Kylie B. Rogalla-Hafley
Counseling & Human Services
Indiana University South Bend
Personal death anxiety is a universal human experience, and many clients seek counseling as they attempt to find meaning of grief experiences due to loss. Counselors are called to provide congruent, empathetic, unbiased, and unconditional support throughout this process, although sparse, research explores how counselor death anxiety may also enter into the therapeutic relationship. Counselors who work with clients presenting with grief and loss needs are vulnerable to imposing personal values or risking potential harm to clients if their own worldview surrounding death remains unexplored and unresolved. Humanistic psychology, terror management, post traumatic growth, and the counselor will to meaning all provide theoretical rationale for the exploration of personal death anxiety. Counselor education programs and professional development opportunities are encouraged to introduce didactic and experiential activities for practitioners to explore new ways of conceptualizing death as it affects clients and understanding death as it relates to personal belief held by each counselor.
Keywords: death anxiety, counseling, competence
Exploring Personal Death Anxiety: Increasing Counselor Competence for Grief and Loss
Death and grief are universal human experiences and enter into counseling relationships in all disciplines of mental health services. Research has shown that ties to a therapeutic environment and a trusted counselor can serve as a foundational support as clients learn to navigate the transition associated with significant loss (Werner-Lin, Biank, & Rubenstein, 2010). This is not a novel concept for counselors to consider and appreciate in their work; however, a vast majority of research in the grief and loss literature is centered upon theoretical approaches and techniques to support diverse clients during the mourning process. Far less explores the counselor position in the relationship, particularly the counselors’ personal comfort and competence in tolerating death, dying, and data points along the entire grief spectrum (anticipatory through complicated grief).
An introspective understanding of our own anxiety in reference to death is valid if counseling a grieving client is to be ethically effective, although this is not a common message passed down the professional pipeline. Overall, the cultural masses in the United States do not handle death well (Durlak, 1994; Eckerd, 2009). Our society has significantly embraced a “death-denying” and “grief-avoiding” approach to this topic (Walters, 2008, p. 277). This trend has affected professional helpers in a variety of fields, and may yield potentially concerning outcomes for those served.
Practicing counselors in the United States may be lacking sufficient education and training around the processes of death and dying as well. Rosenthal (1981) wrote the last accounted introspection of death-awareness education in counselor education programs over three decades ago (Coursol & Folkerds, 2011). The prestigious Council for Accreditation of Counseling and Other Related Educational Programs (CACREP, 2016) recently released an updated set of standards for training and practice for all qualified programs. The words death and grief do not appear in any of these professional benchmarks among any of the eight specialty areas of focus. Additionally, one notable nation-wide study of 161 undergraduate psychology programs revealed that only approximately 20% reported offering a death, dying, and bereavement course to students over the past five years (Eckerd, 2009). Counselor preparation and ongoing professional development for working within this population is limited.
Kirchberg, Neimeyer, and James (1998) found that personal death anxiety significantly predicted the amount of perceived distress experienced by newly practicing counselors when supporting clients enduring grief due to loss. Harrawood, Doughty, and Wilde (2011) interviewed counselors-in-training after a two-credit course in thanatology. The themes uncovered by these participants included increased openness in examining and exploring death and decreased personal fear of death. Mason and Ellershaw (2000) conducted a pre and post assessment of thanatophobia (fear of death) and professional self-efficacy among medical students in palliative care units after a one-day death and dying educational program. Results indicated a significant decrease in overall fear of death and increase in perceived self-efficacy in providing quality care. Bozo, Tunca, and Simsek (2009) discovered that induced contact and increased awareness of death anxiety through a short story narrative significantly increased health-promoting behaviors among adults of various ages compared to a control group. These are only a handful of examples from interrelated fields where evaluation of personal death anxiety yielded benefit for both the practitioner participants and grieving clients served.
Many psychological theories, modern concepts, and philosophical perspectives aid in providing a pool of rationale for counselor exploration of personal death anxiety. Humanistic modalities such as Rogerian, Gestalt, and Existential frameworks encourage counselors to deepen self-awareness in order to provide a clear and ethical foundation of nondirective support for a client enduring grief. The novel concepts of terror management and posttraumatic growth feed into this overall understanding, as well as philosophical ideas rooted in the process of will or desire to pursue meaning in the face of despair. Each is explored in the following section.
