Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.
The individual needs to be in possession of the relevant facts as well as of their reasoning faculties, such as not being intellectually disabled or mentally ill and without an impairment of judgement at the time of refusing. Such impairments might include illness, intoxication, drunkenness, using drugs, insufficient sleep, and other health problems. In cases where an individual is considered unable to give informed refusal, another person (guardian) may be authorised to give consent on their behalf. The concept grew out of and is similar to that of informed consent, but much less commonly used and applied. In the United States, it is recognised in certain state laws (in 2006: California, Nevada, Vermont, and Michigan) as well as in various court decisions.
As applied in the medical field, a physician has made an assessment of a patient and finds a specific test, intervention, or treatment is medically necessary. The patient refuses to consent to this recommendation. The physician then needs to explain the risks of not following through with the recommendations to allow the patient to make an informed decision against the recommendation. While in the past documentation of refusal of treatment has not been important, the widespread use of managed care, cost containment processes, as well as increased patient autonomy have created a situation where documented “informed refusal” is viewed as becoming more important. When refusal of treatment may result in significant damage or death, the interaction needs to be documented to protect the care giver in a potential later litigation against the allegation that the recommendation was either not made or not understood. On occasion, a patient will also refuse to sign the “informed refusal” document, in which case a witness would have to sign that the informed process and the refusal took place.
The pregnant patient represents a specific dilemma in the field of informed refusal as her action may result in harm or death to the foetus. Ethicists disagree on how to handle this situation.
The mature minor doctrine is a rule of law found in the United States and Canada accepting that an unemancipated minor patient may possess the maturity to choose or reject a particular health care treatment, sometimes without the knowledge or agreement of parents, and should be permitted to do so.
It is now generally considered a form of patients rights; formerly, the mature minor rule was largely seen as protecting health care providers from criminal and civil claims by parents of minors at least 15.
Jurisdictions may codify an age of medical consent, accept the judgment of licensed providers regarding an individual minor, or accept a formal court decision following a request that a patient be designated a mature minor, or may rely on some combination. For example, patients at least 16 may be assumed to be mature minors for this purpose, patients aged 13 to 15 may be designated so by licensed providers, and pre-teen patients may be so-designated after evaluation by an agency or court. The mature minor doctrine is sometimes connected with enforcing confidentiality of minor patients from their parents.
In the United States, a typical statute lists: “Who may consent [or withhold consent for] surgical or medical treatment or procedures.”
“…Any unemancipated minor of sufficient intelligence to understand and appreciate the consequences of the proposed surgical or medical treatment or procedures, for himself.”
Medical Emancipation
By definition, a “mature minor” has been found to have the capacity for decisional autonomy, or the right to make decisions including whether to undergo risky medical but potentially life-saving medical decisions alone, without parental approval. By contrast, “medical emancipation” formally releases children from some parental involvement requirements but does not necessarily grant that decision making to children themselves. Pursuant to statute, several jurisdictions grant medical emancipation to a minor who has become pregnant or requires sexual-health services, thereby permitting medical treatment without parental consent and, often, confidentiality from parents. A limited guardianship may be appointed to make medical decisions for the medically emancipated minor and the minor may not be permitted to refuse or even choose treatment.
Brief History
One significant early US case, Smith v. Seibly, 72 Wn.2d 16, 431 P.2d 719 (1967), before the Washington Supreme Court, establishes precedent on the mature minor doctrine. The plaintiff, Albert G. Smith, an 18-year-old married father, was suffering from myasthenia gravis, a progressive disease. Because of this, Smith expressed concern that his wife might become burdened in caring for him, for their existing child and possibly for additional children. On 09 March 1961, while still 18, Smith requested a vasectomy. His doctor required written consent, which Smith provided, and the surgery was performed. Later, after reaching Washington’s statutory age of majority, then 21, the doctor was sued by Smith, who now claimed that he had been a minor and thus unable to grant surgical or medical consent. The Court rejected Smith’s argument: “Thus, age, intelligence, maturity, training, experience, economic independence or lack thereof, general conduct as an adult and freedom from the control of parents are all factors to be considered in such a case [involving consent to surgery].”
The court further quoted another recently decided case, Grannum v. Berard, 70 Wn.2d 304, 307, 422 P.2d 812 (1967): “The mental capacity necessary to consent to a surgical operation is a question of fact to be determined from the circumstances of each individual case.” The court explicitly stated that a minor may grant surgical consent even without formal emancipation.
Especially since the 1970s, older paediatric patients sought to make autonomous decisions regarding their own treatment, and sometimes sued successfully to do so. The decades of accumulated evidence tended to demonstrate that children are capable of participating in medical decision-making in a meaningful way; and legal and medical communities have demonstrated an increasing willingness to formally affirm decisions made by young people, even regarding life and death.
Religious beliefs have repeatedly influenced a patient’s decision to choose treatment or not. In a case in 1989 in Illinois, a 17-year-old female Jehovah’s Witness was permitted to refuse necessary life saving treatments.
In 1990, the United States Congress passed the Patient Self-Determination Act; even though key provisions apply only to patients over age 18, the legislation advanced patient involvement in decision-making. The West Virginia Supreme Court, in Belcher v. Charleston Area Medical Centre (1992) defined a “mature minor” exception to parental consent, according consideration to seven factors to be weighed regarding such a minor: age, ability, experience, education, exhibited judgment, conduct, and appreciation of relevant risks and consequences.
The 2000s and 2010s experienced a number of outbreaks of vaccine-preventable diseases, such as the 2019-2020 measles outbreaks, which were fuelled in part by vaccine hesitancy. This prompted minors to seek vaccinations over objections from their parents. Beginning in the 2020s during the COVID-19 pandemic, minors also began seeking out the COVID-19 vaccine over the objections of their vaccine-hesitant parents.
Laws by Jurisdiction
Canada
The Supreme Court of Canada recognised mature minor doctrine in 2009; in provinces and territories lacking relevant statutes, common law is presumed to be applied.
Province/Territory
Minimum Age
Outline
Alberta
None
The Child, Youth and Family Enhancement Act does not establish a minimum age. In practice, children at 16 are generally considered capable of consent to medical procedures; in some cases, the doctrine has been applied to children as young as 14.
British Columbia
None
The Infants Act does not set an age at which a child becomes capable of consent to medical procedures, but the child must be capable of understanding the procedure and its risks in order to consent.
