is a fairly robust group from a psychological perspective. I don't believe that airline work attracts large numbers of people who are psychologi cally vulnerable or who have overt problems. There are many different stages at which they would be screened out, and their inappropriate interest would be rebuffed. Most work in the airline industry is teamwork, even though an individual's performance is important. Ultimately teamwork is the context in which it is operationalized, and for that reason there are always other people around who are observing or monitoring your work. If you are not a team player, or you bring to the work setting quite serious interpersonal psychological prob lems, you will stand out and risk alienation. It is an industry with a very good safety record. Another reason is that it may attract people who, perhaps much like those in other profes sions—surgeons, for example—are very skilful and techni cally minded but who don't necessarily see their forte or their primary interest as being people-orientated. They may be more interested and focused on technical or operational mat ters, while a focus on communication and relationships may be of secondary importance.

A further reason is that some people who work profession ally in the airline industry have a fairly negative view of

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psychology and mental health practice. This may be through bad experience, folklore, or simply a perception that psychol ogy doesn't have anything positive to say to the individual as it is used to serve the airline's interests and for selecting peo ple out of jobs or for identifying problems. This is an unfortu nate perception. Contrary to some popular wisdom, there are some very well-paid pilots, but if you look at the industry as a whole, a lot of people are paid an average-to-low wage. Those captains of advanced commercial jets who work for big international carriers may do very well financially, but your average worker is going to earn considerably less and may not have the resources to even consider private psychological treatment. They may also find that when going to National Health Service facilities, they encounter waiting lists. In an industry where mental health problems may threaten safe operations, a lengthy wait to see a specialist gives cause for concern. The last would be the anxiety that some may experi ence—particularly pilots and air traffic controllers—that, if it is discovered that they are accessing psychological care and treatment, this may affect their employment. This fear of be ing "discovered" may deter someone who needs to see a men tal health professional from doing so.

BK: I remember one of my mentors in psychotherapy mention ing to me that the three most difficult groups of patients to engage in on-going psychotherapeutic treatment are medical students, nursing students, and actors. This is because they have peripatetic shift timetables and it is very difficult to commit to a regular session every Thursday at 4 o'clock or every Friday at 3 o'clock. It seems to me that one could read ily add pilots, aircrew, air traffic controllers, ground mainte nance staff, and their families to that list. A life in aviation has elements of unreliability, unpredictability, and, unsurpris ingly, a lack of groundedness in terms of being able to predict one's actual lifestyle, of knowing in which country or on which continent you are going to be in next Tuesday!

RB: That is absolutely correct. The challenge for us is to be flex ible around their needs rather than vice versa. There are many

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examples where collaborations and interventions have failed. This is not because what we have offered has been of poor quality, but because the way in which we have offered or delivered the service has not been acceptable to the client group with which we are working. It is highly improbable that we could ever be able to agree with a pilot on a series of meetings or regular slots for psychotherapy over an extended period. Their work pattern wouldn't enable this to happen, and they would probably be faced with considerable anxiety about missing appointments. We might even erroneously in terpret their difficulty with commitment! We need to find a different way to reach them that may be briefer and more flexible. Given some of the apprehension that a few may expe rience about seeing a mental health professional, we should probably use a therapeutic approach that is affirming and of immediate practical help to them. I have worked with some psychotherapist colleagues at trying to develop such an ap proach within similar settings (see Bor, Gill, Miller, & Parrott, 2003). There are many examples that I can think of, where we can offer positive and preventative-type interventions. One example could be with pilots who are about to qualify. I regu larly lecture to a group of them on managing stress and dis ruption in their personal lives. It is not as though they have never thought of these sorts of issues before, but the reality only sets in once they have actually become engaged by an airline and then experience disruption in their personal and professional lives.

BK: What do you advise?

RB: I advise something similar to what I learnt in the field of medical family therapy from Dr Susan McDaniel in Rochester, New York, who pointed out that, when there is illness within the family, the family has to find a place for the illness and they also have to put the illness in its place. The message in aerospace operations is similar—that is, if you are going to be a pilot, the work pattern will dominate many aspects of your life, but if you allow it to dominate every aspect, including your relationships, something will be lost

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along the way. You may be able to allow it to take over your life in the short term, but in time this focus will take its toll. It is important for pilots to be up front with their spouses and families and to discuss their own anxieties about being away from the family as well as perhaps some of the pleasures as well. It may be the case for some people that they chose this particular job and lifestyle because of the separateness that it occasionally brings.