While nearly all counseling theories emphasize the importance of a therapeutic relationship, humanistic approaches often call practitioners to demonstrate their own self-awareness, genuineness, congruence, and empathy without becoming emotionally entangled with the client experience (Rogers, 1957). Van Deurzen (2010) recommends that counselors openly and deeply explore their own personal worldview, which can enable them to navigate the subjective world of another person without losing their own sense of self.Gestalt theory tasks the counselor with staying in the here-and-now as the client faces a sense of impasse due to limitations in external support and self-efficacy. Awareness is the primary goal of this approach, and competent counselors resist all forms of rescuing, infantilizing, advice-giving, or directing the client towards future-focused coping skills outside of the genuine experience taking place in each session (Yontef & Jacobs, 2008).
Existential theory explores the concept of being rather than placing weight on measurable outcomes, and this transcends through both ends of the therapeutic relationship (Loewenthal, 2010). The theory addresses four ultimate concerns in particular, which are experienced in various degrees by all human beings (Yalom, 1980). These existential anxieties include meaninglessness (e.g., “What is my purpose in life?”), isolation (e.g., “I came into this world alone, and I will die alone.”), freedom (e.g., “I am solely responsible for my choices.”), and death (e.g. “Everything and everyone is finite. I will die, and I cannot prevent death.”) (Yalom, 1980; Corey, 2011; Sharf, 2008). The existential counselor is responsible for identifying angst a client may hold for any of these conditions, confronting the reality of that anxiety, and walking alongside the client as a fellow traveler throughout the rebalancing process (Yalom, 1980). Given the suggested counselor identity posed by these humanistic theories, it becomes essential that practitioners have an exceptional understanding of their own humanness and universal angst that may lie beneath current awareness.
Terror Management Theory
The origination of terror management theory (TMT) was born with Becker’s (1973) early work examining cultural systems, perceived immortality through religious beliefs, and sense of self-esteem or significance tied directly to predetermined group norms (Tomer, 1994). Many individuals strive for self-preservation amidst the constant awareness of death, and this may inadvertently create defensiveness or dismissal of alternative life questions that do not align with a spiritual or cultural belief (Furer & Walker, 2008). When reminded of the finiteness of life, TMT posits that individuals may attempt to harbor frequent and impulsive contacts with members of known cultural group while rejecting concepts of death or the afterlife that cause internal dissonance. As a result, individuals who are faced with alternative views may shrink away from authentic intimacy and create a comfortable and distal illusion of true connection. (Basset, 2007).
Solomon, Greenberg, and Pyszczynksi (2015) summarized three empirical themes that have surfaced in the terror management literature among hundreds of professional studies. First, research has shown that momentary boosts in self-esteem and worth within a belief system results in reduced anxiety and physiological arousal. Secondly, facing the reality of death causes many to defend their cultural worldviews and instinctually view alternative beliefs under a negative lens. Lastly, unconscious thoughts of death sharply increase when long-standing beliefs and meaning is threatened by another perspective.
Given the foundation of this theory, counselors who unconsciously manage their terror of death by rejecting diverse values may instinctively distance themselves from the authentic therapeutic relationship and are at risk for directly or indirectly imposing their worldviews in session. The ACA Code of Ethics (2014) devotes a section of guidance directly addressing respect for diversity, increased self-awareness of bias, avoiding harm, and resisting imposition of personal values onto clients (A.4). If a client is experiencing grief, he or she may hold similar, inconsistent, or unknown beliefs in comparison to the counselor. The competent practitioner can be fully present and unconditionally supportive in any category.
The term posttraumatic can automatically create thoughts of extreme adverse events, psychological symptoms or disorders, and possible maladaptive coping strategies (e.g. substance abuse) in response to traumatic experiences (Gerrish, Dyck, & Marsh, 2009). Yet, this is not always the case, and the positive alternative gets far less empirical attention. According to many researchers, individuals who experience a close personal death can develop a fundamental shift in awareness and appreciation for life, an adjustment in priorities, and an improved psychological state as a result of grappling with this hardship (Furer & Walker, 2008; Gerrish et al., 2009; Tedeschi, Park, & Calhoun, 1998). This experience of posttraumatic growth can enable individuals to recognize and appreciate positive changes within interpersonal relationships, self-perception, personal psychological endurance, and a balanced existential life (Sheikh & Marotta, 2005; Tedeschi & Calhoun, 2009).
