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Terror Management Theory Applied Clinically:

Implications for Existential-Integrative Psychotherapy
a
Adam M. Lewis
a
Department of Psychological and Quantitative Foundations , The University of Iowa , Iowa
City , Iowa , USA
Accepted author version posted online: 09 Aug 2013.Published online: 17 Sep 2013.

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Integrative Psychotherapy, Death Studies, 38:6, 412-417, DOI: 10.1080/07481187.2012.753557

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ISSN: 0748-1187 print=1091-7683 online
DOI: 10.1080/07481187.2012.753557

Terror Management Theory Applied Clinically: Implications

for Existential-Integrative Psychotherapy
Adam M. Lewis
Department of Psychological and Quantitative Foundations,
The University of Iowa, Iowa City, Iowa, USA
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Existential psychotherapy and Terror Management Theory (TMT) offer explanations

for the potential psychological effects of death awareness, although their respective lit-
eratures bases differ in clarity, research, and implications for treating psychopathology.
Existential therapy is often opaque to many therapists, in part due to the lack of con-
sensus on what constitutes its practice, limited published practical examples, and few
empirical studies examining its efcacy. By contrast, TMT has an extensive empirical
literature base, both within social psychology and spanning multiple disciplines,
although previously unexplored within clinical and counseling psychology. This article
explores the implications of a proposed TMT integrated existential therapy (TIE),
bridging the gap between disciplines in order to meet the needs of the aging population
and current challenges facing existential therapists.

Awareness of the inevitability of death is inherent to
human experience. The idea of death has profound impact
on the way people think, feel, and relate to themselves and
others (Greenberg, Solomon, & Arndt, 2008; Solomon,
Greenberg, & Pyszczynski, 1991). People are frequently
inundated with literal and symbolic reminders of their
mortality, whether through hearing about the death of
someone close, receiving the diagnosis of a chronic illness,
exposure to images of violence and death in the media, or
through experiencing death-symbolic losses, such as the
ending of a relationship or job (Abdollahi, Pyszczynski,
Maxeld, & Luszczynska, 2011; Yalom, 1980).
Philosophers have described death awareness as
bittersweet, because not only is it associated with anxiety,
fear, and experiential avoidance, but also with inspira-
tion, innovation, and the drive to contribute to something
greater than ones self (Greenberg, Koole, & Pyszczynski,
2004). Eminent existential therapist Irvin Yalom wrote,
The idea of death saves us . . . [it] plunges us into more
authentic life modes, and it enhances our pleasure in
Received 18 June 2012; accepted 24 October 2012.
Address correspondence to Adam M. Lewis, Department of
Psychological and Quantitative Foundations, 361 Lindquist Center,
The University of Iowa, Iowa City, IA 52245. E-mail: adam-m-lewis@
uiowa.edu
the living of life (1980, p. 33). Researchers have also
observed positive effects associated with death encoun-
ters; including positive meaning attributed to a traumatic
experience, increased sense of social connectedness, and
enhanced recall on memory tasks (Barboro-Val &
Linley, 2006; Boyarz, Horne, & Saygert, 2012; Davis,
Nolen-Hoeksama, & Larson, 1998; Hart & Burns,
2012). Nevertheless, existential psychotherapists and
researchers of terror management theory (TMT) have
devoted signicant attention to the potential role of death
anxiety as it pertains to negative phenomena, such as a
clients presenting concern, and intergroup hostility.
Existential psychotherapy consists of a diverse set of
treatment practices theoretically derived from existential-
ism, psychoanalytic theory, and humanistic psychology.
Although many nonexistential therapists and students
are intrigued by the approach, many are unclear about
what existential therapy looks like in practice
(Schneider, 2008). Some of this may be due to its theore-
tically dense literature base, which often lacks research
and practical clinical examples. By contrast, TMT is sup-
ported by hundreds of empirical studies across multiple
disciplines, many of which clearly illustrate the theorys
underlying principles. Although TMT dovetails well with
existential theory, and several TMT studies have utilized
clinical populations, its potential clinical utility has never
 TERROR MANAGEMENT AND EXISTENTIAL THERAPY
been explored. This article explores the implications of a
proposed TMT integrated existential therapy (TIE) to
treat clients and elucidate existential clinical practices.
