See

discussions, stats, and author profiles for this publication at:

https://www.researchgate.net/publication/233662306

Death Anxiety: A Cognitive-

Behavioral Approach

Article in Journal of Cognitive Psychotherapy · June 2008

DOI: 10.1891/0889-8391.22.2.167

CITATIONS READS

41 12,899

2 authors:

Patricia Furer John Walker

University of Manitoba University of Manitoba
36 PUBLICATIONS 492 CITATIONS 227 PUBLICATIONS 6,996 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Health Anxiety View project

All content following this page was uploaded by Patricia Furer on 30 September 2014.

The user has requested enhancement of the downloaded file.

Journal of Cognitive Psychotherapy: An International Quarterly
Volume 22, Number 2 • 2008

Death Anxiety: A Cognitive-Behavioral

Approach

Patricia Furer, PhD

John R. Walker, PhD
University of Manitoba, Canada

Over the years, there has been a considerable amount of psychological research focused on
death anxiety. However, little attention has been given to clinical aspects of this problem. This
paper focuses on a practical approach to assessment and treatment of death anxiety for the
clinician. We discuss situations where it is wise to evaluate death anxiety and provide questions
to address this topic in a sensitive manner. Death anxiety is clearly a central feature of health
anxiety and may also play a significant role in other anxiety disorders. While there is very little
specific research on treatment of fear of death, research on the anxiety disorders in general
and health anxiety in particular has facilitated the development of an approach we have found
useful in treating death anxiety. The main components of this treatment include exposure to
feared themes related to death, reduction of safety behaviors, cognitive reappraisal, increased
focus on life goals and life enjoyment, and relapse prevention.

Keywords: death anxiety; health anxiety; CBT; exposure

J ust as anxiety is a normal emotion, anxiety concerning death is also a normal experience.
Death anxiety has been a focus of interest for philosophers and psychologists for many years,
and there is extensive research on death anxiety in nonclinical populations. The research on
death anxiety in clinical populations, such as individuals with anxiety and somatoform disorders,
is also developing and provides important information about how death anxiety cuts across diag-
nostic categories and should be considered in assessment and treatment.

THEORETICAL PERSPECTIVES ON DEATH ANXIETY

Freud was one of the earliest theorists to discuss death anxiety. He suggested that death-related
fears reflected unresolved childhood conflicts rather than fear of death itself, as he was skeptical
about our ability to accept mortality. For example, in his paper Thoughts for the Times on War and
Death, Freud (1952) noted that “our unconscious does not believe in its own death; it behaves as
if immortal” (p. 765). Freud viewed the unconscious as the fundamental source of thought and
behavior, and thus he argued that while we pay lip service to the reality of death, “at bottom no
one believes in his own death” (p. 761).
Modern theories are more commonly based on Becker’s existential view of death (Becker,
1973). He suggested that death anxiety is a real and basic fear that underlies many forms of

© 2008 Springer Publishing Company 167

DOI: 10.1891/0889-8391.22.2.167
168 Furer and Walker

anxiety and phobia. Becker argued that humans manage this anxiety by living in accord with
cultural worldviews that “offer immortality either literally (i.e., belief in an afterlife) or symboli-
cally (i.e., identification with entities greater and longer lasting than an individual life, such as
achievement, families, or nations)” (Strachan et al., 2007, p. 1138). Becker’s view was that much
of people’s energy is focused on the denial of death as a strategy to keep death anxiety under
control.
Becker’s work led to the development of terror management theory (TMT), which proposes
that while humans strive for self-preservation, they are also aware of the inevitability of death
(Pyszczynski, Greenberg, & Solomon, 1999). According to TMT, when people are reminded of
their mortality, their need for structure and meaning increases, and this results in enhanced
focus on personally and culturally valued goals. This theory also suggests that those with greater
self-esteem will have greater tolerance for death-related situations and that those with lower self-
esteem will experience greater death anxiety. TMT has generated extensive research providing
substantial experimental support for its basic hypotheses (for reviews, see Bassett, 2007; Solo-
mon, Greenberg, & Pyszczynski, 2004).
Posttraumatic growth theory (PTG), another recent death anxiety theory, suggests that fac-
ing a life crisis, in particular death of self or a loved one, can result in positive changes, such as
a greater appreciation for life, a shift in priorities toward intrinsic goals, and improved interper-
sonal relationships (Tedeschi & Calhoun, 1996, 2004). Lykins, Sergerstrom, Averill, Evans, and
Kemeny (2007) compared TMT and PTG and suggested how these theories might be reconciled.
Briefly, PTG suggests that facing mortality can lead to positive intrinsic changes (described previ-
ously), whereas TMT posits that facing mortality increases striving toward extrinsic goals that
are personally and culturally valued. Lykins et al. outlined several methodological differences
between the research approaches developed by proponents of the two theories. TMT studies
generally involve experimental manipulations of death reminders on a single occasion, such as
briefly presenting death-related words. PTG research typically examines naturally occurring chal-
lenges, such as dealing with serious illness or natural disaster. Such threats are uncontrollable and
may be present for many days, months, or years. Lykins et al. suggested that these two methods
elicit different types of processing of the death-related material with the short-term exposure
in TMT experiments eliciting “more defensive processing such as distraction and optimistically
biased appraisals,” while the longer-term situations examined in PTG promote a focus for the
participants “on their own death . . . including an imagined real death, a life review, and the
opportunity to take the perspective of others” (p. 1089). Lykins et al. presented a series of three
studies designed to explore these issues and demonstrate that “when people encounter death
over a longer period of time or in a manner consistent with their goal structure, they move to
transcend their defensiveness, maintain or become more intrinsically oriented, and may end up
healthier in the long-term” (p. 1097). The procedures that we discuss in the treatment section of
this article are more consistent with the long-term exposure to death concerns described in the
PTG studies.

