What is the mindset of “anti-vaxxers,” and how can you connect with them as a clinician?
The past 2 years have seen the global emergence of a new, dangerous, and readily communicable virus. More than 1 million US and 4 million worldwide deaths from COVID are remarkable, tragic statistics that now stand among humankind’s historic catastrophes. Perhaps more than in any recent public health crisis, resistance to public health initiatives and hesitancy to accept life-saving vaccines have characterized the pandemic, recalling historic public resistance to the smallpox vaccine and water fluoridation. Yet there may be a collaborative way through the hesitancy and outright rancor that still characterizes public discussions.
How We Got Here
Early hesitancy focused on blame: Who was responsible? This was a relatively brief distraction as the predicted overload of hospitals—like New York City’s outdoor ICUs—fostered appeals for handwashing, quarantines, and public masking. These pleas restricted the movement of a good segment of the population and were soon followed by denial, opposition, and active resistance from those who did not see the benefits of taking public health precautions for themselves or others. This soon extended to becoming vaccinated. Reasons for resistance were technical, political, religious, and personal, too often fueled by misinformation and distortion. Concurrently, the US government’s understaffed response was slow, playing easily into the preexisting divisions among communities.
The available rhetoric of division was seemingly prebaked: “It is my body,” “It is only the flu,” “It is all a political tactic,” and “It is a pharma marketing scheme.” Appeals to public health and the common good were parried with classic appeals to personal autonomy and control of one’s body, supported by geographic and political divisions. By spring 2021, a New York Times analysis identified the single greatest predictor of US citizens choosing vaccinations was the individual’s voting record in 2020.1 We will leave aside the question of which voters and regions were most hesitant in order to focus on the neutrality of the approaches that seem most helpful.
How then should citizens and clinicians best go about talking through the fraught balance between risk and responsibility—between personal freedom and public health?
As potential risks have become appreciated within medical circles, strategies of immediate melioration and longer-term prevention have clearly been adopted, moving communities into a direction supportive of public health. Government restrictions have been adopted by employers and businesses; vaccine cards and testing kits have become widespread. Yet disbelief and entrenched denial of both the pandemic itself and public health interventions continue to spread and factionalize, occurring almost as rapidly as communication technologies allow.
The Roots of Hesitancy
Vaccine hesitancy itself has many psychological roots. Among them is that people, in general, are afraid of making bad decisions. Social psychologist Adam Galinsky, PhD, is clear in writing that incurring regret from a more passive decision—not getting vaccinated—may be preferable to taking the initiative.2 A viral infection just happens—vaccination, though, involves both risk and choice. This consequently evokes regret if there is an adverse effect, a breakthrough infection, or a newer, better alternative. Hesitancy and denial may therefore require parsing belief systems into smaller pieces. Only then may more productive, open discussions occur.
Psychologist and behavioral economist Daniel Kahneman, PhD—known for distinguishing fast and slow thinking (emotional and cognitive decision-making)—famously recognized the instinctive emotional response to danger.3 Individuals are governed by their most recent emotional and negative experiences. The alternative—a careful, analytic response—takes time and patience.
Loss aversion also played a role in Kahneman’s Nobel Prize-winning work: Decision-makers are more likely to avoid loss than risk gain. Behavioral economists point this out among stock traders who hold onto a losing stock long after they should sell. The commitment to the falling stock, like the presumption of good health in a pandemic (“It will not happen to me”), is far greater than it deserves.
Public Health and the People’s Consent
Resistance in the United States has been most poignantly exemplified by resisters’ disproportionately occupying ICU beds. The beds first filled with the unprepared later became filled with those hospitalized because they were unvaccinated. Thus, the late waves of those who were “sick by choice” exhausted and dispirited health care systems and workers, even as new variants reduced the available workforce itself. Deathbed anecdotes of penitence were tragically frequent but offered small consolation. Targeted information that is sensitive to the needs of such hesitant individuals must provide the first step toward overcoming these heartbreaking losses.
Acronymic frameworks of traditional vaccine hesitancy, such as the 5C model—confidence, complacency, constraints, calculation of risks, and collective responsibility—initially played out well and helped would-be users sort out competing concerns. Individuals who lack confidence, for example, are more likely to mistrust health systems and medical treatments in general, while complacent individuals do not feel vulnerable.4,5 Understanding their reasons for hesitancy and identifying their most trusted sources of information are critical tools for overcoming low vaccination rates. Consequently, websites, media platforms, doctors’ offices, and churches can be attuned to counteract the particular political, religious, and medical reasons for declining preventive treatment.
Exposure to medical experts over time does seem to have an effect on hesitancy, as does the positive framing of new choices.6,7 Indeed, multiple groups and agencies studying the phenomenon find that vaccine information and promotion should be culturally and linguistically attuned to its community.8,9 This aligns well with medicine’s expanding understanding of the social determinants of health, as well as psychiatry’s recognition that individuals are born into families and cultures that invariably influence their perspective.
Scholars of international hesitancy note that nations, like communities, may have similar reasons for their behavior. The most common reason for vaccine refusal in 1 large study was potential adverse effects, with the second most common reason being vaccine efficacy.10 In that study of 12 nations and more than 44,000 respondents, unvaccinated US respondents commonly expressed a lack of concern for the severity of infection, a kind of denial known both to psychological and economic models of decision-making.
