1111.J Nun. Pud.. Vol. 27. No. 3. pp. 167-276. Prlntcd in Great Britam.
1990
oow7489/90 13.00 + 0.00 B 1990 Pcrgamon Press plc
Expressed emotion and psychosocial intervention: a review C. BROOKER,
M.Sc., B.A. (Hors).,
R.M.N.,
R.N.T.,
Dip.N.Ed.
Senior Research Fell0 w, Department of Nursing, University of Manchester, Stopford Building, Oxford Road, Manchester Ml3 9PT, U.K.
Abstract-For thirty years research has been consistently demonstrating the validity of the concept of ‘High Expressed Emotion’ (HEE). After early pioneering work by Brown it was established that environmental influences, particularly, the emotion expressed by relatives to sufferers of schizophrenia, are strongly implicated in relapse. Consequently, the predictive validity of HEE has been revealed in a number-of cross-cultural studies around the world. In addition, there is strong evidence from well designed intervention studies, that relapse, in schizophrenic clients living at home, can be prevented by the manipulation of social and environmental factors. The combined body of research that has now accumulated allows an hypothesis to be made about the aetiology of the illness, schizophrenia, itself. This theory has been described as the ‘stress vulnerability’ model. The paper concludes that psychosocial intervention strategies are effective but that, unfortunately, to date, their application has been mostly restricted to the intervention studies themselves.
Introduction
Historically, the treatment of schizophrenia, has spawned a number of widely differing causal explanations, ranging from St Joan of Arc’s supposed ‘witchcraft’ to some modernday psychiatrist’s views that the illness is potentiated by the protein, gluten, commonly found in wheat products. However, at the beginning of the century, the most popular view of schizophrenia was that it had a biological basis. Kraepelin (1906) believed, for instance, that it was a metabolic disorder. However, there were other views and, interestingly, Bleuler (191 l), who first used the term ‘schizophrenia’, surmised that one group of schizophrenic disorders had a psychological cause, namely, extreme outside pressure or stress. 267
268
C. BROOKER
The ‘outside’ or social factors could play a part in causal mechanisms related to schizophrenia was a theme taken up by Sullivan in 1926. In a paper to the American Psychiatric Association he postulated that: “at this stage, however, there seems little reason to doubt that cultural distortions provided by the home are of prime importance. We have not seen maladjustment which was without a foundation of erroneous attitudes which parents had thrust upon their child” (p. 105). However, for the next 25 years or so the biological organic model of schizophrenia was to reign supreme with its major emphasis on physical treatments such as electroconvulsive therapy, narcosis and insulin therapy and even the use of the drug LSD. It is of no surprise, therefore, to discover that the role of the psychiatric nurse was described by Henderson (1945) as follows: “Cleanliness, order, punctuality, discipline, attention to detail, observation and what to report to the Doctor collectively, they are the basis of good mental nursing”. Psychiatric nursing, at this point in time was very similar to general nursing, and indeed there were psychiatric theatre nurses whose sole role was to assist at leucotomy operations. In 1952 a revolution was to occur as Delay and Deniker described the pharmacological action of a drug they had used to treat schizophrenia which was eventually marketed under the trade name of ‘Largactil’. The phenothiazine group of drugs were extremely potent in controlling the more florid symptoms of schizophrenia, so much so that sufferers became much more amenable to other interventions of a ‘social’ or ‘interpersonal’ nature. The drug revolution also determined that a patient’s stay in a psychiatric hospital became shorter, indeed, it was now possible to discharge people who had previously been in hospital for many years. Consequently, bed occupation in hospitals reduced from 154,000 in 1954 to 105,000 in 1979 (Royal Commission on NHS, 1979). This is in fact the climate which gave rise to the first CPN service in 1954 (see Brooker, 1987 for a fuller discussion) and indeed foreshadowed ‘Care in the Community’ policies, in general, for those suffering from a mental illness. It was also the climate which was to antecede George Brown’s early research into schizophrenia.
