Can death be good for your health?
University of South Florida. August 19, 2022.
In an obvious sense, death does not bode well for an individual's physical health. Despite the physical connection between death and health, research in health psychology had not considered the unique implications of how people manage psychological concerns about mortality. In 2008, my colleague, Jamie Arndt, and I developed the terror management health model (TMHM, Goldenberg & Arndt, 2008) to address this gap. It seemed reasonable to us that a theory about how people cope with and defend against concerns about death would have some insights into the decisions people make – both good and bad – with respect to their physical health.
In this article, I provide an overview of the TMHM, illustrating the distinction between health concerns rooted in the conscious awareness of death, compared to health implications of motivations toward meaning and personal significance that are rooted in the non-conscious awareness of death. Next, I lay out implications for the latter set of concerns that complicate people’s—especially women’s—relationship with their physical body. I suggest that this too can interfere with, but also potentially bolster, behaviors important for physical health. In a final section, I discuss some recent work applying the TMHM to health decisions made in the context of the deadly the COVID-19 pandemic.
The Terror Management Health Model
A diagram of the terror management health model (TMHM; Goldenberg & Arndt, 2008).
The basic idea behind the TMHM (see Figure 1) is that health threats and communications have the potential to activate both conscious and nonconscious thoughts of death, and conscious thought of death can move out of focal conscious awareness, to become nonconscious, after a delay or after defending against them. Based on a series of foundational studies, we know that when thoughts of death are conscious, people engage in efforts to remove death thought from consciousness (e.g., via suppression Arndt et al., 1997; or via denial, Greenberg et al., 2000). In the health domain, this translates into the proximal motivational goal of reducing perceived vulnerability. So, when death is conscious an individual may decide, for instance, that they’re going to reduce their salt consumption because the doctor told them that their blood pressure is high, or they may decide to stop smoking, or start going to the gym. The point is that, when consciously aware of the concept of death, one’s decisions tend to be informed by direct considerations of one’s health.
In contrast, when mortality concerns are active but outside of focal attention (non-consciously active), a different set of motivations arise. A considerable amount of research has examined how mortality salience operates from outside of conscious awareness to increase adherence to cultural norms (Greenberg et al., 1997), as well as strivings to live up to the standards upon which an individual’s self-esteem is based (Pyszczynski et al., 2004). In the behavioral health domain, the TMHM suggests that when death is non-consciously activated, “health” decisions are guided not by health considerations but by the distal motivational goals of bolstering self-esteem and maintaining one’s symbolic conception of self. Again, the implications may promote health or put it at risk, but it’s not health that is the pressing concern.
To illustrate this dual process model and how health outcomes can be informed by conscious and non-conscious death thought activation, some early research applied this framework to decisions about tanning (e.g., Routledge et al., 2004). The more intuitive prediction is that, when seeking to minimize conscious concerns with death, intentions to protect one’s skin from the sun may be increased because, as a vast majority of people are aware, tanning increases susceptibility to skin cancer. However, at a cultural level, tanned skin is often perceived as physically attractive and physical attractiveness is one way many people derive self-esteem. Therefore, the TMHM predicts that for people whose associate being tan with self-esteem, the distal response to non-conscious mortality concerns could, ironically, be to purposefully engage in more tanning behavior.
Clay Routledge, Jamie Arndt, and I (2004) tested this idea. We recruited women who said they derived self-esteem from being tan, and explicitly primed thoughts about either death or a control topic, and then measured the outcome variable either immediately (with no delay, so death thought was still at the center of conscious awareness) or after a delay and distracter task (thus death thought was freshly “activated” but no longer in conscious attention). For the outcome variable, participants were shown sunscreen products with high SPF and asked to rate how much they would like to buy and use them that day (1 = No, 9 = Yes). The data patterns were consistent with the TMHM. In the no delay (conscious awareness) condition, participants expressed greater interest in buying protective sunscreen when primed with mortality awareness compared to a control topic; however, when a delay/distraction was provided (making the primed topic non-consciously active), the participants primed with mortality salience expressed lower interest in sun protection—in line with the cultural goal of getting tanned skin.
