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https://doi.org/10.1177/0963721416689563

Current Directions in Psychological Science 2017, Vol. 26(2) 126 –131 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0963721416689563 www.psychologicalscience.org/CDPS

People routinely navigate choices with important conse- quences for their physical health. They go to the gym, smoke a cigarette with friends, work on their tan, order a salad instead of a double bacon cheeseburger, and get that recommended colonoscopy. Concerns about death would seem relevant to these and other everyday health decisions. Yet it was not until the terror management health model (TMHM) that this relevance was program- matically considered (Goldenberg & Arndt, 2008). The model was born, in fact, from observations of reciprocal neglect. Health psychology largely ignored motivational implications associated with awareness of mortality, whereas terror management theory, despite inspiring considerable research about social psychological conse- quences of this awareness, was relatively silent about decisions with implications for physical health. In the present article, we consider how the TMHM bridges this intersection of health and death. We articulate the theo- retical foundation for the model and then highlight insights it has generated for how health-relevant contexts implicate awareness of mortality, how this awareness affects everyday health decisions, and how it can be used to foster better health outcomes.

The Genesis of the Terror Management Health Model

Terror management theory (Greenberg, Pyszczynski, & Solomon, 1986) builds from a tradition of existential and psychodynamic theory (e.g., Becker, 1973) to posit that people need to psychologically manage the unsettling implications of knowing not just that death is inevitable but that it could happen at any time. They do this by identifying with cultural belief systems (i.e., worldviews), which enable people to view themselves as valuable members (reflecting self-esteem) of a cultural reality that persists beyond their own physical demise. The theory has inspired hundreds of studies around the globe and been applied to an array of human social behaviors (see, e.g., Pyszczynski, Solomon, & Greenberg, 2015).

After the initial wave of research on terror manage- ment theory, studies increasingly suggested that people

689563CDPXXX10.1177/0963721416689563Arndt, GoldenbergHealth and Death research-article2017

Corresponding Author: Jamie Arndt, McAlester Hall, Department of Psychological Sciences, University of Missouri, Columbia, MO 65201 E-mail: arndtj@missouri.edu

Where Health and Death Intersect: Insights From a Terror Management Health Model

Jamie Arndt1 and Jamie L. Goldenberg2 1Department of Psychological Sciences, University of Missouri, and 2Department of Psychology, University of South Florida

Abstract This article offers an integrative understanding of the intersection between health and death from the perspective of the terror management health model. After highlighting the potential for health-related situations to elicit concerns about mortality, we turn to the question, how do thoughts of death influence health-related decision making? Across varied health domains, the answer depends on whether these cognitions are in conscious awareness or not. When mortality concerns are conscious, people form healthy intentions and engage in healthy behavior if efficacy and coping resources are present. In contrast, when contending with accessible but nonconscious thoughts of death, health-relevant decisions are guided more by the implications of the behavior for the individual’s sense of cultural value. Finally, we present research suggesting how these processes can be leveraged to facilitate health promotion and reduce health risk

Keywords health, decision making, risky behavior, terror management, death, mortality salience

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Health and Death 127

defend against conscious and nonconscious awareness of mortality in different ways (Pyszczynski, Greenberg, & Solomon, 1999). When thoughts of mortality are con- scious, people try to remove them from focal attention. (After all, ending up as fertilizer is a thought on which people generally don’t like to dwell.) Such proximal defenses push death-related thought to the mental back- ground. It is when thoughts of death are active but out- side of conscious awareness that people more strongly engage in distal defenses that address the problem of death on an abstract and symbolic level. For example, people cling more vigorously to their cultural beliefs (i.e., worldview defense) and try harder to live up to cultural standards (i.e., self-esteem striving). Proximal and distal defenses are often inferred in experimental research by measuring outcomes immediately after a mortality reminder or after a delay, respectively. Conceptual and meta-analytic reviews (i.e., statistical approaches that average across different studies) have supported the unique time course of death-thought activation and the distinct effects elicited (e.g., Steinman & Updegraff, 2015).