Manitoba
None
It is presumed minors 16 and older can provide consent; minors 15 and younger and presumed to be incapable of consent but this can be rebutted.
New Brunswick
None
Under the Medical Consent of Minors Act, minors 16 and older can consent to medical procedures. Minors under 16 can consent to treatment if they can demonstrate an understanding of the procedure and its consequences.
Newfoundland and Labrador
None
The Advanced Health Care Directives Act presumes minors 16 and older are capable of consent to treatment.
Northwest Territories
None
No statute exists in Northwest Territories dictating an age of consent; absent a statute, common law applies.
Nova Scotia
None
Medical procedures can be performed on any person capable of providing informed consent.
Nunavet
None
No statute exists in Nunavut dictating an age of consent.
Ontario
None
The Health Care Consent Act allows all persons capable of informed consent to agree to treatment. The Substitute Decisions Act presumes all persons 16 or older can give or withhold consent to care.
Prince Edward Island
None
Medical procedures can be performed on any person capable of providing informed consent.
Quebec
14
Minors 14 and older may consent to medical care but still require parental consent for optional procedures that involve significant risks, e.g. cosmetic surgery.
Saskatchewan
None
Medical procedures can be performed on any person capable of providing informed consent.
Yukon
None
Medical procedures can be performed on any person capable of providing informed consent.
United States
Several states permit minors to legally consent to medical treatment without parental consent or over parental objections. In addition, many other states allow minors to consent to medical procedures under a more limited set of circumstances. These include providing limited minor autonomy only in enumerated cases, such as blood donation, substance abuse, sexual and reproductive health (including abortion and sexually transmitted infections), or for emergency medical services. Many states also exempt specific groups of minors from parental consent, such as homeless youth, emancipated minors, minor parents, or married minors. Further complicating matters is the interaction between state tort law, state contract law, and federal law, depending on if the clinic accepts federal funding under Title X or Medicaid.
State
Minimum Age
Outline
Alabama
14
Minors 14 years or older or who have graduated high school can consent to medical procedures. No evaluation of maturity required. Parental consent is required for abortion but can be bypassed.
Alaska
None
No evaluation of maturity required. Parental consent is not required for abortion, as this violates the Constitution of Alaska’s clause protecting privacy.
Arkansas
None
Any minors capable of informed consent.
California
12
CA Family Code 6926 permits minors to consent to immunization against sexually transmitted infections.
Delaware
None
“Reasonable efforts” must have first been made to secure parental consent. Minors can consent to vaccinations for sexually transmitted infections.
Idaho
None
Any minors capable of informed consent.
Illinois
None
Any minors capable of informed consent, but informed refusal of medical treatment can be overruled.
Kansas
16
Minors aged 16 are permitted de jure to consent to medical treatment when no parent is available. Mature minors are permitted to consent to medical treatment, but maturity must be assessed on a case-by-case basis.
Louisiana
None
Minors are allowed to consent to any medical procedure they deem necessary.
Maine
None
A mature minor’s wishes expressed in a living will must be considered.
Massachusetts
None
Mature minors meeting are permitted to consent to medical treatment, but only if their “best interests … will be served by not notifying his or her parents of intended medical treatment.”
Minnesota
None
Minnesota Statutes §144.3441 permits minors to consent to immunisation against Hepatitis B.
Montana
None
Any minors who have completed high school are able to consent to medical treatment.
Nevada
None
Mature minors meeting are permitted to consent to medical treatment, but only if the healthcare worker believes the minor would risk a “serious health hazard” absent treatment.
New York
None
NY Public Health Law §2305 permits minors to consent to treatment for and immunization against sexually transmitted infections.
Oregan
15
Minors aged 15 and up have the authority to consent to (but not necessarily refuse) medical treatment.
Pennsylvania
18
Minors aged 18 or who have completed high school can consent to medical treatment.
South Carolina
16
Minors aged 16 and up can consent to any medical treatment other than “operations”.
Tennessee
7
Any mature minors capable of informed consent can consent to medical procedures. The courts make the rebuttable presumption that minors aged 7 to 13 are not mature, while minors 14 and up are.
Washington
None
Mature minors may consent to medical procedures, including immunisations.
Washington D.C.
12
Minors 12 and older may consent to immunisation with CDC-approved vaccines, even over parental objections. The law compels healthcare providers to seek payment directly from insurance companies without notifying parents.
West Virginia
None
Any minors capable of informed consent can consent to medical procedures.
Withholding of Consent
United States
In the United States, bodily integrity has long been considered a common law right; the United States Supreme Court, in 1891’s Union Pacific Railway Company v. Botsford, found, “No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law.” The Supreme Court in 1990 (Cruzan v. Director, Missouri Department of Health) allowed that “constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred” in the Due Process Clause of the Fourteenth Amendment to the United States Constitution, but the Court refrained from explicitly establishing what would have been a newly enumerated right. Nevertheless, lower courts have increasingly held that competent patients have the right to refuse any treatment for themselves.
In 1989, the Supreme Court of Illinois interpreted the Supreme Court of the United States to have already adopted major aspects of mature minor doctrine, concluding:
Although the United States Supreme Court has not broadened this constitutional right of minors beyond abortion cases, the [Illinois] appellate court found such an extension “inevitable.” …Nevertheless, the Supreme Court has not held that a constitutionally based right to refuse medical treatment exists, either for adults or minors. …[U.S. Supreme Court] cases do show, however, that no “bright line” age restriction of 18 is tenable in restricting the rights of mature minors, [thus] mature minors may possess and exercise rights regarding medical care… If the evidence is clear and convincing that the minor is mature enough to appreciate the consequences of her actions, and that the minor is mature enough to exercise the judgment of an adult, then the mature minor doctrine affords her the common law right to consent to or refuse medical treatment [including life and death cases, with some considerations].
An ongoing case of Z.M is being heard in Maryland regarding the minor’s right to refuse chemotherapy.
In Connecticut, Cassandra C. a seventeen-year-old, was ordered by the Connecticut Supreme Court to receive treatment. The court decided that Cassandra was not mature enough to make medical decisions.
Canada
In 2009, the Supreme Court of Canada ruling in A.C. v. Manitoba [2009] SCC 30 (CanLII) found that children may make life and death decisions about their medical treatment. In the majority opinion, Justice Rosalie Abella wrote:
“The result of this [decision] is that young people under 16 will have the right to demonstrate mature medical decisional capacity. …If, after a careful analysis of the young person’s ability to exercise mature and independent judgment, the court is persuaded that the necessary level of maturity exists, the young person’s views ought to be respected.”
