Journal of Environmental Health Research, Volume 5 issue 2
Kevin Maguire1 MSc BSc BA CPsychol MCIEH and Dr Kevin Love1
1 Division of Criminology, Public Health and Social Policy, Nottingham Trent University.
Correspondence: Kevin Maguire, York House, Mansfield Road, Nottingham NG1 33A, United Kingdom.
Telephone +44 (0)115 848 5540.
Fear has long been used as a technology of governance, often in a very crude form. In the modern governance of the public’s health, however, it is argued that fear is deployed only paternalistically, to secure changes of behaviour that are clearly in the best interests of the individuals concerned Accordingly, fear continues to play an important role as a motivator in contemporary health communications, which now aim to ‘market’ healthy behaviour. In looking at the use of fear, the current paper begins with a short review of marketing processes, and social marketing in particular, and follows it with a theoretical introduction to evaluation. A multi-phased qualitative study is then described consisting of a focus group, a series of reflexive interviews, and two triangulating interviews; the first two phases included the showing to the participants of health promotion video clips on the effects of smoking. An analysis of data generated points to a psychological effort by the participants to distance themselves from the frightening contents of the video clips; it also identified a series of thought tactics used to achieve this. The theoretical and practical implications of the findings for devising health promotion messages are discussed.
Key words: environmental health; evaluation; public health; health promotion; social marketing
Qualitative research points up the role of the researcher in the research process accepting, in its reflexive nature, that different researchers affect the nature of the data in different ways (the matter is discussed further in the body of the text). In view of this fundamental principle, parts of the paper will be written in the first person (singular and plural), rather than the convention of third person accounts.
Mass-mediated health communication enjoys a history almost as long as the mass-media itself. From their earliest days, radio and television, for instance, have been used by the state to convey health information to the populace. Early health education films such as Coughs and Sneezes (National Archives, 1945), illustrate the simple fact that health communications of this sort were (and are) conceived as an attempt to influence individual behaviour, in order to protect the wider public health. Traditional mass-media health communications of this type, along with their contemporary equivalents, are often conceptualised methodologically using the metaphor of the “hypodermic”: the public body, inoculated by an injection of information that dissuades individuals from engagements in risky health behaviours. The readiness of this clinical analogy is not without significance, and testifies to the powerful post-war trend toward medicalisation, even in the less obviously clinical arena of health education, which until recently all but eclipsed the broader social understanding of health. In these communications, it is as though the public body is itself conceived as a “physiological entity,” where injection of carefully prescribed doses of information is expected to lead, in a “linear sequential” fashion (Hastings and MacFadyen, 2002), to the activation of specific processes within rational actors, from which follow the remediation of identified behaviours. The fact that many contemporary health communications perpetuate this approach (albeit with varying degrees of sophistication) is indicative of a continuing reliance on socially decontexualised methods of health intervention.
The recent trend toward the adoption of social marketing techniques in health communication aims to ameliorate some of the inadequacies of traditional, mass-media, health education in this regard. Social marketing has been defined as:
“the application of commercial marketing technologies to the analysis, planning, execution and evaluation of programmes designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of society” (Andreasen, 1995).
The principles of this method have, to some extent, implicitly underpinned health communication initiatives from the beginning. Nonetheless, these principles remained unexplored and undeveloped until the 1970s, when Kotler & Zaltman (1971) first coined the term. In brief, social marketing conceives health communication along commercial lines. Proponents argue that the highly successful, promotional marketing techniques, which have been used to such obvious effect in encouraging certain purchasing behaviours, can similarly be used to encourage desirable health and social behaviours. The method appropriates the ‘4 Ps’ of marketing practice and redefines them in line with its own agenda.