BK: May I be psychoanalytically provocative for a moment? In the field of psychoanalysis we use the term "flight" often preceded by the term "manic": we speak of "manic flight" when a relationship or a situation becomes too difficult, pa tients will flee. They will fly away, either into an internal psychic retreat by altering their mental state through drugs, or alcohol, or promiscuous sex, or they will go to the Bahamas for a year, to paint and to try to discover some new aspect of themselves, or how they feel that through a geographical so lution they can achieve a psychic solution to a problem. And we know that flight does not work. Manic flight often does not work, because one takes one's psychic luggage with one. I would like to ask whether people who have a tendency or a propensity towards manic flight actually end up in a job where they take a flight every other day, and whether the very wish to work in the airline industry represents a verit able concretization of this tendency? Are these people fleeing from difficulties or complications in intimate relationships? Do they actually prefer not to see their partners or spouses on a regular b a sis . .. that is potentially a gross generalization, but I am posing it as a question. . . . I wonder.

RB: The terms you use are evocative, and it is an interesting metaphor. I can't say that I have sufficient experience to say that most people who work in the industry are fleeing from problems. That is a compelling idea from a therapist, but it is highly unlikely! That is not to say that that doesn't happen, but I do not recognize it on a scale where it seems like a general problem. That said, there are positive ways of looking at this process too. For some people, a journey is necessary at

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a particular life stage. And it may be that this then becomes their life and lifestyle, and they become trapped in that jour ney. Their disaffection with the jo b —be it piloting, or being a flight attendant, etc.—may have its roots in the fact that they actually no longer wish to "get away from it". Most people I have worked with professionally in the airline industry are actually either very "grounded" in themselves or searching for a new place to "ground" themselves. The transitions they seek are mostly healthy and reflect normal growth and every day struggles. Yes, there are a few who exhibit signs of greater emotional distress. "Flight" from something unpleas ant or emotionally hurtful might be more characteristic of flight attendants. The job provides a mix of stability in the work or peer group and instability in parts of their personal lives for a while. It is interesting that a sizeable proportion give up their work within ten years, and one of the reasons for that may well be that they either form stable relationships back home or seek greater stability in their lives. So, if any thing, psychological "flight" is mostly transient. I think it is an interesting thing for us to discover more about attachment patterns among airline employees.

BK: I think that shows that we, as mental health professionals, actually know very little about the lives, backgrounds, or motivations of people who are attracted to this industry. Yet it is an industry that pretty much all of us have used or will use extensively, as passengers on plane flights.

RB: It is interesting that, perhaps in the last two to three years, we have witnessed on television quite a number of fly-on-the- wall documentaries about air travel, some to do with an air line, some to do with a particular airport. There have also been some documentaries on the life and lifestyles of pilots, what happens on board aircraft, and about passenger behav iour. We are moving to a stage where we are peeling back the facade and removing some of the mystique that we associate with air travel. It is much like, perhaps, learning a bit about the private life of a psychotherapist. . . it is intriguing to pa tients, but it can perhaps sometimes be quite unnerving and

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potentially unattractive in other ways! They recently screened a documentary showing pilots consuming large quantities alcohol while abroad and then being hardly fit to fly the plane back. There have been documentaries about pilot suicide and crashes being associated with this. A few incidents of air rage have actually been filmed showing passengers and crew in physical combat with one another. In another, we also hear some slightly sleazy comments by an airline check-in agent at Heathrow Airport, who says that he makes judgements about whether to upgrade passengers based on the size of the man's "packet". We can't hide from this image of air travel where there are sexual connotations ranging from the attractiveness of flight attendants to lewd discussion on the flight deck or some passengers' quest to join the "mile-high club". We have moved away from a kind of innocence, or pleasant mystique, about air travel. The recent events in the United States brought this new reality crashing home to us, both literally and metaphorically. I believe that we are into a new phase in air travel. Our expectations as travellers are different, and how people perceive psychotherapists, aircrew, and airline professionals is changing as w e ll. . . it is not how things were five or ten years ago.

BK: Yes. It is not only a question of psychological curiosity but also an important question for public safety to know about the state of mind of pilots and cabin crew. Although our com ments are in the realm of speculation, I think it is important to be sure about the stability, the robustness of the individuals who are attracted to this type of work. It is work that can influence the fate of our lives. We could die at the hands of these individuals if they are in a mentally compromised state, so I think the study of the mental health of airline personnel is utterly crucial. Can mental health professionals, aviation psy chologists, or psychotherapists work consultatively with air lines and with pilots? Where do you think we can offer our services?

