EXPRESSED EMOTION AS A THERAPY FOR SCHIZOPHRENIA

EXPRESSED EMOTION

A01 THEORY OF EXPRESSED EMOTION (EE)

Expressed Emotion theory (EE) was developed in the late 1970s.

Because proving psychological theories about the cause is problematic, researchers started looking at how families might contribute to the course of a schizophrenic’s illness rather than the cause of it. Therefore, this theory does not look at childhood or any past living conditions; rather, it looks at how families affect the progression of the illness after treatment success. However, findings from EE can be extrapolated to theories about what causes schizophrenia as it shows that schizophrenia is affected by psychological factors such as hostile and critical communication. But be careful how you introduce this theory and explicitly link it to the cause.

To understand the origins of the “Expressed Emotion” concept, one has to go back to the 1950s for the influential research by George Brown. In 1956, George Brown joined the Social Psychiatry (MRCSP) Unit of London, established in 1948. When George Brown joined the MRCSP unit, the antipsychotic drug chlorpromazine was widely used to treat schizophrenia patients, which led to the discharge of long-stay patients after they became symptomatically stable and recovered functionally. However, many of these patients were to be readmitted soon after discharge due to symptom relapse. To understand the basis for the symptom relapse, a study was initiated by George Brown and his colleagues with 229 men discharged from psychiatric hospitals, 156 of them with a diagnosis of schizophrenia.

The study observed that the strongest link between relapse and readmission was the type of home to which patients were discharged. Surprisingly, the patients who were discharged from the hospital to stay with their parents or wives were more likely to relapse and need readmission than those who lived in lodgings or with their siblings. It was also found that patients staying with their mothers had a reduced risk of relapse and readmission if patients and/or their mothers went out to work. It suggested that relapse was probably due to the adverse influence of prolonged contact of patients with their family members.

Theoretically, then, a high level of EE in the home can worsen the prognosis in patients with Schizophrenia (Brown et al., 1962, 1972) or act as a potential risk factor for the development of psychiatric disease.

COMPONENTS OF EXPRESSED EMOTION

The five components of Expressed Emotion are

  • Critical Comments

  • Hostility

  • Emotional Over involvement

  • Warmth

  • Positive Regard.

  • High Expressed Emotion

  • Family members with highly expressed emotions are hostile, very critical, and not tolerant of the patient. They feel like they are helping by having this attitude. They criticise not only behaviours related to the disorder but also behaviours unique to the patient's personality. High-expressed emotion is more likely to cause a relapse than low-expressed emotion.

HIGH EXPRESSED EMOTION

  • HOSTILITY: Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient is choosing not to get better. Problems in the family are often blamed on the patient, and the patient has trouble problem-solving in the family. The family believes that the cause of many of the family’s problems is the patient’s mental illness, whether they are or not.

  • EMOTIONAL OVER-INVOLVEMENT: Emotional over-involvement reflects a set of feelings and behaviours of a family member towards the patient, indicating evidence of over-protectiveness or self-sacrifice, excessive use of praise or blame, preconceptions and statements of attitude. Family members who show high emotional involvement tend to be more intrusive. Therefore, families with high emotional involvement may believe patients cannot help themselves. Thus, high involvement will lead to strategies for controlling and doing things for the patients. In addition, patients may feel very anxious and frustrated when interacting with family caregivers with high emotional involvement due to such high intrusiveness and emotional display towards them. Overall, families with high EE appear to be poorer communicators with their ill relatives, as they might talk more and listen less effectively.

  • CRITICAL COMMENTS: Careful observations of direct communications between patients and caregivers prove that critical caregivers get involved in angry exchanges with the patients they seem unable to prevent or to step away from. These potentially lead to physical violence, and it is the nature of some families with high EE. Patients who are unable to get up in the morning, who fail to wash regularly, or who do not participate in household tasks are criticised for being lazy and selfish; unfortunately, in this context, the caregivers fail to understand that these could be potential manifestations of negative symptoms of schizophrenia or any other psychotic disorder. By contrast, low EE caregivers are more capable of recognizing aspects of the patient’s behaviour that manifest the illness. Examples: Family caregivers may express in an increased tone, tempo, and volume that the patient frustrates them, deliberately causes problems for them, family members feel the burden of the patient, living with him is harder, commenting that the patient is ignoring or not following their advice.