DEATH ANXIETY IN NONCLINICAL POPULATIONS

Kastenbaum (2000) provided an overview of death anxiety research with nonclinical populations
and outlined a number of consistent findings. These findings, which are likely also relevant to
clinical populations, include the following:
1. Fear of death is common in the general population, although most respondents in the
community do not report a high level of death anxiety. Agras, Sylvester, and Oliveau (1969)
reported that 16% of their community sample reported fear of death, and 3.3% reported
intense fear of death. Noyes et al. (2000) found that 3.8% of community respondents
 CBT for Death Anxiety 169

indicated they were much more nervous than most people about death or dying, and 9.8%
indicated they were somewhat more nervous than most people.
2. Females report higher levels of death anxiety than males.
3. In cross-sectional studies, older adults do not generally report higher levels of death
anxiety than younger people even though they are closer to death. Specific concerns about
death differ at different ages and in different life situations.
4. Higher levels of education and higher socioeconomic status are modestly related to lower
levels of death anxiety.
5. Higher levels of religious belief and participation in religious practice are not associated
with lower levels of death anxiety.

WHEN DEATH ANXIETY BECOMES A PROBLEM

Many people manage their concerns about death effectively. It is difficult to define precisely what
we mean by “effective coping with death,” and there is no single best way to manage feelings and
anxiety about death and dying. However, individuals who cope well with death-related issues
may share some common behaviors, attitudes, and experiences. This may include a willingness
to engage in behaviors related to themes of death (e.g., going to funerals, visiting sick friends,
or writing a will), regular involvement in verbal interchange about death and dying (e.g., having
conversations with spouse about death and implications of this for the family), and a focus on
living life to the fullest. For some individuals, however, death anxiety may become a distressing
problem involving avoidance of situations related to illness and death, significant and disabling
worry, and decreased enjoyment of life.

CASE EXAMPLE
Jane is a 43-year-old social worker in a general hospital. She has four children, ranging in age
from 6 to 14. Her primary concern is death anxiety. She does not worry about developing a spe-
cific disease but thinks constantly about when she will die and what the process of dying will be
like. She worries about dying a slow and painful death and feels devastated when she thinks about
telling her children that she is dying. Jane does not usually worry about dying soon but rather is
focused on the thought that she will die in the future. She is a religious person but struggles with
issues around the meaning of death. Her way of coping with the anxiety involves trying to avoid
reminders of the passage of time. For example, Jane never looks at her children’s photo albums
because seeing pictures of her children as babies and then getting progressively older as she flips
the pages of the album distresses her immensely. She also has a very difficult time with birthdays.
She celebrates her children’s birthdays because she does not want to disappoint them, but she
tries to avoid marking her own and her husband’s birthdays. Jane never attends funerals, does not
have a will, and cannot read the obituaries in the newspaper. She finds that her preoccupation
with death spoils her enjoyment of family events and distracts her from enjoying life.
The degree of disruption in life caused by Jane’s fear of death is not at all unusual when we
compare her to other clients with death anxiety seen in our clinic. Her situation differs from
many others in that she does not generally worry about illness and is not preoccupied by the
possibility of imminent death.

DEATH ANXIETY AND HEALTH ANXIETY

Not surprisingly, fear of death is common in individuals with health anxiety and hypochondri-
asis. Concern about death and dying is often the central reason why people fear serious disease.
170 Furer and Walker

Several researchers have described this association between fear of death and health anxiety.
Kellner, Abbott, Winslow, and Pathak (1987), for example, compared matched groups of psy-
chiatric outpatients with hypochondriasis, outpatients with nonpsychotic psychiatric disorders
(not including hypochondriasis), outpatients in a family medicine clinic, and workers at local
companies on subscales of the Illness Attitudes Scale (IAS; Kellner, 1986), a popular measure
of health anxiety. They found that patients with hypochondriasis were much higher than all
the other groups on many of the subscales, including Thanatophobia (death phobia). Similarly,
Noyes, Stuart, Longley, Langbehn, and Happel (2002) found a high correlation between scores
on a fear of death scale and measures of hypochondriasis, somatization, and health anxiety in
a sample from a general medicine clinic. Those patients who met the diagnostic criteria for
hypochondriasis outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th
ed.; DSM-IV; American Psychiatric Association, 1994) scored considerably higher on the fear
of death scale than patients who did not meet criteria for hypochondriasis. As in Jane’s situa-
tion, individuals may also have specific fear of death without hypochondriasis or specific fear
of illness.

DEATH ANXIETY AND OTHER ANXIETY PROBLEMS

Death anxiety is prominent in many clients with anxiety disorders, although it is more common
in some disorders than others. Individuals with panic disorder frequently fear they will faint, col-
lapse, die, or suffer some other medical catastrophe as a result of a panic attack. In a study in our
clinic (Furer, Walker, Chartier, & Stein, 1997), patients with panic disorder reported substantially
greater anxiety about death than did social anxiety disorder and healthy control samples. Almost
half of panic disorder patients (48%) also met DSM-IV criteria for hypochondriasis, as compared
to less than 5% with social anxiety disorder. Those individuals who met criteria for both panic
disorder and hypochondriasis reported particularly high death anxiety.
Concerns about death of oneself or family members may also be part of a broader pattern
of worrying in generalized anxiety disorder (GAD). Starcevic, Fallon, Uhlenhuth, and Pathak
(1994) found that 18% of their sample of patients with GAD met criteria for hypochondriasis,
while 50% of patients with panic disorder met the criteria for this problem. Individuals with
GAD reported worries about a broad range of issues, including family (61%), finances (57%),
jobs and work (41%), and health/illness (31%). A similar pattern of worry themes in GAD was
found in a nonclinical community study of women with and without GAD (Becker, Goodwin,
Holting, Hoyer, & Margraf, 2003). A significant proportion reported worries about their health
and the health of family members, although these were not the most common worry themes.
These studies did not assess death anxiety.
Individuals with posttraumatic stress disorder (PTSD) often have very high levels of con-
cern about their physical safety and about their health. In some cases, health- or treatment-
related events (such as surgery, a stay in the intensive care unit, or a heart attack) are triggers for
an episode of PTSD or related patterns of anxiety and depression (Tedstone & Tarrier, 2003).
Concerns about health- or future health–related events may be a prominent part of the overall
picture. Studies that have specifically evaluated the relationship between posttraumatic stress
and death anxiety have found evidence for a positive relationship (Chung, Chung, & Easthope,
2000; Martz, 2000).

