Expressed Emotion as a Precipitant of Relapse in Psychological Disorders

Expressed emotion is an attitude displayed by family members or people in direct relationships with a patient that has harmful effects and often ignites relapse. McDonagh summarized the attitudes of expressed emotion, how it is measured, and disorders commonly associated with it.

McDonagh stressed the point that expressed emotion is initiated from family member's attitudes toward the patient and his or her disorder. Expressed emotion does not involve only the patient and his or her family members. Ball, Moore, and Kuipers (1992) showed the effects of an unqualified staff of health care workers at a hostel caring for mentally ill patients. The results of a modified Camberwell Family Interview showed that expressed emotion levels in workers played a significant role in the relapse of these patients in the same way family members ignite expressed emotion. Moore and Kuipers (1999) conducted a similar study using a qualified health care professional with knowledge about expressed emotion and training to specifically work with those who have psychological disorders. There was also evidence of expressed emotion in this day hospital setting. The results of this study also touched upon the idea that it does not matter how much training and knowledge one has on the topic of the psychological disorder itself, expressed emotion, or ways to prevent it, because expressed emotion may be an inevitable outcome in any relationship with a patient.

Expressed emotion in a patient's living environment can sometimes be prevented or at least lessened. The ways in which this can be accomplished deserve to be clearly stated and emphasized. Therapy is used to educate the family on the psychological disorder. It is described as a legitimate disorder with symptoms that do not appear and disappear at the patient's own will. The understanding that the family has for the disorder will lessen high expressed emotion exhibited by hostility and criticism towards the patient. The guilt or sympathy that the family may feel that could lead to the low expressed emotion of emotional over-involvement is also addressed and reduced.

Health care staff can also be trained in order to reduce expressed emotion seen in clinical settings. A hospital in Nottingham utilized a system of familiarizing staff with the challenges that a patient faces in the midst of a psychological disorder (Whittaker & Stickley, 2003). The staff can then begin to understand the pain and stress that a recovering patient is feeling and sympathize in an ultimate goal of eliminating negative reactions towards a patient.

Brown, Carstairs, and Topping (1958) measured relapse rates of people in differing living arrangements following a rehabilitation period after a psychological disorder. These quantified results are noteworthy and can be used to directly measure and compare factors that contribute to relapse. The study found that patients living by themselves or with siblings had the lowest relapse rate of 17%. About 32% of patients living with parents experienced relapses. The highest relapse rates, 50% of patients, were found in patients living with spouses. A second study compared relapse rates between those experiencing high expressed emotion versus those experiencing low expressed emotion; 56% of patients experiencing high expressed emotion relapsed, whereas only 21% relapsed after encountering low expressed emotion (Brown, Carstairs, & Topping, 1962).

Brown et al.'s (1962) results can be the basis for hypothesizing the reasons for the results of the initial study. Those living alone have no family or friends to receive incessant expressed emotion from, for a constant period of time. They are likely to experience expressed emotion only while periodically talking to family members, friends, or significant others but are able to retreat from the issues to their own safe environment when the stress increases to unbearable levels. These patients are able to escape from relapse with personal coping methods before it is too late, therefore contributing to low levels of expressed emotion and low relapse rates. Yet this is also perplexing, because a means of social support is a necessity to maintain optimal mental health in most people. Those living alone may not have a solid network of support at their fingertips, therefore decreasing their ability to cope with life's stresses. This decreased ability to cope could result in a relapse not directly associated with expressed emotion.

Those living with spouses have a greater relapse rate than those living with parents. These results coincide with the outcome of the second study that patients exposed to high expressed emotion are more likely to relapse compared to patients exposed to low expressed emotion. Examples of high expressed emotion are criticism and hostility towards the patient. Spouses are likely to feel anger and frustration towards the patient due to the fact that the he or she can no longer be depended upon. His or her inability to regularly function and the excessive help and patience that must be received from the spouse by the patient could also be overwhelmingly stressful for the spouse. Low expressed emotion exhibited by emotional over-involvement is more likely to be seen in parents towards their children. Parents are protective of their offspring and would do anything to take the blame off of the child including transferring feelings of guilt and burden onto themselves. Parents care so deeply for the child that they smother them with excessive attention hoping to take their stress and pain away. In reality, this extreme interest isolates a child causing them to relapse.