RB: In a number of ways. It is not that we bring entirely new skills to this particular field but that we bring our traditional

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skills to a field that is untapped when it comes to psychologi cal and mental health input. We also have to recognize—and I put this in a traditional context—that we are working with a resistant population. So if we go into the field with "all guns blazing", no matter how insightful and interesting some of our interventions and ideas may be, we will be rejected, and we will almost certainly fail. I would firstly identify those core areas that we can work in. I would start with passengers. The reason for that is that, more than ever, many passengers are aware of their own fears associated with flying. We have a role today in providing psychological counselling services for passengers to help them to manage their anxieties. The other is with aircrew themselves. I doubt that there will ever be sufficient mental health professionals to fully serve the airline industry. It is important that those professionals who have day-to-day responsibility, such as medical examiners, have greater support and input from psychologists, so they know what to look for, how to look for it, and what to do about psychological problems. In other words, they need to perceive a multi-disciplinary team around them. Some au thorized aviation medical examiners work in isolation, with little direct recourse to mental health services, unless they access it through specialists at the Civil Aviation Authority, which is possible.

BK: Could forensic psychologists and forensic psychiatrists make a contribution here, in terms of our specialist knowl edge over the prediction and identification of dangerousness? The very last thing that we would want would be a dangerous pilot, a pilot with dangerous conscious or unconscious sui cidal or even homicidal tendencies. How much would the average medical examiner know about the prediction of dan gerousness?

RB: It is difficult to say. The prediction of dangerousness or level of threat from an individual is a very difficult thing to assess as we know, and there is always the problem of litiga tion. If you pull somebody "off lin e"—meaning that you with draw them from a flying position—when there is perhaps a

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suggestion that they are mentally unstable but there is no intent or immediate threat, that could have severe legal con sequences. We would have to think that one through quite carefully.

On the other hand, I think there are some areas to get involved in, and perhaps this would be the beginning of de veloping a collaborative relationship. One of them would be to do with helping those who train pilots to cope with a number of different aspects of their work that involve psycho logical factors. These range from how to manage their per sonal relationships to coping with jet lag, dislocation from their family, homesickness, and the stresses of medical assess ments that they frequently undergo. Another would be how pilots communicate, or whether they communicate with pas sengers. I am not sure of your experience, but there is a ten dency to reduce the amount of communication from the flight deck to passengers, and this raises the anxiety of passengers, as we have seen from some recent research. This revealed that when the flight deck door is left closed and there is minimal verbal contact from the flight deck, passenger anxiety in creases. In the new area, where the flight deck door is bolted closed and where the people responsible for safely flying us will be perceived to be more remote, there will be an in creased need for communication. Passengers need the reas surance that the pilots are there and that they are in control. Whatever the form of communication—whether it is an up dated weather report, or an on-time announcement—it is the value in the communication with passengers that needs to be stressed.

BK: I agree. We would all hate to fly on a plane piloted by someone with extremely good social skills but very poor tech nical knowledge. People who have excellent technical knowl edge and a willingness to improve their psychological savvy, their ability to communicate with passengers and fellow crew, would be the ideal situation. How can we get pilots and cabin crew to communicate more rather than less with pas sengers? For example, a few years back I took a flight that was

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unbelievably turbulent. The plane was going up and down and sideways, and I really did think that we were going to die. There were no announcements at all from the captain, so I had to use my observational skills in studying the air host esses. I saw that they had sufficient experience of different types of turbulence to realize that (a) this was not a hijacking and (b) this was not perilous turbulence. It was bad but not life-threatening, and that brought me some comfort. But I had to scan for visual clues from the flight attendants. It would have been incredibly helpful if the Captain of the plane had spoken, if only for five seconds, and said something like, "La dies and gentlemen, this is particularly bad turbulence, but it is only turbulence, and we will see you through th is"—the same way that a parent offers reassurance and comfort to the troubled and anxious child.

RB: You are absolutely right. There are deterrents to in-flight verbal communication. One is the perception among pilots that this is an intrusion into the passengers7 desire for quiet and calm on board. This is derived from surveys among busi ness and first-class passengers who are their premium flyers. A preference among them is to be left alone so that they can have privacy, no distractions, and can get on with their own work. But we all know that even for the most seasoned travel ler it is still an unfamiliar environment. I think what tends to happen is that the flight crew and the cabin crew tend to make an assumption that people may either be frequent flyers or that they may appear docile and that they are coping well. And that is a pity, because they may misread the situation. Most people who are anxious on board aircraft tend to with draw and endure the unpleasant feelings alone rather than become visibly agitated and display other signs of their dis tress.