DEATH ANXIETY AND MEDICAL ILLNESS

Noyes, Carney, and Langbehn (2004) note that specific phobia of illness may arise in the context
of a medical illness or a related threat to health and that these phobias may be more common in
 CBT for Death Anxiety 171

those people with medical problems. In our clinic, we have seen some individuals with serious
illness (cancer or chronic obstructive lung disease) who struggle with intense fear of death.
It is not surprising to find that levels of health anxiety may be higher for some people
dealing with threats to their health or serious illness, and this is supported by the research. For
example, a large epidemiological study of the general population in Germany that included an
assessment of health problems by a physician (Jacobi et al., 2004) indicated that poor health
status was strongly associated with anxiety, depressive, and somatoform disorders. Studies in
North America also indicate that the presence of a chronic medical condition is associated with
higher rates of anxiety, mood, and substance disorders (Katon & Ciechanoswki, 2002; Patten
et al., 2005). Consequently, the rates of these disorders are higher in health care settings than in
the general population.
It is important to note, however, that many individuals with life-threatening or terminal
illness do not experience intense fear of death. In some situations, this may reflect the person’s
efforts at avoiding or denying the reality of impending death, but in other situations, this may
reflect the person’s healthy focus on a life well lived and acceptance of the inevitability of death.
It is certainly understandable, however, that anxiety may increase for some people as they
negotiate the challenges of the health care system. Waiting for tests and test results, receiving
ambiguous test results, obtaining conflicting feedback from different health care providers, and
so forth all contribute to the uncertainty of the situation. Often the goals of treatment in these
cases are to assist the person to negotiate these challenges, to accept and tolerate the uncertainties
involved in serious illness, and to face the prospect of death more calmly and realistically.
While clinicians may feel more comfortable dealing with health anxiety and death anxiety
in healthy young people, they may be less familiar and less comfortable in dealing with patients
with serious health threats, illness, and risk of death. The treatment strategies discussed later in
this article may be adapted to these special situations and are generally well accepted by patients
and family members when they are introduced in the context of a supportive relationship and a
comprehensive approach to treatment. For a more detailed description of these adjustments, see
Furer, Walker, and Stein (2007).

RESEARCH ON TREATMENT OF DEATH ANXIETY

Even though there is a very extensive literature on death anxiety (Kastenbaum, 2000; Neimeyer,
1994), there are, to our knowledge, no controlled studies on the treatment of death anxiety in
a clinical context. Studies of cognitive-behavioral therapy (CBT) treatment of hypochondriasis
and other forms of health anxiety (Barsky & Ahern, 2004; Bouman &Visser, 1998; Clark et al.,
1998; Warwick, Clark, Cobb, & Salkovskis, 1996) generally do not report the impact of treatment
on measures of death anxiety. A few case studies describing treatment of hypochondriasis or
illness phobia have addressed this issue. Tearnan, Goetsch, and Adams (1985) describe the treat-
ment of disease phobia in a young man who reported the onset of intense fear of having a heart
attack and dying following the sudden death of his father-in-law due to a heart attack. The treat-
ment involved exposure to a range of disease-related situations, including imaginal exposure to
cues related to death from a heart attack. The client was much improved by the end of treatment
and maintained the improvement at follow-up. Papageorgiou and Wells (1998) describe the suc-
cessful use of attention training as a CBT intervention with three clients (all age 65 or over) with
the onset of hypochondriasis and prominent fear of death more than 10 years earlier after the
death of family members. The attention training procedure (ATT; Wells, 1990) is summarized by
Papageorgiou and Wells (1998) as follows:
ATT consists of regular practice of external auditory attention exercise (i.e., selective attention,
attention switching, and divided attention) aimed at diminishing self-focus and increasing the
172 Furer and Walker

meta-cognitive control of attention. ATT is not intended as a distraction from anxious thoughts
and symptoms, but it is intended to facilitate the “switching off ” of perseverative self-focused
processing. (p. 194)

All the participants had a very positive outcome with attention training as a single component
treatment, with no work on exposure, response prevention, or cognitive change beyond the refo-
cusing of attention.
In a preliminary analysis of a study conducted at our clinic (Hiebert, Furer, McPhail, &
Walker, 2005), 39 adults with DSM-IV hypochondriasis completed questionnaires regarding
illness and death concerns and then were randomized either to a group CBT condition or to a
4-month wait-list condition. The group CBT approach (14 weekly sessions) included in vivo and
imaginal exposure to illness-related situations, reduction of bodily checking and reassurance
seeking, and cognitive reappraisal. Death concerns were addressed via exposure to death-related
situations and worries, increasing acceptance of the reality of death, enhancing life satisfac-
tion, and cognitive reappraisal with regard to beliefs about death and dying. Death anxiety was
measured with the Thanatophobia subscale of the IAS (Kellner, 1986) and the Death Anxiety
Scale (DAS; Templer, 1970). Health anxiety was measured with the IAS and the Whiteley Index
(Pilowsky, 1967). Participants reported very high levels of death anxiety. Results from the IAS
Thanatophobia subscale and the DAS revealed that 93% of respondents were very much afraid
to die, 87% were afraid of dying a painful death, 84% often thought about how short life really
is, and 75% were afraid of news that reminded them of death. Only 3% said they were not at
all afraid to die, and 7% said they were not particularly afraid of getting cancer. Mean scores
on the death anxiety measures were compared to mean scores reported in the literature, reveal-
ing higher scores among individuals with hypochondriasis, than for other samples with panic
disorder, healthy control groups, and HIV-positive males (Furer et al., 1997; Hintze, Templer, &
Cappelletty, 1993; Templer, Ruff, & Franks, 1971). Positive correlations were found between the
IAS (without Thanatophobia subscale) and the measures of death anxiety (IAS Thanatophobia
subscale: r = .62; DAS: r = .51). The analysis found significant decreases in death anxiety and
hypochondriacal symptoms for the group CBT condition. There were no significant pre–post
differences for the wait-list condition.