LOW-EXPRESSED EMOTION: Low-expressed emotion occurs when family members are more reserved with their criticism and feel that the patient doesn't have control over the disorder. When the family is more educated, they are more likely to have low-expressed emotions.

  • WARMTH: It is assessed based on the caregiver's kindness, concern, and empathy while talking about the patient. It depends significantly on vocal qualities, with smiling being a common accompaniment, which often conveys an empathic attitude by the relative.  Warmth is a significant characteristic of the low EE family. Examples: Caregivers state that the patient tries to get along with everyone, he makes a lot of sense, he is easy to get along with, and it is good to have him around; the patient’s behaviour is appropriate since it is not his/her pre-morbid self.

  • POSITIVE REGARD: Positive regard comprises statements that express appreciation or support for the patient’s behaviour and verbal/nonverbal reinforcement by the caregiver. Examples: The family states that they feel very close to the patient, they appreciate the patient’s little efforts or initiation in his day-to-day functioning, and they can cope with the patient and enjoy being with him/her.

HOW DO YOU MEASURE EE?

Expressed emotion (EE) is a psychological term specifically applied to psychiatric patients. It measures the family environment based on how the relatives of a schizophrenic patient spontaneously talk about the patient.

  • Typically, whether a person or family has high-expressed or low-expressed emotions is determined through a taped interview known as the Camberwell Family Interview (CFI). Answers to questions and non-verbal cues are used to determine if someone has highly expressed emotions.

  • Another measurement is taken from the patient's perspective. It rates the patient's perception of how his family feels about him and the disorder. If the patient feels that the parents are too protective or not caring, the patient feels that his parents don't care about his independence or trust his judgement. This attitude may cause the patient to relapse, and patients who rate their parents poorly in this test have a harder time coping with their illness if too much time is spent with the parent.

  • An alternative measure of expressed emotion is the Five Minutes Speech Sample (FMSS), where the relatives are asked to talk about the patient for five uninterrupted minutes. Although this measure requires more training, it becomes a quicker assessment form than the former method.

A01 RESEARCH EXPRESSED EMOTION

  • It is well established that high family levels of Expressed Emotion are consistently associated with higher rates of relapse in patients with schizophrenia. The first study to undertake the EE measure and connect it to the course of schizophrenia was investigated by Brown et al., where the patients were followed up for nine months after they were discharged and sent to their home from the hospital. It was found that prolonged contact with patients with critical caregivers determines the relapse in schizophrenia.

  • Btzlaff and Hooley (1998) meta-analysis

  • Kavanagh reviewed 26 studies on EE and found that the mean relapse rate was 48% for patients residing with high EE families and 21% for those in low EE families.

  • A comprehensive analysis by Bebbington and Kuipers of data from 1,346 patients established the relationship between family caregivers’ EE and relapse and the protective factor of reduced face-to-face contact for patients in high EE families.

  • These studies have been supported by Linszen, who found relapse to be four times more likely in high EE homes. This study suggests that a high level of emotion in the family environment plays a role in the SZ patients’ disorder becoming worse.

  • There is also support for this explanation from Vaughn and Leff, who also found that the level of expressed emotion had an effect on relapse rates amongst discharged patients. However, they also studied the amount of face-to-face contact patients had with relatives after discharge, and they found an increase in relapse rates as face-to-face contact increased, and even more so with higher levels of expressed emotion. This study suggests that the more time an SZ patient spends with a family with high levels of EE, the more likely they are to relapse.

