Today's air travel experience-from standing shoeless in security lines to accommodations that can seem comparable to 19th-century steerage class-is enough to grate on anyone's nerves.

"With all the security cues-beginning with the orange or red threat level colors-it's an incubator for stress," says psychologist Daniel Shapiro, PhD, a negotiation expert who has worked with police hostage teams.

But for Americans with a serious mental illness, air travel these days is more than stressful. It can be catastrophic.

The case of Carol Anne Gotbaum is among the most prominent examples. Last September, on her way to an alcohol treatment program, Gotbaum was detained in Phoenix Sky Harbor International Airport. When she became frantic after missing her connecting flight, police put her alone in a cell, where she accidentally strangled herself.

In another well-publicized incident, in 2005, Rigoberto Alpizar, a man with bipolar disorder, became upset on a flight preparing for takeoff at Miami International Airport. Determined to get off the flight, he ran up the aisle of the parked plane and onto the tarmac. Federal marshals, convinced that he had a bomb in his backpack, shot and killed him.

Disruptive incidents with passengers on airplanes are not new. But since 9/11, passengers with mental disorders may be increasingly mistaken for possible terrorists.

"There is zero tolerance for anything happening on a plane," says University of Akron business professor and transportation expert Andrew R. Thomas, PhD, who is the editor in chief of the Journal of Transportation Safetyand has written several books about air rage including "Aviation Insecurity: The New Challenges of Air Travel" (Prometheus, 2003).

Making matters worse is a lack of training for airport and airline personnel to manage customer expectations, let alone differentiate between a security risk and mental illness, adds Thomas.

"There's been so much focus on terrorism that responding to people in psychiatric distress is not even on the radar," says Ron Honberg, JD, national director for policy and legal affairs at the National Alliance on Mental Illness (NAMI).

Turbulence ahead

The Transportation Security Administration (TSA) employees who staff the security lines receive no specific behavioral training. In the event of an altercation or potential problem, they summon airport security personnel, who themselves may not even be in the immediate vicinity.

While the TSA-part of the Department of Homeland Security-did develop specialized behavioral training for certain personnel in 2006-the Screening Passengers by Observation Techniques (SPOT) program-its emphasis is on detecting potential security risks rather than harmless but stressed passengers. Once a plane is in the air, passengers are the in-flight crew's responsibility. Federal Aviation Administration (FAA)-a part of the Department of Transportation-regulations require the airlines to have procedures in place for handling passengers who are disruptive or may not be in touch with reality, according to FAA spokeswoman Alison Duquette. However, the airlines design their own programs, and the training is basic, covering such topics as how to handle an intoxicated passenger but not giving specific strategies for spotting or calming someone with a mental health issue, says Corey Caldwell, spokeswoman for the Association of Flight Attendants.

If a passenger becomes disruptive and an armed federal air marshal is aboard, the stakes can become considerably higher.

The marshals service, part of the Department of Homeland Security, sends all candidates to a 15-week training program, says Gregory Alter, the spokesman for the Federal Air Marshals Service. The first part of the program consists of basic law enforcement training and is similar to the training other federal law enforcement officers receive. The second part of the training uses decommissioned airliners and role-playing exercises to prepare candidates for any scenario they might face, explains Alter.

"All air marshal training programs prepare federal air marshals to effectively deal with a broad range of conceivable contingencies," he says. "Should a threat or imminent danger require the use of force, marshals are trained to use the least amount absolutely necessary."

Citing security concerns, Alter could not discuss what scenarios are covered and whether air marshals are specifically trained to recognize mental illnesses. Nonetheless, marshals must make safety decisions with limited information and often in a very short time frame.

In case of emergency

How can the system prevent tragedies with people who have mental illnesses?

"Training is really important," says Honberg. That means teaching air marshals, police at airports and other personnel about the symptoms of mental illness and how to use de-escalation techniques, he says.

The money for such training would have to come from multiple sources-the marshals program, the Transportation Security Administration and individual airlines, and Honberg doesn't see that happening anytime soon.

NAMI has worked with police departments around the country to develop de-escalation protocols for use in crisis situations involving mental illness. They include not crowding the person and speaking calmly and honestly.

"The key is building some kind of alliance with the challenging person," says Shapiro.

Hostage negotiators use empathetic techniques-for example, saying to the agitated person that it's normal to feel nervous when flying. The best negotiators have the ability to keep a thread of personal connection throughout the incident.

"If I approach as if we are adversaries, I'm creating a highly reactive situation," says Shapiro. In contrast, simply asking, "How can I help you?" may defuse the situation.

Creating allies and using all sources of information or assistance are also important. Police trained in crisis intervention know, for example, that families can help calm a loved one, says Honberg.

Of course, as Honberg emphasizes, it's always easy to play Monday-morning quarterback. The goal is to prevent situations from escalating to the point where federal marshals have to make a split- second decision.

"Training needs to be aimed at more than law enforcement personnel," he says. "It needs to include airline employees, flight attendants, security and screening personal at airports. How they respond can make the difference between life and death."