COGNITIVE-BEHAVIORAL INTERVENTION
Our approach to intervention with health anxiety and death anxiety (Furer et al., 2007) focuses
on careful assessment, case formulation, and tailored intervention. In the majority of cases, where
health anxiety and death anxiety are both important concerns, treatment of both problems is
woven together. In this article, we emphasize the approach we use with death anxiety. Treatment
of death anxiety has not been emphasized in most CBT approaches to health anxiety. We believe
it is important to address death anxiety in treatment because events related to death are common
in everyday life.
The intervention phase begins with a review of the treatment rationale. Avoidance is one of
the most common ways of dealing with fear of death, so we place particular emphasis on expo-
sure (both in vivo and imaginal) to feared themes related to death. Other important components
of treatment include reducing checking, safety, and reassurance seeking behavior; cognitive reap-
praisal; increased focus on life goals and life enjoyment; developing a healthy lifestyle; and relapse
prevention. While we describe each component of CBT separately in the following sections, the
interventions are integrated in therapy sessions and homework. Homework assignments focus
on devoting some time to treatment goals every day. We particularly emphasize balancing work
on facing difficult situations (exposure to death themes) with work on increasing enjoyment and
satisfaction in life.
 CBT for Death Anxiety 173

Assessment
Clinical Interview. In situations where there may be significant anxiety about health or
death, it is important to ask specifically about fear of death during the assessment interview. We
ask every client a general question about whether they worry a lot about death and dying. If they
indicate that they do, we ask a number of additional questions to broaden our understanding of
the problem:
• Could you tell me more about your worries about death? How often do these worries
come to you? How do you react when you experience these worries?
• When did you notice that you started to have more concerns about death than most
people? Were there any extra stresses in your life at that point?
• What have your personal experiences with illness and death been like over the years?
Could you describe them?
• Are there situations you avoid because of concerns about death?
• How do you cope when you are dealing with anxiety about death?
• Do you check your body to see if you are healthy or to see if there is something wrong?
[If yes] How do you do that? How often?
• Do you talk to your family, friends, or professionals about your concerns about death?
[If yes] How often?
As in all clinical assessments, it is important to address suicidality, especially in situations
where the person reports substantial fear of death. Most people with death anxiety are not sui-
cidal and are frightened by the idea of ending their lives. Occasionally, however, the person’s
anxiety and distress is so great that the certainty of suicide becomes more appealing than the
uncertainty of a “natural” death due to disease. Sometimes, when individuals are asked what they
would do if they were told they had 6 months left to live, their initial response is “I would kill
myself.” This response typically reflects their intense distress at having to cope with impending
death and the belief that they would be unable to deal with this situation. For some, suicide may
seem preferable to a protracted period of anxiety, uncertainty about the process of dying, and
fear of substantial physical suffering. As of yet, there is no empirical evidence that we are aware
of to suggest that individuals with death anxiety are at high risk for suicide (and our clinical
experience suggests that this is probably not the case). Nonetheless, it is important to consider
the possibility of suicidal ideation and intent and to approach this topic with sensitivity and
compassion.
Self-Report Questionnaires. Although there are a range of measures available relating
to death anxiety and attitudes toward death (Neimeyer, 1994), none of these has widespread
clinical use. The Thanatophobia subscales of the IAS (Kellner, 1986; Kellner et al., 1987) and
the Health Anxiety Questionnaire (Lucock & Morley, 1996), which are used by clinicians with
a special interest in health anxiety, each provide three items that address fear of death. The
information from these items can assist the clinician in determining the level of death anxiety.
The most commonly used measure of death anxiety reported in the research literature is the
DAS (Templer, 1970). Templer indicates that this questionnaire, which consists of 15 true–false
statements, has satisfactory stability and internal consistency. Stevens, Cooper, and Thomas
(1980) provide normative data for adults of ages 16 to 83 on this measure. It has been translated
into many languages, and there is a version with a Likert rating scale that has higher internal
consistency and a wider range of scores on individual items and the total scale (McMordie,
1979). Templer and colleagues have recently published a longer version of this measure: the
DAS—Extended (Templer et al., 2006). This measure incorporates the 15 original items and 36
new items to provide increased breadth.
174 Furer and Walker

We typically supplement the death and health anxiety measures with several brief self-report
questionnaires targeting other issues: the Beck Depression and Anxiety Inventories (Beck, 1996;
Beck, Epstein, Brown, & Steer, 1988) and the Symptom Checklist-90—Revised (SCL-90-R;
Derogatis, 1975). Comorbid disorders are very common with death anxiety, so it is helpful to
assess and monitor symptoms of anxiety and depression. The SCL-90-R is useful as a broad
measure of distress that inquires about a range of health and mental health issues and includes a
useful Somatization subscale that assesses symptoms such as headaches, dizziness, stomach pain,
and back pain.

Case Formulation
The formulation pulls together the information from the assessment and the clinician’s under-
standing of predisposing, precipitating, and perpetuating factors involved in the development of
the problems identified by the client. Often the problems are related to one another, and these
relationships are explored. The formulation describes the client’s personal strengths and assets
in dealing with these problems. Assets may be factors such as strong intellectual or interpersonal
skills, clear values and goals, a supportive family, or a supportive work environment. The formu-
lation clarifies the client’s values and goals and guides the development of an intervention that
fits the individual. The clinician and client together decide on how treatment will be approached,
which areas will be addressed first, and which techniques will be used in treatment. The case
formulation process is a fluid one, and the initial assessment will be modified as necessary over
the course of treatment to accommodate new information, life events, health events, and chang-
ing symptoms.

Treatment Rationale
It is helpful to provide clients with a clear rationale for the difficult work of dealing directly with the
issue of death. The rationale and instructions for exposure treatment that we use are provided next.

Why Face the Fear of Death?

One of the challenges that all of us face as the years go on is coming to terms with the reality of
death. Avoiding the issue of death seems to work for most people most of the time. However, at
times the usual ways of coping are compromised by intense stress or because of difficult experiences
with death and illness. People may find themselves constantly preoccupied with fears of death, ill-
ness, accident, injury and harm. These fears create distress, limit pleasure and satisfaction in life,
disrupt relationships with other people, distract from working effectively, and consume unneces-
sary energy.
Fears of illness and death are different from many other fears. Many of the things that people
fear are unlikely to happen. People who are afraid of flying, for example, are extremely unlikely to be
injured or killed in a plane crash. People who are afraid of dogs are unlikely to be injured by a dog. In
contrast, all of us will have to deal with serious illness at some time in our life and all of us will die.
As the years go by we will also have to deal with illness and death in people who are close to us.
Some people are so preoccupied by their fears of death that this fear consumes much of their
attention and energy. They feel that they cannot enjoy anything unless they can be certain that
they will not be dying soon. Without realizing it, they use up the precious days of life worrying
about something that may not happen for many years. They convert possibly happy days into
unhappy days. Other people are able to accept the reality of death, come to some peace with the
idea, and trust that they will be able to cope with these situations when they come up. They can
focus on the task of living a satisfying and happy life.
The most powerful way to deal with fear of death is to face the fear rather than avoiding it. At
first glance, this may seem foolish to you. You might say that you are distressed because you are
 CBT for Death Anxiety 175