Expressed Emotion: Development of the Concept
Brown (1985) recounts the stages involved in the development of the concept of ‘expressed emotion’ and states that the crucial early finding was that “schizophrenic patients were more likely to relapse if they returned to live with parents or wives than if they went to live in lodgings or with brothers or sisters.” This particular study (Brown et al., 1958) also began to suggest that it was relationships at home which were of critical importance. Those clients who returned to live with their mother and whose mother worked were far less likely to relapse than homes where both client and mother were employed. This finding was to lead to an hypothesis in the next research study that there would be an effect on relapse if face-to-face contact, between the key relative and the client, was lowered in an adverse home environment. In the 1962 paper, Brown and his colleagues, employed a prospective design to test the assertion directly that emotional atmosphere at home was related to relapse. One hundred and twenty-eight male schizophrenic patients and their key female relative were interviewed on three separate occasions after discharge. Clients were assigned to one of two groups, either a ‘high’ or ‘low’ emotional involvement group depending on the rating of their relative on two dimensions, namely, ‘expressed emotion’ or ‘hostility’. Relapse in clients was found
EXPRESSED
EMOTION
AND
PSYCHOSOCIAL
INTERVE,VTION:
A REVIEW
269
to be significantly associated to high ratings of ‘expressed emotion’ in the key relative. A second important result was that low face-to-face contact could ‘insulate’ those patients returning to live in homes with high emotional involvement. However, important though these findings were, Brown was unhappy about both the reliability and validity of the measure used in the study. So for the next 2 years he and Rutter worked on a much more sophisticated measurement instrument which became known eventually as the Camberwell Family Interview (CFI). A detailed description of the way in which the CFI evolved can be found elsewhere (Brown and Rutter, 1966; Rutter and Brown, 1966). In summary, it allowed trained interviewers to assess, reliably and validly, emotional relationships within families over a defined period of time, i.e. in the 3 months preceding the admission to hospital. The CFI taps two main areas: first, events and activities in the household during the 3 months preceding admission, e.g. distribution of household tasks, quarrelling, contact by patient and other members of the family; second, it is concerned with the measurement of attitudes and feelings which are teased out using the CFI as a semi-structured interview guide. The actual scales of emotion which are rated are of two types: (a) ratings of observed emotion, e.g. warmth, hostility and emotional over-involvement; (b) frequency counts of the number of positive or critical remarks the relative makes about the client. The interviews were tape-recorded, an operation which took 4-5 hr to complete. Brown et al. (1972) proceeded to use the CFI, in the field, in a study which sought to test the hypothesis that: “A high degree of expressed emotion is an index of characteristics in the relatives which are likely to cause a florid relapse of symptoms independently of other factors such as length of history, type of symptomatology or severity of previous behaviour disturbance” (p. 242). A sample of 101 clients were identified who had been recently discharged from one of five London psychiatric hospitals with a diagnosis of schizophrenia. The CFI interview was carried out with the client’s relative(s) on tw’o occasions: first, prior to the client’s discharge and second, 9 months after they had returned home. Brown’s et al. findings in this study do indeed go a long way to confirm the earlier research begun in 1958. First of all, a significant association was demonstrated between relapse and high EE in a relative. At 9 month follow-up, 58070of clients in the high EE group had relapsed compared with 16% in the low EE group. Similarly, face-to-face contact time was found again to be important. In the high EE group, those in contact with relatives for 35 + hr a week had a relapse rate of 79% whereas for those whose contact was under 35 hr the relapse rate was only 29%. Brown et al. surmise that this may be because there is “a tendency for some patients when in difficulty to withdraw from close social contacts”. Brown’s personal involvement with this particular field of research inquiry had begun in 1958 and lasted for 14 years and he undoubtedly made a significant contribution-the stage was now set however for others to explore and verify (or otherwise) the utility of the concept.