The validity of posttraumatic growth can assist practitioners and clients alike in reframing death and grief as an intolerable and purely negative experience into a catalyst for potential expansion beyond previous functioning. Counselor examination of their own worldviews in the wake of past losses provides a reflective opportunity to not only face death anxiety, but also to make room for consideration of new gains unveiled by these events. Firestone and Catlett (2009) claim that allowing individuals to openly address the concept of death can help them challenge their habitual patterns used to avoid psychological pain and develop life-affirming death awareness. As a result, people may feel more alive, experience more independence, report stronger feelings of freedom, and have a greater chance to tap into full human potential. This mindset is shown to offset complicated bereavement for clients, yet also may require tolerance and willingness by the counselor to achieve such benefits.
Will to Meaning
Aligned with potential growth in the wake of death and grief, Viktor Frankl (1988; 2006) introduces a related concept known as the will to meaning. Frankl asserts that there is more to human nature than a basic strive to homeostasis or to maintain a perceived status quo. Human beings are open systems, creative beings, and each strives to form a value system. He positions that when humans experience a sense of meaninglessness, they do meaningless things. When this search is frustrated, a person may resort to power and pleasure-seeking actions in order to unconsciously rid him or herself of freedom to make active choices in shaping their reality.
When an individual feels despair (e.g., grief), Frankl firmly affirms that this is not an ailment or catastrophic symptom but rather it is an experience of doubt that there is such a thing as meaning in the world. He believes this is a fundamental human achievement rather than a negative experience to be removed as soon as possible. If an individualized process of questioning the meaning of life in the face of death can be viewed as a profound accomplishment, counselors who explore personal death anxiety and are choosing to achieve a greater sense of the human experience. A counselor open to self-exploration for sake of greater self-actualization is less likely to withdraw or project with a grieving client, and more likely to experience a sense of fascination and empathy for another unique journey.
The foundations of humanistic psychology and suggestions for the competent practitioner of such theories draw common attention to a highly self-aware way of being with clients facing the human reality of death and grief. Terror management theory illustrates how unawareness can potentially cause a counselor to retract from therapeutic intimacy, and even impose his or her own value system into the relationship in order to avoid terror associated with death. Posttraumatic growth assists in demonstrating how not all experiences that shock or alter our worldview or sense of safety end in a painful return to previous functioning, but can result in a newfound sense of meaning and increased actualization. Finally, the philosophical notion of will to meaning calls all people to actively question the meaning they hold in their lives and embrace the freedom such activity requires.
Strategies of Exploration
Personal death anxiety can be uncovered through use of a variety of accessible tools found throughout decades of cultural expressions. Fictional literature (i.e., novels), music, poetry, and film each present unique opportunities for counselors to examine their instinctual reactions to stimuli that promote death awareness. On a broader level, death education seminars, workshops and courses within a counseling curriculum offer students in training or practicing professionals a space to gain distinctive exposure and valuable information for navigating personal death anxiety as well as pronounced grief present in any therapeutic relationship.
Bibliotherapy (Literature, Music, Poetry, and Film)
In his monumental work, “The Gift of Therapy,” Yalom (2002) discusses how therapists who expect to work with the dying or those anxious about death should, and often are, asked to read historic literature such as “The Death of Ivan Ilyich” or “War and Peace” by Tolstoy, and “A Christmas Carol” by Charles Dickens. Within Ivan Ilyich, readers observe a callus bureaucrat realize that he is dying horribly because he was living horribly. Through interpersonal insight into this acknowledgement, Ilyich finds a previously unachieved sense of inner peace and meaning which accompany him for the last few days of his life. In “War and Peace,” the character Pierre faces a firing squad, and is internally changed after a last second exoneration from his death. Finally, in “A Christmas Carol,” we watch the infamous Mr. Scrooge respond and alter his frame of reference due to a visit from his future spirit who allows him to witness his own lonely death (Yalom, 2002). Reading novels and stories such as these provides an opportunity for the reader to engage within the character development process and feel the profound shift these characters experience after an exploration of death anxiety.