preoccupied with death at every moment. How much more can you face it? How will that help
you to feel better? There is, however, a difference between being preoccupied with death and facing
and accepting it. We have learned that the best way to overcome fear, including fear of death, is to
face the feared situation. Usually it is best to face the fear gradually, a step at a time. The idea of
facing one’s fears can be quite frightening, at first, but usually this can be accomplished in a way
that is not too difficult or painful. (Furer et al., 2007, pp. 151–152)

We also provide clients with brief reading material encouraging acceptance of the reality of
death. This material emphasizes that seeing the balance in life (i.e., enjoying positive experiences
and relationships and accepting that there will be sadness when they end) enhances the joy in life
and reduces fear of death. We also encourage clients to consider where they stand with respect to
religious and spiritual beliefs but emphasize that people with traditional religious beliefs, nontra-
ditional beliefs, and no beliefs are all able to come to terms with the issue of death.

REDUCING EXCESSIVE CHECKING, REASSURANCE SEEKING,

AND SAFETY BEHAVIORS
Bodily checking, reassurance seeking, and other safety behaviors are often prominent in health
and death anxiety. Examples of checking behaviors include monitoring pulse rate and blood
pressure, checking for weight loss or gain, monitoring pain levels or unusual bodily sensations,
checking the skin for changes in moles, and frequent breast self-examinations. Reassurance seek-
ing may include asking a family member, friend, health care provider, or religious adviser about
symptoms or death concerns and researching symptoms or diseases in medical textbooks or on
the Internet. Safety behaviors may include excessive or stereotyped use of health foods or vita-
min supplements, superstitious behavior related to concerns about death, and religious practices
beyond what is expected in the cultural group.
Once these behaviors are identified, clients are asked to monitor them using a diary. The
goals of monitoring include identifying the baseline frequency of the behaviors and impor-
tant antecedents or consequences of the behaviors. Clients record the situation, thoughts
related to the behavior, and the initial anxiety level (on a scale of 0–100). They provide a
detailed description of the behavior and record their subsequent anxiety level (to deter-
mine whether the behavior increases or decreases anxiety). Some clients report immediate
anxiety reduction, but generally this is short lived; the anxiety rebounds, and the individual
may then engage in the behavior again. Interestingly, many individuals describe either no
anxiety reduction or even an increase in anxiety related to checking and reassurance seek-
ing. However, they may believe that checking is a preventive strategy; that is, “If I don’t
check my moles today, then I will be even more worried about them tomorrow, so I better
check.” Understanding the pattern of anxiety in relation to checking and reassurance seeking
will help in planning the response prevention approach. If the client has many checking or
reassurance-seeking behaviors, we may focus on a few frequent or disruptive behaviors at
first to facilitate monitoring.
The client and therapist then select behaviors to be reduced. We discuss various approaches
to response prevention, including postponing the target behaviors, gradually decreasing their
frequency, or simply stopping the behavior altogether (Foa & Wilson, 2001). Response preven-
tion homework is determined collaboratively with an emphasis on choosing goals that the client
sees as challenging but achievable. We inform the client that there is often a temporary increase
in anxiety as this change in behavior takes place but that the long-term result is usually a reduc-
tion in preoccupation with the behavior and the related anxiety. We emphasize the importance
of keeping these behaviors at a realistic level, even when there are periods of increased stress and
anxiety, such as during exposure to death-related themes.
176 Furer and Walker

In our assessment with Jane in the previous case example, we found that she was weighing
herself on a daily basis to make sure that she was neither gaining nor losing weight. Her thought
was that if she was losing weight, she might have a serious health problem, while if she was
gaining weight, she might be worsening her overall fitness level. Jane found that she was able to
change from daily to weekly to monthly weigh-ins. She found that as she made this change, there
was less preoccupation with her weight.

EXPOSURE
Research on anxiety reduction indicates that exposure to feared situations is one of the most
important aspects of treatment for anxiety problems (Furer & Walker, 2005). Exposure may
be implemented through in vivo exposure to avoided situations, imaginal exposure focused on
thoughts and memories related to death, and interoceptive exposure in the case of bodily symp-
toms that are cues for death anxiety.
In planning exposure, pacing is very important. It is important to arrange the exposure
assignments so that clients move quickly enough to be able to see progress but not so quickly
that they feel overwhelmed. We often describe a variety of possible exposure goals and ask clients
which areas they feel ready to work on first. In planning assignments it is important to plan for
exposure to be repeated often enough and for adequate time periods so that there is a significant
reduction in anxiety.
In vivo exposure can be applied to any situations that may be avoided because of fear of
death, such as reading the obituaries in the newspaper, reading literary accounts of death and
loss, and watching television and movie programs with themes related to death. These situations
may not be intentionally avoided, but if the situations cause anxiety, exposure may be very help-
ful in reducing death anxiety. In our program we use exposure to challenging situations, such as
writing a will, planning funeral arrangements and leaving instructions for family members, visit-
ing the cemetery plot of a family member or friend, and writing one’s own obituary, as methods
of approaching the issue of death in a realistic but emotionally strong way. To facilitate exposure,
it is helpful to have resource material available, such as funeral planning material and the titles
of books and movies dealing with death issues. Elizabeth Kübler-Ross (1975) edited an excellent
series of accounts from individuals, family members, and friends addressing death issues. Sher-
win Nuland’s book How We Die (1994) provides detailed accounts both from a medical perspec-
tive and in the first person of how people die from common causes such as cancer, heart disease,
Alzheimer’s disease, accidents, and crime. Although the content is difficult, the presentation is
compassionate. If this material is used, it may be best to provide a chapter at a time so the client
is not overwhelmed with the intensity of the material.
Given how common the discomfort with issues regarding death is in our culture, it is not
surprising that family members are often uncomfortable with some of these assignments (e.g.,
making a will or considering funeral arrangements). It is useful to help clients prepare for dis-
cussions with these family members. Naturally, the therapist must use clinical judgment about
the best timing for these assignments. We tend to introduce them early in therapy, but if a client
is depressed and reporting suicidal thoughts, we focus on treating the depression first and would
not focus on death anxiety until there were a clear and persistent improvement in mood.
Imaginal exposure is especially useful in dealing with death anxiety because many of the
situations that are difficult do not come up frequently and many of the worries are about situa-
tions that have not occurred. We usually arrange for clients to write an exposure story about their
own death or their own fears concerning death. Some people express concern that if they write
a story about a feared future event, their fears will come true. One humorous way we deal with
this concern is to suggest to the client to first write a story about the therapist winning the lottery.
 CBT for Death Anxiety 177

