EXPRESSED EMOTION AS A THERAPY FOR SCHIZOPHRENIA

EXPRESSED EMOTION

A01 THEORY OF EXPRESSED EMOTION (EE)

The Expressed Emotion (EE) theory was developed in the late 1970s. Because proving psychological theories about the cause of schizophrenia is problematic, researchers began focusing on how families might influence the course of the illness rather than its cause. EE research does not examine childhood experiences or past living conditions; it explores how family dynamics affect relapse rates after treatment success. The theory is primarily used in the treatment of schizophrenia, as patients from high-EE households are more likely to relapse.

However, findings from EE can be extrapolated to theories about what causes schizophrenia, as they suggest that psychological factors, such as hostile and critical communication, impact the disorder. This has led some researchers to argue that environmental stressors within the family may contribute to the onset of schizophrenia. However, EE is primarily a treatment-based theory, focusing on relapse prevention rather than the initial development of the disorder. Therefore, while EE findings highlight the importance of family interactions, they should not be confused with direct causal explanations of schizophrenia.

To fully understand the origins of Expressed Emotion (EE), one must trace its foundations to the 1950s, specifically to the pioneering research of George Brown. In 1956, Brown joined the Social Psychiatry (MRCSP) Unit in London, an institution established in 1948 to investigate the social determinants of mental illness. At the time, psychiatric treatment was undergoing a significant transformation, largely due to the introduction of chlorpromazine, the first widely used antipsychotic drug. This medication allowed patients with schizophrenia to achieve symptomatic stability, leading to their discharge from long-term psychiatric hospitals. However, what initially seemed like a breakthrough in treatment was soon overshadowed by the high relapse rates observed among discharged patients. Many of these individuals, despite their apparent recovery, would find themselves re-admitted to psychiatric care in a short period. This raised a critical question: What factors were responsible for these relapses?

To investigate this phenomenon, Brown and his colleagues conducted a comprehensive study of 229 men who had been discharged from psychiatric hospitals, with 156 of them diagnosed with schizophrenia. They aimed to determine the key factors influencing relapse rates and subsequent hospital readmission. The findings were startling and contradicted prevailing assumptions. Rather than medication non-compliance or symptom severity being the primary drivers of relapse, the study revealed that the strongest predictor of symptom recurrence was the type of home environment to which patients returned.

Patients who were discharged to live with their parents or wives were significantly more likely to relapse and require re-hospitalisation than those who went to live in lodgings or with their siblings. This suggested that the family dynamic played a crucial role in the post-treatment trajectory of schizophrenia. A particularly intriguing discovery was that patients who lived with their mothers had a reduced risk of relapse if they or their mothers were employed. This indicated that extended and intense family contact might contribute to emotional strain, thereby increasing the likelihood of relapse. In contrast, maintaining some level of external engagement, such as employment, appeared to serve as a protective factor by reducing the frequency of highly involved family interactions.

The implications of this study were profound. It highlighted the potential for social and familial factors to act as psychological stressors in individuals recovering from schizophrenia. This research laid the foundation for Expressed Emotion (EE) theory, which proposes that high levels of emotional involvement, criticism, and hostility within the family environment can significantly worsen the prognosis of schizophrenia (Brown et al., 1962, 1972). The study suggested that family dynamics were not just background influences but active determinants in the stability or deterioration of a patient’s mental health

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, 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 IS EXPRESSED EMOTION (EE) MEASURED?

EXPRESSED EMOTION (EE) is assessed through structured interviews and speech analysis to determine the level of criticism, hostility, and emotional over-involvement within family interactions. The three main methods used to measure EE are the CAMBERWELL FAMILY INTERVIEW (CFI), the PATIENT’S PERCEPTION OF EE, and the FIVE-MINUTE SPEECH SAMPLE (FMSS).

CAMBERWELL FAMILY INTERVIEW (CFI)

The CAMBERWELL FAMILY INTERVIEW (CFI) is the most comprehensive and widely used method for assessing EE. This is a semi-structured taped interview where family members discuss their thoughts and feelings about the patient. The analysis focuses on both verbal and non-verbal cues, evaluating critical comments, hostility, and emotional intensity. High EE is characterised by frequent criticism, emotional over-involvement, or hostility, while low EE suggests a neutral or supportive family environment.