High Expressed Emotion and Validity (1976-1987)
Since Brown’s early research a number of prospective studies have been undertaken which have sought to demonstrate a relationship between post-hospital discharge relapse in schizophrenic clients and high and low expressed emotion homes. In the main, relapse in these reports has been defined not merely on the basis of rehospitalisation but on the
270
C. BROOKER
deterioration of the positive symptoms of schizophrenia. Generally, it has been established that relapse occurs more frequently in HEE homes but that reduced face-to-face contact and maintenance phenothiazine medication seems to have a protective effect. Vaughn and Leff (1976a) in a preliminary report prior to their main predictive study explain how they shortened Brown’s original measure of expressed emotion, the CFI, without impairing its validity. As Brown et al. (1972) had shown that the singlemost important predictor of relapse was the number of critical comments made by the relative about the client, Vaughn and Leff were able to demonstrate that by shortening the CFI to 2 hr no significant number of critical comments were lost. Vaughn and Leff (1976b) followed 43 schizophrenic (as defined by the Present State Examination, PSE) clients from three London psychiatric hospitals at the point of their discharge home. Thirty-seven of the original 43 patients were still in contact with the research team at 9 month follow-up. The male-female ratio of the patient group was 1: 1.5 and there were interesting differences in the type of household patients were discharged to on the basis of sex: 73% of the men returned to live in a parental home whereas only 27% of the women did so, the majority, 72% returning to live with either a spouse, other adult or relative. However, the researchers were to establish that there was no significant difference in the number of critical comments expressed in the CFI on the basis of ‘living group’. The relationship established between EE status of relatives and subsequent relapse was found to be highly significant (_D= 0.007) (Table 1). In summary, relapse in HEE homes Table 1. High expressed emotion and relapse at 9 month follow-up (adapted from Vaughn and Leff, [1976b]) Relatives EE
No relapse
Relapse
YoRelapse
High
II
IO
48%
Low
15
1
6%
Total
26
11
42%
was 48% but in LEE homes only 6%. However, the variable ‘HEE’ only explained 48% of relapse variation and more than half the client sample living with HEE relatives remained well. Vaughn and Leff next set out to try and establish which other variables were related to relapse apart from EE status. Two major factors emerged, namely, maintenance drug therapy and the amount of face-to-face contact with relatives. Pooling Brown et al. 3 original data with their own, Vaughn and Leff were able to demonstrate an additive model of discharge risk in schizophrenia which is outlined in Fig. 1. Those clients at highest risk of relapse on discharge were those returning to HEE homes, not on drugs, and in high face-to-face contact with a relative (92%). Whereas the risk for those returning to LEE homes, on drugs, and in low face-to-face contact was very small (12%). Of further interest is that Leff and Vaughn (1982) report a 2 year follow-up of this sample and were able to trace 25126 of the original clients who did not relapse at 9 months in the 1976 study. Although relapse is still highly associated with relatives’ EE status perhaps the most significant finding is that no relapse had occurred in clients from either high or low EE homes if they had remained on maintenance medication between 9 month and 2 year follow-up. The authors suggest that whilst drugs may not be protecting those in low EE homes against stress of relatives they may be insulating clients against the stress of independent life events (Birley and Brown, 1970).
EXPRESSED
EMOTION
AND
PSYCHOSOCIAL
INTER
VENTIOtv:
A REVIEW
271
TOTAL. GROUP High EE 5 I4
/\ hr IXC;
1990
oow7489/90 13.00 + 0.00 B 1990 Pcrgamon Press plc
Expressed emotion and psychosocial intervention: a review C. BROOKER,
M.Sc., B.A. (Hors).,
R.M.N.,
R.N.T.,
Dip.N.Ed.
Senior Research Fell0 w, Department of Nursing, University of Manchester, Stopford Building, Oxford Road, Manchester Ml3 9PT, U.K.
Abstract-For thirty years research has been consistently demonstrating the validity of the concept of ‘High Expressed Emotion’ (HEE). After early pioneering work by Brown it was established that environmental influences, particularly, the emotion expressed by relatives to sufferers of schizophrenia, are strongly implicated in relapse. Consequently, the predictive validity of HEE has been revealed in a number-of cross-cultural studies around the world. In addition, there is strong evidence from well designed intervention studies, that relapse, in schizophrenic clients living at home, can be prevented by the manipulation of social and environmental factors. The combined body of research that has now accumulated allows an hypothesis to be made about the aetiology of the illness, schizophrenia, itself. This theory has been described as the ‘stress vulnerability’ model. The paper concludes that psychosocial intervention strategies are effective but that, unfortunately, to date, their application has been mostly restricted to the intervention studies themselves.
