Insights: Death Anxiety And Mental Health – Dr Rachel Menzies
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It has been argued that fear of death may be a transdiagnostic variable contributing to the development and maintenance of many chronic mental health conditions. In addition, it’s been suggested that fear of death may have a role in the revolving door phenomenon of mental health conditions. What implications could this have on the way that we practice? What should clinicians be aware of, thinking about, or even doing differently?
We sat down with Dr Rachel Menzies, co-author of ‘Death anxiety and mental health: Requiem for a dreamer’, published in the Journal of Behavior Therapy and Experimental Psychiatry (2023). We discussed current thinking on death anxiety and what that might mean for the field generally, as well as for practicing clinicians.
Death anxiety – asking more questions than we answer.
Can you give us a 2-minute summary of your paper?
The paper is really about the role of death anxiety and different mental health conditions. Broadly speaking, death anxiety refers to a person’s fear about their own death or the death of other people. This paper is an attempt to summarize where research on this topic is up to currently, as well as making some recommendations for where we think it should go next. We discuss the increasing amounts of evidence that links death anxiety to numerous different mental health conditions, such as anxiety disorders, mood disorders, addictions, eating disorders, and so forth. Essentially, we’re trying to give people a snapshot of the state of research in this area, summarizing what we know about treatment for this construct and the questions that are still currently unanswered in the field.
What do you think is the most interesting part of the paper?
In my view, the most interesting aspect of the paper is all of the questions that are currently unanswered. In many ways, this paper asks more questions than it actually answers!
I think the key questions are as follows:
- What are our current treatments doing to address death anxiety, if anything?
- Could our treatments be improved by specifically targeting this construct?
Can you explain more about the suggestion that death anxiety could be responsible for the relapse or emergence of new disorders in clients that have successfully treated earlier conditions?
There’s a common clinical occurrence that many clinicians reading this will have observed, called the ‘revolving door phenomenon’. This refers to how it’s very common for people to experience numerous different mental health conditions across their life. They might have gone to numerous different psychologists, for instance, receiving treatment for the separation anxiety they had as a kid and treatment for OCD as a teenager, but now they’re presenting to you with something that looks quite different. We know that there’s data to back up the observation that people, on average, will experience double the amount of mental health disorders across their life as the number they’re currently presenting with. So, if someone is coming to you for treatment and they currently have two mental health conditions, on average, they’re going to end up having four. In the paper, we discuss that this could be because all of those different conditions are underpinned by a fear of death, and that our current treatments, if they’re not actually targeting this fear, are probably contributing to that revolving door phenomenon.
We first proposed this idea in a 2014 paper in Clinical Psychology Review, arguing that death anxiety could be transdiagnostic and that our current treatments might not be addressing it. Now, this is a theoretical argument and, at the moment, we don’t know whether it’s true. There are no studies so far that look at whether our standard treatments for panic disorder or OCD, for example, are actually doing anything to address that fear of death. The question is largely unanswered in terms of data, but theoretically we would argue that they aren’t. If you think about typical treatment for OCD, it involves trying to help the client see that their estimates about the chance of falling ill or the chance of a household fire from leaving the stove on, are wrong. However, we don’t typically look at the person’s fear of death. Instead, we tend to focus on the specific causes of death that they’re fearing. It’s possible that if we actually start to focus on death anxiety, we might be able to see better long-term outcomes for patients and they might be less likely to develop a new disorder down the track.
What are the most promising current treatment approaches for targeting death anxiety?
Currently, evidence suggests that cognitive behavioral therapy (CBT) is most effective for treating death anxiety. The studies that have been done so far have focused on graded exposure for death anxiety. This would involve deliberately and systematically exposing people to reminders of death, such as visiting cemeteries, watching documentaries about death, or planning a will. However, we also know that treatments involving cognitive restructuring (i.e., looking at people’s beliefs around death that might be maladaptive), also seem to be effective. There’s only been one study that’s looked at it, but that seems to suggest that these treatments improve a number of different aspects of death anxiety. If used correctly, they can help reduce people’s fear of their own death, fear of loved one’s death, and fear of the dying process itself.
Are there nuances regarding treatment components based on the specific element of a person’s fear of death?
There are going to be nuances in terms of the types of exposures, depending on the specific fear itself. For example, with patients who fear non-existence you might use more cognitive approaches and things like stoic philosophy, which I regularly use in cognitive treatment approaches. However, it’s very early days in this field and there have only been a handful of studies really looking at this. I think that one of the big areas we need to look at next is what specific treatment components are producing the greatest benefit and for what aspect of the fear.
Clinical takeaways for professionals.
What recommendations do you have for clinicians who would like to incorporate this recent thinking on death anxiety into their practice? What could they be aware of?
- Explore outside your area. One general recommendation would be encouraging people to read outside their own area. I often think that all of us tend to focus on our own silo (i.e., clinical psychologists tend to read clinical psychology journals), but I would strongly encourage starting to read outside of your specialism. A lot of the work on death anxiety has come from social psychology and terror management theory, which most clinicians will never have been exposed to. I think that we should start reading in other areas of psychology and philosophy, as well as looking to other approaches that can offer different perspectives. Philosophers have been writing about death and how to deal with it for thousands of years, but we don’t tend to use all of that rich material clinically. I think there is a lot people can learn from this work.
- Look for common threads. It’s important to look out for common themes and patterns when patients are talking about the things they’ve worried about across their life. Often you might not even need to do a downward arrow technique, and just from listening to the themes, you’ll start to connect the dots between the various ways that this fear of death has manifested for them. For example, maybe when they were a child, they were worried about being kidnapped or their mum dying in a car crash, and then later in life, they worried about whether their chest pain was a heart attack. If we start to pull apart the patterns and reflect back to the client, what might be that common thread for them? I think clinicians often expect that they’re going to have to dig very deep to try and get to this underlying fear with patients, but, if you start to scratch beneath the surface, it’s often right there.
