PGY-1 Pharmacy Resident
Adventist Shady Grove Medical Center
Terror Management Theory, or TMT, is a theory first developed by Greenberg, Solomon, and Pyszczynski in 1984 to explain the need for self-esteem and the creation of belief systems that are exclusive and protective. The motivation behind this theory is the primal urge to survive and the associated fear of death. According to this theory, individuals are inclined to follow cultures with defined values that make their lives significant.1 For instance, in many religions, values are related to following the teachings of the deity or deities and doing so can not only give followers a sense of self-worth and approval from others but also potentially lead to a proposed better “outcome” such as reincarnation or paradise after death.
Because these belief systems are so deeply ingrained into an individual’s sense of self-worth, contradicting ideas are viewed as a personal attack. Other cultures may have differing ideas on what values are significant in a person and therefore an esteemed individual from one culture may be considered worthless in another. This leads to an immediate aversive and aggressive reaction when these values are called into question and can explain why stereotypes and prejudice towards other cultures has been perpetuated and even sometimes lauded. When trying to address these topics, maintaining a non-accusatory and neutral attitude during the conversation and allowing for the other person to discuss their feelings openly will help them to feel less threatened.
There are four types of initial reactions to ideas contradicting a person’s worldview – assimilation, derogation, annihilation, and accommodation. In assimilation, the person will attempt to convert the person with a conflicting worldview to their own. In derogation, the opposing worldview will be belittled and dismissed. Annihilation involves aggression and violence to eliminate those with opposing worldviews, and accommodation attempts to reconcile aspects of the opposing worldview with their own.2 As with the stages of grief or the stages of change, it is important to assess what type of response the person has and address it accordingly, and it can be a repetitive process to work towards tolerance and acceptance.
The basic purpose of healthcare is to prevent mortality, and therefore it can come into conflict with worldviews that offer death transcendence when mortality salience occurs. For example, with the current COVID-19 pandemic, a TMT healthcare model explains that individuals apply both proximal and distal defenses to avoid the thought of mortality. In proximal defenses, this involves actively avoiding thoughts related to the pandemic by avoiding exposure to information and minimizing the perception of the threat. Distal defenses involve strengthening the belief in one’s worldview to boost one’s sense of self worth and the perception that death can be avoided.3 In a maladaptive response, this can lead to engaging in high-risk behaviors and/or developing a distrust in healthcare that can lead to not seeking proper treatment.
These coping mechanisms lead to a lack of accurate information and a false sense of immortality that require intervention with proper education. It is important to recognize these diversions so that the method of education can also be tailored for what is needed. For example, Jessop et al. found that individuals who associated driving faster with a higher self-esteem were more likely to engage in riskier driving behaviors and less likely to heed warnings related to mortality compared with those who do not.4 Hansen et al. found that warnings related to mortality led to more positive attitudes towards smoking in those who associate smoking with high self-esteem. These individuals responded more to warnings devaluing the act itself, such as stating that smoking decreases attractiveness or brings “severe damage” to those around them. However, the effects of these types of warnings were delayed, as initially individuals had a negative response to the warning, as their self-esteem was being called into question.5 This suggests that when attempting to rectify high-risk behaviors in these patients, it may be beneficial to use intrapersonal and interpersonal justification more than the prevention of mortality. In addition, these individuals may need additional reinforcement for subconscious behavioral change to happen after the initial conscious aversive reaction. These situations also parallel the vaccine hesitancy situation. Healthcare providers often educate patients on the positive effects of obtaining the COVID-19 vaccine, such as drastically decreasing the probability of severe illness requiring hospital stay. However, this appeal to mortality often falls on deaf ears, seeing as how our country’s percentage of fully vaccinated individuals is a meager 56%. 6 According to TMT, for patients that are identified to have strong beliefs against the vaccine and/or aversive reactions to recommendations, healthcare providers should instead focus more on social benefits of getting the vaccine such as protecting their family members or that refusing the vaccine is not a sign of strength or looking “cool”.
TMT explains why it is extremely important to perform an audience analysis prior to providing education, particularly in a healthcare setting. A patient’s worldview will affect how they react to and process information regarding mortality and self-esteem. Maintaining a non-aggressive stance, addressing the individual’s perception of their values, and managing the aversive initial reaction that will occur are all part of the continued reinforcement that will allow a person to correct high-risk behaviors and maladaptive coping mechanisms that are associated with increased mortality.
References:
1. Terror Management Theory in Social Psychology - iResearchNet [Internet]. Psychology. 2016. Available from: http://psychology.iresearchnet.com/social-psychology/social-psychology-theories/terror-management-theory/
2. Kessel CV, Heyer KD, Schimel J. Terror management theory and the educational situation. Journal of Curriculum Studies. 2019 Sep 4;52(3):428–42.
3. Pyszczynski T, Lockett M, Greenberg J, Solomon S. Terror Management Theory and the COVID-19 Pandemic. J Humanist Psychol. 2021 Mar;61(2):173–89.
4. Jessop DC, Albery IP, Rutter J, Garrod H. Understanding the Impact of Mortality-Related Health-Risk Information: A Terror Management Theory Perspective. Personality and Social Psychology Bulletin. 2008 May 9;34(7):951–64.
5. Hansen J, Winzeler S, Topolinski S. When the death makes you smoke: A terror management perspective on the effectiveness of cigarette on-pack warnings. Journal of Experimental Social Psychology. 2010 Jan;46(1):226–8.
6. US Coronavirus vaccine tracker. USAFacts. 2021 Oct 5.
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