Introduction
Historically, the treatment of schizophrenia, has spawned a number of widely differing causal explanations, ranging from St Joan of Arc’s supposed ‘witchcraft’ to some modernday psychiatrist’s views that the illness is potentiated by the protein, gluten, commonly found in wheat products. However, at the beginning of the century, the most popular view of schizophrenia was that it had a biological basis. Kraepelin (1906) believed, for instance, that it was a metabolic disorder. However, there were other views and, interestingly, Bleuler (191 l), who first used the term ‘schizophrenia’, surmised that one group of schizophrenic disorders had a psychological cause, namely, extreme outside pressure or stress. 267
268
C. BROOKER
The ‘outside’ or social factors could play a part in causal mechanisms related to schizophrenia was a theme taken up by Sullivan in 1926. In a paper to the American Psychiatric Association he postulated that: “at this stage, however, there seems little reason to doubt that cultural distortions provided by the home are of prime importance. We have not seen maladjustment which was without a foundation of erroneous attitudes which parents had thrust upon their child” (p. 105). However, for the next 25 years or so the biological organic model of schizophrenia was to reign supreme with its major emphasis on physical treatments such as electroconvulsive therapy, narcosis and insulin therapy and even the use of the drug LSD. It is of no surprise, therefore, to discover that the role of the psychiatric nurse was described by Henderson (1945) as follows: “Cleanliness, order, punctuality, discipline, attention to detail, observation and what to report to the Doctor collectively, they are the basis of good mental nursing”. Psychiatric nursing, at this point in time was very similar to general nursing, and indeed there were psychiatric theatre nurses whose sole role was to assist at leucotomy operations. In 1952 a revolution was to occur as Delay and Deniker described the pharmacological action of a drug they had used to treat schizophrenia which was eventually marketed under the trade name of ‘Largactil’. The phenothiazine group of drugs were extremely potent in controlling the more florid symptoms of schizophrenia, so much so that sufferers became much more amenable to other interventions of a ‘social’ or ‘interpersonal’ nature. The drug revolution also determined that a patient’s stay in a psychiatric hospital became shorter, indeed, it was now possible to discharge people who had previously been in hospital for many years. Consequently, bed occupation in hospitals reduced from 154,000 in 1954 to 105,000 in 1979 (Royal Commission on NHS, 1979). This is in fact the climate which gave rise to the first CPN service in 1954 (see Brooker, 1987 for a fuller discussion) and indeed foreshadowed ‘Care in the Community’ policies, in general, for those suffering from a mental illness. It was also the climate which was to antecede George Brown’s early research into schizophrenia.
Expressed Emotion: Development of the Concept
Brown (1985) recounts the stages involved in the development of the concept of ‘expressed emotion’ and states that the crucial early finding was that “schizophrenic patients were more likely to relapse if they returned to live with parents or wives than if they went to live in lodgings or with brothers or sisters.” This particular study (Brown et al., 1958) also began to suggest that it was relationships at home which were of critical importance. Those clients who returned to live with their mother and whose mother worked were far less likely to relapse than homes where both client and mother were employed. This finding was to lead to an hypothesis in the next research study that there would be an effect on relapse if face-to-face contact, between the key relative and the client, was lowered in an adverse home environment. In the 1962 paper, Brown and his colleagues, employed a prospective design to test the assertion directly that emotional atmosphere at home was related to relapse. One hundred and twenty-eight male schizophrenic patients and their key female relative were interviewed on three separate occasions after discharge. Clients were assigned to one of two groups, either a ‘high’ or ‘low’ emotional involvement group depending on the rating of their relative on two dimensions, namely, ‘expressed emotion’ or ‘hostility’. Relapse in clients was found
EXPRESSED
EMOTION
AND
PSYCHOSOCIAL
INTERVE,VTION:
A REVIEW
269
to be significantly associated to high ratings of ‘expressed emotion’ in the key relative. A second important result was that low face-to-face contact could ‘insulate’ those patients returning to live in homes with high emotional involvement. However, important though these findings were, Brown was unhappy about both the reliability and validity of the measure used in the study. So for the next 2 years he and Rutter worked on a much more sophisticated measurement instrument which became known eventually as the Camberwell Family Interview (CFI). A detailed description of the way in which the CFI evolved can be found elsewhere (Brown and Rutter, 1966; Rutter and Brown, 1966). In summary, it allowed trained interviewers to assess, reliably and validly, emotional relationships within families over a defined period of time, i.e. in the 3 months preceding the admission to hospital. The CFI taps two main areas: first, events and activities in the household during the 3 months preceding admission, e.g. distribution of household tasks, quarrelling, contact by patient and other members of the family; second, it is concerned with the measurement of attitudes and feelings which are teased out using the CFI as a semi-structured interview guide. The actual scales of emotion which are rated are of two types: (a) ratings of observed emotion, e.g. warmth, hostility and emotional over-involvement; (b) frequency counts of the number of positive or critical remarks the relative makes about the client. The interviews were tape-recorded, an operation which took 4-5 hr to complete. Brown et al. (1972) proceeded to use the CFI, in the field, in a study which sought to test the hypothesis that: “A high degree of expressed emotion is an index of characteristics in the relatives which are likely to cause a florid relapse of symptoms independently of other factors such as length of history, type of symptomatology or severity of previous behaviour disturbance” (p. 242). A sample of 101 clients were identified who had been recently discharged from one of five London psychiatric hospitals with a diagnosis of schizophrenia. The CFI interview was carried out with the client’s relative(s) on tw’o occasions: first, prior to the client’s discharge and second, 9 months after they had returned home. Brown’s et al. findings in this study do indeed go a long way to confirm the earlier research begun in 1958. First of all, a significant association was demonstrated between relapse and high EE in a relative. At 9 month follow-up, 58070of clients in the high EE group had relapsed compared with 16% in the low EE group. Similarly, face-to-face contact time was found again to be important. In the high EE group, those in contact with relatives for 35 + hr a week had a relapse rate of 79% whereas for those whose contact was under 35 hr the relapse rate was only 29%. Brown et al. surmise that this may be because there is “a tendency for some patients when in difficulty to withdraw from close social contacts”. Brown’s personal involvement with this particular field of research inquiry had begun in 1958 and lasted for 14 years and he undoubtedly made a significant contribution-the stage was now set however for others to explore and verify (or otherwise) the utility of the concept.