Relapse and rehabilitation are a cycle. As McDonagh touched upon, not only the patient is affected by the illness but all family members in contact with the patient. High and low expressed emotion a common response that helps the family members cope with a patient with a psychological disorder. They both help to reduce the stress experienced by the patient's family while inversely and unintentionally adding stress to the patient. While in a fragile state of rehabilitation, this added stress serves in a diathesis-stress model pushing the patient into relapse. After relapse occurs, expressed emotion can be recognized and attempted to be eliminated. Knowledge can be gained by the family members to decrease stigmas and allow them to cope with the patient properly. Relapse may or may not occur after a family is aware of the disease and how to deal with it, although it is easy to state that rehabilitation from a psychological disorder is an ongoing lifetime process because a patient can never be fully "cured." As long as there is a process of rehabilitation, there is a process of fighting or giving in to expressed emotion.

It is a universally known fact that cultures vary greatly all across the world. These varying cultures include a variety of differences in almost an infinite number of categories involved in human life. Family relationships and interactions are just one of the many categories that vary greatly from culture to culture across the world. When dealing with a topic such as expressed emotion, which has deep roots in family relationships and interactions, it is essential to note that the effects of expressed emotion could potentially vary greatly between cultures.

Many of the studies that have taken place in relation to expressed emotion have demonstrated that a high level of expressed emotion from family members associates directly with schizophrenic relapse (Butzlaff & Hooley, 1998). A majority of the studies conducted were from western countries, which neglects to take into account the variation in culture into the effect of expressed emotion on patients with schizophrenia. In an entirely different study of schizophrenia patients in the city of Kelantan, Malaysia, found quite contrary results to the previous mentioned study. It was found that the majority of the families (72.3%) had low expressed emotion while only 25.3% had high expressed emotion and only 2.4% families were equivocal in this respect (Azhar & Varma, 1996). This example clearly illustrates that it is entirely possible for expressed emotion to have entirely different effects depending on the culture in which it takes place. Another example of potential gaps in the bridging of expressed emotion across cultures is that of facial expression interpretation. One of the methods used to judge the level and attitudes of family members of psychiatric patients was the Camberwell Family Interview. McDonagh describes the interview as a method of interpreting verbal and non-verbal actions to determine an accurate assessment. This clearly illustrates that the interview uses non-verbal reactions to judge attitudes and intensities of family members towards the patient. There have been many studies to point out the fact that the meaning of facial expressions differs from culture to culture. American respondents associate facial behavior with one internal emotional state, but the meaning of facial behavior is more complex for the Japanese. This example also suggests that the determination of expressed emotion requires the inclusion of different cultures in order to be accurate.

The above examples of the effect of expressed emotion on western versus eastern schizophrenic patients also illustrates that expressed emotion may be more dimensional than previously described by McDonagh. A universal model of the effects of expressed emotion and its effects on psychiatric patients would contain the previous elements discussed by McDonagh, but also be able to specify the effects to a broad cultural range as well. McDonagh’s discussion on the three attitudes of expressed emotion is clearly an essential element is describing the effects of expressed emotion, as is the distinction between high and low levels of expressed emotion. The key element to complete the description of the effects of expressed emotion is perhaps a broader category above both the attitudes and levels of expressed emotion that discerns different cultures. The reason for the culture category to be above both the attitudes and levels of expressed emotion is mainly due to the fact that it is entirely possible and even likely that attitudes towards individuals with mental disorders vary between cultures.

A more representative study of expressed emotion would be one that included studies from many different cultures from around the globe, and discussed not only similar results, but also the cultures in which the similar results were found. Though it is clearly not feasible to scour the globe and search out every culture and then determine each cultures attitudes and reactions towards those with mental disabilities. However, the differences between eastern and western culture are numerous and apparent in many aspects of expressed emotion, and it benefits the discussion of the effects of expressed emotion to include such cultural variations. A realistic, improved description of expressed emotion effects on psychiatric patients would be one that gives the attitudes of not only western societies, but also from cultures that are known to be substantially different from western societies.

The attitudes and levels of expressed emotion discussed by McDonagh have been shown to be accurate by many studies conducted in western society. However, these attitudes and levels, along with the methods for determining such things, clearly vary from culture to culture. Inclusion of these findings would provide a much more complete and rounded view of the effects of expressed emotion, one that is not just limited to western societies, but holds worldwide.

