Can CBT help you overcome one of the greatest challenges humans face?
‘I’m not afraid of death, I just don’t want to be there when it happens.’ Woody Allen
Cognitive behavioural therapy (CBT) is most often used to treat anxiety and depression, but can also be useful for other mental and physical issues. It is a talking therapy, but manuals are also available which allow you to learn more, and also to self-administer the treatment. I have found it to be a very useful way of thinking about emotional problems. Essentially, CBT argues that your thoughts, feelings and physical senses are all connected. This can lead you to be trapped in negative cycles. For example, you might feel bad about something you did, which leads you to think that you are a bad person, which leads to a behaviour of lying in bed all day, which in turn makes you feel even worse, think even worse things, and engage in even more counterproductive behaviours.
In a negative cycle, your feelings, thoughts and physical behaviour all work against you, making you feel really stuck. The good news is that there are ways to intervene in a positive way. Suddenly this interconnectedness becomes an advantage, as one good choice leads to a chain reaction of good consequences. For example, you could challenge the validity of your negative thoughts, or you could force yourself out of bed and go on a run. Both of these actions could then lead you to feel better, which then will result in more positive thoughts and more positive actions.
It’s a beautifully simple theory which challenges the ‘truth’ of your negative thoughts and feelings and behaviours. It can be hugely empowering because it gives you permission to feel okay. No matter what your problem is, I can guarantee your negative thinking will fall into the category of one of CBT’s ‘thinking traps’. To name just a few: ‘all or nothing thinking’ (something hasn’t gone perfectly and so it was a complete failure), ‘mind-reading’(assuming someone is thinking something negative about you), ‘fortune-telling’ (predicting situations will have a negative outcome) or ‘labelling’ (saying ‘I’m a failure’, rather than simply ‘I failed the exam’). Once you identify the thinking trap, you’re in a position to challenge the thought. Or if you don’t have the energy to do that, you can engage the body instead. That might mean connecting to your five senses or doing some exercise, which will also have a beneficial impact on your thinking. CBT is hard work, it’s not an easy solution, but with will power, it’s a really good way to improve how you’re feeling.
I have been exploring a number of the different CBT manuals in the ‘Overcoming’ series, which are designed to help people to ‘take control of their own recovery program’. Most recently, I was enjoying ‘Overcoming Health Anxiety’, which as an experienced hypochondriac, felt worth exploring. In it, I was fascinated to discover a chapter on ‘Overcoming A Fear Of Death’. This interested me because I didn’t really consider death to be a health issue. You don’t die of death, death is the consequence of a real health problem, one you had a right to be anxious about! But there it was. My trusty guides Rob Willson and David Veale were ready to tackle the issue head-on. They’d written a chapter which is only 12 pages long, which they felt would give a good, if not completely comprehensive, overview of the issue. I couldn’t help thinking this was rather audacious of them. After all, a fear of death is probably one of the biggest issues in the entire history of philosophy. Millions of pages must have been written on the subject. And yet, Rob and David were proposing to give the subject a good go in only 12 pages. The chapter is the 10th in the book, and sits between advice on getting the most from your doctor and ‘overcoming a fear of vomiting’. Both important issues for sure, but subjects that the canon of Western thought had probably spent less time dwelling on.
For some context, fear of death has been a fairly defining issue in my life. I have struggled not to see almost all life decisions in the context of my finite mortality. Whether you should pursue your dreams feels to me intricately connected to that finitude. We don’t get a second chance at life, so for me, you should spend every second using it in the ways that feel most valuable for you. This position has served me well in terms of motivation, but admittedly can be pretty anxiety-inducing. I liked the idea of reducing that anxiety but felt concerned that doing this would be incompatible with what I saw as a personal ‘truth’ about the importance of life’s limited duration.
The chapter starts by informing you that fears of death occur much more frequently in people with health anxiety. This is an eye-catching fact. I’ve always been convinced that my position on death is ‘true’ and ‘rational’ but as I mentioned earlier, the CBT model asks you to constantly challenge those kinds of thoughts. If you think your anxiety is ‘correct’ or ‘true’, then one of the first useful things you can do is to question that certainty. In other words, if people with health anxiety were more scared of death, was it more likely they happened to hold a specific truth about the awfulness of death, or more likely that this was just another manifestation of their more generally anxious natures? Surely, the latter.
The chapter then goes onto common beliefs about death. First up, ‘the process of dying is likely to be very painful and involve a lot of suffering’. The manual reassures you that the brain releases endorphins at the time of death, so you will likely have a warm pleasant feeling at the moment of passing away. This is good stuff and has already done work for me. I definitely have spent time obsessing over the moment of death, and this was a comforting thought. Great.
Next up, ‘the afterlife may be an experience worse than living’. OK, well I don’t need to spend too long on this. I’m an agnostic but basically believe with no evidence either way, there is definitely no point dwelling on the possibilities of heaven or hell. There are a few others like this. ‘I might go to Hell’ and ‘I have doubts about what will happen after death’.
A different one is ‘my partner might marry someone I hate or my children won’t cope without me as a parent’. Lacking a wife or children, it’s hard for me to empathise with these, but again I feel comfortable applying a simple logic here which is that you won’t be aware of anything after death, so trying to control things will be a meaningless endeavour.