TMT
TMT (Greenberg, Solomon, & Pyszczynski, 1986;
Greenberg, Solomon, & Pyszczynski, 1997) posits that
anxiety and fear are associated with mortality salience
(MS) or the state of awareness of ones eventual death.
Because anxiety associated with MS has the potential to
be overwhelming, people manage it unconsciously through
a buffer system consisting of cultural worldview, self-
esteem, and close interpersonal relationships (Greenberg
et al., 2008). Through cultural worldview one achieves
a sense of purpose, order, and meaning through culturally
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prescribed values and standards for living, as well as expla-
nations for existence and an afterlife. When people believe
they are living up to cultural standards, they have high
self-esteem, which temporarily relieves death anxiety.
It should be noted that in this instance, self-esteem is
akin to a barometer for how well people believe they live
congruously with cultural values rather than the clinical
notion of self-worth as having a generally negative
opinion of oneself (Center for Clinical Interventions, 2008).
Research on mostly healthy men and women supports
the following TMT hypotheses: (a) MS increases peoples
positive response to others who support their worldview,
and negative responses to those who threaten it; (b) MS
elicits increased striving for self-esteem, and people with
higher self-esteems are less vulnerable to anxiety follow-
ing MS; and (c) threats to self-esteem or worldview result
in increased accessibility of death-related thoughts, which
is eliminated by priming people with a cultural expla-
nation for an afterlife (Abdollahi et al., 2011; Greenberg,
Solomon, & Arndt, 2007; Pyszczynski et al., 2004).
The results from a few studies point to the potential
therapeutic utility of TMT to both conceptualize and
treat clients. DeWall and Baumeister (2007) found that
MS increased the accessibility of positive emotional
information, both immediately and after a delay. They
suggested MS leads to an immediate unconscious coping
process, which may explain why a delay is usually neces-
sary to produce effects consistent with TMT (DeWall &
Baumeister, 2007). Among mildly depressed individuals,
MS led to an increased sense of meaning for individuals
given the chance to defend their worldview (Simon,
Arndt, Greenberg, Pyszczynski, & Solomon, 1998).
In addition, TMT has been used to gain insight into
clinical phenomena. Anxiety buffer disruption theory,
an area within TMT research, has been used to under-
stand the impaired processes through which individuals
with posttraumatic stress disorder (PTSD) respond to
traumatic experiences, including women who have
413
experienced domestic violence in Poland, earthquake
victims in Iran, and survivors of war violence in
the Ivory Coast (Abdollahi et al., 2011; Kesebir,
Luszczynska, Pyszczynski, & Benight, 2011; Pyszczynski
& Kesebir, 2011). According to the anxiety buffer dis-
ruption theory, individuals with trauma histories rely
on cognitive resources, rather than their cultural world-
view and self-esteem, to manage death anxiety. The
compensatory reliance on cognitive resources, in res-
ponse to MS, was associated with diminished capacity
to resist engaging in risky behaviors (Ben-Ari, Florian,
& Mikulincer, 1999; Hart, Schwabach, & Solomon,
2010), and increased obsessive-compulsive and phobic
symptoms (Strachan et al., 2007).
Results from these studies offer some evidence that
MS might be useful in therapy, like giving the therapist
insight into a clients presenting concerns, and improv-
ing the clients ability to access positive information.
In addition, MS might help clients achieve a greater life
meaning when challenged by a therapist, provided cli-
ents are able to defend their worldview. The potential
clinical role of MS, self-esteem, and faith in cultural
worldview will be explored in more detail later.
EXISTENTIAL PSYCHOTHERAPY
There is no single, unifying approach to existential psy-
chotherapy. For the purpose of this article, existential
therapy involves helping clients confront what is central
to human experience through their point-of-view
(Schneider, 2008). Existential therapists recognize
diverse inuences affecting phenomenological experi-
ence and strive to create a new therapy consistent with
the clients cultural worldview, values, and past experi-
ences (van Deurzen & Adams, 2011; Hoffman, 2006).
