Patrick Boyd and Jamie L. Goldenberg
Department of Psychology, University of South Florida, Tampa, FL, USA
The terror management health model (TMHM) builds on terror management theory (TMT), a social psychology theory concerning how people manage the psychological awareness of their own mortality, to offer unique insights into how concerns about mortality affect decision making with respect to health. The model assumes that in the context of health decision making, thoughts of death are likely to be activated; before the TMHM was introduced, no theory in health psychology had been offered to account for the unique defensive responses associated with the awareness of mortality.
In the early 1970s, cultural anthropologist Ernest Becker (e.g., 1973) was arguing that cultures provide belief systems that enable individuals to derive meaning and a sense of personal value in the face of existential uncertainty, brought about by the awareness of death. Then, in the late 1980s, a team of social psychologists (Greenberg, Pyszczynski, & Solomon, 1986) extended Becker's theorizing and developed TMT, providing an empirical framework for Becker's ideas. The first of two primary hypotheses proposed by this research team was that if culture functions to help individuals cope with death, cultural investments (or derogation of cultural belief systems that threaten one's own) should increase when death is salient. The second hypothesis concerned self‐esteem striving: because self‐esteem is derived from the cultural system within which one is embedded, attempts to bolster self‐esteem by living up to cultural standards should also increase in response to the awareness of death.
After a decade of research supporting TMT, the theory underwent some conceptual fine‐tuning. The researchers observed that worldview defense and self‐esteem striving occurred reliably when individuals were reminded of their mortality and then distracted from it, or when death was subliminally primed. A dual‐defense model was proposed (Pyszczynski, Greenberg, & Solomon, 1999) to explain the time course of worldview defense and self‐esteem striving, and critically, specifying that symbolic defenses concerning meaning and self‐esteem are most strongly manifested when thoughts of death are activated outside of focal awareness. Specifically, the dual‐defense model explains that when death thoughts are in focal awareness, individuals focus their cognitive resources on suppressing death thoughts. After suppression, worldview defense and self‐esteem striving occur to ameliorate the residue of unconscious death thoughts.
Jamie Goldenberg and Jamie Arndt (2008) developed the TMHM to extend TMT to the health domain—a seemingly obvious but unexplored application of TMT. The TMHM begins with the assumption that health conditions have varying potential to make people think about death. The model then provides a formal framework for explaining, predicting, and ultimately intervening in behavioral health outcomes as a function of the accessibility of death thoughts.
Integrating the insights from the dual‐defense model of TMT, the TMHM specifies that when mortality concerns are conscious, health decisions will be guided by the proximal motivational goal of removing death‐related thoughts from focal attention by reducing perceived vulnerability to the health threat. This process can entail efforts to better one's health, but perceptions of vulnerability can also be reduced through less productive means, such as denial. In contrast, when mortality concerns are active but outside of focal attention, health relevant decisions are guided by the distal motivational goals of bolstering self‐esteem and maintaining one's symbolic conception of self. Again, the implications can be both good and bad for health (e.g., sun protection or sun tanning)—but here motivations are focused on the value and meaning of the self.
To examine responses to conscious death thoughts with experimental methods, participants are typically asked to contemplate their mortality, usually with open‐ended questions (e.g., “Jot down, as specifically as you can, what you think will happen to you as you physically die and once you are physically dead”), and immediately thereafter health responses are assessed. Perhaps not surprisingly, under such conditions people increase their intentions to exercise (Arndt, Schimel, & Goldenberg, 2003) and protect their skin from the sun (Routledge, Arndt, & Goldenberg, 2004) and also deny their vulnerability to health risk factors (Greenberg, Arndt, Simon, Pyszczynski, & Solomon, 2000).
Moreover, supporting the assumption that such responses reflect efforts to reduce perceived vulnerability to the health threat, variables relevant to coping with the health threats have been shown to moderate health outcomes when thoughts of death are conscious. This has been demonstrated by measuring perceived vulnerability (Arndt, Cook, Goldenberg, & Cox, 2007), response efficacy (Cooper, Goldenberg, & Arndt, 2010), active coping strategies (Arndt, Routledge, & Goldenberg, 2006), and health optimism (Arndt et al., 2006; Cooper et al., 2010). These studies converge to indicate that when individuals maintain optimism about their health, perceive a health response as effective, or approach health situations with active coping strategies, they respond to conscious reminders of death with health promotion. For example, Cooper et al. (2010) found that when death was in conscious awareness, participants high in health optimism responded with increased intentions to screen for cancer, whereas individuals low in this resource decreased their intentions. Moreover, these moderating effects were not found when death thoughts were allowed to recede from consciousness, nor were they observed in a health domain unrelated to death (i.e., cavity protection), further supporting the assumption that these defenses are aimed at managing death‐related thoughts.
When mortality concerns are active but outside of focal attention, the TMHM predicts that health decisions will be guided by the implications of the behavior for meaning and self‐esteem rather than by the relevance for health. This research has examined the moderating potential of worldview beliefs (e.g., the effects of religious fundamentalism on prayer as a medical substitute; Vess, Arndt, Cox, Routledge, & Goldenberg, 2009) and the potential for physical inspection of the body (e.g., breast self‐exams) to undermine symbolic value (e.g., Goldenberg, Arndt, Hart, & Routledge, 2008).