A reproduction of data patterns from Cox et al., 2009, Study 1.
For both theoretical and practical reasons, we next tested whether we could manipulate the relevance to self-esteem and facilitate health promoting behavior in response to non-conscious death thought (Cox et al., 2009). In this study, a mortality salience manipulation (followed by a delay) was paired with a self-esteem contingency manipulation in the form of a fashion article highlighting either that “pale is pretty” or “bronze is beautiful” or a control condition that talked about a “natural” look without mentioning skin tone. Subsequently, the all-female sample rated their intentions to suntan in the future. The findings revealed that, relative to the control condition, mortality reminders had no effect in the natural look condition, but increased tanning intentions when participants read “bronze is beautiful,” and reduced tanning intentions when participants read that “pale is pretty.” We then replicated the pale is pretty effect behaviorally on Clearwater Beach, Florida. When “pale is pretty” was combined with a communication that subtly (non-consciously) primed death awareness, participants became more likely to select a “free gift” of high SPF sunblock.
In addition to tanning, empirical research has examined other behaviors that are relevant to both esteem and health, such as diet (e.g., Goldenberg et al., 2005), exercise (e.g., Arndt et al., 2003), and smoking (e.g., Arndt et al., 2009). Together this body of research highlights how, in the context of non-conscious death awareness, concerns about the symbolic value of the self take precedence over concerns about physical health.
The Body as an Existential Threat
Left: Da Vinci’s “Vitruvian Man”, the timeless symbol of mankind. Right: Erich Fromm’s The Sane Society, which argued in part the human’s symbolic and timeless body is worth but around 98¢.
Erich Fromm (1955) wondered, in The Sane Society: “Why did man not go insane in the face of the existential contradiction between a symbolic self, that seems to give man infinite worth in a timeless scheme of things, and a body that is worth about 98¢?” (p. 34). Likewise, I have spent much of my research career trying to better understand the complicated relationship that people have with their physical bodies. I have been particularly interested in the question of how people cope with their physical body—the part of themselves that is absolutely certain to die and decay into a seemingly worthless nothingness?
Ernest Becker surmised, “Man is a worm and food for worms … he is out of nature and hopelessly in it; he is dual, up in the stars and yet housed in a heart-pumping, breath-gasping body.” In other words, he quipped, people are “gods with anuses,” and it is this paradox that makes the body such a problem. One prominent theoretical perspective, in the science of existential psychology, builds on Becker’s idea and proposes that people cope with the threat of death by embedding themselves in a meaningful cultural worldview and living up to the culture’s standards. In this way, they elevate themselves above the crude natural world.
A large part of my research program has been aimed at testing that idea, that the body is a problem and that the threat is rooted in existential mortality concerns (Goldenberg et al., 2000). This perspective can shed light why people are so disgusted by natural bodily products and functions (Goldenberg et al., 2001), why there is so much ambivalence surrounding the physical aspects of sex (e.g., Goldenberg et al., 1999), and why people sometimes prefer to ignore or deny our physical health vulnerabilities (Goldenberg & Arndt, 2008).
While this framework offers a general view of a psychological predicament associated with the physical body, it can also help explain why such reactions may be particularly exaggerated when women’s bodies are considered (Goldenberg & Roberts, 2004). As evolutionary psychologists have long noted, there is an inequity between men and women in terms of the “creaturely” phenomena involved in reproduction. Women menstruate for their entire reproductive life, carry offspring in their womb, and lactate afterwards. In contrast, the obligatory phenomena for men is much less—and even for perhaps just 15 minutes or so! In my research, evidence suggests that when existential concerns about death are salient people avoid and even deride the creaturely reproductive aspects of women’s bodies: menstruation (Morris et al, 2014), pregnancy (Goldenberg et al., 2007), and breast feeding (Cox et al., 2007)—aspects we’ve called the “trio of terror.”