The TMHM (Fig. 1) builds from these ideas. It begins with the assumption that health conditions have varying potential to make people think about death. The model then integrates insights about how people manage con- scious and nonconscious death-related cognitions with the recognition that health decisions can be influenced by concerns central (proximal) and more tangential (dis- tal) to the health context. The foundational idea is that when mortality concerns are conscious, health decisions

are largely guided by the proximal motivational goal of reducing perceived vulnerability to a health threat and thus concerns about mortality. In contrast, when mortal- ity cognition is active but outside of focal attention, health-relevant decisions are guided by distal motiva- tional goals concerning the symbolic value of the self.

TMHM Research

The link between health and death

Every time people undergo routine cancer screenings, there is the possibility that what they discover could mark the beginning of the end. It is perhaps not surprising that over 60% of people in a population-level survey reported that when they think of cancer, they automatically think of death (Moser et al., 2014). Even presentations of the word “cancer” that participants report not having seen (i.e., subliminal primes) increase the cognitive availability of death-related thought (Arndt, Cook, Goldenberg, & Cox, 2007). Performing breast self-exams (among women; Goldenberg, Arndt, Hart, & Routledge, 2008) or reading about risks of cancer from smoking (Hansen, Winzeler, & Topolinski, 2010) or unprotected sun exposure (Cooper, Goldenberg, & Arndt, 2014) also makes thoughts about death accessible. But cancer is just one of many health domains sharing this connection. Appeals about binge drinking ( Jessop & Wade, 2008) or risky sex (Grover, Miller, Solomon, Webster, & Saucier, 2010) and even insurance advertisements (Fransen, Fennis, Pruyn, & Das,

Health Scenarios/Threats

Conscious Death- Thought Activation

Motivation: Reduce Vulnerability/

Awareness of Death Health-Behavior-

Oriented Outcomes

Health-Defeating Outcomes

Health-Facilitating Outcomes

Threat-Avoidance Outcomes

Motivation: Bolster Meaning and Symbolic Self-Conception

Nonconscious Death- Thought Activation

Fig. 1. The terror management health model.

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2008) also activate thoughts of death. Such findings prompt the critical question, how do cognitions about mortality influence health-related decision making and behavior? Across domains such as tanning, smoking, can- cer screening, nutrition, and fitness, the answer often depends on whether thoughts of death are in conscious awareness or not.

The proximal and distal health implications of mortality salience

Routledge, Arndt, and Goldenberg’s (2004) studies on sun protection provide an illustration of divergent health- relevant responses to conscious and nonconscious death- related thought. Women reported greater interest in sun protection immediately after answering two short ques- tions about their mortality (vs. a control topic), presum- ably because it would reduce their vulnerability to a health risk. However, after a delay, they indicated stronger interest in tanning, in line with appearance-based esteem contingencies assessed as part of the experiment.

McCabe, Vail, Arndt, and Goldenberg’s (2014) studies on product endorsement provide another illustration. One study featured an ostensible taste test. Participants sampled a brand of bottled water purportedly endorsed by a medical doctor (to appeal to health) or a popular celebrity (to appeal to social status). Immediately after reminders of mortality, participants drank more of the water if it had been endorsed by a medical doctor, whereas after a delay, they drank more of the celebrity- endorsed water. Such effects highlight the distinction between health and esteem motivations that follow from conscious and nonconscious thoughts of death.

Because people are motivated to reduce vulnerability to health concerns when consciously thinking about death, explicit thoughts of mortality render health- promoting (proximal) responses such as exercising more, using sun protection, and undergoing a screening exam more likely when people have sufficient coping resources, optimism, or beliefs in the efficacy of the behavior (and themselves) to effectively mitigate the health concern. When lacking these resources, people may respond to conscious thoughts of death by avoiding or denying the health threat (e.g., Cooper, Goldenberg, & Arndt, 2010). Thus, the effect of conscious concerns about mortality on health decisions depends on factors of immediate rele- vance to the health context, much as has been found in research based on rationally oriented models of health behavior (e.g., Prentice-Dunn & Rogers, 1986).