In “Expressed Emotion as a Precipitant of Relapse in Psychological Disorders,” McDonagh explored how expressed emotion causes a patient with a disorder to relapse. She also looked at the concept and prevalence of expressed emotion in individual disorders. Expressed emotion, according to McDonagh is, “the critical, hostile, and emotionally over-involved attitude that relatives have toward a family member with a disorder.” If this definition is indeed valid, expressed emotion can possibly come from people other than a family member. Expressed emotion among employees of a clinic or other places in which people are in close proximity to patients with disorders also may put patients at a risk of relapse.

Expressed emotion by the family of a patient with a disorder is characterized by having a critical, hostile, or emotionally over-involved relationship. The professional relationship between the worker and the patient is not the same as a family relationship; therefore, the expressed emotion cannot be characterized the same way, as it would come from a family member. Professionals working with patients tend not to show an emotionally over-involved attitude towards the patients. This is caused by their low amount of contact with the patient, or their professional training. Professionals with high expressed emotion tend to have near-impossible or unattainable goals and expectations for their patients. They also tend to focus more on the patients weaknesses. Professionals with low expressed emotion often set the boundaries of their relationship with the patient before anything happens between them. They also tend to focus on the patients positive attributes and believe in the patient’s strengths (Van Humbeeck & Van Audenhove, 2003).

A large difference between professionals with high expressed emotion and low expressed emotion is that those with lower expressed emotion tend to be able to understand and see the world in the eyes of the patient. A professional who cannot relate well enough to a patient may have a hard time dealing with a patient whose illness involves uncontrollable physical actions and mental instability, and therefore may generate a high expressed emotion (Van Humbeeck & Van Audenhove, 2003).

Another difference between professionals with high expressed emotion and low expressed emotion is education. A couple of studies considered this idea of education, and each study came out with the same answer: less educated professionals tend to have higher expressed emotion than more educated professionals (Barrowclough et al., 2001; Van Humbeeck et al, 2002).

A career in the field of professional social working is not an easy one, and dealing with mental health patients every day can cause many stressors. These stressors can wear down on the social worker and cause him or her to become less effective at their job. This phenomenon is what people in the human services like to call “burnout.” This “burnout” can lead to the social worker accidentally creating high expressed emotion. (Van Humbeeck & Van Audenhove, 2003). Websites and other such supportive resources are in place to help these social workers. These websites contain information on how to deal with daily stressors, and actual activities to reduce stress. Resources like these describe burnout with three symptoms. The social worker becomes chronically exhausted, then gain a feeling of increasing infectiveness on the job, then they become cynical and detached from their work. (Maslach & Leiter, 1997). Each of these symptoms has the potential to create high expressed emotion between the patient and the social worker, however the more ‘burned out’ a social worker becomes the higher the risk for expressed emotion becomes.

It is apparent that clinics should hold sessions regarding expressed emotion and its damaging effects on patients. These types of programs should be created to make under educated social workers more aware of how they can actually cause set backs to a patient’s recovery. McDonagh is correct is saying, “Patients are more likely to relapse when there is high expressed emotion present in their living environment. The stress from remarks and attitudes of the family is overwhelming because they feel like the cause of all the problems.” The environment in which the patient is being treated also has to be considered for the reduction of expressed emotion. Patients will relapse less if there is a combined effort between the family and the professionals to understand the disease, relate to the patient, and therefore reduce the amount of expressed emotion.

Expressed emotion from family members of one trying to recover from a mental disorder or disability has a great impact on the course of rehabilitation. Laura A. McDonagh’s paper on this topic offered blanket explanations and brief elaborations pertaining to the main points associated with expressed emotions in the family dynamics surrounding a patients’ recovery. The paper more than aptly described expressed emotion and explained how it is a major contributing factor in the success rate of a patient's recovery. How family members perceive the patients’ illness is internalized by the patient and, if negative, can add undue stress on the patient thereby sending his or her into a relapse.

Commenting on the differences between low expressed emotion and high expressed emotion, McDonagh touched on the fact that the educational level of the surrounding family members and knowledge of the disorder plays an important role in the way the family members respond to the patient at hand. The differences between low and high expressed emotion families are striking. “It appears that low EE relatives ... are actively supporting the patient. They provide a positive nonverbal climate, show concern for the patient, and try to find solutions to problems” (Hahlweg et al., 1989, p. 18). They interact with the patients recovery, seeing that they indeed have a disorder and need support rather than criticism in order to overcome the obstacles they face. I question whether it is the actual educational level of the family members in regards to the disorder that causes them to have lower expressed emotion. I am curious seeing as though family members with high expressed emotions interact with the patients the same amount as those with low expressed emotion and therefore have been exposed to the disorder just as much. Whereas knowledge of the disorder clearly is important in understanding and supporting one throughout recovery, having knowledge of the disorder is not a sufficient cause of low expressed emotion due to the amount of other outside contributing factors.