According to Coursol and Folkerds (2011), exploration of music lyrics, poetry, and films can promote a deepened self-exploration of issues activating death awareness in practitioners and counselors-in-training. These researchers propose song lyrics by musicians from various genres, which include: U2: “Stuck in a Moment You Can’t Get Out Of,” Sarah McLaughlin: “Will You Remember Me?,” Eric Clapton: “Tears in Heaven,” Dixie Chicks: “Travelin Soldier,” and Barry Manalilow: “If Tomorrow Never Comes.” Listening to these pieces along with examining the written lyrics can show to be a powerful experience. Poetry suggestions include “Wild Geese” by Mary Oliver and “Invictus” by William E. Henley. Additionally, “Loss” by Conyne (2008) and “Death, Loss, and a Sacred Moment” by Mazza (2004) also portray elements of bereavement and are published with the Journal of Humanistic Counseling. Poetry and short stories provide similar experiential moments for participants in a less time-intensive manner than the prior novel suggestions. Finally, film options include: “Grand Torino,” “Ghost,” “A Walk to Remember,” “My Sister’s Keeper,” “Bryan’s Song,” “Last Song,” “The Lovely Bones,” and “My Girl.” Additionally, Sullivan and colleagues (2009) conducted a study comparing the death-fearing themes of “Rosemary’s Baby,” and “Straw Dogs” to examine the motivations of the characters facing death and the death imagery presented throughout each film. Watching films that illustrate the death and dying process can invoke a personal sense of awareness of finite human life. This promotes an ample opportunity to explore the anxiety that may arise as a result of witnessing the various reactions of different characters in the film, both who are directly and indirectly touched by death.
Death Education (Workshops, Seminars, or Courses)
According to Eckerd (2009), individuals within the United States have less personal experience with death than was the case 50-100 years ago, urging for formal education regarding death, dying, and bereavement. Death education courses have increased in frequency, although these tend to be reserved for clinicians in the fields of pharmacy, nursing, and medicine (Eckerd, 2009). In his review of death education, Durlak (1994) claims that a range of 13-40% of programs in pharmacy, nursing, medicine, dentistry, and social work offered a course on death, while 43-83% integrated such instruction on a diluted level into their preexisting courses.
Lastly, Durlak (1994) discusses the difference between didactic and experiential death education. According to his research, didactic education focuses on cognitive development and awareness of death-related issues. This involves reading empirical studies, lectures, large group discussions, and witnessing guest speakers from medical and religious professions. However, in experiential death education, the goal is to combine traditional cognitive instruction with a personal exploration of feelings associated with death and bereavement. A holistic approach to fostering counselor self-awareness in relation to death and dying employs both methods.
All human beings experience existential anxieties, including the profound impacts of death anxiety (Yalom, 1980). Exploration of personal death anxiety offers a wide array of benefits to practicing counselors. By learning to manage terror and considering encounters with grief and loss as an opportunity for posttraumatic growth, counselors can overcome personal fear associated with death and dying. This can lessen potential harm to clients by removing elements of personal values and beliefs held by the counselor. Further, counselors can examine their personal meaning-making of death, grief, and loss in contrast to how a client might view his or her own beliefs. In response, by engaging in forms of personal bibliotherapy (literature, music, poetry, and film), counselors can observe and process their personal reactions to character encounters with death anxiety. Finally, death education provides an opportunity for cognitive development, increased empathy, and an overall deeper understanding of death, grief, and loss as it applies to counselors themselves and the clients they serve.
American Counseling Association (2014). ACA code of ethics. Alexandria, VA.
Bassett, J. F. (2007). Psychological defenses against death anxiety: Integrating terror
management theory and firestone’s separation theory. Death Studies, 31(8), 727-750.
Becker, E. (1973). The denial of death. New York, NY: Free Press.
Bozo, Ö., Tunca, A., & Šimšek, Y. (2009). The effect of death anxiety and age on health-
promoting behaviors: A terror-management theory perspective. Journal of Psychology,
Conyne, R. K. (2008). Loss. Journal of Humanistic Counseling, Education & Development,
Corey, G. (2011). Theory and practice of group counseling (8th ed.). Belmont, CA: Brooks/Cole.
Coursol, D. H., & Folkerds, A. S. (2011, October). Shaping the future of the profession:
Strategies for teaching and approaching death and loss with counselor trainees. Education
session conducted at the National Association for Counselor Education Conference at
Durlak, J. A. (1994). Changing death attitudes through death education. In Neimeyer, R. A.
(Ed.). Death anxiety handbook: Research, instrumentation, and application. (pp. 3-28).