BK: Of course. We know only too well from working with survi vors of various traumas, such as rape or war, that often one of the first cognitive capacities to disappear is the capacity for verbalization. People become literally stony silent with fear and cannot ask for help precisely at the moment they most

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need it. I know of a child patient who had been trapped in an earthquake and came up from the earthquake totally mutistic (Dermen, 2002). I think that a lot of passengers are often im mobilized by such crippling fear. Even asking a flight attend ant "Is this turbulence" or "Are we going to crash?" becomes a very difficult question. I think we need to alert cabin crew that these may be the overt clinical or, in fact, sub-clinical anxieties of most passengers. I wonder as well, Robert, whether air rage might actually represent the extremes of terror of being in a life-or-death situation and that one way more volatile passengers might handle the fear of being sus pended at 35,000 feet in the care of somebody else who is not communicating with you is to go mad by having an air rage attack.

RB: That is an interesting idea. We have yet to study the minds of so-called air rage perpetrators, and there are various rea sons for this, not least of which is those pertaining to litigation and just having access to perpetrators. A number of people have speculated as to why passengers should want to endan ger an aircraft or disrupt a flight. While each situation is unique, there are also commonalties. It may well be that there is a link between all these different situations. Some fear be ing entrapped, being at the mercy of someone unknown to them, and perhaps feeling infantilized or resenting how they have been communicated with, and this has led to acting-out behaviour. The other side of it is that many of these people have a history of antisocial behaviour, and, in certain condi tions when they are not in control, they will act out violently, either verbally or physically.

BK: That is such a fascinating area. Given that a certain number of passengers will inevitably have had a history of antisocial behaviour, what we have to tell the airline industry is that because we cannot screen people for their criminal histories before letting them on board, what the airlines need to learn is that the potentiality for criminal acts can either be contained or exacerbated, depending on the psychological atmosphere created on board.

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RB: Those are very good points. My experience is that the air line industry has actually been quite slow in their response, and containment has only recently become part of the agenda. The issue of exacerbation is not entertained by many manag ers in the airline industry. The belief is that passengers pay good money, take their seats, and are then expected to behave in a reasonable way and comply with all the instructions. That is an interesting belief, but it is not borne out in the reality of air travel. There have always been passengers who have mis behaved on planes and an increasing number who act aggres sively. Airlines are not keen to look at the behaviour and actions of their own crew in exacerbating situations, and there are certainly a number of cases where their crews' poor man agement of a particular incident on a plane has probably made it worse. That said, a zero-tolerance approach to any acting-out behaviour on board an aircraft is a necessary one because, unless all passengers are aware of the penalties and the consequences of this kind of behaviour, these acts will continue. However, we don't really fully understand all of the relationship dynamics that take place at 35,000 feet that may maintain or exacerbate—or, for that matter, eliminate—the threat of air rage, and that is another important area on which those with a mental health interest can shed light.

BK: You see, I think that we, as mental health workers, under estimate how radical Sigmund Freud's concept of the talking cure remains even today. We take it for granted that any psychological intervention that we provide, whether we are psychologists or psychotherapists or counsellors or what ever, involves talking and helping our clients or patients to develop a richer vocabulary so that difficult emotions, diffi cult affects, can be transformed into words rather than into self-destructive or other-destructive actions. I think that even encouraging pilots to engage in simple speech-intensifying acts, such as talking to passengers, or training cabin crew, for example, to help passengers who fight with one another to talk out the situation would be of help. Although we regard this as common sense or perhaps old hat, I think we under-

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estimate how important the encouragement of simple talking can be in a potentially life-threatening situation such as in an aircraft.

RB: One thing that binds all of us together, as therapists and mental health practitioners, is the fact that we're all per suaded that talking solves problems wherever they have been identified.. . .

And effective dialogue must involve listening too. Therapy has to be a unique personal encounter. Broadcasting relaxa tion skills to passengers over their headsets or in the in-flight entertainment system is insufficient. On the other hand, it would probably be inconceivable (though quite popular!) to have a therapist or a psychologist on board to talk people through their particular stresses and worries and provide a programme of relaxation that has been has been personal ized—maybe something that is more interactive, somewhere between those two positions, could still be useful to passen gers.