(Sadly, we have yet to win anything this way.) Clients identify the point of this quickly, and this
often reduces their reluctance to write the story of their own death.
Over the weeks of treatment, Jane wrote a number of stories related to different aspects of
her fear of death, including stories about her fear of a painful death and her devastating images
of saying good-bye to her young children. She also wrote the following story about her fears
of “nothingness.” She spent time reviewing and elaborating on these stories each day until her
anxiety diminished.
I am thinking about dying, and it makes me nervous. I feel helpless, desperate, worried. I can’t
stop thinking about it. What is it about death that bothers me so much but doesn’t bother other
people? The feeling of no control, of a dead end, the thought of not existing, of not being anyone,
not being able to pinpoint where I am. It’s about nothingness. I won’t feel, speak, or hear. Life
is so short. I am worried that mine will pass me by. I’m scared of time, of getting old and closer
always to what I fear. I am afraid of not being able to escape these thoughts, of not enjoying
my life. I’m afraid of the world going on without me. I’m afraid of going from being central
to my whole world to being nothing, forgotten. What is the point of living life if it just ends in
nothing, emptiness.
This is a worry I can’t be rid of, a problem that can never be solved. How can I have such
difficulty in accepting what everyone else must go through too? Death doesn’t leave my mind.
I have my religious beliefs, but I don’t seem to have enough faith. If I had enough faith, I would
be confident about what happens after death. But I don’t believe in a life after death, that there is
someone else as me. I won’t really be me. Not knowing. Not accepting.
Everyone must experience death, but no one can share how I feel. You can’t sympathize
with something bad that happens to everyone. Death is the worst thing that exists. I just can’t
believe that I will die one day. I have been “me” all my life, and one day I will be nobody.
I will disappear forever, longer than I have lived, like before I was born, but that doesn’t seem
bad. I wasn’t me then either, but I never knew how it felt to live. After I die, I will have known.
But when you die, you don’t know. It’s not bad unless you suffer. The thought of nothingness is
scaring me.

Clients who fear the death of a close family member (parent, spouse, or child) often benefit
from writing a story about this situation. Many people find this exercise even more difficult
and emotional than writing about their own death, and they may require additional support in
working on this task. For some individuals, there may be issues regarding past losses that benefit
from therapeutic attention and an exposure approach (e.g., discussing and writing about the
memories and feelings associated with the loss).
Interoceptive exposure can be useful when particular bodily sensations (such as rapid heart
rate or dizzy feelings) are cues for worries about death. Activities such as stair climbing (for
increasing heart rate) or spinning (to create dizzy feelings) are used to produce the feared sensa-
tions repeatedly for exposure practice. A more detailed description of interoceptive exposure is
provided by Antony and McCabe (2004).
Jane also worked hard on exposure to various situations related to her fear of death. She
practiced going through photo albums and reading obituaries and made plans to celebrate her
husband’s upcoming birthday. Jane and her husband did not have a will despite having young
children, so they spent time discussing potential guardians and drew up a will. Jane also found it
helpful to work out plans for funeral arrangements, even though the discussion of this area with
her husband was emotionally challenging.

COGNITIVE REAPPRAISAL
Certain thoughts and beliefs about death are common. In exploring this area, it is helpful to
review clients’ personal experiences with death. Helping the client move toward more balanced
178 Furer and Walker

views of these issues may help them cope more calmly with the prospect of death. Therapists
may be able to provide corrective information based on their personal experiences with illness
and death. Some of the unrealistic beliefs about death that we commonly encounter include the
following: (a) “If I find out that I am going to die, I will not be able to cope with my feelings”;
(b) “Dying is likely to involve terrible pain and suffering”; and (c) “If I die before my children
are grown, it will ruin their lives forever.” More realistic beliefs for the client and the clinician to
work toward are the following (a) “Many people are understandably frightened when they find
out that death is approaching. They manage to cope with these emotions as time goes on, and
most people approach the end of life with dignity”; (b) “People have help to deal with the illness
and pain and are able to get through this with a good deal of support. Relief of pain is now a
high priority in treatment of the dying”; and (c) “Leaving my children behind will be difficult,
but there are other people who care about them who will help them. It is important to do the
best job possible of parenting now. Part of this job is making sure that the children have others
who care about them.” Exposure exercises involving education about death experiences and the
adjustments that family members make can help the client move from catastrophic thoughts
about death to a more realistic appraisal of death.
In our work with Jane, some of the thoughts that were related to death anxiety focused on
uncertainty about what happens after death and the sense that if she only had a stronger faith,
she would have more of a certainty about death. We encouraged her to meet with a religious
adviser in her faith community to discuss her concerns in this area. We also encouraged reading
that would clarify that these issues are difficult for many other people and that in the end it is
helpful to develop some tolerance and acceptance of uncertainty. She found it helpful to discuss
with others a range of views in this area. She found it helpful to hear that even people with no
religious faith are able to come to peace about the issue of death.