The first of those Ps, product, might thus relate to a physical, health-related article (a condom for instance), but might equally refer to health services (e.g. screening), health practices (e.g. breastfeeding), or indeed, less tangible ideas about lifestyle and identity. Price can similarly be a simple monetary cost, but more commonly refers to the time, effort or perceived level of “sacrifice” a particular health behaviour requires. The perceived level of social risk is also an important factor in this respect, especially where particular behaviours touch upon issues of identity. The third P, place, rather misleadingly refers to the means employed to bring the product to the individual, which for the purposes of mass-media health communication comprises mediating channels such as broadcasting, newspapers and the like. Finally, promotion relates to the mode and scale of visibility appropriate to the communication. The essence of the social marketing technique is to tailor the communication to maximum effect for a given “audience.” To do so, it utilises a range of demographic (gender, age, ethnicity, cultural factors, socioeconomic status, sexual preference, level of education), psychographic (aspirations and lifestyles, neophobia and risk aversion, cultural role-models, degree of social integration/ introversion) and geographic data. On the basis of this data, the broad heterogeneous audience is segmented into smaller homogenous units, and the communication then developed in a targeted way. Musham and Trettin (2002) provide an example relating to the promotion of breast-feeding in the low-income, Hispanic population of South Florida. Having previously established the target group’s perception that “the primary benefit of motherhood is being loved by the child” (Musham and Trettin, 2002: 284), the television commercials utilised during the intervention emphasised how breast feeding strengthened the mother-infant bond. It takes little analytical prowess to appreciate the fact that social marketing is able to generate significantly more coercive force than traditional, broad-brush methods of mass-media health education.
The UK has recently witnessed television campaigns of a similar style in respect of smoking, clearly targeted at a specifically segmented audience of 18-35 year olds. In the first (NHS, 2005a), a girl is rejected by a prospective suitor under the unremittingly direct strapline, “If you smoke, you stink”; in the second (NHS, 2005b), a rather limp-looking cigarette butt masquerades as a penis, while the commentary informs the listener of the relationship between smoking and impotence. Neither of these cases intends to provoke a consideration of the health risks associated with smoking. Instead, they exploit what is undoubtedly a culturally more important issue for the target audience, the better to sell the product: quit smoking – you will have a more successful sex-life.
The consequent ethical issues are legion1. For some, utilisation of coercive power in this way exceeds any accepted notion of state paternalism, far surpassing the strictures of the “harm principle.”2 For others, the advanced marketing antics of, for instance, the tobacco industry (nicely exposed by a number of authors: Dewhirst & Sparks, 2003; Ernster et al., 2000; Gonzales et al., 2004) warrant similar action from the other side. Yet others, given the seriousness of the consequences of particular health behaviours, concentrate exclusively on questions of effectiveness and fail to even acknowledge that the issue of cultural coercion is at all significant (for example, Biener & Taylor, 2002). We lack the space to explore the panoply of emergent issues that attend the efforts of health communicators to now conceive of health in commercial terms. Concentrating instead on only one aspect of social marketing – the use of fear as a tool for behavioural change – the paper hopes to indicate that studies using rational cognitive processing models may indeed suggest that the persuasive power of massmedia communications increases with increasing arousal of fear (Biener & Taylor, 2002), but that such models are unable to capture the subtle interplay of a subject’s conscious and unconscious reactions, which thus result in a more complex and equivocal pattern of response. In short, efforts to “bring the message home” with force and persuasion using fear-based conduits of communication, often result in the entrenchment of an underlying, psychological distance between the intended message and particular audiences. As a consequence, even those mass-media, health communications that employ social marketing techniques remain insufficiently contextsensitive, since they fail to account adequately for the nuanced complexity of target subject responses.
We consider this paper to be a form of evaluation since we are interested in an output (people’s behaviours) following an input (the campaigns that use fear to promote health). There are, however, many theoretical pitfalls in thinking about evaluation, some of which we cannot ignore, especially within the frame of “social marketing”, since essential to good marketing is good evaluation. Here lies the major challenge in evaluation, one which is encapsulated in the old joke of the marketing director who declares that 10% of her marketing effort works; “but I don’t know which 10%”.
Books on evaluation will list its types (see, for example, Pawson and Tilley (1997) or Patton M, 1997)) but it is helpful, for this study, to be aware of the major division into two: empirical (or instrumental) and theoretical (or theory-based).
Figure 1.0 Black box illustrating empirical evaluation
The more empirical approach is a black box of inputs and outputs where the nature of the link between the two is not important (see diagram 1). In this approach, if a particular effort (e.g. healthy eating campaign) is regularly associated with a desired behaviour change (e.g. more vegetables are sold in the shops), then that is all there is to be concerned about. This kind of evaluation is sometimes referred to as goal-driven3 since the achievement of the goal is all that is required. It is the evaluation of our marketing director above. The evaluation of an alcohol drinking campaign among US college students by Clapp et al., (2003) exemplifies such an approach where their post-campaign evaluation found improved knowledge of alcohol drinking but found no changes in drinking behaviour other than increased drinking in one group. Their subsequent discussion in the paper was largely about how they had been very careful in the design and that, therefore, their results were genuine. Only one sentence of the paper contained any consideration of the “why?” question.
