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Expressed Emotion; What Is It And How To Manage It?

An Expressed Emotion (EE) is a care giver’s attitude towards a person with a mental disorder or an addiction. This is reflected by comments about the patient made to an interviewer. Various clinical and research studies show that expressed emotion is one of the major psychosocial stressors, and has direct association with recurrence of illness or addiction relapse. This effectively means that persons who live with close relatives who have high levels of expressed emotion, are significantly more likely to relapse than those who don’t.

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Origins Of Expressed Emotion

To understand the origins of the concept “Expressed Emotion,” one has to go back to the 1950s. In 1956, George Brown joined the Medical Research Council Social Psychiatry (MRCSP) Unit of London. At the time, the antipsychotic drug chlorpromazine was being widely used to treat schizophrenia patients that led to the discharge of long-stay patients after they recovered functionally. However, many of these patients were to be readmitted soon after discharge due to symptom relapse.

To understand the reasons for relapse, Brown and his colleagues decided to initiate a research study with men discharged from psychiatric hospitals, most of them with a diagnosis of schizophrenia. From the study, it was observed that the strongest link with relapse and readmission was the type of home

to which patients were discharged.

Surprisingly, patients who discharged from hospital to stay with their parents or wives were more likely to relapse and need readmission than those who lived alone 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. This was a breakthrough in the field of Psychiatry and Psychology, and the concept of expressed emotion was extended to all psychiatric illnesses and addictions.


Components Of Expressed Emotion

There are five components of EE, which includes critical comments, hostility, emotional over involvement, positive remarks, and warmth. The three dimensions of high EE are critical comments, hostility, and emotional over-involvement, while dimensions of low EE are positive remarks, and warmth. Let’s talk about them one by one.

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1. Critical Comments

Critical caregivers get involved in angry exchanges with the patient whom they seem unable 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, the caregivers fail to understand that these could be a part of their illness or addiction recovery.

Examples: A family caregiver may express in an increased tone, tempo, and volume that the patient frustrates them, deliberately causes problems for them, family members feel burdened, living with him/her is hard, commenting that patient is ignoring or not following their advices.

2. Hostility

Here, the family feels that the patient’s condition is controllable, and that the patient is choosing not to get better. The family believes that the cause of many of the family’s problems is the patient’s mental illness or addiction, even if this belief is entirely false.

Examples: Caregivers state that patient causing problems for them, wishing to live away from the patient, shouting at the patient, easily getting angry and getting irritated, saying that the patient can control himself/herself; he/she is acting.

3. Emotional Over Involvement (EOI)

EOI manifests itself by over-emotionality, excessive self-sacrifice, over-identification, and extreme overprotective behaviour towards the patient. Family members who show high emotional involvement tend to be more intrusive. This is because families with high emotional involvement feel guilty themselves.

They may believe that patients cannot help themselves and that their problems are due to causes external to them, and thus high involvement will lead to taking control and doing things for the patients. Also, 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. The relative becomes so overbearing that the patient can no longer live with this kind of stress from pity, and falls back into their illness or addiction as a way to cope. This EOI is most commonly shown by parents, especially mothers, but rarely by other relatives.

Examples: Caregivers blame themselves for everything, showing pity, not allowing the patient to carry out his/her day-to-day activities, neglecting themselves, giving less important personal needs rather than patient needs.

4. Positive Remarks

Positive regard comprises statements that express appreciation or support of the patient's behaviour and positive reinforcement by the caregiver.

Examples: Family states that they feel very close to the patient, they appreciate patient's little efforts or initiation in his/her day-to-day functioning, they state that they can cope with the patient and enjoy being with him/her.

5. Warmth

Here, kindness, concern, and empathy are expressed by the caregiver while talking about the patient. As a general rule, if a relative smiles while talking about the patient, he/she has warmth towards the patient.

Examples: Caregivers state that patient tries to get along with everyone, he/she makes a lot of sense, he/she is easy to get along with, and it is good to have him/her around.

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How Is Expressed Emotion Reduced?

Family Psycho-education (FP) is the mainstay of treatment for high EE. But before we talk about family psycho-education, we need to talk about the models of psycho-education. There are 2 main models of psycho-education:

1. Deficit model suggests that an inadequate knowledge of information about the illness results in negative attitudes and behaviours in the family caregivers, and providing that knowledge will reduce them.

2. Interaction model suggests that people make their own explanations of illness and that information provided by professionals will be understood, organised, and possibly rejected on the basis of the person's own perceptions and explanations.

Family Psycho-education includes education to the patient and caregiver about their illness or addiction, crisis management, improving problem-solving skills, clarifying myths and misconceptions, and offering emotional support. The length and duration of the intervention varies across the cultures. It depends upon the person's socioeconomic, education, and domicile status. The aim of such strategic interventions is to not only educate, but also to reduce the direct contact with high EE caregivers to less than 35 hours per week. In fact, it is so effective, that it can reduce the relative risk of relapse by upto 40%.

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