Expressed emotion across cultures

Dinesh Bhugra is Professor of Mental Health and Cultural Diversity and heads the Section of Cultural Psychiatry at the Institute of Psychiatry (Health Services Research Department, PO Box 25, De Crespigny Park, London SE5 8AF. E-mail: d.bhugra{at}iop.kcl.ac.uk). His research interests include cultural psychiatry, spirituality, sexual dysfunction and diversity. Kwame McKenzie is a senior lecturer in psychiatry at the Royal Free & University College School of Medicine, London, and an honorary consultant psychiatrist with Barnet Enfield and Haringey Mental Health NHS Trust. His research interests include public health impact of mental illness, discrimination and social capital.

Abstract

TOP Abstract The components of expressed... Findings from Western countries Findings from non-Western... Ethnic minority groups Clinical implications Implications for management Conclusions Multiple choice questions References

The first research instrument to record the range of feelings and emotions found in ordinary families was the Camberwell Family Interview, developed by Brown. This is conducted with the key carers of the patient, and from it the interviewer tries to create a picture of how things have been in the household in the months leading to the onset of illness. In the first phase of development of the interview, Brown and colleagues (Brown, 1959; Brown et al, 1958, 1962, 1972) reported that theoretical constructs were being developed at the same time as the interviews were being conducted. In a historical account of the process, Brown (1985) suggested that the term ‘expressed emotion’ emerged only after several studies had been carried out.

After the instrument had been in use for a while, the researchers developed a semi-standardised interview, distinguishing between critical comments and dissatisfaction (although they clearly go together). The original interview was very long and it has now been shortened so that it can be completed in 2–2 hours. In current usage, the interview is taped and its transcript is rated on a number of parameters. Two types of information are elicited: objective information about events and circumstances in the home in the months before the admission and subjective information concerning the relative’s feelings and attitudes towards the patient when talking about the illness. Leff & Vaughn (1985) point out that the interview is in a ‘mental conversational style ... rather than a clinical one’. All judgements on the relative’s expressed emotion are based on this interview.

The components of expressed emotion

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The interaction between expressed emotion and patient outcome is complex. Research has demonstrated that patients from households with high expressed emotion do not differ in their pathology from those in households with low. It is the relatives who differ markedly in their response to the patients and their illnesses. Of the five scales, critical comments, hostility and emotional overinvolvement have been shown to be the most predictive of relapse (i.e., of increased symptoms) (Kuipers, 1992).

It should be noted that the interactions between the patient and the family are also important, especially cross-culturally. In some cultures, for example in parts of India, emotional overinvolvement is the norm. If a carer does not show emotional overinvolvement it is seen as lack of care. Interviewers should try to understand and follow cultural norms. Expressed emotion is best measured by a person from the same cultural group: it is difficult for a researcher who is not familiar with the nuances of language and cultural expression of an interviewee to rate any of the components of expressed emotion. If measures of expressed emotion are being applied in cultures where they have not been used before, they must be accompanied by fieldwork to establish the norms and the context. The most important factor for the researcher is to embed emotional overinvolvement, hostility and warmth in the specific cultural context. Measurement is also dependent on an assessment of the interviewee’s general style of emotional expression.

Findings from Western countries

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Butzlaff & Hooley’s study agrees with Bebbington & Kuipers’ (1994) aggregate analysis of 25 studies with 1346 patients. This found that for patients living in situations rated as showing high expressed emotion (the ‘high expressed emotion group’; n = 705) the relapse rate was 50%, whereas in the ‘low expressed emotion group’ (n = 641) the rate was 21%. In the majority of the studies, high expressed emotion was predictive of relapse in symptoms of schizophrenia 9 months later for both genders. A large amount of face-to-face contact (more than 35 hours per week) with a relative with a high expressed emotion score increased the risk of relapse, but in households with a low expressed emotion score, high levels of contact appeared to be protective. Both warmth and positive comments were predictive of good outcome. Interestingly, medication had an independent effect on relapse rate, suggesting that medication is useful for patients irrespective of the expressed emotion status in the family. One of the criticisms of the applications of this construct, therefore, is that it can ‘pathologise’ the family or specific relatives who might in reality be struggling hard to cope with a difficult home situation.