The lion's share of research, however, has focused on esteem contingencies. For example, in contrast to the immediate increase in sun protection intentions when death thoughts were conscious, Routledge et al. (2004) found that the women in their study (who had previously indicated being tan as relevant to their self‐esteem) increased their intentions to tan when a delay followed the mortality salience prime and thoughts of death were presumably no longer in consciousness. Likewise, Arndt et al. (2003) not only found increased intentions to exercise immediately following the mortality reminder, but after a delay, participants who derived self‐esteem from exercising also increased their intentions to exercise, whereas those low in fitness‐contingent self‐esteem did not. Similarly, Hansen, Winzeler, and Topolinski (2010) first identified individuals who derived self‐esteem from smoking and then showed that they had more positive responses toward questions assessing smoking attitudes after viewing anti‐smoking packaging that reminded them of their mortality. In another series of studies, women restricted their consumption of a healthy but fattening food when mortality concerns were activated, a behavioral decision presumably driven by esteem concerns rather than health (men's eating was unaffected; Goldenberg, Arndt, Hart, & Brown, 2005).
The TMHM framework informs what health outcomes can be expected as a function of the consciousness of death thoughts, and it also provides a framework for intervening in such outcomes. One interventional direction is to use conscious death‐related thoughts to bolster the influence of more conventional health cognitions. For example, Cooper, Goldenberg, and Arndt (2014) found that presenting beach patrons with a communication that highlighted risk of death from cancer and simultaneously framed sun protection as effective resulted in increased sun protection intentions compared with when sun protection was framed as ineffective. This relationship was not observed in the non‐death condition, or when a delay followed the cancer prime.
Given the finding that responses to nonconscious death thoughts depend on esteem contingencies and cultural beliefs, a complementary and more extensive wave of research targets the malleability of these bases so as to affect more productive health outcomes. In the domain of tanning, for example, Cox et al. (2009) found that participants given a mortality prime followed by a delay, who also read a fashion column touting “bronze is beautiful,” increased tanning intentions, whereas participants primed with “pale is pretty” decreased intentions to tan under the same conditions. These findings were replicated among beach patrons in South Florida who, in response to “pale is pretty” and nonconscious death thought activation, indicated that they would prefer sample lotions with higher SPFs.
Along similar lines, when thoughts of mortality are accessible but not conscious, smokers have been shown to be more persuaded by health communications highlighting the social disadvantages of being a smoker (Arndt et al., 2009), and women are more persuaded by feedback targeting appearance rather than health consequences of tanning (Morris, Cooper, Goldenberg, Arndt, & Gibbons, 2014). People are also more willing to get a flu shot when it is endorsed by a cultural icon (e.g., a celebrity) than when it is endorsed by a doctor, but only when death thoughts are outside of conscious awareness (McCabe, Vail, Arndt, & Goldenberg, 2014). This pattern is reversed when death thoughts are conscious, with participants showing greater willingness to get a flu shot when a doctor endorses it. In a naturalistic setting, supermarket shoppers were found to make healthier purchases when they were exposed to a questionnaire that nonconsciously primed mortality and then asked them to visualize a prototypical healthy eater (McCabe et al., 2015). These studies indicate that targeting social norms and bases of self‐esteem can be effective routes to influencing health decisions and, importantly, that these motivations are most influential when death thoughts are activated but not conscious.
Integrating insights about how people manage existential concerns into a model of health decision making, the TMHM connects previously unconsidered factors influencing health decision making. Research in health psychology has identified important health cognitions (e.g., perceived vulnerability) and concerns about esteem and social norms, but until the TMHM was developed, the impact of mortality awareness on health had not been investigated. The TMHM offers a framework for understanding how conscious and nonconscious death thoughts interact with these other variables and identifies when health risk and health promotion outcomes will occur.
In addition, the TMHM offers insights that explain why some health promotion efforts fail. Consider the tactic of fear appeals. Though people may very well heed a cancer warning and put down their cigarette or lather on sunscreen, the TMHM predicts that these effects may be short lived. Once death thoughts have been suppressed, self‐esteem concerns become paramount, and smoking or tanning efforts may increase to the extent that a person derives self‐esteem from looking cool as a smoker or appearing bronzed and beautiful.
Since the inception of the TMHM in 2008, a growing body of support has accumulated. In addition, there is evidence documenting the effectiveness of an interventional approach informed by the TMHM. Going forward it will be important to investigate the durability of TMHM effects, as well as to continue to apply interventions utilizing the TMHM in naturalistic settings.
Patrick Boyd received a BA in psychology from the University of Southern California in 2007 and an MA in social psychology from San Francisco State University in 2012. He began pursuing his PhD at the University of South Florida in 2013. His research generally focuses on terror management theory, and within this paradigm he has explored how self‐worth that is contingent upon being healthful can globally predict behaviors in a variety of health contexts.
Jamie L. Goldenberg is a professor of psychology at the University of South Florida. Her area of specialization is social psychology with a focus on health behavior and women's health in particular. She is the developer of the terror management health model (TMHM) along with coauthor Arndt. Research on the TMHM has been funded for 10 years by the National Cancer Institute (NCI) and has resulted in dozens of publications, including a manuscript in Psychological Review depicting the model.