A “dissenting” opinion by Justice Ian Binnie would have gone further:
“At common law, proof of capacity entitles the ‘mature minor’ to exercise personal autonomy in making medical treatment decisions free of parental or judicial control. …[A] young person with capacity is entitled to make the treatment decision, not just to have ‘input’ into a judge’s consideration of what the judge believes to be the young person’s best interests.”
Analysts note that the Canadian decision merely requires that younger patients be permitted a hearing, and still allows a judge to “decide whether or not to order a medical procedure on an unwilling minor”.
Secretary of the Department of Health and Community Services v JWB and SMB, commonly known as Marion’s Case, is a leading decision of the High Court of Australia, concerning whether a child has the capacity to make decisions for themselves, and when this is not possible, who may make decisions for them regarding major medical procedures.
“Marion”, a pseudonym for the 14-year-old girl at the centre of this case, suffered from intellectual disabilities, severe deafness, epilepsy and other disorders. Her parents, a married couple from the Northern Territory sought an order from the Family Court of Australia authorising them to have Marion undergo a hysterectomy and an oophrectomy (removal of ovaries). The practical effect would be sterilisation and preventing Marion from being able to have children and many of the hormonal effects of adulthood.
Under the Family Law Act the primary concern for matters involving children is that the court must act in the child’s best interests. The majority of the High Court made it clear that it was merely deciding a point of law and that the decision about what was in the child’s “best interests” would be left to the Family Court of Australia after the case.
The main legal debate that arose was who has the legal authority to authorise the operation. Three options existed: the parents (as legal guardians of their daughter), Marion or an order of a competent court, such as the Family Court of Australia. The Full Court of the Family Court was asked to decide:
Could the parents, as joint guardians authorise the sterilisation procedure;
If not, does the Family Court have jurisdiction to: (a) authorise the carrying out of such a procedure; (b) enlarge the powers, rights or duties of the parents to enable them to authorise such a procedure; or (c) approve the consent of the Applicants, as to the proposed procedure.
The majority of the Family Court, Strauss and McCall JJ held that the parents, as joint guardians could authorise the sterilisation procedure. Nicholson CJ held that the Family Court had jurisdiction to authorise the procedure.
The department, together with the Attorney-General for Australia, argued that only a court could authorise such a major operation and that the Family Court jurisdiction included any matter relating to the welfare of a child even if it was not a dispute about custody, guardianship or access.
The parents, however, “argued that the decision to sterilise a child is not significantly different from other major decisions that parents and guardians have to make for children and that the involvement of the Family Court is optional and only of a ‘supervisory nature’. Their argument was that, provided such a procedure is in the best interests of the child, parents as guardians can give lawful consent to a sterilisation on behalf of a mentally incompetent child.”
Judgement
The High Court recognised the right of everyone to bodily integrity under national and international law, and made a distinction between therapeutic and non-therapeutic surgical procedures as well as the duty of surrogates to act in the best interests of the incompetent patient.
In the case, the High Court ruled that while parents may consent to medical treatment for their children, the authority does not extend to treatment not in the child’s best interests. Also, the Court held that if medical treatment has sterilisation as its principal objective, parents do not have the authority to consent on behalf of their child.
Obiter Dictum
The statement by Deane J that parents may grant surrogate consent for the non-therapeutic circumcision of male children is obiter dictum and not part of the judgment. Male circumcision was not at issue in the case and no evidence or testimony was offered regarding male circumcision.
Behavioural addiction is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behaviour – sometimes called a natural reward – despite any negative consequences to the person’s physical, mental, social or financial well-being. Addiction canonically refers to substance abuse; however, the term’s connotation has been expanded to include behaviours that may lead to a reward (e.g. gambling, eating, or shopping) since the 1990s. A gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioural and drug addictions, which are associated with the same set of neural adaptations in the reward system.
Psychiatric and Medical Classifications
Diagnostic models do not currently include the criteria necessary to identify behaviours as addictions in a clinical setting. Behavioural addictions have been proposed as a new class in DSM-5, but the only category included is gambling addiction. Internet gaming addiction is included in the appendix as a condition for further study.
Behavioural addictions, which are sometimes referred to as impulse control disorders, are increasingly recognised as treatable forms of addiction. The type of excessive behaviours identified as being addictive include gambling, eating, having sexual intercourses, using pornography, computers, video games, internet and digital media, physical exercise, and shopping.
In August 2011, the American Society of Addiction Medicine (ASAM) issued a public statement defining all addiction in terms of brain changes. “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.”
The following excerpts are taken from the organisation’s FAQs:
The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This is the first time that ASAM has taken an official position that addiction is not solely “substance dependence.” This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction.
We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors. So, anyone who has addiction is vulnerable to food and sex addiction.
Meanwhile, DSM-5 has deprecated the term “addiction”.
Treatment
Behavioural addiction is a treatable condition. Treatment options include psychotherapy and psychopharmacotherapy (i.e. medications) or a combination of both. Cognitive behavioural therapy (CBT) is the most common form of psychotherapy used in treating behavioural addictions; it focuses on identifying patterns that trigger compulsive behaviour and making lifestyle changes to promote healthier behaviours. Because cognitive behavioural therapy is considered a short term therapy, the number of sessions for treatment normally ranges from five to twenty. During the session, therapists will lead patients through the topics of identifying the issue, becoming aware of one’s thoughts surrounding the issue, identifying any negative or false thinking, and reshaping said negative and false thinking. While CBT does not cure behavioural addiction, it does help with coping with the condition in a healthy way. Currently, there are no medications approved for treatment of behavioural addictions in general, but some medications used for treatment of drug addiction may also be beneficial with specific behavioural addictions. Any unrelated psychiatric disorders should be kept under control, and differentiated from the contributing factors that cause the addiction.
Research
A recent narrative review in 2017 examined the existing literature for studies reporting associations between behavioural addictions (pathological gambling, problematic internet use, problematic online gaming, compulsive sexual behaviour disorder, compulsive buying and exercise addiction) and psychiatric disorders. Overall, there is solid evidence for associations between behavioural addictions and mood disorder, anxiety disorder as well as substance use disorders. Associations between ADHD may be specific to problematic internet use and problematic online gaming. The authors also conclude that most of current research on the association between behavioural addictions and psychiatric disorders has several limitations: they are mostly cross-sectional, are not from representative samples, and are often based on small samples, among others. Especially more longitudinal studies are needed to establish the direction of causation, i.e. whether behavioural addictions are a cause or a consequence of psychiatric disorders.