The CFI provides a detailed and reliable assessment of EE, making it the gold standard in research and clinical practice. However, it is time-consuming and requires trained professionals to conduct and analyse, limiting its accessibility in some settings.

PATIENT’S PERCEPTION OF EE

Another way to measure EE is from the patient’s perspective. This approach assesses how the patient perceives their family’s emotional responses toward them and their illness. Patients rate their relatives’ attitudes, including how protective, critical, or emotionally distant they seem. If a patient feels that their family members are overprotective or emotionally neglectful, this can increase stress levels and elevate the risk of relapse.

The patient’s perception of EE is particularly useful because it considers subjective experience, which may differ from external observations. However, it is important to acknowledge that patients with schizophrenia may have distorted perceptions due to paranoia or cognitive impairments, making this method less objective than direct family assessments.

FIVE-MINUTE SPEECH SAMPLE (FMSS)

The FIVE-MINUTE SPEECH SAMPLE (FMSS) is a quicker alternative to the CFI, often used in clinical settings where time is limited. In this method, a relative speaks uninterrupted for five minutes about the patient. The speech is then analysed for critical comments, hostility, and emotional over-involvement. While less comprehensive than the CFI, it allows for a fast, initial assessment of EE in families.

The FMSS is time-efficient, making it useful for large-scale studies and clinical practice. However, it is less detailed than the CFI and may require additional assessment methods to fully determine the family’s EE levels.

CONCLUSION

The CFI remains the most detailed and reliable method for assessing EE, but its complexity makes it difficult to use in every setting. The FMSS offers a faster but less detailed alternative, while the patient’s perception of EE provides valuable insight into how family interactions are experienced from the patient’s point of view. Each method plays an important role in predicting relapse risk and understanding the impact of family dynamics on schizophrenia

A01 RESEARCH EXPRESSED EMOTION

Research has consistently demonstrated a strong association between high levels of Expressed Emotion (EE) within families and increased relapse rates in individuals with schizophrenia. The pioneering study in this field was conducted by George Brown et al., who followed patients for nine months after their discharge from the hospital. They found that patients returning to live with critical caregivers had a higher likelihood of relapse, suggesting that prolonged exposure to such environments adversely affects the course of schizophrenia.

Building upon this foundation, Kavanagh reviewed 26 studies examining the relationship between EE and schizophrenia relapse. The analysis revealed that the mean relapse rate was 48% for patients residing with high-EE families, compared to 21% for those in low-EE families, underscoring the significant impact of family emotional climate on patient outcomes.

Further reinforcing these findings, Bebbington and Kuipers analyzed data from 1,346 patients and confirmed the link between high EE in family caregivers and increased relapse rates. Their study also highlighted the protective effect of reduced face-to-face contact for patients in high-EE families, suggesting that limiting exposure to high-EE environments can mitigate relapse risk.

In a meta-analysis, Butzlaff and Hooley examined the predictive power of EE on psychiatric relapse. Their results confirmed that EE is a reliable predictor of relapse in patients with schizophrenia, with high-EE environments significantly increasing the likelihood of symptom recurrence.

Additionally, Linszen et al. found that patients living in high-EE homes were four times more likely to experience relapse than those in low-EE environments. This study suggests that a high level of emotional expression in the family environment plays a critical role in exacerbating the patient's condition.

The influence of face-to-face contact was further explored by Vaughn and Leff, who discovered that increased interaction with high-EE relatives correlated with higher relapse rates among discharged patients. Their findings indicate that the more time a patient with schizophrenia spends with a high-EE family, the greater the risk of relapse.

Cultural factors have also been examined in EE research. For instance, Kalafi and Torabi studied EE within Iranian families and identified high levels of EE as a leading cause of relapse among patients with schizophrenia. This suggests that cultural dynamics, including mixed emotional expressions from parents, significantly influence patient outcomes.

