A review of expressed emotion research in health care

Abstract

Much research has been carried out on the impact of family relationships on the development and course of different illnesses. Research on Expressed Emotion (EE) developed out of studies of the impact of family members on patients with schizophrenia, and has provided us with a robust measure of relatives' emotional attitudes towards patients, which has now been applied in the study of numerous psychiatric and medical illnesses. This review outlines the history of EE research in schizophrenia, and discusses the evidence for the association between family EE and the course of schizophrenic illness. Some of the factors which might moderate the association between EE and illness course are outlined and the issues of the meaning and development of EE are discussed in the light of recent theoretical advances. The application of the EE methodology in other psychiatric and medical conditions is then reviewed and conclusions are drawn about the extent to which EE predicts illness course in conditions other than schizophrenia. Consideration is given to the ways in which the application of the paradigm to a variety of illnesses or conditions with different features can enhance our understanding of the EE construct.

Introduction

EVIDENCE CONTINUES TO accumulate highlighting the link between health status and family relationships (Cole & Reiss, 1993). It is now widely accepted that psychological, family, and social factors influence disease susceptibility, adaptation to disease and recovery with effects on utilization of health care services, disability status, and quality of life. For a number of decades, research has attempted to document (a) families' understanding of and reaction to various states of illness and health, (b) specific features of illnesses and their associated impact on the family, and (c) families' approaches to short- and long-term management of illness. Out of one particular stream of research examining the quality of relationships between patients and their relatives, and the course of psychiatric illness, a unique method has emerged for measurement of interpersonal attitudes. Expressed Emotion (EE) refers to a construct representing some key aspects of interpersonal relationships. It includes measurements of criticism, hostility, warmth, positive comments, and emotional over-involvement, and is rated from a semi-structured interview known as the Camberwell Family Interview (CFI). EE has been extensively researched in the context of patients with schizophrenia and their families.

The original impetus for research on the impact of families on schizophrenia arose when it was noted that the rate of relapse among patients with schizophrenia during the year following hospitalization was significantly related to the living situation into which they were discharged Leff & Vaughn 1985, Vaughn and Leff 1976. Following the initial work, this line of research has continued for over 30 years (Vaughn, 1989) and has confirmed the relationship between family EE and the course of schizophrenic illness, leading to the development of interventions based on modifying EE. More recently, research on EE has been extended to other psychiatric disorders and many medical conditions. The aims of this research have been twofold—first to attempt to discover whether EE is an important predictor of illness outcome and response to treatment in conditions other than schizophrenia, and second, to attempt to gain further understanding of the meaning of EE by comparing ratings of EE in illnesses with different features.

This paper will provide a review of Expressed Emotion research in health care, drawing together work on the many different conditions to which the measure has been applied. A brief history of the EE construct, describing the early work on schizophrenia will be presented. Next, we will present an outline of some of the theoretical issues that have been tackled in the subsequent literature, including attempts to explain how and why EE is related to the course of illness, and models of the development and meaning of EE. Work on EE in psychiatric conditions other than schizophrenia will then be reviewed, including that on emotional and behavioral conditions in children, and also on Alzheimer's disease in the elderly. These sections will not be exhaustive, but the main studies which have contributed to our understanding of the role of EE in the course of the conditions studied, or which have addressed theoretically or practically important relations between EE and illness or family variables, will be covered. Finally, published work on EE in medical conditions will be described. The discussion and conclusions will then examine similarities and differences in the findings from the psychiatric and nonpsychiatric literature and will attempt to draw out some of the main questions which are posed for future Expressed Emotion research.