  • Kalafi and Torabi (1996) studied expressed emotion within families in Iranian culture. They found that a higher prevalence of expressed emotion was one of the main causes of relapse. This suggests that a mixture of emotions from parents in Iranian culture plays a role in the SZ patient's relapsing.

A03: EVALUATION OF EXPRESSED EMOTION

There are several strengths to this theory. For example, there has been a lot of supporting research conducted to make the theory more valid. The EE is a well-established “maintenance” model of SZ, and many prospective studies have been conducted that support the EE hypothesis across many cultures; therefore, the theory is also applicable cross-culturally.

The EE model has become widely accepted, and research is now focussing on relatives of those with SZ to understand better which aspects of high and low EE relate to relapse. For example, there is evidence to support that the family members do not display High EE when their relative displays positive symptoms such as hallucinations and delusions as they think these are part of their relative’s mental illness. They cannot control them through free will. On the other hand, there is also evidence that family members attribute negative symptoms, for example, social withdrawal, to the person’s personality characteristics, and it has been observed that they become over-critical in an attempt to change those behaviours. In other words, family members think negative symptoms are considered to be due to the free will of the schizophrenic. As a result, family members will display high EE to get their relatives to stop behaving with negative symptomology.

Which EE variable is the most damaging? Overall, it was concluded by Lopez that families characterised by negative affect (criticism) have much higher relapse rates in comparison to those with positive affect (warmth).

Another criticism of this theory, in general, is that many patients with SZ are either estranged from their families or have minimal contact. Yet, there is no evidence that such people are less prone to relapse. Therefore, it is unclear whether there is an impact.

What is not yet clear is precisely how to interpret the effects of EE. Is EE causal, or does it reflect a reaction to the patient’s behaviour? It should be remembered that relationships within the family work both ways and that there is some evidence that certain aspects of High EE behaviour are now associated with the abnormalities in the patient. For example, if the condition of a patient with schizophrenia begins to deteriorate, a family member’s concern and involvement might increase. Indeed, disorganised or dangerous behaviour by the patient would warrant limit setting and other family efforts that could raise the level of EE.

There has also been an argument about whether the EE model is a cause or an effect of SZ. Indeed, it has been found that high EE is less common in the families of first-episode patients than in those of first-symptom patients. This suggests that High EE may well develop as a response to the burden of living with a Schizophrenic.

A03: ALL PSYCHOLOGICAL EXPLANATIONS

DETERMINISM VERSUS FREE WILL

All psychological theories are deterministic and suggest that you have no free will against developing or personally overcoming Schizophrenia. There are negative and positive aspects to this. On the negative side, parents will be blamed for causing Schizophrenia.  Family and theories are unconstructive as they blame the parents and families for a child developing SZ. Suggesting that a parent has caused SZ is at least unhelpful and, at most, highly destructive, as they not only have to cope with living with someone with SZ but are then told that it is their fault, which will lead them to feel guilty and hurt as they are blamed for a poor upbringing.

On the positive side, your family may see it worthwhile to try to change their behaviour, and individuals will not be perceived to be at fault as their illness results from their upbringing. Matthijs Koopmans of City University in New York states: "There is a very persistent misconception that models connecting family processes to schizophrenic symptomatology in effect blame the parents for their children's ills, rather than recognising the potential of such models to empower parents and caretakers to modify their interactive patterns to accommodate the identified patient better, and perhaps even prevent dysfunctional patterns of interaction from occurring in the first place."

NATURE VERSUS NURTURE (DIATHESIS STRESS MODEL).

Psychological theories are nurture, yet nurture cannot be the only answer, as MZ twins have a 48% concordance rate, and DZ twins have a 17% concordance rate. If it were purely psychological, then MZ and same-sex DZ twins would have the same rate. This means nature must play a role, too. Indeed, current thinking now believes that both nature and nurture play a role in the aetiology of Schizophrenia, e.g. that individuals are born with a genetic predisposition or biological trigger but may not develop the disorder unless they are exposed to an environmental or psychological trigger. These triggers can be Psychological factors that include disturbing family dynamics and stress. This is known as the Diathesis Stress Model (DSM). Tienari’s ‘Finnish adoption study’ supported the DSM as only children of schizophrenic mothers developed schizophrenia themselves if their adopted family was disturbed. Genes alone did not cause the illness. However, if there was a high genetic risk and it was combined with mystifying care during upbringing or abuse, the likelihood was greater. This suggests that genes can be implicated, but only if the family environment is of the kind that fulfils schizophrenic genetic potential.