In contrast, the relevance of the behavior for esteem and cultural identification often directs health decisions once thoughts of death are no longer conscious. For example, when distracted from mortality reminders, indi- viduals who derive self-esteem from fitness increase

exercise intentions (Arndt, Schimel, & Goldenberg, 2003), whereas those who derive self-esteem from smoking report less interest in quitting (Hansen et al., 2010). These findings mesh well with evidence that self-esteem and self-presentational motives influence health-related deci- sion making (e.g., Leary, Tchividijian, & Kraxberger, 1994; Mahler, Kulik, Gibbons, Gerrard, & Harrell, 2003) but extend it by demonstrating the role of mortality concerns in these processes. The TMHM further suggests that worldview beliefs function similarly. Consider, for instance, people subscribing to a fundamentalist religious worldview. Terror management processes may play a role in their willingness to rely on faith alone for medical treatment (Vess, Arndt, Cox, Routledge, & Goldenberg, 2009). Taken together, this work helps to delineate when health decisions will be influenced by factors tangential to the health context and why people sometimes do the seemingly irrational things they do when it comes to tak- ing care of their health.

Leveraging the Terror Management Health Model to Improve Health Decisions

The implications of the TMHM framework invite consid- eration of a number of different ways to improve health- related decision making. Indeed, research has begun to examine how death-related cognition can be used as a motivational catalyst to facilitate health promotion and reduce health risk.

Augmenting conventional approaches to health-related cognition

One research direction involves using conscious death- related thought to bolster the influence of conventional approaches to health-related cognition. For example, Cooper et al. (2014) presented beachgoers with health communications that did or did not highlight the risk of death from skin cancer and did or did not elaborate on the efficacy of sun protection to mitigate these risks. When appeals emphasized sun-protection efficacy and raised the conscious risk of mortality, sun-protection intentions were greater. Such findings offer promise for using explicit mortality concerns to augment educational health campaigns that incorporate fear-related messages.

Notably, there are differing views about the potential of the TMHM to inform research on the use of persuasive fear messages (see Hunt & Shehryar, 2011; Tannenbaum et al., 2015). When considering this potential, it is impor- tant to recognize that appeals need not explicitly men- tion death to conjure up death-related cognition; implicating serious health consequences can do so as

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well. Further, whether people are actively thinking about death is an important issue for evaluating whether the appeal encourages health- or esteem-based responses and necessitates careful attention. Fine-grained measure- ment of this issue may be necessary, although it is likely challenging in the context of much health-communica- tion research. But carefully considering the source of fear and the potential for health communications to activate conscious or nonconscious death-related thought may help to illuminate when and why such appeals are effec- tive, when they fall flat, and when they backfire (Ruiter, Kessels, Peters, & Kok, 2014).

Targeting malleable bases of cultural value

The TMHM suggests that when mortality concerns are active but not conscious, efforts to change health behav- ior may benefit from targeting malleable bases of cultural value. For example, when smokers viewed a public ser- vice announcement concerning the social consequences of smoking (e.g., “Who wants to date someone with bad breath?”), participants reminded of mortality reported increased intentions to quit (Arndt et al., 2009; see also Wong, Nisbett, & Harvell, 2017). Conveying positive social norms can also be useful in this regard. Grocery store patrons were reminded of mortality or a control topic; then, based on research from the prototype-will- ingness model (Gibbons & Gerrard, 1995), they visual- ized exemplars of healthy eaters or did not. As determined from their shopping receipts, those who were primed with mortality and visualized healthy eaters purchased healthier foods (McCabe et al., 2015).