Despite the recency of the Clapp et al., (2003) paper, most evaluators view the empirical/instrumental approach as belonging to a former age. Bonner (2003) labelled it as “traditional” and “naïve”, and, referring to a 1999 publication, pointed out that the UK’s National Health Action Zone Evaluation Team was not content with this form of evaluation; rather they advocated theory based-evaluation “to promote policy and practice learning for future planning and development” (Bonner 2003:78). Theory-based evaluation tries to identify and explain the connection or mechanism between the effort and the outcome (see Figure 2.0). As its name suggests, this approach relies on various theoretical approaches to knowledge since it looks for theory that explains the link between the input and output. It answers the question implicit in our marketing director’s statement, i.e. it tries to find which 10% of her marketing works and why. Put another way by Pawson and Tilley, it can help to explain “what works for whom in what circumstances?” (Pawson and Tilley 1997: 85 quoted in Van der Knaap 2004). Such an approach is particularly helpful where the targetbased evaluation tells us that our effort did not result in the desired outputs. Jason et al., (2003) exemplify theory-based evaluation in looking at the effects of enforcement activity (including fines) on under-age smoking in Illinois in the US. The campaign outcomes and explanations fitted together to make a useful addition to knowledge and understanding which would help with future campaign design and running.
Figure 2.0 Theory-based evaluation
Van der Knaap (2004) would appear largely to concur with much of the import of Pawson and Tilley (1997) (see below) but he does seem to distance theory-based evaluation from “the positivist ideal” (van der Knaap 2004:17). In contrast, Pawson and Tilley defensively write “evaluation needs another round of positivism bashing like a hole in the head” (1997: xv). There are other differences in their critical realist approach.
As critical realists, Pawson and Tilley (1997)4 have a particular perspective but they also take a most rigorous approach to evaluation theory. Their analysis of evaluation and its place in a knowledge framework (its epistemology) is very useful in considering notions of evaluation since they ask the question “what is the deepseated and underlying mechanism in this particular, observed regularity?” Within their own theoretical approach, they give examples of questioning, not only the use of regularities noted between inputs and outputs, but also the very nature of the observations and what they are thought to mean. In this way they can explain why the same campaign will work in one situation but not another. For them, the context is allimportant but for each local situation, their approach remains realist rather than idealist and thus might still be seen as looking from an empiricist vantage-point.
The process of getting hold of ideas and thoughts regarding the use of fear to promote health is, almost by definition, not an approach which lends itself to the use of number. Rather, in a survey of ideas, thoughts, and attitudes, a wider trawl is required which avoids preconceptions or attempts to drive people’s thought patterns into a set of pre-determined categories. Thus, a qualitative interpretative approach became essential (see Maguire 1997). This does not deny the validity of the use of number; nor does it preclude its use from following on from this study (see Gouldner 1953). In the spirit of Strauss’s notion of progressive focusing (see Atkinson 1979), and trying to answer the question “what is the main story here” (Wiseman 1974), a phased approach appealed, especially if the method used in each phase built upon the findings of the previous phase and method.
Within this qualitative approach, three phases (primary sorting phase, secondary focusing phase, tertiary confirmatory triangulation phase) were considered to be needed and three methods identified (focus group, interview, second interview).
The value of focus groups is increasingly recognised in gathering a pool of ideas (see Bloor 2000); for example, a wide variety of views can be brought together and be built upon from individual comments. Our study used it to identify potential areas to explore during the second (and main) phase of the study.
The interview is not one method but spans many styles from the most directive and structured (where specific closed questions are asked) to the reflexive and unstructured, the latter end of this continuum being more phenomenological and interpretative: in view of the needs of the study, the latter end was selected as of more use for the study.
While it might be overstating the situation to talk of hypothesis generation (at least in the normal scientised use of the word), the tentative nature of discovery or conjecture5 in any study (positivist or relativist, realist or idealist) is such that it should be subjected to some sort of testing. In our study, the possible knowings identified from the interviews (the “hypotheses”) seemed best to be tested by their presentation to further members of the study area not previously concerned with the study.