High Expressed Emotion and Validity (1976-1987)
Since Brown’s early research a number of prospective studies have been undertaken which have sought to demonstrate a relationship between post-hospital discharge relapse in schizophrenic clients and high and low expressed emotion homes. In the main, relapse in these reports has been defined not merely on the basis of rehospitalisation but on the
270
C. BROOKER
deterioration of the positive symptoms of schizophrenia. Generally, it has been established that relapse occurs more frequently in HEE homes but that reduced face-to-face contact and maintenance phenothiazine medication seems to have a protective effect. Vaughn and Leff (1976a) in a preliminary report prior to their main predictive study explain how they shortened Brown’s original measure of expressed emotion, the CFI, without impairing its validity. As Brown et al. (1972) had shown that the singlemost important predictor of relapse was the number of critical comments made by the relative about the client, Vaughn and Leff were able to demonstrate that by shortening the CFI to 2 hr no significant number of critical comments were lost. Vaughn and Leff (1976b) followed 43 schizophrenic (as defined by the Present State Examination, PSE) clients from three London psychiatric hospitals at the point of their discharge home. Thirty-seven of the original 43 patients were still in contact with the research team at 9 month follow-up. The male-female ratio of the patient group was 1: 1.5 and there were interesting differences in the type of household patients were discharged to on the basis of sex: 73% of the men returned to live in a parental home whereas only 27% of the women did so, the majority, 72% returning to live with either a spouse, other adult or relative. However, the researchers were to establish that there was no significant difference in the number of critical comments expressed in the CFI on the basis of ‘living group’. The relationship established between EE status of relatives and subsequent relapse was found to be highly significant (_D= 0.007) (Table 1). In summary, relapse in HEE homes Table 1. High expressed emotion and relapse at 9 month follow-up (adapted from Vaughn and Leff, [1976b]) Relatives EE
No relapse
Relapse
YoRelapse
High
II
IO
48%
Low
15
1
6%
Total
26
11
42%
was 48% but in LEE homes only 6%. However, the variable ‘HEE’ only explained 48% of relapse variation and more than half the client sample living with HEE relatives remained well. Vaughn and Leff next set out to try and establish which other variables were related to relapse apart from EE status. Two major factors emerged, namely, maintenance drug therapy and the amount of face-to-face contact with relatives. Pooling Brown et al. 3 original data with their own, Vaughn and Leff were able to demonstrate an additive model of discharge risk in schizophrenia which is outlined in Fig. 1. Those clients at highest risk of relapse on discharge were those returning to HEE homes, not on drugs, and in high face-to-face contact with a relative (92%). Whereas the risk for those returning to LEE homes, on drugs, and in low face-to-face contact was very small (12%). Of further interest is that Leff and Vaughn (1982) report a 2 year follow-up of this sample and were able to trace 25126 of the original clients who did not relapse at 9 months in the 1976 study. Although relapse is still highly associated with relatives’ EE status perhaps the most significant finding is that no relapse had occurred in clients from either high or low EE homes if they had remained on maintenance medication between 9 month and 2 year follow-up. The authors suggest that whilst drugs may not be protecting those in low EE homes against stress of relatives they may be insulating clients against the stress of independent life events (Birley and Brown, 1970).
EXPRESSED
EMOTION
AND
PSYCHOSOCIAL
INTER
VENTIOtv:
A REVIEW
271
TOTAL. GROUP High EE 5 I4
/\ hr IXC;
