8
Journal or Consulting and Clini 1989, №1.57, No. 1,11-18 Copyright 1989 by the American Psychological Association, Inc. Expressed Emotion and Patient-Relative Interaction in Families of Recent Onset Schizophrenics Kurt Hahlweg Max-Planck Institute of Psychiatry Munich, West Germany Jeri A. Doane Yale Psychiatric Institute Michael J. Goldstein, Keith H. Nuechterlein, Ana B. Magana, and Jim Mintz University of California, Los Angeles David J. Miklowitz and Karen S. Snyder University of California, Los Angeles This article examines the interaction patterns of relatives of young, recent onset schizophrenic pa- tients classified as displaying either high or low expressed emotion (EE) by two measures, the original Camberwell interview method and a recently developed brief method. The former was administered during the hospitalization period and the latter was administered approximately 2 months later when the patient was in the community. Family interactions were coded with an observational coding system that permitted sequential patterns to be analyzed as a function of the EE status of the family. No relation between the Camberwell EE rating and interactional behavior was found. However, high EE-critical relatives, defined by the brief EE method, were more negative in direct interactions than low EE relatives or high EE relatives classified as emotionally overinvolved. Sequential analyses indicated that high EE-critical relatives showed extreme negative escalation patterns. Patients' reac- tions to high EE-critical relatives were characterized by self-justification and negative nonverbal behavior. Levels of family expressed emotion (EE) have been repeat- edly found to predict relapse rates in schizophrenic patients 9 or 12 months after hospital discharge (Jenkins et al., 1986; Left" & Vaughn, 1985; Nuechterlein, Snyder, et al., 1986). These studies have shown that the chance of relapse increases by a factor of approximately 4 when a patient returns to a family environment marked by high levels of criticism or emotional overinvolvement. In contrast to the 50-60% relapse rate among high EE families at 9 months, the relapse rate among low EE families averages 15%. Expressed emotion is coded from the individual Camberwell Family Interview (CFI; Vaughn & Leff, 1976) with a relative of the psychiatric patient, and ratings are based on statements made by the relative about the patient. The number of critical comments (statements of irritation, dislike, or resentment about the patient's behavior or personality, usually expressed with corresponding voice tone) in the interview are counted. The degree of emotional overinvolvement (markedly overcon- This research was supported by National Institute of Mental Health Grants MH08744, MH37705, MH30911, and MH14584 and by a grant from the John T. and Catherine D. MacArthur Foundation for the Network on Risk and Protective Factors in the Major Mental Disor- ders. The authors would like to thank interviewers Portia Loughman, Sandra Rappe, and Marianna Lopez; speech sample coder Dorothy Feingold; and KPI coders Manhal Al-Khayyal, Nicole Bussod, Marilyn Conrad, Julio Diaz, and Valerie Marshall. Correspondence concerning this article should be addressed to either Kurt Hahlweg, Max-Planck Institute of Psychiatry, Kraepelinstrasse 2, D-8000 Munchen, West Germany or to Michael J. Goldstein, Depart- ment of Psychology, University of California, 1283 Franz Hall, Los An- geles, California 90024-1563. cerned, overprotective, or self-sacrificing attitudes and behav- ior) is rated on a 6-point scale for the whole interview. Relatives are classified as high EE if they shew evidence of excessive criti- cism or emotional overinvolvement. Generally, this interview is administered while the patient is hospitalized for an index episode of the disorder, and it is assumed that the EE rating reflects the type of family environment that the patient will en- counter after discharge. Recent studies have shown that the EE measure is relevant not only to schizophrenia but also as a valuable predictor of relapse in depression (Hooley, Orley, & Teasdale, 1986; Vaughn & Leff, 1976) and in recent-onset mania (Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz, 1988). Despite the strong association between EE and relapse, we still know relatively little about the mechanism underlying the correlation between family attitudes and the return of symp- toms in psychiatric patients (Hooley, 1986a). Because the CFI measures relatives' attitudes toward the patient that are ex- pressed within the context of an interview with a mental health professional, we need to know whether and in what ways these attitudes are also expressed in face-to-face contact with the pa- tient. One approach to investigating the construct validity of EE is to systematically analyze the behavior of high EE and low EE relatives as they interact with the patient after the patient has left the hospital and returned home. In three previous studies, the relation between EE attitudes and directly observed interactional behavior has been assessed using a standardized situation to elicit interactional behavior and a coding system to reflect the behavioral analogues of EE attitudes (Strachan, Goldstein, & Miklowitz, 1986). Using a modification of an interaction task developed originally by Goldstein, Judd, Rodnick, Alkire, and Gould (1968) for a longi-

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Journal or Consulting and Clini1989, №1.57, No. 1,11-18

Copyright 1989 by the American Psychological Association, Inc.

Expressed Emotion and Patient-Relative Interaction inFamilies of Recent Onset Schizophrenics

Kurt HahlwegMax-Planck Institute of Psychiatry

Munich, West Germany

Jeri A. DoaneYale Psychiatric Institute

Michael J. Goldstein, Keith H. Nuechterlein,

Ana B. Magana, and Jim MintzUniversity of California, Los Angeles

David J. Miklowitz and Karen S. SnyderUniversity of California, Los Angeles

This article examines the interaction patterns of relatives of young, recent onset schizophrenic pa-

tients classified as displaying either high or low expressed emotion (EE) by two measures, the original

Camberwell interview method and a recently developed brief method. The former was administered

during the hospitalization period and the latter was administered approximately 2 months later

when the patient was in the community. Family interactions were coded with an observational coding

system that permitted sequential patterns to be analyzed as a function of the EE status of the family.

