Imagining Your Death: How CBT Techniques Can Reduce Death Anxiety

Death anxiety is transdiagnostic, meaning that it is present in a variety of psychological disorders. Death anxiety is commonly experienced by those with health anxiety. Sure, people have a variety of reasons for experiencing health anxiety. But after I do a bit of digging with my clients, many of them realize that their health anxiety stems, at least in part, from a fear of death.

Now, most people don’t like the idea of death. But even though they don’t like it, they are able to accept to some degree that they are going to die one day. However, for others the fear of death leads to a host of worries around anything that could potentially kill them. And health is an easy target. After all, aside from being a victim of violence or experiencing an accident of some kind, most people die from illness-related causes, right?

How CBT Helps With Death Anxiety

Treating health anxiety is done through a range of cognitive and behavioral interventions. We usually start by identifying my client’s assumptions and specific fears about death and dying. In my clinical experience, I have found that my clients tend to fear death for several reasons:

• Fears about the dying process
• Fears about the final destination
• Fears about leaving people behind

Fears about the dying process are based on assumptions that dying will inevitably involve being in intense physical or emotional pain, feeling humiliated in front of others, causing loved ones to be in emotional pain, or being completely dependent on others. Fears about the final destination often involve fears about not existing anymore as well as fears about going to hell, purgatory, or some other “non-heavenly” place. Fears about leaving people behind often involve the fear of leaving children, spouses, and other loved ones behind when they die. The goal in CBT is to help my clients challenge some of these inaccurate assumptions and see death and dying in a new, more accurate and balanced way.

Another CBT intervention is the use of imaginal and in-vivo exposures. Why? Because exposure rocks. Think of it this way. The scariest movie I ever saw was The Ring. For about a week after I saw that movie, I couldn’t sleep or even go to the bathroom without being accompanied by a friend. The anxiety I experienced from watching it was overwhelming. But after watching it several times, that feeling faded. What was the scariest movie you ever saw? Think back to the anxiety you felt right after watching it. Do you think you would feel that same level of fear after watching it four times? What about the eighth or 13th time? Probably not, right?

Exposure is based on the very simple idea that the more you expose yourself to the feared stimulus, the less afraid of it you will become. Now, in the case of death, some components of exposure will be imaginal and some will be in-vivo (or in-person).

Imaginal Exposures

Imaginal exposures can be really useful for having you expose yourself to what you fear about death the most. For example, many of my clients’ biggest fear is dying young(ish) and leaving their children behind. In these cases, I have them write out a detailed story about their death scene (e.g., their children and relatives surrounding their bedside, the immediate aftermath of their death). Whatever the focus is, I then have them audio-record their written story and play it for themselves at least once per day. Note that it is important that your imaginal story is tailored to your own specific fears and triggers or pressure points. It needs to be detailed and vivid so it can feel as real as possible. Often, my clients feel immense anxiety and/or sadness while writing out the detailed story and perhaps the first couple of times they listen to the audio recording. But soon after, they notice the anxiety and/or sadness around the imagined story start to fade.

In-Vivo Exposures

In-vivo exposure exercises related to the fear of death can take a range of forms. The idea is to help you move from seeing death as horrifying to accepting it as a normal, bearable part of the life experience. So the goal of the in-vivo exercises is to normalize death instead of having it be the proverbial monster in the closet. In-vivo activities could include visiting a cemetery and reading people’s headstones, reading the obituary section of the newspaper, watching movies with death scenes, participating in a death dinner (yes, this is an actual thing), writing a will, and/or writing letters to loved ones you would leave behind. The list goes on. As with other exposure hierarchies, this process is extremely idiosyncratic and creative. We collaboratively work together to create an exposure hierarchy of death-related events and activities that can help reduce this fear in your life.