Biomolecular Mechanisms
ΔFosB, a gene transcription factor, has been identified as playing a critical role in the development of addictive states in both behavioural addictions and drug addictions. Overexpression of ΔFosB in the nucleus accumbens is necessary and sufficient for many of the neural adaptations seen in drug addiction; it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, phenylcyclidine, and substituted amphetamines as well as addictions to natural rewards such as sex, exercise, and food. A recent study also demonstrated a cross-sensitization between drug reward (amphetamine) and a natural reward (sex) that was mediated by ΔFosB.
Besides increased ΔFosB expression in the nucleus accumbens, there are many other correlations in the neurobiology of behavioural addictions with drug addictions.
One of the most important discoveries of addictions has been the drug based reinforcement and, even more important, reward based learning processes. Several structures of the brain are important in the conditioning process of behavioural addiction; these subcortical structures form the brain regions known as the reward system. One of the major areas of study is the amygdala, a brain structure which involves emotional significance and associated learning. Research shows that dopaminergic projections from the ventral tegmental area facilitate a motivational or learned association to a specific behaviour. Dopamine neurons take a role in the learning and sustaining of many acquired behaviours. Research specific to Parkinson’s disease has led to identifying the intracellular signalling pathways that underlie the immediate actions of dopamine. The most common mechanism of dopamine is to create addictive properties along with certain behaviours. There are three stages to the dopamine reward system: bursts of dopamine, triggering of behaviour, and further impact to the behaviour. Once electronically signalled, possibly through the behaviour, dopamine neurons let out a ‘burst-fire’ of elements to stimulate areas along fast transmitting pathways. The behaviour response then perpetuates the striated neurons to further send stimuli. The fast firing of dopamine neurons can be monitored over time by evaluating the amount of extracellular concentrations of dopamine through micro dialysis and brain imaging. This monitoring can lead to a model in which one can see the multiplicity of triggering over a period of time. Once the behaviour is triggered, it is hard to work away from the dopamine reward system.
Behaviours like gambling have been linked to the newfound idea of the brain’s capacity to anticipate rewards. The reward system can be triggered by early detectors of the behaviour, and trigger dopamine neurons to begin stimulating behaviours. But in some cases, it can lead to many issues due to error, or reward-prediction errors. These errors can act as teaching signals to create a complex behaviour task over time.
Reduced affect display, sometimes referred to as emotional blunting, is a condition of reduced emotional reactivity in an individual.
It manifests as a failure to express feelings (affect display) either verbally or nonverbally, especially when talking about issues that would normally be expected to engage the emotions. Expressive gestures are rare and there is little animation in facial expression or vocal inflection. Reduced affect can be symptomatic of autism, schizophrenia, depression, posttraumatic stress disorder, depersonalisation disorder, schizoid personality disorder or brain damage. It may also be a side effect of certain medications (e.g. antipsychotics and antidepressants).
Reduced affect should be distinguished from apathy and anhedonia, which explicitly refer to a lack of emotion, whereas reduced affect is a lack of emotional expression (affect display) regardless of whether emotion (underlying affect) is actually reduced or not.
Types
Constricted Affect
A restricted or constricted affect is a reduction in an individual’s expressive range and the intensity of emotional responses.
Blunted and Flat Affect
Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect. “The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. They may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression”.
Shallow Affect
Shallow affect has equivalent meaning to blunted affect. Factor 1 of the Psychopathy Checklist identifies shallow affect as a common attribute of psychopathy.
Brain structures
Individuals with schizophrenia with blunted affect show different regional brain activity in fMRI scans when presented with emotional stimuli compared to individuals with schizophrenia without blunted affect. Individuals with schizophrenia without blunted affect show activation in the following brain areas when shown emotionally negative pictures: midbrain, pons, anterior cingulate cortex, insula, ventrolateral orbitofrontal cortex, anterior temporal pole, amygdala, medial prefrontal cortex, and extrastriate visual cortex. Individuals with schizophrenia with blunted affect show activation in the following brain regions when shown emotionally negative pictures: midbrain, pons, anterior temporal pole, and extrastriate visual cortex.
Limbic Structures
Individuals with schizophrenia with flat affect show decreased activation in the limbic system when viewing emotional stimuli. In individuals with schizophrenia with blunted affect neural processes begin in the occipitotemporal region of the brain and go through the ventral visual pathway and the limbic structures until they reach the inferior frontal areas. Damage to the amygdala of adult rhesus macaques early in life can permanently alter affective processing. Lesioning the amygdala causes blunted affect responses to both positive and negative stimuli. This effect is irreversible in the rhesus macaques; neonatal damage produces the same effect as damage that occurs later in life. The macaques’ brain cannot compensate for early amygdala damage even though significant neuronal growth may occur. There is some evidence that blunted affect symptoms in schizophrenia patients are not a result of just amygdala responsiveness, but a result of the amygdala not being integrated with other areas of the brain associated with emotional processing, particularly in amygdala-prefrontal cortex coupling. Damage in the limbic region prevents the amygdala from correctly interpreting emotional stimuli in individuals with schizophrenia by compromising the link between the amygdala and other brain regions associated with emotion.
Brainstem
Parts of the brainstem are responsible for passive emotional coping strategies that are characterised by disengagement or withdrawal from the external environment (quiescence, immobility, hyporeactivity), similar to what is seen in blunted affect. Individuals with schizophrenia with blunted affect show activation of the brainstem during fMRI scans, particularly the right medulla and the left pons, when shown “sad” film excerpts. The bilateral midbrain is also activated in individuals with schizophrenia diagnosed with blunted affect. Activation of the midbrain is thought to be related to autonomic responses associated with perceptual processing of emotional stimuli. This region usually becomes activated in diverse emotional states. When the connectivity between the midbrain and the medial prefrontal cortex is compromised in individuals with schizophrenia with blunted affect an absence of emotional reaction to external stimuli results.