BK: And one wonders as well whether airline cabin crew could also be encouraged to initiate contact with passengers in non- practical ways. I wonder what it would do to the anxiety level on an airline carrier if flight attendants went up to each pas senger and said, "are you enjoying your flight, sir? Are you enjoying your flight, madam? Is there anything I can do for you?" rather than coming around with a trolley to say "chicken or beef" or "do you want duty-frees" — to ask a more open-ended question, actually, that does not involve a practi cal answer, just to see if one can try to root out any problems or difficulties. Now that might seem utopian or fanciful, but I wonder whether by the simple encouragement of conversa tion by each passenger, during the lulls between the film and the main course, for example, whether promoting talking in that way could occur?

RB: That's a good idea. I think that the difficulty arises in terms of the pressure of the job. Their task is one of being there primarily for people's safety and, as a secondary task, the one

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of serving and attending to people's needs. The term "flight attendant" is not really a valid job title for many of these people. The pressure of work prevents this from happening because of the multitude of duties that attendants have to be involved in. But you are absolutely right that simply person alizing attention would decrease anxiety. I remember sitting on one flight at an emergency exit with a flight attendant sitting opposite me in one of the jump seats. The woman sitting next to me was seriously anxious, and this was picked up on by the flight attendant sitting opposite us. The flight attendant asked the woman if she was "OK", and the passen ger said "no", she was feeling very anxious. The flight attend ant said "don't worry, we also sometimes get a bit anxious", and it was quite remarkable how the anxiety of that passenger completely dissipated through that very brief interchange. There was no false reassurance; there was just respect and acknowledgement of the fear that that person had.

BK: And I wonder, following on from that, whether educating cabin crew into realizing that, not only can passengers suffer from overt air rage and fear of flying and panic attacks, but from sub-clinical anxiety as well. This does not usually be come verbalized, but each passenger experiences a private madness in his or her own head. Cabin crew could better understand that (a) they have a parental transferential role, as lookers-after of passengers, and that (b) passengers are people who are often travelling alone, away from loved ones, or away from familiar structures, and who are also leaving fa miliar territory and are in transit from one situation to an other, perhaps between jobs, perhaps between meetings, perhaps between relationships, and it might be that the act of travelling might help put passengers in a more vulnerable state. I think that if we could help, by even providing just a simple seminar with psychologists or psychotherapists to as sist pilots and particularly the cabin crew to realize the poten tial vulnerability of passengers at that particular moment, I think that that would be so useful. Back in 1957, Donald Winnicott gave a lecture for midwives, and he said that the

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woman in stirrups, on the verge of delivering her baby, may in fact be the head of a major corporation, highly competent in her own right. But at this moment, she has become vulnerable and dependent, and thus the midwife must look after her (Winnicott, 1957a, 1957b). And I would suggest that each of us as passengers experiences a different degree of vulnerability. We lose part of our competencies, whether we want to admit this consciously or not; we are being flown by somebody else, we are not flying the plane, and I think if we can help the air personnel to realize the parental, transferential role that they adopt in our minds and in our reality, that that might help to change their attitude towards passengers.

RB: There isn't enough psychologically oriented material that is discussed with people in their busy training schedules, be it cabin or flight-deck crew, and I think we can make a case for increasing it without this turning into a psychotherapy train ing! What you say is also borne out in research: we know that in aircraft accidents, when passengers have to leave or escape from the aircraft as quickly as possible, many will turn to, and rely on, flight attendants to guide them out. These flight at tendants are trained literally to yell at passengers, some of whom become immobilized at that very terrifying moment. That role, of the parental figure, of somebody in control, is a very important one, particularly in emergency situations. Even when the flight is going well, we still look to others to provide a degree of structure and safety, and that is a very important thing. Unfortunately, the popular image of flight attendants may partly undermine that kind of professional ism with which we want to hold figures in.