Such people, with some independence and freshness, could shine further light and give further view upon the validity of the ideas. Testing or examination from another angle in qualitative work is often referred to as triangulation, an analogy being drawn with the surveyor or geometrist who use an additional (vantage) point to confirm the location of the point of interest.
Method and materials
The study area consisted of all students between the ages of 18 and 25 at the Nottingham Trent University who regularly read their emails (see below). A multiphase qualitative approach was adopted in the following phases: a focus group consisting of 12 people; 10 interviews that had both a semi-structured part and an unstructured reflexive part; 2 final interviews used for triangulation.
For all three phases, self-selected volunteers were sought via several pan-university mails, which requested an hour or two of their time, offered a £20 gift voucher for a local shopping centre as a reward for taking part, and explained in simple terms the intentions regarding the study. Volunteers were then sent documents giving more detailed explanations of the intention and method of the study plus an explanatory consent form, which included assurances of confidentiality. This was signed by the volunteers and returned either before or, at the time of, the particular phase in which they were participating.
Focus group. The volunteers for this group consisted of three men and nine women. After initial explanations and further assurances of confidentiality, the group were shown, at intervals, a data-projected digital version of four UK Government-sponsored public information broadcasts, each lasting between 20 and 40 seconds down-loaded from the UK’s Department of Health (DoH) Website (see DoH undated). After each an unstructured discussion was opened by a facilitator, the intention being to give voice to and identify as many as possible different thoughts and ideas held by the focus group members about health and fear. After showing all 4 broadcasts, a more general discussion was held about health and fear.
The proceedings of the focus group were audio-recorded via a ceiling suspended microphone onto standard audio-tape and were then transcribed by an audio-typist employed specifically for the purpose. The transcription was used to identify any themes running through the discussions. In turn, the themes (identified in the results section) fed into the next phase.
Main interviews. 10 interviews (of four men and six women) were carried out, each lasting about 40 minutes, in a neutral area (university meeting rooms containing only table and chairs) with the interview being recorded onto mini-disc. Before the recorded interview began, the interviewee was reminded of the confidentiality of the interview and therefore the importance of not giving their name or other identifying aspects of their life (e.g. the name of a school or a workplace). They were also reminded that they could terminate the interview at any time that they wished without losing their entitlement to the £20 gift voucher. There were five parts to the recorded interview, namely: an additional reminder of confidentiality; an invitation to give a short (about two minutes) summary of the interviewee’s career; an unstructured reflexive part exploring the interviewee’s schema and attitudes towards health, fear and the use of fear to “promote” health; a semi-structured section which centred upon the themes identified in the focus group; a closing opportunity for the interviewee to revisit previous parts of the interview or to make any additional comments.
For technical reasons, each mini-disc recording was transferred to conventional audio-tape, which was then used by the typist to transcribe the interview. From the transcriptions the research team again looked for regularities across the separate interviews (see results and discussion).
Confirmatory Interviews. Two confirmatory interviews (of a man and a woman) were held in a method similar to that of the interviews above with a more structured content aimed at exploring the validity of the findings from the main interview phase.
The use of fear in promoting health, in this study, would seem to be less effective than would have been expected, as will become apparent in this part of the paper where the emergent ideas are discussed without attempting to set them into a theoretical context; this will come later.
Focus group themes
The findings from the focus group are not the main concern of the current paper, only the emergent themes which are pursued in the semi-structured section of the next (and main) phase of the study. The themes were: use of statistics, use of children, use of real people rather than actors, feelings of disgust and fear, aesthetics and beauty.
Main and confirmatory interview emergent themes
The following themes were noted by the researchers:
Notions of fear
Notions of health
Fear about health and reactions to that fear
Other emotions involved as identified by interviewees
Ethical considerations regarding the use of fear
These themes are elaborated further below and used to develop a proto-model intended to describe the emergent conceptual structures:
Notions of fear
Feeling fear was best articulated by an interviewee as follows:
“Fear … is wanting not to be there … if you can get away, you will, or deal with it in some way. The feeling, the actual feeling in the body is perhaps is one of – er – being completely on edge and like wanting to get away and perhaps in some circumstances, not wanting to let yourself down and – er – deal with that, deal with that fear …”
Some variation was shown in the response of others with associated feelings including shock, being scared, being frightened, being on edge, cringing, and feeling numb. There was not universal agreement, however; for example one of the triangulating interviewees considered that “numbness was more of a sensation” rather than feeling fear.