The existential discomfort with the body, especially the creaturely aspects of women’s bodies, can have important impacts on health-related behaviors. For example, consider the screening techniques involving examining one’s breast for breast cancer. Breast exams are potentially existentially threatening not only because they could result in the discovery of cancer, and are therefore associated with death, but also because of the physicality, or creatureliness, of the exams which can remind us that we are merely animals that will—like all other animals—return to the dust from which we arose.
Data patterns from Goldenberg et al., 2008, Study 1.
In our research, we’ve examined the effect of being more aware of the creaturely aspects of the body, using manipulations that either do or do not make participants aware of the physical nature of their bodies (Goldenberg et al., 2008). In a first study we randomly assigned our all-female participants to briefly think and write about either the concept of death or a control topic. Then, we randomly assigned them to read an article about either the similarity between humans and animals (a reminder of their creatureliness) or the cultural achievements of humans (a reminder of the way humans have a “symbolic self” elevated “out of nature” as Fromm and Becker put it). Then we had them rate their willingness to conduct breast cancer self-examinations. The data patterns showed that when they had read about human creatureliness, increased death awareness motivated women to report lower intentions to conduct breast exams. Additional analyses also found this effect occurred regardless of how worried the women were about breast cancer.
This same avoidance was replicated behaviorally in a second experiment. Women were asked to practice breast cancer self-examinations on a realistic breast model, which pilot tests showed increased death awareness. And, indeed, we found that when we primed an awareness of human creatureliness, women conducted shorter practice breast exams on the model.
Data patterns from Goldenberg et al., 2008, Study 2.
In a final study, we utilized the “misattribution of arousal” paradigm (e.g., Zanna & Cooper, 1974) to further examine whether discomfort was the mechanism behind the abovementioned results. A sample of female community members, all aged 35+ and thus all at a higher risk of cancer than average college students, were primed with creatureliness (versus a control or a reminder of ‘human uniqueness’). We then asked them to sample a water product, and told them it contained herbal additives that either had an energizing or calming effect, with side effects that could include mild anxiety or drowsiness, respectively. Then, the women performed breast cancer self-exams on their own breasts in a private exam room. Data showed the women primed with creatureliness spent significantly less time in the exam room when they could not externalize the source of their anxiety (i.e., after drinking the “calming” drink), whereas this effect was eliminated when they were led to misattribute their discomfort as a side effect of the “energizing” drink.
These and other similar studies (Goldenberg et al., 2009), highlight a heath-defeating outcome that arises in response to non-conscious death awareness. But my research also suggests a mechanism for health-promotion via the body as a symbol.
Objectification and Existential Threat
Combining Tomi-Ann Roberts’ work on objectification theory (Fredrickson & Roberts, 1997) with my research on the existential threat of the creatureliness of the human body (e.g., Goldenberg, 2005), Tomi-Ann and I proposed that the objectification of women’s bodies can function as a psychological defense (Goldenberg & Roberts, 2011). We argued that in the same way that concerns surrounding physical death are managed symbolically, though investment in a meaningful cultural worldview, the threat associated with women’s bodies is managed by “elevating” the physical female body into a cultural symbol. That is, we posit in order to compensate for the threat aroused by women’s bleeding, lactating, and pregnant bodies, and men’s attraction to these bodies (see Landau et al., 2006), women’s bodies are held to elevated standards of uniquely human beauty and perfection. This can explain why, for instance, an experiment showed that people report that it is more important for women to be beautiful when they have just observed a female college student drop a tampon, versus a hair clip, out of her backpack (Roberts et al., 2002).
Data patterns from Morris et al. (2014), Study 4.