McDonagh discussed how the Camberwell Family Interview is used to assess the family environment as the patient transitions back into the family setting. Although I agree that the Camberwell Family Interview is a useful, proven tool in assessing family dynamics and underlying prejudices regarding mental disorder, I believe that there is another point that needs to be taken into consideration and that is the family’s cultural background. McDonagh discussed the use of the Camberwell Family Interview in the United States and also looks at the patients point of view of the family in United States culture. When one looks cross-culturally, however, one finds that results vary depending on socio-economic status, cultural morals, and accepted norms of society. Many of the studies conducted take into account white Western culture yet very few have looked into other eastern cultures to see if any differences occur for expressed emotion in families of other non-white descent. According to "A Cross-Cultural Study on Expressed Emotion in Careers of People With Dementia and Schizophrenia: Japan and England" (Nomura et al., 2005), the Camberwell Family Interview holds up well when used in other cultures, yet the research also points out large differences in scores cross-culturally. “There was a tendency for lower expression of both positive and negative emotional reactions towards family members in the Japanese sample” (Nomura et al., 2005, p. 566). Western cultures tend to be more expressive with their emotions than Eastern cultures and this can have a large effect on the scores . Along with this, "A Study of Three Measures of Expressed Emotion in a Sample of Chinese Families of a Person With Schizophrenia" (Li & Arthur, 2005) also shows that while there can be high levels of expressed emotion in families from these cultures, many times the cultural norms of the society must be taken into account in order to see the full picture of what is going on within the family environment. “Further research and replication is necessary to deepen our understanding of EE in Chinese families” (Li, Arthur, 2005, p. 433), as few studies have yet addressed this point. In Western culture, although family values are important, the concepts of family honor and tradition are not so rigid as in the East. The above studies support the idea that when looking into the issue of high expressed emotion and its correlation with relapse of psychological disorders one needs to not only consider family dynamics but also social and economic factors to see what would be within the acceptable norms for the patient to be interacting with on a daily basis. Only then can the clinician or assessor begin to form a plan of action to take to counteract these affects and encourage the patient along his or her way to recovery.

I agree with McDonagh that the patient and family must go through family therapy together in order for all parties involved to become aware of the needs of one another and to help the patient avoid a relapse. I feel that family therapy has much more to offer than simply an explanation for the disorder and how the patient may react. Family therapy is a chance for all members to express any concerns they might have for upcoming situations and to work through past mistakes in order to help everyone involved make a smooth transition. This is an essential step in the recovery of the patient and should begin before his or her return home and continue well after. Overall, although McDonagh did an excellent job in portraying the main points on expressed emotion and the problems that can be associated with it, one must not overlook the importance of outside contributing factors to the onset of high expressed emotion and the essential contributing factors of cultural and economical influences.

There was a lot of good information on expressed emotion and psychological disorders. However, I could not write about all of these topics in my paper because there was too much information. The peer commentaries did a good job on expanding the topic of my paper and providing more information. Czarnecki did a good job of expanding the information on others who contribute to expressed emotions and relapses in psychiatric patients. She was informative about how expressed emotion is unavoidable by everyone, even with training. Expressed emotions is found in everyone, but the lower the expressed emotion, the lower the chance of relapse.

Lalone pointed out is that there is a difference in facial expressions in every culture. The Camberwell Family Interview is more accurate for the people of the Western hemisphere. It is known that every culture is different, and distinctions in emotions should vary from culture to culture. Lalone did a good job of showing the flaws to the interview that determine high and low expressed emotion.

Nilosek expanded on the stress from others that causes relapse in psychological patients. The attitude of professionals affects the way patients recover. Information on expressed emotion is helpful in reducing the chances of relapse in patients. Nilosek showed that family is not the only contribution to expressed emotion that can cause a relapse in the patient.

Swain's commentary expanded on the negative side of testing for expressed emotion. Tests are not perfect, and there are always going to be flaws with them, especially when it comes to emotions. However, everything should be taken into consideration to improve the outcomes of the tests and to help those living in environments that cause relapse.

All of the peer commentaries were informative and expand farther on topics that I did not discuss. They did a good job getting their points across about expressed emotion and what causes it. They also gave good insight on how to improve the situation of expressed emotions with psychological patients.