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A Large-Group 1-Day RCT Investigating the Effectiveness of Four Different Strategies to Promote the Outcome of Exposure Therapy in 519 Patients with Phobic Fear of Flying
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DOI：10.1159/000550395.png)
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Abstract
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Introduction: Despite its status as the gold standard for treating fear and anxiety, exposure therapy leaves room for optimization. Clarifying and testing the clinical relevance of proposed mechanisms may enhance outcomes. This randomized controlled trial (DRKS00031220) examined the effects of four psychological strategies aimed at facilitating exposure outcomes in individuals with clinically significant fear of flying due to specific phobia or agoraphobia (N = 519). Methods: All participants underwent a standardized large-group one-session treatment (LG-OST) including psychoeducation, debriefing, and an in vivo exposure flight. Participants were randomized to one of four conditions targeting distinct mechanisms: peer support (SUPPORT), self-efficacy (SELF-EFFIC), expectancy violation (EXPECT), or coping with bodily fear symptoms (COPE). These mechanisms were reinforced prior and during paralleled exposure flights, conducted in separate aircraft per condition. Results: Across all conditions, LG-OST led to substantial symptom reduction short- and long-term. Fear ratings halved, over 50% flew again within the 6-month follow-up interval, and similar to 70% no longer met diagnostic criteria. However, no condition yielded superior outcomes. While manipulation checks confirmed partial activation of target mechanisms (e.g., greater perceived peer support in SUPPORT, increased use of breathing techniques in COPE), these effects did not translate into differential clinical benefits. Conclusion: Findings support the efficacy and scalability of LG-OST, while suggesting that tailoring preparatory strategies to specific mechanisms may have limited added value. They also highlight the need to advance mechanistic research to better understand the intertwined processes underlying exposure success. Future work should focus on improving accessibility and sustaining long-term gains. This study tested a 1-day, large-group exposure treatment for people with a strong fear of flying (FoF), including those who also experience anxiety in situations where escape might be difficult (agoraphobia). Exposure therapy involves facing the feared situation - in this case, a real flight. The researchers also aimed to enhance the effects of exposure in four ways: by fostering peer support, increasing confidence in coping with anxiety, highlighting and testing feared outcomes, and teaching techniques to manage physical anxiety symptoms. Overall, the treatment was highly effective. Participants reported much less FoF. About half of the participants flew again after treatment, and 6 months later, around 70% no longer met criteria for their main anxiety problem. Most participants said they would recommend the program to others. Interestingly, none of the four strategies led to clearly better results than the others. While some strategies influenced the intended psychological processes, these changes did not affect the overall outcome, suggesting that the main benefit comes from facing the feared situation itself. A challenge was that nearly 15% of patients dropped out before the session, often due to strong anticipatory fear. Helping people start treatment may, therefore, be as important as improving therapy itself, for example, through motivational support, psychoeducation, peer encouragement, or digital pre-treatment tools. In conclusion, one-session, large-group exposure therapy is safe, practical, and highly effective for FoF. Future work should focus on both understanding the psychological processes that make exposure work and reducing barriers that prevent people from accessing treatment.
Keywords:
Phobia
Exposure
Fear of flying
Violation of expectancy
Mechanisms of exposure
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