Fear of Death: How CBT Can Decrease Fears of the Dying Process

People who fear the dying process itself often imagine catastrophic scenarios, such as being in intense pain, feeling humiliated in front of others, or burdening/causing pain to loved ones. My clients have described many unpleasant scenarios about how they envision themselves on their ‘deathbed.’ Their stories paint quite a morose picture of the dying process.

Thoughts are not facts

But, it is important to note that this is all fiction—these scenarios came from my clients’ imaginations. Which begs the question, what assumptions are these fictional stories based on and how accurate are they? Keep in mind that people with anxiety tend to have cognitive biases. Future scenarios, including death scenarios, are perceived to be more catastrophic than they likely will be in reality. So, let’s break down your assumptions about the dying process and subject them to a critical analysis.

Before we dive in, grab my free guide on improving health/death anxiety with CBT! 

Fears about physical or emotional pain

Many people with death anxiety assume that dying inevitably involves intense physical and emotional pain. But this may not necessarily be true, at least not to the extent one might think. The very goal of palliative and hospice care is to reduce physical, emotional, and spiritual suffering among people with serious diseases through a patient-centered approach. Research suggests palliative care improves symptom burden and quality of life.^1-3 The availability of palliative care has grown steadily, as 72 percent of hospitals in the United States have palliative care teams.⁴

I spent several years surrounded by death and dying as a clinical social worker in hospice and hospital settings. I served on large teams of medical, mental health, and spiritual experts collaborating to ensure patients were emotionally and physically comfortable. The patients I worked with amazed me with their resilience, strength, and determination. Many of them, just weeks or even days before death, were having intimate conversations with family and friends, laughing, making jokes, watching their favorite TV shows, eating junk food, and even drinking their favorite beer. Sure, I was with my patients during some intensely hard moments. But they also shared a lot of meaningful moments with family, friends, and their wider support system. Anticipatory grief, regrets, anxiety, and heartbreak were interspersed with reflection, vulnerability, honesty, reconciliation, support, gratitude, acceptance, and even joy.

Fears about burdening loved ones

People with death anxiety also often assume that dying inevitably means that loved ones will be burdened by caring for them, resentful and/or inconsolable and unable to cope. They tend to assume that if a loved one struggles, they will surely collapse and face utter ruin. Indeed, grief, caregiver burden, and other difficult experiences related to losing a loved one are common and even expected. But we must consider the many factors that influence how loved ones will cope. Personal characteristics, resources, and support systems all play a vital role in how one is able to deal with adversity.

In my work with terminally ill patients, I spent a lot of time supporting their loved ones. Through these experiences, do you know what stands out in my mind? Not their sadness or exhaustion (even though that was certainly present) but their incredible strength, resilience, commitment, and determination. They showed up for the patient and for each other. They drove or flew in from long distances, stayed up for days, made each other meals, and comforted each other. Further, a key priority of hospice and palliative care is to ensure that the needs of loved ones are met. Research highlights the benefits of palliative care in reducing caregiver burden, financial costs, anxiety, depression, and grief.^5-6

A revised perspective

It is possible that how you have envisioned your death is based on inaccurate assumptions. Of course, as is true with anything in life, we cannot be guaranteed a pleasant death. Unfortunate circumstances surrounding how one dies are possible. But it is likely that your death will not be as painful, terrifying, or depressing as you think it will be. With the support of family, friends, faith, pain management, and other palliative/hospice care interventions as well as personal strength and resilience, there is sound reason to assume that you and your loved ones will be able to cope with this difficult process.

Socratic questions about the dying process

I could prattle on about all the reasons your assumptions might be inaccurate. But you will be more likely to change your view if you challenge your own assumptions. Below are some questions for you to consider, inspired by the type of Socratic dialogue used in CBT.