Figure 3.0 Proto-model of use of tactics used by interviewees to distance themselves from a health message
This interview also placed the terms on a continuum as follows (mildest first) on edge – numbness – shock – frightened – scared. While such an ordering may not accord with others, it is helpful for evaluating the effects of the use of fear (see later).
Notions of health
It is not surprising that, from a pool of interviewees which included students studying a health-related topic, some of the replies regurgitated the World Health Organisation (WHO) definition of health (Ewles and Simmett1992) but further probing soon dissolved such a coherent face. Health, for many, reverted back to not being unhealthy and then to unhealthy behaviours including smoking, drinking alcohol, and poor diet. The nearest that interviewees came to a positive aspect to health was in their use of the word “fitness”. For one interviewee this became synonymous with sport and then linked to the “health-fitness-beauty” triad and thence to ideas of disgust (see later).
Fear about health and reactions to that fear
Linking the two not only illuminated interviewees’ understandings of the two separate ideas further but also showed how they were linked in their minds. Of use here was an interviewee who saw fear as not being able to move or act. This person talked of finding a lump on their body when they were 17 and their being “too frightened to do anything”. The reactions to the fear were both distancing (see proto-model below) and annoyance: “you can’t do that really; it’s not your place to make me feel like that”.6
Other emotions involved
As well as fear, other emotions that interviewees considered to have been used in health messages were: shock, disgust and revulsion, shame, and loneliness. While seen as separate from fear, all were seen as negative.
The ethics of using fear
Participants generally felt uncomfortable, with the use of fear; for example:
“I felt it was very er, like I was being manipulated”.
An ambivalence arose, however, in that while a respondent thought it was wrong to use fear generally in selling commodities, it was legitimate where health was concerned. For one interviewer, his discovery of his ambivalence surprised himself:
“… I’m sounding like a Marxist here. If awareness should be briefed so people are looking after themselves and leading better lives, then, I thought I’d never say that, but erm perhaps it’s a good idea, but I mean the fear factor of it … I don’t know if people should be imposed, there should be an imposition on people to make them scared to stop them doing something which erm an expert says they shouldn’t be doing…”
The model developed from the interviews centres on distance (see Figure 3.0). If we see a space between the individual and a potentially threatening message, then the person will try to distance themselves from the threat, i.e. open up the space. The challenge, in the words of another interviewee, is for the promoter to
“… bring it [the message] home …”.
Techniques that create distance between an individual and the health message (the perceived threat) were also recognised by interviewees as being used by health messages to reduce that distance. Within the strategy of distancing, the techniques employed were mainly the making of attributions to the message which removed the relevance of the message to the individual. They are summarised in Table 1.0.
Table 1.0 Summary of thought tactics used by interviewees to distance themselves from a health message
Table 2.0 Ways suggested by interviewees that might “bring the message home”
For one of the triangulating interviewees, habit was seen as something far more powerful than, and different to, creating distance. Another who saw himself as “addicted” did, however, use the distancing technique by seeing his addiction as being taken advantage of:
“just cos I am addicted, you see“.
According to the interviewees, health promoters need to shorten that distance by “bringing the message home”, an expression used by one of the interviewees which encapsulates the idea of reduction of distance: the message has to mediate the full length of the space between person and message in Figure 3.0. “Bringing the message home” involves working on the boundaries and helping to reshape not only behaviour but, depending on the degree to which the health message accords with the individual, may need to change mental schemata, perhaps having to address deep-seated unconscious aspects of the person. Doing this, however, may not always work in the desired way (see below in discussion). Some of the techniques suggested by interviewees are listed in Table 2.0.
The model identified by the interviewees was an implicit psychological model, i.e. it aimed to get a message from the transmitter to each individual’s mind with the premise that this would change their behaviour – if it reached home. The implicit model could be interpreted in a variety of cognitive models such as Festinger’s (1957 see, for example, Hayes 1994) famous cognitive dissonance model where the dissonance between two cognitions (thoughts)7 create such discomfort that one has to change; either to give up smoking or to deny the message. Other psychological models, upon which marketers (and presumably social marketers) tend to rely, involve a causal link where thought and or feeling drive behaviour as in traditional attitudinal models (something questioned by various authors, e.g. Ajzen and Madden 1986). Such is the approach in rational choice models, where a knowledge message is supposed to lead to a change in behaviour. It is also the basis for attempts to change feelings in order to change behaviour and for the use of short-term changes in behaviour with the hope that they change thoughts and feeling and thence to longer-term changes in behaviour8.