Prefrontal Cortex
Individuals with schizophrenia, as well as patients being successfully reconditioned with quetiapine for blunted affect, show activation of the prefrontal cortex (PFC). Failure to activate the PFC is possibly involved in impaired emotional processing in individuals with schizophrenia with blunted affect. The mesial PFC is activated in aver individuals in response to external emotional stimuli. This structure possibly receives information from the limbic structures to regulate emotional experiences and behaviour. Individuals being reconditioned with quetiapine, who show reduced symptoms, show activation in other areas of the PFC as well, including the right medial prefrontal gyrus and the left orbitofrontal gyrus.
Anterior Cingulate Cortex
A positive correlation has been found between activation of the anterior cingulate cortex and the reported magnitude of sad feelings evoked by viewing sad film excerpts. The rostral subdivision of this region is possibly involved in detecting emotional signals. This region is different in individuals with schizophrenia with blunted affect.
Diagnoses
Schizophrenia
Flat and blunted affect is a defining characteristic in the presentation of schizophrenia. To reiterate, these individuals have a decrease in observed vocal and facial expression as well as the use of gestures. One study of flat affect in schizophrenia found that “flat affect was more common in men, and was associated with worse current quality of life” as well as having “an adverse effect on course of illness”.
The study also reported a “dissociation between reported experience of emotion and its display” – supporting the suggestion made elsewhere that “blunted affect, including flattened facial expressiveness and lack of vocal inflection … often disguises an individual’s true feelings.” Thus, feelings may merely be unexpressed, rather than totally lacking. On the other hand, “a lack of emotions which is due not to mere repression but to a real loss of contact with the objective world gives the observer a specific impression of ‘queerness’ … the remainders of emotions or the substitutes for emotions usually refer to rage and aggressiveness”. In the most extreme cases, there is a complete “dissociation from affective states”. To further support this idea, a study examining emotion dysregulation found that individuals with schizophrenia could not exaggerate their emotional expression as healthy controls could. Participants were asked to express whatever emotions they had during a clip of a film, and the participants with schizophrenia showed deficits in behavioural expression of their emotions.
There is still some debate regarding the source of flat affect in schizophrenia. However, some literature indicates abnormalities in the dorsal executive and ventral affective systems; it is argued that dorsal hypoactivation and ventral hyperactivation may be the source of flat affect. Further, the authors found deficits in the mirror neuron system may also contribute to flat affect in that the deficits may cause disruptions in the control of facial expression.
Another study found that when speaking, individuals with schizophrenia with flat affect demonstrate less inflection than normal controls and appear to be less fluent. Normal subjects appear to express themselves using more complex syntax, whereas flat affect subjects speak with fewer words, and fewer words per sentence. Flat affect individuals’ use of context-appropriate words in both sad and happy narratives are similar to that of controls. It is very likely that flat affect is a result of deficits in motor expression as opposed to emotional processing. The moods of display are compromised, but subjective, autonomic, and contextual aspects of emotion are left intact.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) was previously known to cause negative feelings, such as depressed mood, re-experiencing and hyperarousal. However, recently, psychologists have started to focus their attention on the blunted affects and also the decrease in feeling and expressing positive emotions in PTSD patients. Blunted affect, or emotional numbness, is considered one of the consequences of PTSD because it causes a diminished interest in activities that produce pleasure (anhedonia) and produces feelings of detachment from others, restricted emotional expression and a reduced tendency to express emotions behaviourally. Blunted affect is often seen in veterans as a consequence of the psychological stressful experiences that caused PTSD. Blunted affect is a response to PTSD, it is considered one of the central symptoms in post-traumatic stress disorders and it is often seen in veterans who served in combat zones. In PTSD, blunted affect can be considered a psychological response to PTSD as a way to combat overwhelming anxiety that the patients feel. In blunted affect, there are abnormalities in circuits that also include the prefrontal cortex.
Assessment
In making assessments of mood and affect the clinician is cautioned that “it is important to keep in mind that demonstrative expression can be influenced by cultural differences, medication, or situational factors”; while the layperson is warned to beware of applying the criterion lightly to “friends, otherwise [he or she] is likely to make false judgments, in view of the prevalence of schizoid and cyclothymic personalities in our ‘normal’ population, and our [US] tendency to psychological hypochondriasis”.
R.D. Laing in particular stressed that “such ‘clinical’ categories as schizoid, autistic, ‘impoverished’ affect … all presuppose that there are reliable, valid impersonal criteria for making attributions about the other person’s relation to [his or her] actions. There are no such reliable or valid criteria”.
Differential Diagnosis
Blunted affect is very similar to anhedonia, which is the decrease or cessation of all feelings of pleasure (which thus affects enjoyment, happiness, fun, interest, and satisfaction). In the case of anhedonia, emotions relating to pleasure will not be expressed as much or at all because they are literally not experienced or are decreased. Both blunted affect and anhedonia are considered negative symptoms of schizophrenia, meaning that they are indicative of a lack of something. There are some other negative symptoms of schizophrenia which include avolition, alogia and catatonic behaviour.
Closely related is alexithymia – a condition describing people who “lack words for their feelings. They seem to lack feelings altogether, although this may actually be because of their inability to express emotion rather than from an absence of emotion altogether”. Alexithymic patients however can provide clues via assessment presentation which may be indicative of emotional arousal.
“If the amygdala is severed from the rest of the brain, the result is a striking inability to gauge the emotional significance of events; this condition is sometimes called ‘affective blindness'”. In some cases, blunted affect can fade, but there is no conclusive evidence of why this can occur.
Affective labour is work carried out that is intended to produce or modify emotional experiences in people.
This is in contrast to emotional labour, which is intended to produce or modify one’s own emotional experiences. Coming out of Autonomist feminist critiques of marginalised and so-called “invisible” labour, it has been the focus of critical discussions by, e.g., Antonio Negri, Michael Hardt, Juan Martin Prada, and Michael Betancourt.
Although its history is as old as that of labour itself, affective labour has been of increasing importance to modern economies since the emergence of mass culture in the nineteenth century. The most visible institutionalised form of affective labour is perhaps advertising, which typically attempts to make audiences relate to products through particular effects. Yet there are many other areas in which affective labour figures prominently, including service and care industries whose purpose is to make people feel in particular ways. Domestic work, frequently ignored by other analysts of labour, has also been a critical focus of theories of affective labour.