Existential therapy often involves integrating techniques
from cognitive, humanistic, psychodynamic, and third
wave behavioral approaches (Schneider, 2008). Schnei-
der described several core assumptions underlying exis-
tential-integrative therapy: (a) human existence is
surrounded in mystery, and limited to what is accessible
to consciousness; (b) freedom is characterized by will,
creativity, and expressiveness; limitation signied by bio-
logical and social restraints, vulnerability, and death; (c)
dread of freedom or limitation is associated with dys-
function, and defensive reactions like oppression and
impulsivity; and (d) confrontation with both freedom
and limitation promotes a more vibrant life character-
ized by increased sensitivity, exibility, and choice.
In light of these assumptions, the existential therapist
facilitates client awareness of choice, limitation, and
freedom to act in any situation (van Deurzen & Adams,
2011). The therapist also reinforces client authenticity to
cope with intrapersonal and interpersonal isolation and
 414 A. M. LEWIS
other forms of existential anxiety (Bugental, 1981). In
addition, clients develop awareness of their emotional
and experiential avoidance in response to existential
anxiety, and learn to cope with existential concerns by
making meaning (Hoffman, 2004).
Although many examples of existential therapy focus
on long-term work, time-limited interventions can be
effective if there is adequate therapeutic alliance (Center
for Substance Abuse Treatment, 1999). Brief existen-
tial interventions stress the importance of attending,
reective listening, and conveying empathy to hasten
the formation of a therapeutic alliance (Center for
Substance Abuse Treatment, 1999). The following sec-
tion is an exploration of one proposed brief existential
intervention.
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TMT TIE
The author proposes a TMT TIE with the following as
its basis: (a) conceptualizing the clients presenting con-
cern in terms of MS and decits in the anxiety buffer
system; (b) eliciting MS therapeutically in-session to
inform the therapists treatment plan and progress; (c)
exposing the client to existential anxiety, and (d) helping
the client create new meaning. The following sections
will address potential client and therapist consid-
erations, what a therapist might do in initial sessions,
how to elicit therapeutic MS, and multicultural
considerations.
Client and Therapist Considerations
The therapist will need to consider whether a TIE inter-
vention is appropriate for a particular client. Possible
factors to consider are the nature of the clients present-
ing concern and whether talking about death might be
benecial, or increase clients risk for harm. The present-
ing concern may be one indicator of how the client will
respond to a TIE intervention. For example, an anxious
client who recently received a diagnosis of HIV probably
has a different perspective on death than a client who
developed depressive symptoms in response to a near
fatal automobile accident. TMT researchers have sug-
gested that the greater the immediate threat to ones life,
the more defensive or positive the persons response to
elicited MS (Greenberg et al., 2004). Processing the
clients response, whether defensive or positive, may help
clients make meaning out of their presenting concern.
A TIE intervention may not be appropriate for
clients who are actively self-harming or suicidal.
Although research on the effects of talking about death
with suicidal clients is limited, experts dispel the notion
that talking openly about suicide will introduce or
reinforce suicidal thoughts and behaviors (American
Association of Suicidology, n.d). Further, some research-
ers argue that avoiding the topic of death amplies
its power and emotional salience (Caffrey, 2009). Never-
theless, therapists should always monitor suicidality
and safety plan when necessary.
Clients who are grieving an acute loss may not be
appropriate for a TIE, especially if they are coping in
a healthy, nondefensive manner. Existential interventions
are often focused on the problems that may arise when
individuals repress and avoid emotions associated with
existential issues, rather than experiencing them as they
occur. For clients experiencing complicated bereavement,
however, there is some evidence to suggest that an MS
exposure might be helpful. For example, a combined beha-
vioral activation and exposure therapyinvolving places
associated with death of a loved oneled to signicant
reduction in complicated bereavement, PTSD, and major
depressive symptoms in older adults (Acierno et al., 2012).
Therapists should consider their own comfort
level with talking about death, and how this might affect
their judgment of whether a client might benet from
a TIE intervention. Yalom (1980) noted that many
therapists avoid talking about death with their clients.
Researchers found that MS elicits little or no immediate
emotional response in individuals without history of
trauma or PTSD (Greenberg, Simon, Pyszczynski,
Solomon, & Chatel, 1992). This nding suggests that
for many people, prompting them to think about
their death is generally benign from an emotional
standpoint.