Even psychological models however can point up problems with the distancing – bringing home opposition. Anna Freud’s (see Stevens, 1983) models have a special place for resistance and how they are formed and used; these, in particular, explain the problem of ‘comfort’ removal. Sigmund Freud’s concept of Thanatos9 (Stevens 1983) can also explain activities that result in harm; coming from the unconscious, this drive is particularly difficult to identify and resolve. Sometimes described as an economic model, the constituents of the Freudian model of the psyche may move but the overall energy (the libido) remains the same. Bearing in mind these psychodynamic models, our interviewees provide evidence contrary to the hypodermic model (see above). Thus rather than having enough information injected into a person to inoculate her or him against the undesired behaviour, the ‘affective charge’10 it initiates is subverted into building up defence against the initiant force (here the health message).
Of course an individual model is not the only approach to promoting health. Indeed, a more socially embedded approach would appear to overcome many of the problematic responses to health communication highlighted here. A wider social model would accordingly consider not simply the health communication message, but also issues concerning empowered choice and the relative economic power of the various actors (not only the resourcing of promotion activities but also such matters as the power of tobacco companies).
The study has looked at artefacts and outcomes in a campaign to encourage people to quit smoking. It has identified a largely individualistic approach to the desired outcome and also that it often falls at an early hurdle, even within its own methodological approach. While the approach may induce fear, it may not have the desired change in behaviour. If this is the case, it will not be the first time that a health promoter has damaged rather than helped his or her charge: the history of medicine is often a history of dangerous quackery.
The immediate implication from the study is that care has to be taken when designing and delivering messages so that a counter and resistant psychic force is not induced by the message and its medium. It was heartening to find from the research that the appeal to altruism, inspired by the video clip of children ‘smoking’, had an effect on smokers and non-smokers alike.
The study does not, however, overcome the important emergent issues of dealing with the habituated addicted smoker through these campaigns and, more fundamentally, redressing the strong social/political oppositions to quit smoking in the form of the tobacco industry’s efforts to promote smoking. The ethical issues of what is acceptable in campaigns to reduce unhealthy behaviour also remain unresolved.
Finally, while some parts of public health have only recently become aware of social marketing as a concept (see for example Spear, 2005), this preliminary study throws up questions about an individualistic approach to promoting health; an approach found by the Royal Society (1993) in its report on risk not to have delivered. Rather, they advocated more social and cultural avenues to explore in changing behaviours and outcomes. Such an approach, characteristic of the health development movement, requires a more serious examination by all public health practitioners.
We would like to acknowledge the great help given to us in this study by our colleague Andrea Lyons, also from Nottingham Trent University, who organised the successful call for volunteers, helped to facilitate the focus group, and interviewed some of the participants. We would also like to acknowledge the financial support given to the study by the Chartered Institute of Environmental Health via its research funding initiatives.
Musham and Trettin (2002) consider a number.
In his famous, On Liberty, JS Mill establishes what has become known as the harm principle. Under this principle, if an agent is both competent (i.e. an adult in full control of his/her faculties) and sufficiently well informed, coercion to prevent that agent choosing to engage in behaviour that risks self-harm cannot be justified.
And no doubt those goals should be – as the management books tell us – SMART, i.e. Specific, Measurable, Achievable, Reasonable, and with Time scales.
In fact he refers positively to their work on several occasions.
Hence the ‘hypo’ prefix in hypothesis.
Such annoyance might, of course, also be a thought tactic for distancing themselves from the message – see below.
Here between the implications of a health message (the need to give up smoking) and enjoyment of the current activity (the pleasure etc. from smoking).
The latter being exemplified by newspaper campaigns involving free newspapers to build the habit.
Sometimes reduced to “death wish.”
i.e. a "charge" attached to particular ideas (Evans and Tsatsaroni 1996). This is also referred to as cathexis which Stevens translates as “psychic energy invested in a desire, relationship or object” (Stevens 1983: 48).
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