The utility of targeting how individuals derive a sense of value in conjunction with mortality reminders also shows promise in the context of safe sun behavior. The guiding idea is that if people can be steered away from thinking of tanned skin as attractive, subtle primes of mortality might lead to more interest in sun protection. Using such an approach, Cox et al. (2009) observed requests for sunscreen samples with higher SPF among (Caucasian) beachgoers. Furthermore, framing a UV pho- tograph of participants’ faces as revealing damaging effects on appearance, rather than health, interacted with mortality reminders to lead participants to take more samples of sunscreen and report greater intentions to use it (Morris, Cooper, Goldenberg, Arndt, & Gibbons, 2014). Thus, there seems to be potential for nonconscious thoughts of mortality to engage healthier behavioral practices if aspects of social value are targeted.

Recognizing the body problem

The TMHM also fosters recognition of underappreciated barriers to promoting health behavior. Goldenberg,

McCoy, Pyszczynski, Greenberg, and Solomon (2000) suggested that the physicality of the body undermines people’s capacity to maintain the symbolic, cultural value of the self as a means to manage concerns associated with mortality. This helps illuminate when and why peo- ple may avoid health behaviors that involve intimate con- frontation with the body’s physicality or creatureliness (e.g., breast self-exams and mammograms; Goldenberg et al., 2008). That these behaviors are threatening not only because of their health implications (i.e., what one might find) but also because of a non-health-related threat suggests that, like other distal defenses, highlight- ing the symbolic aspects of the self may benefit efforts to foster health behavior. Opportunities to affirm symbolic representations of the body may be effective when health contexts elicit both mortality concerns and discomfort with the body’s physicality (Morris, Cooper, Goldenberg, Arndt, & Routledge, 2013).

The potential for behavioral durability

An important question is whether the effects observed in TMHM research are just a brief blip on the behavioral- change radar. Concerns about inevitable mortality are an ever-present condition with which people must contend, and moreover, people are reminded of mortality—some- times blatantly and sometimes subtly—on a routine basis. Two recent studies provided initial insight as to how an enduring influence of awareness of death may affect health behavior as it unfolds over time.

In Morris, Goldenberg, Arndt, and McCabe (2016), when participants were primed with mortality and rode an exercise bike, they later reported exercising more in the 2 weeks that followed than did participants who were not reminded of mortality, and this led them to report basing their self-esteem more on fitness. In a second study, smokers who visualized a prototypical unhealthy smoker after being reminded of mortality reported more attempts to quit smoking in the following 3 weeks and became more committed to an identity as a nonsmoker, and this in turn inspired continued attempts over the next 3 weeks. These studies lay the groundwork for a longitu- dinal model in which death-related thought encourages identity-relevant behavior, the behavior fosters more identity relevance, and this in turn promotes more of the (healthy) behavior.

Becoming comfortably numb

Research has also begun to examine other processes through which death-related cognition might influence health-relevant choices. For example, perhaps because of the potential for anxiety involved, death reminders can motivate people to become “comfortably numb” (to

130 Arndt, Goldenberg

borrow from a colleague who borrowed from Pink Floyd) and increase desire for intoxicants like marijuana (Nagar & Rabinovitz, 2015) and purchasing and consumption of alcohol (Ein-Dor et al., 2014). Such risky behavior may be most likely for those who lack secure terror management buffers. Indeed, nightclub patrons with low self-esteem drank more alcohol (as indicated by breathalyzer analy- sis) when primed with mortality reminders (Wisman, Heflick, & Goldenberg, 2015).

Conclusion

The TMHM integrates research on existential motivation, self-threats and psychological defense, risky behavior, fear appeals, and vulnerability, esteem, and normative factors influencing health-related decision making. Like other applied theoretical research, research guided by the TMHM enriches our understanding of the target domain as well as the basic theory. Although additional research is needed in the areas outlined above, the model offers a foundation for understanding how people man- age existential insecurity as well as harnessing the effects of death-related thought to engage productive health- behavior change.