Initial Sessions
The therapist should seek informed consent, gather
information, and build rapport in initial sessions. Gath-
ering information should include a phenomenological
assessment of the clients cultural worldview and
self-esteem. The questions could help the therapist could
gain insight into these aspects of the clients anxiety buf-
fer system based on cultural considerations for integrat-
ive therapy (Jones-Smith, 2012): (a) Describe yourself
culturally; (b) To what extent do you think you abide
by your cultural values?; (c) Describe your views on
the nature of people; (d) To what extent do you think
people have the ability to change themselves and
others?; (e) To what extent are people able to control
their own lives?; (f) Do you think people are con-
trolled by early life events, or can they change and
move beyond what happened to them when they were
young?; (g) How much are people inuenced by
their environment, past experiences, genes, spiritual or
unexplained forces?; (h) What is your explanation
for the reason you are in counseling? Why now?; and
(i) In what ways have you tried to resolve your problem
before, and how effective were these?

Therapeutic MS
When elicited initially, the purpose of MS might be to
further inform the therapists cultural conceptualization
of the client and identify the clients coping strategies.
MS increases the accessibility of cultural values, which
the client may be able to better articulate in session, as
opposed to when just asked to describe their values
(Greenberg et al., 2004; Greenberg et al., 1986;
Pyszczynski, Greenberg, Solomon, Arndt, & Schimel,
2004). The initial MS exposure might also help the
therapist identify and process any of the clients past
or ongoing experiences with discrimination. In addition,
TMT researchers have suggested that MS decreases cog-
nitive exibility (Greenberg et al., 2004). If in a bolstered
state, the clients negative coping strategies might become
more apparent to the therapist and serve as potential
teaching examples in subsequent sessions.
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Therapists can elicit MS through the standard
method in the TMT literature. Thus, therapists might
ask clients to write down their responses to the prompts,
Please briey describe the emotions that the thought of
your own death arouses in you, and Jot down, as
specically as you can, what you think will happen to
you as you physically die. Eliciting MS in this manner
is consistent with the existential emphasis on choice by
allowing the client graded control over the exposure. It
also serves to keep clients from immediately repressing
thoughts of death, and as a reminder of the activity
outside of session.
Researchers have described two ways healthy indivi-
duals generally respond to MS, one in which the person
wakes up to living, and the other in which the person
responds with defensiveness (Greenberg et al., 2004). In
a study examining nurses experiences with their rst
exposure to a patients death, over half (53%) reported
positive, satisfying, or rewarding aspects; the rest repor-
ted no benets (Kent, Anderson, & Owens, 2012). The
nurses who reported positive aspects had signicantly
higher preparedness scores and were more likely to have
talked about the experience with others afterward, com-
pared to nurses who reported no benets. It may be
necessary to take preventive measures to prepare clients
who might respond defensively and have limited means
of coping, like spending additional time seeking infor-
med consent, and ensuring clients have adequate social
support to cope afterward.
To monitor treatment progress, the therapist might
administer psychopathology symptom measures before
and after the MS exposure, in addition to social psycho-
logical measures (e.g., religious orientation, right-wing
authoritarianism, moral vignettes) and qualitative jour-
nal. The therapist could also use the clients responses
to facilitate insight and help the client make meaning.
The goal of subsequent MS exposures might be to allow
TERROR MANAGEMENT AND EXISTENTIAL THERAPY 415
the client to rely on cultural and personal beliefs, and
reinforce treatment gains. Further, therapeutic MS
might eventually help the client better distinguish every-
day problems from existential concerns.
Because therapeutic MS is, in part, an exposure tech-
nique, third wave behavioral techniques dovetail well
with the underpinnings of a TIE intervention. Poten-
tially useful techniques from these approaches include
work on increasing client acceptance of death-related
thoughts and experiencing uncomfortable emotions as
they occur (Hayes, Luoma, Bond, Masuda, & Lillis,
2006; Hayes, Masuda, & de Mey, 2003). Researchers
found that mindful individuals are less susceptible than
nonmindful individuals to the negative effects of MS
(Niemiec et al., 2010). Third wave behavioral appro-
aches also stress the importance of increasing cognitive
exibility, which is consistent with the existential emp-
hasis on client exploration of existential paradoxes, such
as the duality of freedom and limitation.