ALTERNATIVE THEORY: The fact that some two-thirds of people diagnosed as schizophrenic have suffered physical or sexual abuse is shown to be a significant cause of the illness.

John Read (2004) collected 40 studies that reveal childhood or adulthood sexual or physical abuse in the history of the majority of psychiatric patients (see also Read's book, Models of Madness). A review of 13 studies of schizophrenics found rates varying from 51% at the lowest to 97% at the highest. Importantly, psychiatric patients or schizophrenics who report abuse are much more likely to experience hallucinations. Read believes the content of these often relates directly to the trauma suffered. At their simplest, they involve flashbacks to abusive events, which have become generalised to the whole of their experience. For example, an incest survivor believed that her body was covered with sperm. The visual hallucinations or voices often scare and belittle the patients, just as their tormentors did in reality, creating a paranoid universe in which people/family/friends cannot be trusted.

JOINT A03 DEBATES:  IS PSYCHOLOGY A SCIENCE? CLASSIFICATION ISSUES

Psychologically based theories have not gained much support, for they are considered to be less scientific. Examples include poorly controlled studies, no controls, retrospective data, internal invalidity, and not the same results when replicated.

Family studies are more complex, and conducting experimental procedures is less possible because real-life/individual family dynamics are challenging to control. Therefore, cause-and-effect conclusions are not possible; psychological research is often correlational.

What clouds the validity and reliability of any of the psychological theories is the fact that many researchers (Bentall, 1990, Rosenhan) believe that Schizophrenia is an impossible illness to classify. Since 1911 the illness was first described, there has been great controversy concerning what symptom and description should be used to define the illness. Indeed, DSM IVR and ICD 10 have different criteria for the diagnosis and classification of Schizophrenia. Moreover, the last few years have been critical in the evolving definition of Schizophrenia as the criteria for the illness have slimmed down considerably. Not only have two distant subtypes emerged, type one and type two (which incidentally have had psychologists arguing that two very different illnesses may exist and not one!), but the condition has many categories, e.g. Paranoid and Hebephrenic. If we cannot rely on what the ever-changing definition of schizophrenia is, then how can research test its prevalence? Especially research conducted in the 1960s when the definition bore little resemblance to what the illness translates to today.

Rebecca Sylvia

I am a Londoner with over 30 years of experience teaching psychology at A-Level, IB, and undergraduate levels. Throughout my career, I’ve taught in more than 40 establishments across the UK and internationally, including Spain, Lithuania, and Cyprus. My teaching has been consistently recognised for its high success rates, and I’ve also worked as a consultant in education, supporting institutions in delivering exceptional psychology programmes.

I’ve written various psychology materials and articles, focusing on making complex concepts accessible to students and educators. In addition to teaching, I’ve published peer-reviewed research in the field of eating disorders.

My career began after earning a degree in Psychology and a master’s in Cognitive Neuroscience. Over the years, I’ve combined my academic foundation with hands-on teaching and leadership roles, including serving as Head of Social Sciences.

Outside of my professional life, I have two children and enjoy a variety of interests, including skiing, hiking, playing backgammon, and podcasting. These pursuits keep me curious, active, and grounded—qualities I bring into my teaching and consultancy work. My personal and professional goals include inspiring curiosity about human behaviour, supporting educators, and helping students achieve their full potential.

https://psychstory.co.uk
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COGNITIVE EXPLANATIONS FOR SCHIZOPHRENIA

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THE INTERACTIONIST APPROACH TO SCHIZOPHRENIA