- Ask the question. Often, we can be a bit worried about this subject and don’t want to talk about death. As clinicians, we need to be willing to ask patients whether they have any worries about death or dying. For example, discussing with a patient that they seem to worry a lot about the people close to them, about losing them or them dying, and asking whether that’s something they think they’re troubled by or bothers them? People will usually be upfront about whether or not this is something that troubles them. If it is, you can move forward from there to explore how it’s impacting them.
- It’s not easy work. This isn’t easy work to do – unlike most of the fears we work with clinically, this one is guaranteed to happen. I think it’s important for people to be aware of that, and that’s why trying to learn and read more about this topic is so valuable for clinicians.
- Use your existing tools a little differently. When thinking about the shift from challenging specific threat appraisals to trying to pinpoint the underlying fear of death, I would suggest using the therapy tools that you probably already use but in slightly different contexts. For example, using the downward arrow technique to ask a person “What would be so bad if you contracted that illness?…And what would be so bad about that?”, and though it might sound like a silly question, “What would be so bad about death or dying?…Or a specific person dying?”. You’re trying to uncover what the belief is that they have about death that’s really driving the fear for them. Is it that they fear dying will be painful? Is it that they fear they wouldn’t be able to cope if their partner or parent died?
- Look at behaviors. We don’t just want to focus on the beliefs, we also want to look at the behaviors. What are the things that they’re avoiding? How is that avoidance playing into their anxiety? Are they engaging in any other safety seeking behaviors or any reassurance seeking? It’s really using a lot of the same CBT techniques that many clinicians are already familiar with, but trying to target the death fear itself rather than those more surface level causes of death, such as the heart attack or plane crash.
What do you think the main challenge might be for clinicians thinking about integrating this work into their practice?
Unlike most clinical presentations and things that people tend to fear, death is something that applies to all of us. Your average clinician might not have a fear of flying or public speaking, but fear of death is something that tends to be universal – a given of human existence. So, I think one of the big obstacles is that clinicians’ own death anxiety might make this a difficult topic to bring into the discussion with clients and face exposure to. I think that, as a clinician, you should try to practice what you preach and challenge your own beliefs about death, really trying to expose yourself to reminders of death to help you accept it. I think this is a very important thing to keep in mind for people who are wanting to integrate this work into their practice.
From a student’s perspective, is this topic typically covered in training?
No, that’s the short answer. To the best of my knowledge, I’m not aware of any master’s programs or any clinical training programs that would cover this. I think there’s more and more awareness of it, but it’s currently the sort of topic that most people would have to seek out after their training, for instance, to do more learning in this area. I suspect that’ll change as there’s been a real shift towards people thinking more about this topic, but currently, you’d have to be quite interested to go out and pursue this information yourself. However, this also means it feels very exciting and that’s why I really loved writing this paper. I don’t think I’ve ever written such a long section on future research directions in a paper– it’s close to two pages long! There are just so many avenues that people can go down with this research. It’s really such a fantastic and promising space for students, whether they’re looking for research projects or wanting to start a career in research. It’s a very exciting time to be working in this space.
And what was your hope for this paper? What is next for you on this specific area?
My hope is that this paper will stir people’s interest and that they will find something in the list of research directions that sparks their interest and leads them to become passionate about this topic.
Over the next few years, my own research in this area will focus more on treatment, trying to answer those questions about whether standard treatments address this fear at all. What is the best way to integrate this treatment? Do we want to be doing purely death anxiety focused treatments, or do we want to add them to complement our standard treatments? Does targeting death anxiety slow that revolving door? Does it reduce the development of new disorders?
Overall, I just really hope that this paper broadens people’s interest and their understanding of the topic, as well as encouraging them to read in other areas outside of clinical psychology.
Menzies, R.E., & Menzies, R.G. (2023). Death anxiety and mental health: requiem for a dreamer. Journal of Behavior Therapy and Experimental Psychiatry, 78, 101807.
Menzies, R.E., Julien, A., Sharpe, L., Menzies, R.G., Helgadóttir, F.D., & Dar-Nimrod, I. (2023). Overcoming death anxiety: a phase I trial of an online CBT program in a clinical sample. Behavioural and Cognitive Psychotherapy, 51(4), 374-379. (LINK)
Menzies, R.E., & Menzies, R.G. (2021). Mortals: How the Fear of Death Shaped Human Society. Sydney: Allen & Unwin.
Menzies, R.E., Sharpe, L., & Dar‐Nimrod, I. (2019). The relationship between death anxiety and severity of mental illnesses. British Journal of Clinical Psychology, 58(4), 452-467.
Menzies, R.E., & Veale, D. (2022). Free Yourself from Death Anxiety: A CBT Self-Help Guide for a Fear of Death and Dying. Jessica Kingsley Publishing.
Menzies, R.E., & Whittle, L.F. (2022). Stoicism and death acceptance: integrating Stoic philosophy in cognitive behaviour therapy for death anxiety. Discover Psychology, 2(1), 11. (LINK)
Menzies, R.E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (2018). The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomised controlled trials. Journal of anxiety disorders, 59, 64-73.
Menzies, R.G., Menzies, R.E., & Dingle, G. (Eds.) (2022). Existential Concerns and Cognitive-Behavioral Procedures: An Integrative Approach to Mental Health. Springer Nature Switzerland.
Free related resources, podcasts, and interviews can be found at: https://www.menziesanxietycentre.com/resources