In my more recent research, I have been taking this a step further, testing the idea that existentially-motivated objectification can emerge in a more literal manner – with women’s bodies perceived as actual inanimate objects (Heflick & Goldenberg, 2014). This may represent an existential “purification”, as inanimate objects are not born and do not die the way that humans and other animals do. In five studies, Morris et al. (2014) examined literal self-objectification among women who were primed with death (vs. control topic) and reminded of women’s role in reproduction (vs. control topic). For example, in one study the female experimenter asked female participants if she had a tampon to lend, and in another study, participants saw an image of a woman breast feeding or bottle feeding her baby. Our outcome measurements across these studies included three quantitative measurements of literal self-objectification: 1) an opportunity to accept or deny, on a 1-5 scale, the attribution of essentially human traits to oneself; 2) participants’ quantitative rating of the overlap of their self and inanimate objects; and 3) an implicit associations test (IAT) of participants’ mental association between their “self” and “objects”. In each study, priming mortality led women (but not men, included in Studies 1, 3, 4, & 5) to literally self-objectify, but only in conditions where women’s reproductive features were made salient. In short, when women were primed with an awareness of the more corporeal aspects of women’s bodies, they responded to a mortality salience manipulation by literally objectifying themselves.
What does this have to do with a health-facilitating behavior? As my colleague, Emily Courtney, and I have recently argued: objectification may be adaptive (Courtney & Goldenberg, in press). In line with Becker’s ideas, self-objectification can help reduce the discomfort that might otherwise arise from viewing the body as a temporary, corporeal, animal body. In modern times, for example, self-objectification might help reduce the discomfort associated with breast cancer screening behavior, especially when concerns about mortality are salient (Morris et al., 2014). The life-saving treatments for breast cancer often require a psychological view of the breasts as objects, which may therefore be considered separately from “the self.” That mentality can make it easier to consider the health risks associated with them, and even the possibility of radical treatments such as completely removing them from the body (e.g., surgical mastectomy). Despite the distastefulness of these objectifying slogans, by contemporary sensibilities, this existential psychological perspective suggests that they may be effective. Clearly empirical research is necessary, but there is theoretical, anecdotal, and preliminary empirical evidence to suggest that, in the context of breast cancer prevention and treatment, thinking of the breast in a more object like manner may help enable better outcomes.
The Pandemic: Terror Management Health Model for Pandemics
The COVID-19 pandemic has, unfortunately, provided a perfect storm of mortality salience in a context where behavioral health decisions are of paramount importance. In collaboration with Emily Courtney, and Pat Boyd, we examined the pandemic through the lens of the TMHM, offering insight into people’s behavior – both good and bad – with respect to the spread of the virus (Courtney, Goldenberg, & Boyd, 2020).
One way that people can cope with existential threat is through avoidance and denial. Another way to reduce perceived susceptibility to the conscious threat is by engaging in behaviors that reduce actual risk, such as the Covid lockdowns, masking, and vaccination programs.
We posited that being bombarded with the rising death toll, especially early in the pandemic, is likely to activate conscious death awareness. In response, one way that people can cope with the threat is through avoidance and denial. We saw some very public examples of world leaders downplaying the severity of the threat, for example, when U.K. Prime Minister Boris Johnson downplayed the risk by intentionally shaking hands with COVID patients and when Presidents Jair Bolsonaro and Donald Trump insisted on comparing the novel coronavirus to the seasonal flu. These denial reactions may be a first line of defense when a pandemic health threat is presented. But, while denial can reduce the perceived threat, the model also depicts an adaptive trajectory for reducing perceived threat in response to conscious death thought. That is, one can reduce perceived susceptibility to the conscious threat by engaging in behaviors that reduce actual risk. With respect to COVID-19, this includes engaging in CDC-recommended health behavior, including masks, hand washing, and social distancing.
Of course, what starts as conscious can become non-conscious, after defending, or as a result of desensitization, or because of changing information about fatality rates. As depicted by the TMHM, when thoughts of death are non-consciously activated, health behavior decisions become contingent on how meaning and value are derived. We observed many examples where specific cultural values conflict with the prescriptions for slowing the spread of the virus, with a particular focus on the salient features of individualist, and especially American, and perhaps especially Floridian, worldviews. In the early stages of the U.S. outbreak, beaches in Florida were inundated with Spring Breakers, and we saw protests against social distancing and mask mandates on the steps of capitol buildings throughout the U.S. At the same time, again, there are variables that may facilitate more adaptive responses with respect to the pandemic. Notably, the health behaviors identified as proximal defenses can also function as distal defenses. To a large extent, behaviors like mask wearing, socially distancing, and getting vaccinated have become less about health and more about a liberal ideology of valuing education and science, caring for others (even those outside of our families, different from us, and those we may never meet), and being willing to easily accept changes to the status quo.