The good news is that this study, like others, identified the health care system, family, and friends as the most trusted sources of vaccine information. Hesitant health care workers in the United States also appear to be better influenced by people they know.11
Other techniques identified by mental health experts range from repeated reminders and automatic appointments to personal (and positive) communication with professionals.12 The assumption that clinicians will discuss vaccination and schedule it becomes the default for health care discussions in any clinician’s office.
Optimism From the Darkness
The most important approach clinicians can take as the pandemic lingers is to listen, honor, and understand their fellow human beings, moving each individual toward a fuller understanding of the other. When life and death are at stake—repeatedly the case in each wave of this pandemic—understanding the position of the other is paramount. The validity of assumptions on each side of this battle line—whether to vaccinate or not—may consequently come into tighter focus. Underscoring the need to understand is the way through which minds can widen, compromises may be achieved, and communities can move forward.
This is where Galinsky’s framework is particularly useful for mental health and public health practitioners.13 His model of “empathic firmness” requires listening to the doubters while still putting public health standards in place. Acknowledging the perspective of those who remain uncertain, or even outwardly opposed, eases resistance. Public health mandates consequently externalize the responsibility of decision-making. Perhaps this is why job and school mandates work.2,12 Individuals need no longer be torn by the internal struggle over potential poor outcomes.
Listening and striving to understand consequently open a dialog that is diametrically opposed to efforts that demonize or valorize those who disagree over vaccination. Listening and understanding also allow room for many of the techniques clinicians and communities are now finding useful. Whether it is sharing websites like the CDC’s or the World Health Organization’s; encouraging trust of one’s own doctor, pastor, family, and friends; or otherwise providing positive, repeated communication that expresses care and concern, mental health clinicians have a range of tools that take advantage of their empathy and listening skills. At the same time, these skills provide a much-needed opportunity for improved outcomes in a stubborn pandemic.
Dr Candilis is director of medical affairs at Saint Elizabeths Hospital in Washington, DC, and professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences. Dr Howe is a professor in the department of psychiatry at the F. Edward Hébert School of Medicine at Uniformed Services University. Dr Fallon is clinical associate professor of psychiatry at Drexel University College of Medicine in Philadelphia, Pennsylvania. Dr Nesheim is executive medical director emeritus at Hamm Memorial Psychiatric Clinic in St. Paul, Minnesota. Dr Van Loon is an integrated behavioral health psychiatrist at Gundersen St. Elizabeth's Hospital and Clinics in Rochester, Minnesota. Dr Gennaro is a psychiatrist and psychoanalyst at the William Alanson White Institute, St. Vincent’s Hospital, Westchester, New York.
1. Ivory D, Leatherby L, Gebeloff R. Least vaccinated US counties have something in common. The New York Times. April 17, 2021. Accessed August 4, 2022. https://www.nytimes.com/interactive/2021/04/17/us/vaccine-hesitancy-politics.html
2. Galinsky A. The ‘psychology of regret’ helps explain why vaccine mandates work. The Washington Post. November 11, 2021. Accessed August 4, 2022. https://www.washingtonpost.com/outlook/2021/11/11/vaccine-hesitancy-psychology-regret/
3. Kahneman D. Thinking Fast and Slow. Farrar, Straus, and Giroux; 2013.
4. Machingaidze S, Wiysonge CS. Understanding COVID-19 vaccine hesitancy. Nat Med. 2021;27(8):1338-1339.
5. Betsch C, Schmid P, Heinemeier D, et al. Beyond confidence: development of a measure assessing the 5C psychological antecedents of vaccination. PLoS One. 2018;13(12):e0208601.
7. Barnes K, Colagiuri B. Positive attribute framing increases COVID-19 booster vaccine intention for unfamiliar vaccines. Vaccines (Basel). 2022;10(6):962.
8. Dong Y, He Z, Liu T, et al. Acceptance of and preference for COVID-19 vaccination in India, the United Kingdom, Germany, Italy, and Spain: an international cross-sectional study. Vaccines (Basel). 2022;10(6):832.
9. Ohlsen EC, Yankey D, Pezzi C, et al. COVID-19 vaccination coverage, intentions, attitudes and barriers by race/ethnicity, language of interview, and nativity, National Immunization Survey Adult COVID Module, April 22, 2021-January 29, 2022. Clin Infect Dis. 2022:ciac508.
10. Solís Arce JS, Warren SS, Meriggi NF, et al. COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries. Nat Med. 2021;27(8):1385-1394.
11. Toth-Manikowski SM, Swirsky ES, Gandhi R, Piscitello G. COVID-19 vaccination hesitancy among health care workers, communication, and policy-making. Am J Infect Control. 2022;50(1):20-25.
12. Brewer NT, Abad N. Ways that mental health professionals can encourage COVID-19 vaccination. JAMA Psychiatry. 2021;78(12):1301-1302.
13. Galinsky A, Schweitzer M. Friend and Foe: When to Cooperate, When to Compete, and How to Succeed at Both. Currency; 2015.