Multicultural Considerations
Culturally diverse clients stand to benet from a TIE
intervention, as many evidence-based approaches fail
to take into account cultural variables necessary to form
a therapeutic alliance (Vasquez, 2007). Few researchers
have focused on multicultural differences in response
to MS, despite the importance of cultural worldview in
TMT. Although MS is consistently associated with
intergroup bias, this bias was reduced when individuals
were primed with compassionate religious doctrine spe-
cic to them (Rothschild, Abdollahi, & Pyszczynski,
2009). For clients who are spiritual, therapists may use
MS to strengthen the clients connection to members
within their faith community and reinforce compassion
for individuals outside of the community.
Literature on death and dying suggests that some
clients may be more comfortable talking about their
mortality on the basis of their cultural background.
A literature review on multicultural perspectives of
physician-assisted death described how death percep-
tions in the Black community vary from those in the
White community (Westefeld et al., 2013). For example,
Black individuals often focus on death in the context of
social injustice, poverty, and institutional discrimi-
nation. Also, when researchers elicited MS, East Asians
were more likely than European Americans to think
about life and on striving to enjoy living
(Ma-Kellams & Blascovich, 2012). The researchers sug-
gested these effects may be due to Eastern cultures empha-
sis on more holistic living, and a belief in yin and yang
coexisting in all things. Therapists may need to consider
how the presenting concern may not only be associated
with how the client copes with existential anxiety, but also
with culturally divergent perspectives on death.
 416 A. M. LEWIS
Future Research Directions
At present no researchers have developed and tested a
TIE intervention, and there are no randomized con-
trolled trials of existential therapy. A TIE intervention
may be an ideal starting point for empirical inquiry, as
it is based on empirically derived TMT principles. With
regard to therapeutic efcacy, the goal of a TIE inter-
vention may not necessarily be a reduction in symptoms,
but rather improved cognitive exibility, client authen-
ticity, and life appraisal. The evidence-based practice
framework in psychology is broad in its conceptualiza-
tion of evidence, despite many psychologists insisting
that randomized controlled trials are the only standard
of demonstrating efcacy (Farber, 2012). Regardless of
ones stance on what constitutes sound evidence, res-
earch incorporating multiple methods is needed prior
to the use of a TIE intervention with clients.
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CONCLUSIONS
TMT researchers and existential therapists have been
concerned with the philosophical dilemma and potential
psychological burden of human awareness of the inevi-
tability of death. This awareness provokes anxiety and
may lead to negative defensive responses, however, it
may also have the potential to allow individuals to live
richer, fuller lives and minimize nonlife threatening
sources of anxiety. A TIE intervention involves client
exposure to unconscious death anxiety and exploring
more effective ways of coping when inevitably faced
with losses in life. This intervention involves the use of
therapeutic MS and work improving the clients ability
to cope using psychological and cultural resources.
When allowed the opportunity to rely on their world-
view, clients may feel more afrmed in their cultural
identities through this novel process. Both client and
therapist can mutually benet from the process of auth-
entically engaging in dialogue on the topic of death and
other universals of existence.
Therapists and researchers of existential issues may
receive more demand for their work as the population
ages (Howden, & Meyer, 2011). Although older adults
are less susceptible to MS effects (Maxeld, Pyszczynski,
Greenberg, Pepin, & Davis, 2012), they are also more
likely to be diagnosed with a chronic illness or act as pri-
mary caregivers to a chronically ill loved one (Aldwin &
Yancura, 2012), become widowed, experience the loss of
friends, or see a decrease in nancial status due to retire-
ment (Aldwin & Yancura, 2012). However, it may be
that older adults are less susceptible to the negative
effects of MS due to more frequent exposure to mor-
tality issues. Nevertheless, younger individuals will likely
be involved in their care and exposed to end-of-life
issues in greater numbers.
In addition to meeting the needs of the aging popu-
lation, TIE research provides an opportunity for TMT
researchers and existential therapists to collaborate.
Given the realities of the managed health care system
in the United States, therapists face increased pres-
sures to practice empirically supported techniques.
Researchers also face increased pressures to conduct
interdisciplinary work in order to receive funding.
Although some existential therapists have concerns
about practice-based publications oversimplifying exis-
tential therapy (van Deurzen & Adams, 2011), Schnei-
der (2008) argued, How much longer can existential
theorists justify informality, obscurity, and disunity
simply to oppose rigidity? (p. 2). Many existential
therapists are reluctant to publish treatment manuals,
but they need to make existential practices more
accessible to diverse audiences if the approach is to
live on.
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