The UK
Vaughn & Leff (1976) studied 43 patients with schizophrenia and 32 patients with ‘depressive neurosis’, and were able to follow up 37 and 30 patients respectively in the two groups. Most of the patients with depression came from marital homes. The relapse rate for the patients from homes that showed high expressed emotion was 50%, compared with 12% for those from homes with low expressed emotion. The authors used seven or more critical comments and/or an emotional overinvolvement rating of 4 or 5 to rate expressed emotion as high. They found that the amount of face-to-face contact also reflected the status of expressed emotion. They reported that more than 35 hours of face-to-face contact was the crucial cut-off. Those whose exposure was more than 35 hours had higher relapse rates (89% v. 57%). When they explored the use of medication they found that high expressed emotion subjects who were not on medication were more likely to relapse (78%) than those who were on medication (25%). They argue that low expressed emotion and regular medication act as additive factors in reducing the risk of relapse. Of the patients with depression, 67% of those who had a relative with a critical comments score of more than 2 relapsed, compared with 22% if the score was 0 or 1.

The USA
Using similar methods in California, Vaughn and her colleagues observed that 33% of Californian families had been rated low expressed emotion compared with 52% in the British sample (Leff & Vaughn, 1985). The Californian families were significantly less likely to make no critical comments than the London families, and ratings of hostility were more common in the Californian sample, but there were no cultural differences in emotional overinvolvement. Once again, patients in high expressed emotion settings were more likely to relapse (56% compared with 17% for low expressed emotion). Also, there was a high relapse rate (68%) among those in the non-medicated high expressed emotion group, whereas there were no relapses at all in the medicated low expressed emotion group.

Australia
In Australia, Vaughan et al(1992) recruited 91 suitable patients with schizophrenia and found that 59% in the high expressed emotion group relapsed compared with 36% in the low expressed emotion group. High contact (more than 35 hours per week) was more likely to increase relapse (68%) compared with only 12% in low expressed emotion groups. There was no gender difference and those from high expressed emotion households were still more likely to relapse even when on medication (42%), confirming the previous findings from London and California.

Studies of home and residential settings
In an interesting development, Moore et al(1992) studied expressed emotion in group homes and long-term care settings in the UK and found that high expressed emotion settings were characterised by less tolerance, inappropriate expectations of patient progress and frustration in the keyworker. Criticisms focused on embarrassing behaviours and negative symptoms. In a follow-up UK study, Ball et al(1992) found that higher discharge rates were possible for patients who were ready to return to low expressed emotion hostels.

The study and identification of expressed emotion in the relatives of patients with schizophrenia in different settings have led to the development of intervention strategies with families and carers. The aim of such work is to reduce expressed emotion by education and also to reduce the patients’ faceto-face contact with high expressed emotion individuals to less than 35 hours per week. Most studies have shown that this is possible. Lowering of the expressed emotion can be achieved through relatives’ groups and individual and family work. Another innovation is the use of the ‘5-minute speech’, during which a relative is asked to talk about the patient (Magana et al, 1986). This has been shown to be a useful practical measure of levels of expressed emotion. However, the authors point out that this method may misclassify a proportion of high expressed emotion individuals as low.