BK: Hmm. You are right that it would be inappropriate and complicated to offer a full psychological training to a flight attendant, but in terms of increasing their psychological sensi tivity, I think that could be quite helpful, and I also wonder what we could offer by way of psychological support to the cabin crew to help them deal with what must be their annoy ance with passengers. I was very shocked, Robert, when you told me some time ago that some pilots casually refer to pas-

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sengers as "self-loading cargo", which seems to me a highly contemptuous and derogatory way of describing paying air line passengers. If you are a flight attendant and you have to look after 250 passengers, let us say you have 8 or 10 others to help you, however many are in your designated area, you might have suddenly inherited for that 6-hour flight to America 20 new children who need to go to the loo, who need to have their dinners and their special meals, and extra blan kets and pillows, and so on and so on. They are asking you for pens and paper and their headphones don't work . . . in a way, the flight attendants become very much like mothers whose infants make continual bodily demands on them. I would imagine that, although aircrew are being paid for this, they also experience tremendous unconscious or conscious hatred towards the passengers. And I wonder, do they have a space to take these anxieties to, do they have a supervision group, do they have a support group, just as we would do as clinicians?

RB: They may chat among themselves about their experience of a flight, but there isn't a structured, well-organized, or facili tated context in which to do this. You raise an interesting example of flight attendants having to manage and care for children. If you interviewed flight attendants in the way that we have in our own research, they would allude to the fact that passengers regress psychologically as soon as they get on board the flight. Some become juvenile; they become atten tion-seeking, and within moments a sense of entitlement sets in that can be quite annoying on a good day and soul-destroy ing on a bad day. They will tell you that there is nothing like an ungracious passenger who cannot see that it is not flight attendants' fault that their meal has not been loaded, their headset doesn't work, the movie is jumping, or they haven't been seated with their family, unpleasant as all of these ex periences may be. Because they are the immediate public face of the airline and representatives of the airline, they are the people who must bear the brunt. There are certain expecta tions between crew and passengers. Sadly, crew don't get the

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chance to reflect on psychological processes in their work in a structured context. The closest they may come to doing so is on the crew bus or around the pool of the hotel they are staying at.

BK: It might alter the experiences of cabin crew dramatically if, after each flight, they all congregated in some room in the airport rather than going to the bar, for example, where they could have even a 20-minute discussion about how they man aged the flight, were there any difficult passengers, how did they deal with it, sharing experiences . . .

RB: It is an interesting idea, but I think, much like passengers, most want to leave the airport, get home, or reach their final destination, and turn their back on their work. That said, I think that there is a place for doing it every few flights, briefly before flights, and as part of their initial training.

BK: It would have to be facilitated by someone who is expert at these matters, and I am thinking what tremendous insights the Hungarian psychoanalyst Michael Balint had when he realized that general medical practitioners need to have dis cussion groups to talk about the impact of their very difficult patients. You and I have both taught at the Royal Free Hospi tal Medical School. Teaching medical students, we know how important it is to give medical students a space, a structured space, in which they can talk about their clinical work, and perhaps aircrew also need a space of this kind, like a group for airline workers.

RB: Absolutely. It is also a way of helping them debrief so that complex feelings are not taken away or carried home with them. It might also help to improve their sense of profession alism and bring greater clarity to their role, thereby reducing staff turnover.

Brett, I wanted to ask you if you had any final thoughts about mental health, aviation, and the future?

BK: Final thoughts? Well, I think that clinical aerospace psy chology is a new and potentially exciting area. In view of the

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catastrophic events of 11 September 2001, the meaning of fly ing, even among those of us who had been seasoned travellers and had not really given a second thought to the potential dangerousness of aircraft, have suddenly become aware of the possible terrors. For the foreseeable future, there will be passengers who are more anxious, pilots who are more anx ious, and it may be that we will need to be more proactive as mental health professionals in making our services known. We do know something about working with anxiety, contain ing and alleviating anxiety, and helping organizations through organizational consultation to create a more sensitive working environment. I think that if we can help airline em ployees to create a better working environment, the crew will be happier and feel more contained, and passengers will pick this up, and I think air rage and other problems could be minimized.

RB: I also think it is an exciting and interesting area in which mental health practice can be introduced. This is a new and challenging context into which mental health practice can ex pand and a relationship that has effectively never properly "taken off" can be developed. Out of adversity and tragedy has come a keen interest in mental health processes across the spectrum associated with air travel. The challenge for all of us will be to do so in a way that fits with the lifestyle and the unique needs of both client groups—passengers as well as the ground and aircrew. I hope that some of the ideas that we have written about will stimulate the interest of readers to become more involved so that we can better understand the problems and consult more widely. Although we may some times use different language as mental health practitioners and choose to focus on different levels of intrapsychic and interpersonal systems, the concepts are actually very similar. I have learnt more about psychodynamic concepts applied to the experience of travellers and pilots through our conversa tions. So, thanks to you too!

BK: Thank you.

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