Bristol, PA: Taylor & Francis
Eckerd, L. M. (2009). Death and dying courses offerings in psychology: A survey of nine
Midwestern states. Death Studies, 33(8), 762-770.
Firestone, R. W., & Catlett, J. (2009). Beyond death anxiety: Achieving life-affirming death
awareness. New York, NY: Springer.
Furer, P., & Walker, J. R. (2008). Death anxiety: A cognitive-behavioral approach. Journal Of
Cognitive Psychotherapy, 22(2), 167-182. doi:10.1891/0889-83126.96.36.199
Frankl, V. (1988). The will to meaning: Foundations and applications of logotherapy. New York, NY: Penguin.
Frankl, V. (2006). Man’s search for meaning. Boston, MA: Beacon Press.
Gerrish, N., Dyck, M. J., & Marsh, A. (2009). Post-traumatic growth and bereavement.
Mortality, 14(3), 226-244. doi:10.1080/13576270903017032
Harrawood, L. K., Doughty, E. A., & Wilde, B. (2011). Death education and attitudes of
counselors-in-training toward death: An exploratory study. Counseling & Values, 56(1), 83-
Kirchberg, T. M., Neimeyer, R. A., & James, R. K. (1998). Beginning counselors’ death
concerns and empathic responses to client situations involving death. Death Studies, 22(2), 99.
Loewenthal, D. (2010). Post-existentialism instead of CBT. Existential Analysis: Journal of The
Society for Existential Analysis, 21(2), 320-330.
Mason, S., & Ellershaw, J. (2000). Death anxiety in fourth-year medical undergraduates:
implications for palliative care. Palliative Medicine, 14(3), 246-247.
Mazza, N. (2004). Death, loss, and a sacred moment (Poem). Journal Of Humanistic Counseling,
Education & Development, 43(2), 219.
McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for
understanding the psychological effects of working with victims. Journal of Trauma & Stress,
Papadatou, D. (2009). In the face of death: Professionals who care for the dying and the
bereaved. New York, NY: Springer.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.
Journal of Consulting Psychology, 21.
Rosenthal, N. R. (1981). Attitudes toward death education and grief counseling. Counselor
Education and Supervision, 20, 203-210.
Sheikh, A. I., & Marotta, S. A. (2005). A cross-validation study of the posttraumatic growth inventory. Measurement and Evaluation in Counseling & Development, 38(2), 66-77.
Sharf., R. S. (2008). Theories of psychotherapy and counseling (4th ed.). Belmont, CA: Thomson
Solomon, S., Greenberg, J., & Pyszczynksi, T. (2015). The worm at the core: On the role of
death in life. New York: Penguin Random House.
Sullivan, D., Greenberg, J., & Landau, M. J. (2009). Toward a new understanding of two films
from the dark side: Utilizing terror management theory to analyze Rosemary’s Baby and
Straw Dogs. Journal Of Popular Film & Television, 37(4), 189-198.
Tedeschi, R. G., & Calhoun, L. G. (2009). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.
Tedeschi, R. G., Park, C. L., & Calhoun, L. G. (1998). Posttraumatic growth: Positive changes in the aftermath of crisis. Mahwah, N.J: Lawrence Erlbaum Associates.
Tomer, A. (1994). Death anxiety in adult life—theoretical perspectives. In Neimeyer, R. A.
(Ed.). Death anxiety handbook: Research, instrumentation, and application. (pp. 3-28).
Bristol, PA: Taylor & Francis
Van Deurzen, E. (2010). Everyday mysteries: A handbook of existential psychotherapy (2nd ed.).
Werner-Lin, A., Biank, N. M., & Rubenstein, B. (2010). There’s no place like home: Preparing
children for geographical and relational attachment disruptions following parental death to
cancer. Journal of Clinical Social Work, 38, 132-143.
Yalom, I. (1980). Existential psychotherapy. New York, NY: Harper Collins.
Yalom, I. (2009). Staring into the sun: Overcoming the terror of death. San Francisco, CA:
Yalom, I. (2002). The gift of therapy. New York, NY: Harper Collins.
Yontef, G., & Jacobs, L. (2008). Gestalt therapy. In Corsini, R. J., & Wedding, D. (Eds.),
Current Psychotherapies (pp. 328-367), Belmont, CA: Thomson Higher Education.