The Mile High Therapy Club

Dr. Gary Small

Not long ago, I was on an airplane queued up on the tarmac awaiting its turn to depart, when I noticed the young woman sitting next to me.  She was hyperventilating, holding her knees to her chest in a near-fetal position, and barely masking her panicked state.  I asked if she needed help, but got no response.  I guessed that fear of flying was causing her panic so in a slow, calm voice, I suggested that she plant her feet firmly on the ground and concentrate on wiggling her toes – a technique that a commercial pilot I knew found effective for passengers with these typical symptoms.  She seemed to gain some control.  I handed her the paper bag in the seat pocket and urged her to breathe into it slowly – inhaling her own carbon dioxide back through the bag can often break the hyperventilation cycle caused by rapidly exhaling too much carbon dioxide.  Both strategies seemed to work, and she quickly gained composure.

I recalled this incident after reading Liz Galt’s interesting New York Times article, “Cornered: Therapist’s on Airplanes.”  She describes many of the challenges therapist’s experience when their seat mates learn of their profession.  Some people spill their guts jumping at the opportunity for a free session, which could be more than the standard 50 minutes depending on the duration of the flight.  Others clam up lest the therapist might attempt to delve into and analyze their deepest secrets.  And, there’s the therapist’s discomfort to consider – he may not be interested in working at 30,000 feet.  To avoid such discomfort, some therapists lie about what they do or distort how they describe their professional activities when the inevitable “And what do you do?’ comes up in casual conversation.  I have resorted to this tact when I sense a potentially loquacious neighbor and focus on my research in Alzheimer’s disease.  Of course, that may lead to a cascade of questions about the latest suspected causes and experimental treatments.  Perhaps launching into an update-on-Alzheimer’s lecture is preferable to establishing an impromptu doctor-patient relationship with the potential legal risks that might follow.

My reaction to the panicky woman in seat 11B was a knee-jerk response.  I wasn’t thinking that I’m a licensed physician and that I have not established a professional relationship with her.  I responded instinctively to someone in need and did what I could to help with her distress.  But had I opened myself up for a lawsuit? Perhaps I should have pushed the flight attendant call button when I first noticed that she might be in trouble? I suppose a part of me wanted to play the hero, but what if she had been suffering from some other cause of panic, such as hypoglycemia, a drug side effect, or psychosis?

Fortunately, in this case, it wasn’t one of these other problems, and in my defense, I was just a moment away from pushing the call button for help.  But that might have been a circular plea for assistance, leading to an overhead page of “Is there a doctor on the plane to help a passenger in distress? In particular, is there a psychiatrist in the house who might know how to help someone with a panic attack?”

I recall a related situation that a psychiatrist colleague faced on a cruise ship.  A fellow vacationer with a history of bipolar disorder developed a full-blown manic episode.  The patient was becoming dangerously hyperactive and delusional, expressing the belief that she could fly and that she needed to leave the cruise for an important meeting with the President of the United States.  My colleague was well equipped to make the diagnosis, but he didn’t have the equipment or adequate medication to treat her.  The ship’s doctor found a few minor tranquilizers in the pharmacy, but these didn’t seem to have much effect, and no lithium or antipsychotic medicines were available.  My colleague realized that he could use a drug for treating sea-sickness, compazine, to treat her mania.  Compazine is in the same class of medication originally used to treat acute manic psychosis.  Not the ideal medication, but good enough to calm the patient and make the situation safe until the ship arrived at the next port in the morning.

Whether it’s a cruise ship or an airplane, the close quarters and limited medical resources will always pose these kinds of challenges.  Such settings often loosen us up and create a sense of intimacy that we might not experience in other situations.  It can also lead to anxiety that can be a trigger for some people to start talking about their personal life to a stranger, especially if that neighbor is a therapist.  And, dealing with a chatty neighbor, whose too personal revelations create social discomfort, can be a challenge for anyone, whether it’s a therapist, rabbi, bar tender, or school teacher.

When does it make sense for a psychiatrist or any professional therapist to practice mile high therapy? What do you think?

See my new book, “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

First posted on HuffPost.com

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About Dr. Gary Small

Psychiatrist Neuroscientist Author
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