How to Improve Death Anxiety Using CBT

The fear of death has been shown to play a causal role in a wide range of psychological disorders. Although death anxiety is transdiagnostic, it is a particularly salient feature of health anxiety. And this isn’t exactly surprising. After all, aside from being a victim of violence or in an accident of some kind, the vast majority of deaths are due to illness-related causes, right?

Now, most people don’t relish the idea of their death. But, although it is disconcerting, they are able to accept to some degree that death is an inevitable part of life, and they, more or less, leave it at that. However, many people with health anxiety find that their fear of illness and disease stems, at least in part, from fears related to death and/or the dying process. Only recently have researchers and clinicians started to tackle this issue in their understanding and treatment of health anxiety.

Western culture does not help matters.

Denial and avoidance of death-related concepts only increases the fear of it. As a society, we are guilty of promoting the avoidance of death and dying. Death is not something that is embraced or openly talked about in our culture. In fact, there has been a whole movement against this, sometimes referred to as "death positivity," which has advocated for greater acceptance of death in our culture by encouraging people to speak openly about death and dying (acknowledging, understanding, and talking about our fears, what we want, and organizing or planning for our death). There are many examples of ways this movement takes place. In one, people have death dinner parties to discuss mortality. More than 200,000 people have participated in these dinner parties. In some ways, this "death positivity" movement lends well to the basic tenets behind exposure therapy, which is to expose yourself to the feared stimulus to learn that it is not as terrifying as one might assume.

Health anxiety treatment includes addressing death anxiety.

If we try to improve your health anxiety without tackling your fear of death, we are merely slapping the proverbial Band-Aid on your wound. Researchers refer to this as the “revolving door” problem. Essentially, if a client comes to me for help with health anxiety and I don’t address their death anxiety in treatment, the problem will likely resurface and they will be back again for treatment at some point in the future.

So, how do we treat death anxiety?

In cognitive-behavioral therapy (CBT), we use cognitive restructuring and exposure tasks to help one overcome the fear of death. With cognitive restructuring, we help one to challenge their maladaptive assumptions about death and dying (e.g., fears about the dying process, fears about the "final destination," fears about leaving loved ones behind). In exposure therapy, we help one to systematically expose themselves to death and dying in various ways to slowly and steadily see death as a normal part of life and not the "scary monster in the closet."

For example, we would design exposure tasks (like the ones below) to help you systematically grow more comfortable with the idea of death:

• Watch movies/read books that illustrate scenes of people dying.
• Review hospice materials—many of them talk about the dying process in detail.
• Read about people who have lost loved ones and have cared for them during the dying process (find some books).
• Write (and discuss) an imaginal story about your children's lives after you die.
• Write (and discuss) an imaginal story about you on your deathbed with your loved ones surrounding you.
• Develop a plan for how you would like your dying process to be if you were able to choose. Where would you be, who would be there, what food and drink would you want to enjoy, and what sorts of activities would you like to do?
• Read about death dinners.
• Attend a death dinner and share about how you would like to die if you died from an illness-related cause,

In summary, the key tasks in treating death anxiety with CBT are (a) to help you challenge any rational fears through cognitive restructuring and (b) to help you learn to grow more comfortable with death through engaging in exposure tasks that normalize death instead of avoiding it. Death isn't something we look forward to, but it should not take over your life!