Collectively, these studies underscore the critical role of family emotional environments in the progression and management of schizophrenia. High levels of EE—characterized by criticism, hostility, and emotional over-involvement—are consistently linked to increased relapse rates, highlighting the importance of family-focused interventions in treatment plans.

A03: EVALUATION OF EXPRESSED EMOTION

EVALUATION OF EXPRESSED EMOTION (EE) THEORY

The Expressed Emotion (EE) theory is widely supported as a “maintenance” model of schizophrenia rather than a direct causal explanation. Multiple prospective studies across diverse cultural backgrounds have reinforced the validity of EE, demonstrating its cross-cultural applicability. However, while EE is well-established in predicting relapse rates, ongoing research questions whether it is causal or reactive to the disorder itself.

STRENGTHS OF THE EE THEORY

One of the primary strengths of the EE model is that extensive research supports its role in schizophrenia relapse. Numerous longitudinal studies have consistently shown that high EE families contribute to increased relapse rates. The strength of these findings is further bolstered by the fact that EE has been found across different cultures, suggesting that it is not merely a Western phenomenon but a broader psychosocial risk factor.

In addition, the EE model has shifted research focus toward family dynamics, with studies now investigating which specific elements of EE are most detrimental to individuals with schizophrenia. Interestingly, research suggests that family members respond differently to positive and negative symptoms.

• Positive symptoms (e.g., hallucinations, delusions) are generally perceived by family members as part of the illness and beyond the individual's control. Because of this, families tend to display lower levels of criticism when dealing with positive symptoms.

• Negative symptoms (e.g., social withdrawal, apathy, lack of motivation) are more often attributed to the patient’s personality rather than their illness. Families may assume these behaviours are deliberate and under the individual’s control, leading to increased criticism and high EE. This suggests that family members are more likely to display high EE when they believe their relative’s behaviour is a choice rather than a symptom of schizophrenia.

Furthermore, research by Lopez et al. has examined which aspect of EE is the most damaging. The study concluded that families characterised by negative affect (criticism) showed higher relapse rates compared to families that displayed warmth and emotional support. This suggests that criticism may be the most harmful EE variable in maintaining schizophrenia symptoms and increasing the likelihood of relapse.

CRITICISMS OF THE EE MODEL

One significant limitation of the EE theory is that not all individuals with schizophrenia live in family environments. Many patients are estranged from their families or have minimal contact with relatives, yet they still relapse at similar rates to those who remain in high EE households. If high EE were the primary factor in schizophrenia relapse, we would expect those without family contact to relapse at lower rates, but there is little evidence to support this.

Another major issue concerns causality. While EE is associated with higher relapse rates, it is unclear whether EE causes relapse or is a reaction to the patient’s worsening condition. Family relationships are bidirectional, meaning that high EE could reflect a response to difficult patient behaviours rather than cause schizophrenia symptoms.

• For example, if a patient with schizophrenia becomes more disorganised or exhibits risky behaviour, family members may naturally respond with increased concern and involvement.

• In extreme cases, if a patient is a danger to themselves or others, family members may set stricter boundaries, which could heighten EE levels.

• Rather than EE being an independent factor in relapse, it may simply reflect how families attempt to manage difficult or distressing behaviours.

Research also suggests that EE is less common in the families of first-episode schizophrenia patients than in the families of patients with a longer illness history. This implies that high EE may develop over time as a response to the stress of living with schizophrenia, rather than being a pre-existing factor that causes relapse. In other words, EE might be a consequence of schizophrenia rather than a contributor to it.

CONCLUSION

The EE theory is well-supported in predicting schizophrenia relapse, with extensive research demonstrating its impact across different cultures. The distinction between how families react to positive versus negative symptoms is an important contribution to understanding how EE operates within family dynamics. However, whether EE causes relapse or is a response to patient behaviour remains unclear. The fact that high EE develops over time and is not always present at first diagnosis suggests that it may reflect the burden of caregiving rather than an independent cause of relapse. While EE remains a useful clinical tool, further research is needed to determine its exact role in schizophrenia progression and whether reducing EE in families directly improves long-term patient outcomes

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.