Brief History
The phrase affective labour, seen broadly, has its roots in the Autonomist critiques of the 1970s, in particular those that theorise a dynamic form of capitalism that is able to move away from purely industrial labour. In particular, the “Fragment on Machines,” from Marx’s Grundrisse, and conceptions of immaterial labour decentred the focus of labour theory and sparked debate over what constituted real labour:
No longer does the worker insert a modified natural thing (Naturgegenstand) as middle link between the object (Objekt) and himself; rather, he inserts the process of nature, transformed into an industrial process, as a means between himself and inorganic nature, mastering it. He steps to the side of the production process instead of being its chief actor. In this transformation, it is neither the direct human labour he himself performs, nor the time during which he works, but rather the appropriation of his own general productive power, his understanding of nature and his mastery over it by virtue of his presence as a social body – it is, in a word, the development of the social individual which appears as the great foundation-stone of production and of wealth.
Meanwhile, movements such as Selma James and Marirosa Dalla Costa’s Wages for housework campaign attempted to activate the most exploited and invisible sectors of the economy and challenge the typical, male and industrial focus of labour studies.
Hardt and Negri
Antonio Negri and Michael Hardt have begun to develop this concept in their books Empire and Multitude: War and Democracy in the Age of Empire.
In their recent work, Hardt and Negri focus on the role affective labour plays in the current mode of production (which can be referred to as “imperial”, “late capitalist”, or “postmodern”). In this passage from Multitude they briefly define their key terms:
“Unlike emotions, which are mental phenomena, affects refer equally to body and mind. In fact, affects, such as joy and sadness, reveal the present state of life in the entire organism, expressing a certain state of the body along with a certain mode of thinking. Affective labor, then, is labor that produces or manipulates affects…. One can recognize affective labor, for example, in the work of legal assistants, flight attendants, and fast food workers (service with a smile). One indication of the rising importance of affective labor, at least in the dominant countries, is the tendency for employers to highlight education, attitude, character, and “prosocial” behavior as the primary skills employees need. A worker with a good attitude and social skills is another way of saying a worker is adept at affective labor.”
The most important point in their scholarship with respect to this issue is that immaterial labour, of which affective labour is a specific form, has achieved dominance in the current mode of production. This does not mean that there are more immaterial laborers than material laborers, or that immaterial labour produces more capital than material labour. Instead, this dominance is signalled by the fact that, in developed countries, labour is more often figured as immaterial than material. To illustrate the significance of this claim, they draw a comparison between the early twenty-first century and that of the mid-nineteenth century, famously engaged by Karl Marx, in which factory labour was dominant even if it was not the form of labour practiced by the most people. One popular, albeit slightly less than perfect example, of this might be that, whereas Fred Flintstone, as an average American, drove a crane in a quarry, Homer Simpson sits at a desk and provides safety.
Role in the Political Economy
Michael Betancourt has suggested that affective labour may have a role in the development and maintenance of what he has termed “agnotologic capitalism”. His point is that affective labour is a symptom of the disassociation between the reality of capitalist economy and the alienation it produces:
The affective labor created to address this alienation is part of the mechanisms where the agnotological order maintains its grip on the social: managing the emotional states of the consumers, who also serve as the labor reserve, is a necessary precondition for the effective management of the quality and range of information.
His construction of affective labour is concerned with its role as an enabler for a larger capitalist superstructure, where the reduction of alienation is a precondition for the elimination of dissent. Affective labour is part of a larger activity where the population is distracted by affective pursuits and fantasies of economic advancement.
However, the latter is a reflection of an individual’s mood status rather than their affect.
Affect regulation is the actual performance one can demonstrate in a difficult situation regardless of what their mood or emotions are. It is tightly related to the quality of executive and cognitive functions and that is what distinguishes this concept from emotion regulation.
One can have a low emotional control but a high level of control on his or her affect, and therefore, demonstrate a normal interpersonal functioning as a result of intact cognition.
Specifically, it refers to the idea that explicitly labelling one’s, typically negative, emotional state results in a reduction of the conscious experience, physiological response, and/or behaviour resulting from that emotional state. For example, writing about a negative experience in one’s journal may improve one’s mood. Some other examples of affect labelling include discussing one’s feelings with a therapist, complaining to friends about a negative experience, posting one’s feelings on social media or acknowledging the scary aspects of a situation.
Affect labelling is an extension of the simple concept that talking about one’s feelings can make oneself feel better. Although this idea has been used in talk therapy for over a century, formal research into affect labelling has only begun in recent years. Already, researchers have quantified some of the emotion-regulatory effects of affect labelling, such as decreases in subjective emotional affect, reduced activity in the amygdala, and a lower skin conductance response to frightening stimuli. As a consequence of being a relatively new technique in the area of emotion regulation, affect labelling tends to be compared to, and is often confused with, emotional reappraisal, another emotion-regulatory technique. A key difference between the two is that while reappraisal intuitively feels like a strategy to control one’s emotions, affect labelling often does not. Even when someone does not intend to regulate their emotions, the act of labelling one’s emotions still has positive effects.
Affect labelling is still in the early stages of research and thus, there is much about it that remains unknown. While there are several theories for the mechanism by which affect labelling acts, more research is needed to provide empirical support for these hypotheses. Additionally, some work has been done on the applications of affect labelling to real-world issues, such as research that suggests affect labelling may be commonplace on social media sites. Affect labelling also sees some use in clinical settings as a tentative treatment for fear and anxiety disorders. Nonetheless, research on affect labelling has largely focused on laboratory studies, and further research is needed to understand its effects in the real world.
Brief History
The notion that talking about or writing down one’s feelings can be beneficial is not a recent one. People have kept diaries for centuries, and the use of talk therapy dates back to the beginnings of psychotherapy. Over the past few decades, the idea that putting one’s feelings into words can be beneficial has been shown experimentally. More recently, the concept of affect labelling has grown out of this literature, honing in on the emotion regulation aspect of the benefits of vocalising feelings.
In recent years, research on affect labelling has mostly focused on proving its applicability as an emotion regulation strategy. Although some research exists on the behavioural and neural mechanisms behind its effectiveness, this area of study is still in its early, speculative stages.
Regulatory Effects
Emotional Experience
When engaging in affect labelling, subjects subjectively report lower levels of emotional affect than they do in identical conditions without the affect labelling. This effect is not only found when subjects rate their own emotional state, but also when they label the emotion displayed or evoked by stimuli such as images.