Findings from non-Western countries

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Egypt
In a study from Egypt, Kamal (1995) observed that high expressed emotion was present in 55% of the families of patients with schizophrenia. They reported that Egyptian patients tolerated higher levels of criticism before relapse than have been reported in Western studies. They suggested that these levels were inclusive of benign criticism. A similar observation was reported by Okasha et al(1994), who found that criticism is an accepted and acceptable component of interpersonal relations in Egyptian culture and that it might well reflect an element of care. It is also possible that criticism and overinvolvement are intertwined and that warmth might act as a key protective factor. Emotional overinvolvement is seen in the West as pathological because it crosses the boundaries of individuals (i.e. it acts against the individual, egocentric position), whereas in other cultures such an approach may be the norm. In sociocentric societies emotional overinvolvement is to be expected because the individual is part of the larger kinship group. (Egocentric or individualistic societies are those in which the individual is seen as predominant, whereas in sociocentric or collectivist societies individuals are an integral part of kinship and it is kinship that takes precedence over individuals.)

Israel
Similarly, it has been demonstrated that anger is more openly and more immediately expressed in Israel than in Western countries and a failure to express one’s anger is perceived as a weakness (Heresco-Levy et al, 1990). Thus, it is likely that both hostility and critical comments seen in the context of anger may result in false-positive rates of high expressed emotion. Heresco-Levy et al emphasise that expressed emotion ratings must be adjusted in relation to the normative levels of overt expression of emotions, which vary across cultures. However, changes in levels may be influenced by processes of acculturation if cultural groups move across national and cultural boundaries.

China
In China, Phillips & Xiang (1995) found that, using conventional criteria for rating expressed emotion, over 42% of Chinese family members of patients with schizophrenia were rated as showing high expressed emotion. They also observed a non-significant increase in the relative risk of relapse for Chinese patients from high expressed emotion households when compared with low expressed emotion households. They attribute this to a number of factors. First, the impact on the patient of a high expressed emotion relative may be less significant in Chinese culture than in other cultures. Second, the fact that the role of families (especially small families) in the context of a political system in which an individual’s role is as seen by the state may well act as a protective factor. Third, it might also reflect the diverging attitudes of the community and the individual regarding the individual’s autonomy.

Japan
From Japan, Mino et al(1995) reported that, contrary to their expectations of low expressed emotion (as Japanese tend not to display emotions readily), 48% of Japanese households were classified as high expressed emotion, with criticism being the most common item (39% of households made six or more critical comments).

This brief overview of expressed emotion across cultures suggests that different components of expressed emotion (Box 1) have varying prevalence across different cultures.

Box 1 Indicators of high expressed emotion Critical comments: six or more Emotional overinvolvement: a score of 3 or higher Hostility: present Warmth: absent Positive regard: absent

 

Ethnic minority groups

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Mexican American families
In the study of expressed emotion in ethnic minority groups, Jenkins’ work, especially that dealing with Mexican American families, has been ground-breaking. Highlighting the anthropological and clinical dimensions of individually variable (and sometimes deviant) constructions of family worlds within particular cultural contexts, she argues that emotional overinvolvement is clinically rated on the basis of affective and behavioural features (that may include self-sacrificing and extremely overprotective behaviours) but that it should not be (Jenkins, 1992). In her study of Mexican Americans she suggests that Mexican culture encourages relatives to display a high degree of involvement in kin affairs.

After studying 70 Mexican American families and 109 key relatives, Karno et al(1987) found that only 11% of the relatives were rated as showing high expressed emotion. Nearly all of the 11% were female and almost all of the patients were male. The authors had adapted the expressed emotion rating scales for the Mexican American cultural context and found that the outcome of schizophrenia in their sample was indeed related to expressed emotion in the family, but they caution that the cross-cultural validity of concepts such as overinvolvement must be taken into account.