ENHANCING ENJOYMENT OF LIFE

As noted earlier, the client’s values and goals in life are reviewed in the process of assessment and
case formulation. As therapy continues, further work is necessary to clarify the client’s short-,
medium-, and long-term goals. When people are troubled by fear of death, their attention is
often diverted from a focus on enjoying life. In their struggle to cope with symptoms, they often
direct much less effort toward positive goals. Clients often mention how they miss the enjoyment
that came from activities that have been disrupted because of their anxiety. As much as possible,
the clinician allocates time during each session to a focus on enhancing enjoyment of life and
moving toward personal goals. We emphasize that it is important to experience satisfying and
enjoyable activities on a daily basis and to participate in these mindfully in spite of difficulty with
anxiety. Many of the activities that bring enjoyment in life are everyday activities that are not
costly or time consuming: spending relaxing time with a friend, family member, child, or pet; a
walk in the fresh air; a visit to the park; and interesting reading or television.
In our work with Jane, she found that she was often so busy working, caring for her children,
and taking care of the home that she had little time for enjoyment. We focused on planning more
enjoyable activities and relaxation time and finding ways to enlist more help from family mem-
bers so that all her time was not used caring for others. As she worked on this, she found that she
was able to free up more time for relaxation and enjoyment. It was also important for her to learn
to live in the moment rather than focusing on the possibility of future loss.

HEALTHY LIFESTYLE
During the assessment, the therapist and client often identify problem areas that contribute
to stress and anxiety or that reduce life satisfaction. Common problems include difficult or
 CBT for Death Anxiety 179

disappointing relationships, limited social support, a stressful work situation, and unhealthy
aspects of lifestyle. We use a problem-solving approach to develop approaches to the difficulties
that are identified in these areas (Nezu, Nezu, & Lombardo, 2001). We have also been struck by
the extent to which persons with high levels of health and death anxiety can neglect the impor-
tance of having a healthy lifestyle (healthy diet, adequate exercise, and good health habits).
When possible, we integrate the work on healthy lifestyle into the regular treatment sessions.
In Jane’s situation, she had enjoyed exercise and get-togethers with friends over the years but
tended to neglect these when she was having difficulty with anxiety. She planned more activi-
ties in these areas over the course of treatment and found that these increased her satisfaction
with life.

RELAPSE PREVENTION
Most people recovering from problems with death anxiety experience periods of increased symp-
toms even after significant progress. Many find these setbacks extremely upsetting, feeling that
their work and effort were for nothing, and they may lose confidence in their coping strategies.
We encourage clients to have realistic expectations about the role that anxiety plays in each of
our lives. Sickness and death are normal parts of life, and we will confront these challenges many
times as the years go on. It is normal to think about these issues and to be apprehensive when
facing illness or death.
Certain experiences are often related to setbacks: a new physical symptom or the return of
a previous symptom, a situation related to illness or death that has been avoided for a long time,
serious illness (the client or someone close), loss of or threat to a significant relationship (through
death, moves, or changes in the relationship), and increased life stress. A helpful approach is to
prepare for the inevitability of these life changes and to develop coping strategies. When clients
experience an increase in anxiety, we encourage them to continue applying the coping strategies
they have learned and to maintain a focus on their goals in life. At times, it may be helpful to go
back to an easier level in working on goals in order to rebuild confidence.
In Jane’s situation, during the follow-up period after treatment, she encountered two very
serious illnesses in young family members and one serious threat to her own health. She found
that she was able to handle these threats very effectively by maintaining the approach of facing
her fears and accepting the real threat that these situations presented.

CONCLUSION
There are few clinical studies of death anxiety, especially treatment evaluations. Clinical and
epidemiological studies indicate that it is a frequent concern. This problem may be approached
with CBT in a similar way to other types of anxiety. This approach is well accepted by clients and
works well in clinical applications. It will be important to evaluate the treatment of death anxiety
in controlled studies.

REFERENCES
Agras, S., Sylvester, D., & Oliveau, D. (1969). The epidemiology of common fears and phobia. Comprehensive
Psychiatry, 10, 151–156.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., text
revision). Washington, DC: Author.
Antony, M., & McCabe, R. (2004). Ten simple solutions to panic: How to overcome panic attacks, calm physical
symptoms, and reclaim your life. Oakland, CA: New Harbinger.
180 Furer and Walker

Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: A randomized con-
trolled trial. Journal of the American Medical Association, 291, 1464–1470.
Bassett, J. A. (2007). Psychological defenses against death anxiety: Integrating terror management theory
and Firestone’s separation theory. Death Studies, 31, 727–750.
Beck, A. T. (1996). Beck Depression Inventory—II. San Antonio, TX: The Psychological Corporation.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.
Becker, E. (1973). The denial of death. New York: Free Press.
Becker, E. A., Goodwin, R., Holting, C., Hoyer, J., & Margraf, J. (2003). Content of worry in the community:
What do people with generalized anxiety disorder or other disorders worry about? Journal of Nervous
and Mental Disease, 191, 688–691.
Bouman, T. K., & Visser, S. (1998). Cognitive and behavioural treatment of hypochondriasis. Psychotherapy
and Psychosomatics, 67, 214–221.
Chung, M. C., Chung, C., & Easthope, Y. (2000). Traumatic stress and death anxiety among community
residents exposed to an aircraft crash. Death Studies, 24, 689–704.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psycho-
logical treatments for hypochondriasis. British Journal of Psychiatry, 173, 218–225.
Derogatis, L. R. (1975). SCL-90-R: Administration, scoring and procedures manual II for the revised version and
other instruments of the psychopathology rating scale series. Towson, MD: Clinical Psychometric Research.
Foa, E. B., & Wilson, R. (2001). Stop obsessing: How to overcome your obsessions and compulsions. New York:
Bantam.
Freud, S. (1952). Thoughts for the times on war and death (E. C. Mayne, Trans.). In R. Hutchins (Ed.), The
major works of Sigmund Freud (Vol. 54, pp. 755–766). Chicago: Encyclopaedia Britannica. (Original
work published 1915.)
Furer, P., & Walker, J. R. (2005). Treatment of hypochondriasis with exposure. Journal of Contemporary
Psychotherapy, 35, 251–267.
Furer, P., Walker, J. R., Chartier, M. J., & Stein, M. B. (1997). Hypochondriacal concerns and somatization in
panic disorder. Depression and Anxiety, 6, 78–85.
Furer, P., Walker, J. R., & Stein, M. B. (2007). Treating health anxiety and fear of death: A practitioner’s guide.
New York: Springer Publishing.
Hiebert, C., Furer, P., McPhail, C., & Walker, J. R. (2005). Death anxiety: A central feature of hypochondriasis.
Depression and Anxiety, 22, 215–217.
Hintze, J., Templer, D. I., & Cappelletty, G. G. (1993). Death depression and anxiety in HIV-infected males.
Death Studies, 17, 333–341.
Jacobi, F., Wittchen, H-U., Holting, C., Hofler, M., Pfister, H., Muller, N., et al. (2004). Prevalence, co-
morbidity and correlates of mental disorders in the general population: Results from the German
Health Interview Examination Survey (GHS). Psychological Medicine, 34, 1–15.
Kastenbaum, R. (2000). The psychology of death (3rd ed.). New York: Springer Publishing.
Katon, W., & Ciechanowski, P. (2002). Impact of major depression on chronic medical illness. Journal of
Psychosomatic Research, 53, 859–863.
Kellner, R. (1986). Somatization and hypochondriasis. Westport, CT: Praeger/Greenwood.
Kellner, R., Abbott, P., Winslow, W. W., & Pathak, D. (1987). Fears, beliefs, and attitudes in DSM-III hypo-
chondriasis. Journal of Nervous and Mental Disease, 175, 20–25.
Kübler-Ross, E. (Ed.). (1975). Death: The final stage of growth. New York: Touchstone.
Lucock, M. P., & Morley, S. (1996). The Health Anxiety Questionnaire. British Journal of Health Psychology, 1,
137–150.
Lykins, E. L. B., Segerstrom, S. C., Averill, A. J., Evans, D. R., & Kemeny, M. E. (2007). Goal shifts following
reminders of mortality: Reconciling posttraumatic growth and terror management theory. Personality
and Social Psychology Bulletin, 33, 1088–1099.
 CBT for Death Anxiety 181