Autonomic Response
Autonomic responses characteristic of various emotions may decrease after performing affect labelling. For instance, upon quantifying their level of anger on a rating scale, subjects subsequently experienced decreases in heart rate and cardiac output. Research also indicates that giving labels to aversive stimuli results in a lower skin conductance response when similar aversive stimuli are presented in the future, implying affect labelling can have long-term effects on autonomic responses.
Neuroscientific Basis
Research has found that engaging in affect labelling results in higher brain activity within the ventrolateral prefrontal cortex (vlPFC), and reduced activity in the amygdala when compared to other tasks involving emotional stimuli. In addition, evidence from brain lesion studies also point to the vlPFC’s involvement in the affect labelling process. Subjects with lesions to the right vlPFC were less able to identify the emotional state of a character throughout a film. This implies that the region is required in order for affect-labelling to take place. Additionally, it has been shown through meta-analysis that while the amygdala is found to be active in tasks involving emotional stimuli, activity is lower when subjects had to identify the emotions rather than simply passively viewing the stimuli.
One theory that integrates these findings proposes that the ventrolateral prefrontal cortex works to down-regulate activity in the amygdala during affect labelling. This theory is supported by evidence from several studies that found negative connectivity between the two brain regions during an affect-labelling task. Furthermore, researchers have used dynamic causal modelling to show specifically that increased activity in the vlPFC is the cause of lower amygdala activity.
Comparison to Emotional Reappraisal
Emotional reappraisal is an emotion regulation technique where an emotional stimulus is reinterpreted in a new, usually less negative, fashion in order to reduce its effect. As an example, someone might reinterpret a bad test score as being a learning experience, rather than dwelling on the negative aspects of the situation. As it is a related emotion regulation strategy, affect labelling research often draws insight from the existing literature on reappraisal.
The most salient difference between affect labelling and reappraisal lies in people’s perception of the efficacy of affect labelling. Unlike reappraisal, affect labelling’s effectiveness in regulating emotion is fairly unintuitive. Research has shown that while subjects expect reappraisal to reduce emotional distress, they predict the opposite for affect labelling, expecting the vocalisation of feelings to actually increase their emotional distress. In reality, while the magnitude of the reduction in emotional response is found to be stronger for reappraisal than for affect labelling, both strategies produce a noticeable decrease.
Individuals who respond more to reappraisal after the presentation of emotional stimuli tend to also benefit more from affect labelling, indicating they may act through the same mechanism.
Reappraisal and affect labelling share similarities in their neural signatures. As in affect labelling, reappraisal produces activity in the vlPFC while inhibiting response in the amygdala. However, in contrast to affect labelling, reappraisal has also been found to generate activity in the anterior cingulate cortex, supplementary motor area, and dorsolateral prefrontal cortex.
Possible Mechanisms
Distraction
One possible explanation for affect labelling’s effectiveness is that it is simply preventing the labeller from fully experiencing the emotional response by drawing their attention away. Distraction techniques have been shown to elicit similar neural activity as affect labelling, with increased activity in the vlPFC and decreased in the amygdala. Additionally, some explicit distraction paradigms have been shown to result in similar reductions of negative emotions.
However, evidence is mixed on this front, as other tasks that involve turning attention away, such as a gender labelling task, do not produce the same reduction. Applications of affect labelling seem to suggest that the mechanism of action is not simply distraction. When applied with exposure therapy, affect labelling was found to be much more effective in reducing skin conductance response than distraction. Affect labelling is also known to result in long-term benefits in clinical settings, whereas distraction is generally considered to negatively affect progress.
Self-Reflection
Another proposed mechanism for affect labelling is through self-reflection. Emotional introspection differs from affect labelling in that it does not require explicit labelling of emotion; however, engaging in introspection has similar effects to affect labelling. As such, rather than being the entire process, affect labelling could act as a first-step in an emotional introspective process. Evidence supporting this mechanism uses a measure of dispositional mindfulness to quantify people’s ability to self-reflect. Researchers were able to link dispositional mindfulness to affect labelling by showing that people with higher levels of dispositional mindfulness showed stronger brain activation in regions associated with affect labelling, such as the vlPFC. Additionally, they showed greater reductions in activity in the amygdala, suggesting that mindfulness modulates the effectiveness of affect labelling, and lending support to the idea that introspection is the mechanism of action.
Unfortunately, this theory of affect labelling struggles to explain affect labelling’s benefits on stimuli that do not apply to the self. For instance, the regulatory effects of labelling external stimuli, such as faces or aversive images presented during an experiment, are unlikely to be explained by a self-reflective process.
Reduction of Uncertainty
People are known to be ambiguity averse, and the complexity of emotion can often create uncertainty in feelings that is unpleasant. Some researchers believe that affect labelling acts by reducing uncertainty in emotion. This is supported by neural evidence connecting uncertainty to activity in the amygdala. Affect labelling has been shown to down-regulate activity in the amygdala, and this may be a result of the reduction of uncertainty of feelings.
Evidence against this theory is the fact that while some emotions are characteristically uncertain, such as fear or anxiety, others tend to be more straightforward, e.g. sadness and anger. Since affect labelling is known to work across all these types of emotions, it is unlikely that uncertainty reduction is the only mechanism by which it acts.
Symbolic Conversion
Another theory of affect labelling posits that the act of labelling is a sort of symbolic encoding of information, changing the stimulus into language. It has been proposed that this symbolic conversion may act as a type of psychological distancing from the stimulus, leading to overall lower levels of affect. While affect labelling specifically refers to giving labels to emotions, assigning abstract content labels, such as identifying objects as “human”, “landscape”, etc., has been found to yield many of the same benefits. There is neural evidence to support this as well. Several studies have found that when subjects classify stimuli based on non-emotional categories, they exhibit greater vlPFC activity and less activity in the amygdala, just like in affect labelling. The fact that labelling non-emotional stimuli has similar effects to that of emotional stimuli suggests that the simple act of converting a stimulus into language may be driving the effect.
Applications
Social Media
The act of posting about one’s feelings on social media sites such as Twitter is a type of affect labelling. One research study analysed 74,487 Twitter users’ tweets for emotional contact, classifying tweets as either before or after instances of affect labelling, which were identified as tweets stating “I feel…”. The researchers found that emotions tended to increase in valence over time in tweets preceding the affect labelling tweet, with the greatest positive or negative emotion being experienced closest to the act of labelling. After the affect labelling tweet, the emotional intensity of the following tweets was found to fall off quickly, going back to baseline levels of valence. The results of this study support the application of affect labelling as an emotion regulation strategy in real-world settings, and show that social media users engage, potentially unknowingly, in affect labelling all the time.