In addition, when considering how meaning and value are derived in a pandemic, health behavior decisions have different implications than, say, tanning or conducting a breast exam. Health decisions in pandemic don’t just affect one’s own health but the health of others. The emphasis on ’flattening the curve’ only makes most sense at the level of the collective. The TMHM for pandemics suggests that a mindset rooted in collective responsibility would be an especially effective route to orienting distal defense toward health promotion in the context of the pandemic. This is the route we explored empirically.
Adjustments to some of the official CDC/White House communications, proposed by Courtney, Goldenberg, & Boyd, 2020.
Courtney, Felig, and Goldenberg (2021) conducted two experiments, both using a validated method of orienting people toward the individual or the collective. The task involved reading a short paragraph in which participants are asked to identify pronouns, where those being primed with individualism are instructed to find I, me, and my, while those being primed with collectivism are instructed to find we, us, and ours (see Gardner, Gabriel, & Lee, 1999). In the first study, we primed mortality explicitly related to COVID-19 (see Fairlamb & Courtney, 2021), followed by a measure of intentions to engage in CDC recommended health behaviors (e.g., hand washing, social distancing) in real time during the first peak of the pandemic in the U.S. We found that, when collectivism, but not individualism, was primed, individuals responded to mortality reminders with higher reported intentions to engage in health behaviors helpful for mitigating the spread of the virus.
The second study manipulated mortality awareness (vs. control topic) followed by an assessment of vaccine intentions. The study was conducted on November 12, 2020, right after Pfizer and BioNTech announced that they had been able to produce a candidate COVID-19 vaccination with 90% effectiveness—at this time, vaccination was on the horizon, but not yet available. In this study, the mortality salience manipulation decreased people’s intentions to receive the vaccination when individualism was primed, but not when collectivism was primed. This may reflect the general leariness that many people had (and some still have) about the personal risk of the vaccine compared to its importance for public health. However, in each study, existential concerns altered people’s intentions to engage in behaviors with important health implications amid the COVID-19 pandemic.
Conclusion
In sum, there is now a useful framework to better understand health decisions and behaviors by applying what we know about the specific defenses that people employ when faced with conscious and non-conscious awareness of death . The predictions make sense within the context of the science of existential psychology, and in the ways people defend against the psychological threat associated with their mortality. Today, perhaps especially, as the pandemic ebbs and flows, the rumbling of mortality are continuously activated below the surface of consciousness. And in many ways, that existential concern has become a guiding force. We have witnessed firsthand health decisions being less about health, and more about cultural values, ideology, and identity. Better understanding the impact of these existential concerns about life and death can help set the stage for predictions and interventions aimed at encouraging decisions, generally and during a pandemic, which are good, rather than hazardous, to personal and public health.
Dr. Jamie Goldenberg is Professor of Psychology at University of South Florida. She has conducted extensive research examining the causes and consequences of objectification of women. One approach to these questions is to apply terror management theory, a theory that takes an existential perspective on human motivation. Her research suggests that people are motivated to deny mortality and any connection to animality (or creatureliness) – objectification of women accomplishes this by turning women into literal (and immortal) objects. The focus on women’s appearance and consequent denial of personhood and internal attributes affects perceptions of women and can hinder their success, having implications for political progress for instance, and also affects women’s self-perceptions, undermining self-concept clarity and congruence between the self and bodily experiences (e.g., explaining why women sometimes dress as if they are imperious to the cold). Dr. Goldenberg has also applied the terror management perspective to health outcomes, developing the terror management health model; this line of research led to 10+ years of continuous funding from the National Institutes of Health. Recently, she and her graduate students have been interested in the consequences of social media on women’s health and well-being.