Martz, E. (2000). Death anxiety as a predictor of posttraumatic stress levels among individuals with spinal
cord injuries. Death Studies, 28, 1–17.
McMordie, W. R. (1979). Improving measurement of death anxiety. Psychological Reports, 33, 975–980.
Neimeyer, R. A. (Ed.). (1994). Death anxiety handbook: Research, instrumentation, and application. Wash-
ington, DC: Taylor & Francis.
Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2001). Cognitive-behavior therapy for medically unexplained
symptoms: A critical review of the treatment literature. Behaviour Therapy, 32, 537–583.
Noyes, R., Jr., Carney, C. P., & Langbehn, D. R. (2004). Specific phobia of illness: Search for a new subtype.
Journal of Anxiety Disorders, 18, 531–545.
Noyes, R., Jr., Hartz, A. J., Doebbeling, C. C., Malis, R. W., Happel, R. L., Werner, L. A., et al. (2000). Illness
fears in the general population. Psychosomatic Medicine, 62, 318–325.
Noyes, R., Jr., Stuart, S., Longley, S. L., Langbehn, D. R., & Happel, R. L. (2002). Hypochondriasis and fear
of death. Journal of Nervous and Mental Disease, 190, 503–509.
Nuland, S. (1994). How we die. New York: Knopf.
Papageorgiou, C., & Wells, A. (1998). Effects of attention training on hypochondriasis: A brief case series.
Psychological Medicine, 28, 193–200.
Patten, S. B., Beck, C. A., Kassam, A., Williams, J. V. A., Barbui, C., & Metz, L. M. (2005). Long-term medical
conditions and major depression: Strength of association for specific conditions in the general popula-
tion. Canadian Journal of Psychiatry, 50, 195–202.
Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Psychiatry, 113, 89–93.
Pyszczynski, T., Greenberg, J., & Solomon, S. (1999). A dual process model of defense against conscious and
unconscious death-related thoughts: An extension of terror management theory. Psychological Review,
106, 835–845.
Solomon, S., Greenberg, J., & Pyszczynski, T. (2004). The cultural animal: Twenty years of terror manage-
ment theory and research. In J. Greenberg, S. I. Koole, & T. Pyszczynski (Eds.), Handbook of experimen-
tal existential psychology (pp. 13–34). New York: Guilford Press.
Starcevic, V., Fallon, S., Uhlenhuth, E. H., & Pathak, D. (1994). Generalized anxiety disorder, worries about
illness, and hypochondriacal fears and beliefs. Psychotherapeutics and Psychosomatics, 61, 93–99.
Stevens, S. J., Cooper, P. E., & Thomas, L. E. (1980). Age norms for Templer’s Death Anxiety Scale. Psycho-
logical Reports, 46, 205–206.
Strachan, E., Schimel, J., Arndt, J., Williams, T., Solomon, S., Pyszczynski, T., et al. (2007). Terror misman-
agement: Evidence that mortality salience exacerbates phobic and compulsive behaviors. Personality
and Social Psychology Bulletin, 33, 1137–1151.
Tearnan, B. H., Goetsch, V., & Adams, H. E. (1985). Modification of disease phobia using a multifaceted
exposure program. Journal of Behavior Therapy and Experimental Psychiatry, 16, 57–61.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the positive
legacy of trauma. Journal of Traumatic Stress, 9, 455–471.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical
evidence. Psychological Inquiry, 15, 1–18.
Tedstone, J. E., & Tarrier, N. (2003). Posttraumatic stress disorder following medical illness and treatment.
Clinical Psychology Review, 23, 409–448.
Templer, D. I. (1970). The construction and validation of a Death Anxiety Scale. Journal of General Psychol-
ogy, 82, 165–177.
Templer, D. I., Awadalla, A., Al-Fayez, T. G., Frazee, J., Bassman, L., Connelly, H. J., et al. (2006). Construction
of a Death Anxiety Scale-Extended. Omega, 53, 209–226.
Templer, D. I., Ruff, C. F., & Franks, C. M. (1971). Death anxiety: Age, sex, and parental resemblance in
diverse populations. Developmental Psychology, 4, 108.
Warwick, H. M. C., Clark, D. M., Cobb, A. M., & Salkovskis, P. M. (1996). A controlled trial of cognitive-
behavioural treatment of hypochondriasis. British Journal of Psychiatry, 169, 189–195.
182 Furer and Walker

Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training
approach to treatment. Behavior Therapy, 21, 273–280.

Correspondence regarding this article should be directed to Patricia Furer, PhD, Anxiety Disorders Program,
M5-St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6, Canada. E-mail: furerp@
cc.umanitoba.ca
View publication stats