A final one is ‘I should die at a reasonable old age and it would be terrible and unfair to die any younger than this’. This one is more interesting to me because it resonates with what I was saying earlier about making use of one’s life to the fullest extent. So I read on to see how Rob and David suggested tackling this one. They remind you that an average age of death of seventy-five means you are just as likely to die under the age of seventy-five as over it. Thanks guys, very reassuring. Even if you follow a healthy lifestyle you could still be killed in a freak accident or through a rare cancer. OK, lovely, not sure this is helping really. They reach their overall point. ‘Recognise that there are no rules about whether you should die at an old age… you have a limited influence over the time and date of your death.’ OK, I see, so it’s about giving up control. The consequence of this anxiety is that you’ll spend a lot of time worrying about extending your life, but there’s no point worrying too much about that. I can definitely see the wisdom in that. But, isn’t there a bigger question here? Worrying about dying young may be a waste of time, but that doesn’t change the fact that were it to happen, surely it would be a great tragedy? A wasted opportunity. All that potential for experiences and joy, down the drain.
I tried to put these thoughts to the back of my mind and read on. Rob and David point out something interesting in their conclusion. ‘Unlike other fears, you can’t overcome your fear or test out your predictions about death by ending your life (or at least this is not a solution we would advocate!). Bizarrely cavalier about suicide guys, but I can’t help thinking writing this chapter has put you two in a rather giddy mood. This seems to be brushing over something. Death is different to other fears. Maybe the anxiety at play is the same, but the actual issue is a step-change from other phobias, is it not? Rob and David don’t think it is. Death anxiety leads you to avoid life, interfere with your values, so it isn’t useful or productive. Therefore, apply the same CBT solution to it, as you would other fears.
The chapter ends by providing some exercises. These include, ‘seeking inspirational role models who have accepted death gracefully’, ‘make your will’, ‘write your obituary’ and ‘write out and discuss your wishes for your funeral arrangements’. The idea here is that normally you are engaging in avoidance when you are anxious about death and these exercises will force you to re-engage with the fear. They even suggest you might want to throw an ‘anti-necrophobia’ party. Apparently Rob had wanted to celebrate death in the most fun way possible. So for his fiftieth birthday, he had a coffin in the garden to try getting into, someone dressed as the Devil and a band improvising on the Funeral March. All of this made me very sure that I would like to be friends with Rob and David who are clearly great guys. But I didn’t feel fully satisfied.
CBT is a tool for people with mental health problems who want to feel better. Studies have shown that it has pretty good results in doing just that. People have to want to be helped. A lot of depressed people think that their depressed thoughts are the same as ‘true’ thoughts. CBT won’t work until they are willing to challenge that idea.
So to reiterate, what Rob and David have done here is to apply that same logic to the fear of death. If you’re scared of death that’s just anxiety, which can be alleviated with these quite simple techniques.
And in one sense they are right. When I read this chapter I immediately feel a lot less worried about the moment of death. I even, with some persuasion, can agree that spending time feeling bad about the idea of death is counter-productive behaviour and stops you living a full and good life.
Worrying about death is not a useful way to spend your time. And these techniques are a great way to avoid doing that.
But. None of this, for me, engages with a larger argument which is: is one’s own death a tragedy? And I would say it is. All the things we value and enjoy in life become impossible when we don’t exist anymore. Yes, death doesn’t matter in the sense that you can’t know that you are dead. As many like to argue, you are returning to the situation you were in before you were born, and you didn’t mind that at the time. But that doesn’t change the fact that the feeling of ‘being me’ becomes impossible post-death. The opportunity to experience all that life offers goes away. Yes, in the moment of not existing that isn’t something you’re ‘aware of’, but sitting here right now, looking forward, it is something that feels upsetting to anticipate.
A lot of negative thoughts come from trying to predict the future. You think that something will be terrible, but it then either doesn’t happen or when you experience it you find it isn’t so bad. The latter argument basically works with death. Death will happen, but when it does it won’t be so bad. The actual moment will be painless and then after that, you won’t be conscious of anything, so any feelings of loss are irrelevant.
So Rob and David were utterly justified in including ‘fear of death’ as one of the things that CBT can help you overcome. The logic behind CBT holds up, even with an exceptional phenomenon like the end of your own existence.
But CBT doesn’t tell you how to live. And actually, I suddenly realised, it doesn’t claim to! It only suggests it can help you deal with anxiety. This is the mistake I made when I saw the chapter heading and considered it to be overreaching. Because there’s more to life than feeling ‘not anxious’. There are lots of other values that you might choose to think about. For example, achievement in a chosen sphere or making sacrifices for people you love. CBT can play a part in these things, helping you to minimise suffering in the process, but it doesn’t tell you whether you should be doing them in the first place.
And I guess that’s why I found the concept of this chapter quite funny. It wasn’t claiming to do anything more ambitious than alleviate anxiety about death. But, with a subject so poetic and profound, suddenly the limitations of CBT become quite apparent.
There’s more to life than overcoming your fears. Less anxiety frees you to do exciting things that you otherwise wouldn’t have the capacity or space to do. I do think the fact that life is quite short and then over forever can be helpful in informing you how to spend your time. But this chapter helped me understand that doesn’t have to come from a place of fear. On the contrary, negative thoughts and anxieties can prohibit you from enjoying life to the full. Effectively, CBT allows you to separate the concept of ‘fear of death’ from the closely connected but much more beneficial concept of the ‘importance of life’. Rob and David made me realise that I had been conflating the two.
Therapy can allow you to fulfil potential that you might otherwise not. True, you may not share my enjoyment of trying to meet challenging targets. That might not make you feel good. A full and well-lived life to you might look quiet and calm. I am merely reminding those who do get excited by ambitious plans and goals, that sometimes it can be useful to think of therapy as a quite specific tool for making you feel more stable. It doesn’t have to be an end. Excitingly, it can be just the beginning.