Mental Health
A small body of work has begun to look at affect labelling’s potential as a clinical treatment in conjunction with exposure therapy for phobias, anxiety disorders, and other stress disorders.
One study found that subjects with high public speaking anxiety who chose from a set of predetermined emotion words to describe their feelings before giving a speech in front of an audience showed greater reductions in anxiety, quantified by physiological responses such as heart rate, than subjects who performed a control, shape-matching, task before giving their speeches. These results suggest that combining affect labelling with an exposure treatment is more effective than exposure alone. Notably, the affect labelling and control conditions found no difference in self-reported anxiety; however, physiological responses characteristic of anxiety were reduced for the subjects who performed the affect labelling.
Another study found similar results in spider-fearful individuals, exposing them to a tarantula over two days while simultaneously verbalising their feelings. Compared to subjects in reappraisal, distraction, and control conditions, subjects who engaged in affect labelling showed lower skin conductance response than the other conditions, although there was no difference between conditions in self-reported fear.
Although there is tentative evidence for the value of affect labelling in clinical settings, researchers acknowledge that there is still a need for many more studies drawing from clinical populations in order to deduce the value of using affect labelling in conjunction with other treatments before it can be safely adopted into practice.
Limitations and Concerns
The use of self-report measures of emotion in psychological research may invoke affect labelling, even in studies unrelated to the topic. Whether or not this poses a problem for emotion researchers is still largely unknown.
Although affect labelling appears be effective in laboratory studies with many participants, as with all psychological phenomena, individuals will vary in their experience. The reasons for individual differences in the effectiveness of affect labelling are in need of further research. Furthermore, paradigms used to study affect labelling differ widely, with some providing subjects with pre-prepared labels to select, while others require subjects to self-generate their own labels. These paradigms produce noticeable differences in results, with self-generative paradigms finding more long-term delayed effects of regulation, and pre-prepared paradigms finding immediate effects. The explanation for the differences in these results is still relatively unexplored, though some suspect it may be due to pre-prepared labels implying a kind of interpersonal emotion regulation, since it may be interpreted as a kind of support from the experimenter.
Whether or not the laboratory findings about affect labelling are applicable to affect labelling in the real world is another question researchers must ask. The situations in which people use affect labelling in real life are rich with context, and it is difficult to say whether the particular operationalisations of affect labelling used in a study allow the results to generalise.
In psychodynamic psychotherapy, working through is seen as the process of repeating, elaborating, and amplifying interpretations. It is believed that such working through is critical towards the success of therapy.
The concept was introduced by Sigmund Freud in 1914, and assumed ever greater importance in psychoanalysis, in contrast to the immediacy of abreaction.
Interpretation and Resistance
Interpretations are made when the client comes up with some material, be it written, a piece of art, music, or verbal, and are intended to bring the material offered into connection with the unconscious mind. Because of the resistance to accepting the unconscious, interpretations, whether correct or partially incorrect, consciously accepted or rejected, will inevitably require amplifying and extending to other aspects of the client’s life.
In a process Sandor Rado compared to the labour of mourning, the unconscious content must be demonstrated repeatedly in all its various forms and linkages – the process of working through.
Because of the power of resistance, the client’s rational thought and conscious awareness may not be sufficient on their own to overcome the maladjustment, entailing further interpretation and further working through.
Rat Man
Before formulating the concept of working through, in his case study of the Rat Man, Freud wrote of his interpretations:
“It is never the aim of discussions like these to create convictions. They are only intended to bring the repressed complexes into consciousness…and to facilitate the emergence of fresh material from the unconscious. A sense of conviction is only attained after the patient has himself worked over the reclaimed material”.
Transference
The necessity of working through the transference is stressed in almost all forms of psychodynamic therapy, from object relations theory, through the openings offered for working through by transference disruption in self psychology, to the repetitive exploration of the transference in group therapy.
Abreaction (German: Abreagieren) is a psychoanalytical term for reliving an experience to purge it of its emotional excesses – a type of catharsis.
Sometimes it is a method of becoming conscious of repressed traumatic events.
Psychoanalytic Origins
The concept of abreaction may have actually been initially formulated by Freud’s mentor, Josef Breuer; but it was in their joint work of 1895, Studies on Hysteria, that it was first made public to denote the fact that pent-up emotions associated with a trauma can be discharged by talking about it. The release of strangulated affect by bringing a particular moment or problem into conscious focus, and thereby abreacting the stifled emotion attached to it, formed the cornerstone of Freud’s early cathartic method of treating hysterical conversion symptoms. For instance, they believed that pent-up emotions associated with trauma can be discharged by talking about it. Freud and Breur, however, did not treat the spontaneous emotional reliving of traumatic event as curative. They instead described abreaction as the full emotional and motoric response to a traumatic event necessary in adequately relieving a person of being repetitively and unpredictably assailed by the trauma’s original and unmitigated emotional intensity. Although the element of surprise is not compatible with Freud’s approach to therapy, other theorists consider that, in abreaction, it is an important part of analytic technique.
Early in his career, psychoanalyst Carl Jung expressed interest in abreaction, or what he referred to as trauma theory, but later decided it had limitations in treatment of neurosis. Jung said:
Though traumata of clearly aetiological significance were occasionally present, the majority of them appeared very improbable. Many traumata were so unimportant, even so normal, that they could be regarded at most as a pretext for the neurosis. But what especially aroused my criticism was the fact that not a few traumata were simply inventions of fantasy and had never happened at all.
Later Developments
Mainstream psychoanalysis tended over time (with Freud) to downplay the role of abreaction, in favour of the working through of the emotions revealed through such acting-out of the past. However, Otto Rank explored abreaction of birth trauma as a central part of his revision of Freudian theory; while Edward Bibring revived the notion of abreaction as emotional reliving, a theme subsequently taken up by Vamik Volkan in his re-grief therapy.
Abreaction Therapies
In Scientology, Dianetics is a form of abreaction that science fiction writer L. Ron Hubbard borrowed from the United States Navy when he spent three months in a San Diego hospital in 1943 with the complaints of an ulcer and malaria. Hubbard later wrote, in his autobiography My Philosophy, that he had observed abreactive therapy in the hospital, though in later life he claimed to have made the discovery on his own after being wounded in battle and given up as untreatable.
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