Asian families in the UK
In Birmingham, UK, Hashemi & Cochrane (1999) reported on expressed emotion in 60 families (20 British Pakistanis, 20 British Sikhs and 20 matched Whites), all of which included a relative with a diagnosis of schizophrenia. They observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion. Emotional overinvolvement was significantly higher among the British Pakistani group (55% v. 10% for the British Sikh group). They observed that the modal score for White and Sikh relatives on emotional overinvolvement was 1, whereas for British Pakistanis it was 4. Using the conventional rating criteria the authors found that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups, high expressed emotion did not predict relapse. However, raising the cut-off of emotional overinvolvement for Pakistani families led to significantly better prediction of relapse. Although the numbers are small in this study, these differences indicate that using conventional measures of expressed emotion across different ethnic groups is fraught with difficulties. The authors draw our attention to similarities between the UK Asian and North Indian groups. Hashemi & Cochrane subsequently carried out a population-based normative study for expressed emotion and found that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional overinvolvement may be cultural rather than pathogenic traits (Hashemi & Cochrane, 1999).

Clinical implications

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Implications for management

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For the clinician, several significant factors affect the way prognosis or outcome of schizophrenia can be seen in the context of expressed emotion. Most importantly, the role of normative cultural data for the general population (who do not have a relative with a mental illness) needs to be understood. If the normative data show high levels of expressed emotion then the significance of these components in mental illness has to be seen in that context. The effects of intermediary factors such as explanation of the illness, attitudes towards the illness, the perceived or real autonomy of the individual, the socio- or egocentric status of the individual in the cultural context, role expectations of the individual and the effect of the illness on these roles must be studied further and related to outcome, compliance and treatment adherence (Fig. 1).

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Fig. 1 Family and cultural characteristics that may influence patient outcome through expressed emotion.

In working with families to reduce expressed emotion, clinicians must take into account the role that family therapy may be seen as having in managing patients. Some families see family therapy as intrusive and prescriptive, whereas others welcome it in order to learn more about managing the patient in their midst and the illness. Gender and gender-role expectations also play an important part in this context (Box 2).

Box 2 Family intervention In family interventions, clinicians should take the following family characteristics into consideration: structure, e.g. nuclear or extended significant members cultural and social norms expectations of the patient knowledge of the illness acceptance of medical or psychological intervention gender-role expectations external support systems

 

Family structures contingent on economic interdependence and patriarchal norms are protective in some settings. Therefore, the normative prevalence of the components of expressed emotion should be rigorously established across different cultural groups and its constructs may have to be given different emphasis depending on cultural context.

Conclusions

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Multiple choice questions

TOP Abstract The components of expressed... Findings from Western countries Findings from non-Western... Ethnic minority groups Clinical implications Implications for management Conclusions Multiple choice questions References

1. The following are the components of expressed emotion:
   1. critical comments
      
   2. hostility
      
   3. warmth
      
   4. emotional overinvolvement
      
   5. heated arguments.
      
   
   
2. Expressed emotion has been shown to be associated with:
   1. onset of schizophrenia
      
   2. relapse of schizophrenia
      
   3. personality disorders
      
   4. criminal behaviour
      
   5. relapse in mood disorders.
      
   
   
3. Cross-cultural studies of expressed emotion have shown:
   1. the same incidence of high expressed emotion in both Western and non-Western cultures
      
   2. the same incidence of relapse compared in both Western and non-Western cultures
      
   3. that all five components have equal prominence across cultures
      
   4. relapse rates are similarly influenced across all nations
      
   5. that the impact of relatives with high expressed emotion is the same across cultures.
      
   
   
4. Across ethnic groups:
   1. emotional overinvolvement is higher in some groups
      
   2. the same cut-off points for rating are valid
      
   3. emotional overinvolvement may be valued in some groups
      
   4. it is essential to have normative data for each ethnic group
      
   5. expressed emotion may be influenced by the gender of the carers.
      
   
   
5. The following may play an important role in engaging the family for therapeutic work:
   1. family structure
      
   2. significant family members
      
   3. the family’s expectations of treatment
      
   4. that all members of the family are involved
      
   5. the family’s knowledge of the illness and treatment.
      
   
   

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MCQ answers

References

TOP Abstract The components of expressed... Findings from Western countries Findings from non-Western... Ethnic minority groups Clinical implications Implications for management Conclusions Multiple choice questions References

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