No relation between the Camberwell EE rating and interactional behavior was found. However, high

EE-critical relatives, defined by the brief EE method, were more negative in direct interactions than

low EE relatives or high EE relatives classified as emotionally overinvolved. Sequential analyses

indicated that high EE-critical relatives showed extreme negative escalation patterns. Patients' reac-

tions to high EE-critical relatives were characterized by self-justification and negative nonverbal

behavior.

Levels of family expressed emotion (EE) have been repeat-

edly found to predict relapse rates in schizophrenic patients 9

or 12 months after hospital discharge (Jenkins et al., 1986; Left"

& Vaughn, 1985; Nuechterlein, Snyder, et al., 1986). These

studies have shown that the chance of relapse increases by a

factor of approximately 4 when a patient returns to a family

environment marked by high levels of criticism or emotional

overinvolvement. In contrast to the 50-60% relapse rate among

high EE families at 9 months, the relapse rate among low EE

families averages 15%.

Expressed emotion is coded from the individual Camberwell

Family Interview (CFI; Vaughn & Leff, 1976) with a relative of

the psychiatric patient, and ratings are based on statements

made by the relative about the patient. The number of critical

comments (statements of irritation, dislike, or resentment

about the patient's behavior or personality, usually expressed

with corresponding voice tone) in the interview are counted.

The degree of emotional overinvolvement (markedly overcon-

This research was supported by National Institute of Mental Health

Grants MH08744, MH37705, MH30911, and MH14584 and by a

grant from the John T. and Catherine D. MacArthur Foundation for

the Network on Risk and Protective Factors in the Major Mental Disor-

ders. The authors would like to thank interviewers Portia Loughman,

Sandra Rappe, and Marianna Lopez; speech sample coder Dorothy

Feingold; and KPI coders Manhal Al-Khayyal, Nicole Bussod, Marilyn

Conrad, Julio Diaz, and Valerie Marshall.

Correspondence concerning this article should be addressed to either

Kurt Hahlweg, Max-Planck Institute of Psychiatry, Kraepelinstrasse 2,

D-8000 Munchen, West Germany or to Michael J. Goldstein, Depart-

ment of Psychology, University of California, 1283 Franz Hall, Los An-

geles, California 90024-1563.

cerned, overprotective, or self-sacrificing attitudes and behav-

ior) is rated on a 6-point scale for the whole interview. Relatives

are classified as high EE if they shew evidence of excessive criti-

cism or emotional overinvolvement. Generally, this interview

is administered while the patient is hospitalized for an index

episode of the disorder, and it is assumed that the EE rating

reflects the type of family environment that the patient will en-

counter after discharge.

Recent studies have shown that the EE measure is relevant

not only to schizophrenia but also as a valuable predictor of

relapse in depression (Hooley, Orley, & Teasdale, 1986; Vaughn

& Leff, 1976) and in recent-onset mania (Miklowitz, Goldstein,

Nuechterlein, Snyder, & Mintz, 1988).

Despite the strong association between EE and relapse, we

still know relatively little about the mechanism underlying the

correlation between family attitudes and the return of symp-

toms in psychiatric patients (Hooley, 1986a). Because the CFI

measures relatives' attitudes toward the patient that are ex-

pressed within the context of an interview with a mental health

professional, we need to know whether and in what ways these

attitudes are also expressed in face-to-face contact with the pa-

tient. One approach to investigating the construct validity of

EE is to systematically analyze the behavior of high EE and low

EE relatives as they interact with the patient after the patient

has left the hospital and returned home.

In three previous studies, the relation between EE attitudes

and directly observed interactional behavior has been assessed

using a standardized situation to elicit interactional behavior

and a coding system to reflect the behavioral analogues of EE

attitudes (Strachan, Goldstein, & Miklowitz, 1986). Using a

modification of an interaction task developed originally by

Goldstein, Judd, Rodnick, Alkire, and Gould (1968) for a longi-

12 HAHLWEG ET AL.

tudinal prospective study, investigators asked family members

to discuss in the laboratory two emotionally loaded family

problems derived from a prior interview. The affective style (AS;

Doane, West, Goldstein, Rodnick, & Jones, 1981) coding sys-

tem was used to measure specific verbal behaviors of relatives

during this interaction task. The AS system classifies verbal be-

havior into categories such as support, benign and personal crit-

icism, guilt induction, and intrusiveness (statements indicating

that the relative believes that he or she has knowledge of the

patient's inner states beyond what the patient has actually said).

In the first study investigating the association between EE at-

titudes and interactional behavior (Valone, Norton, Goldstein,

& Doane, 1983), 52 families from the University of California,

Los Angeles (UCLA) Family Project longitudinal prospective

study were investigated. High EE parents, who had been classi-

fied from an interview similar to the CFI (largely on the basis

of EE criticism criteria), expressed significantly more criticism

toward their disturbed but nonpsychotic offspring in direct in-

teractions than did low EE parents. In the second study with a

sample composed primarily of chronic schizophrenic patients

and their families (Miklowitz, Goldstein, Falloon, & Doane,

1984), parents rated as high EE because of criticism (on the

CFI) were distinguished by their frequent use of critical com-

ments during the interaction task, whereas those rated as high

EE on the overinvolvement criteria used more intrusive state-

ments. In the third study, conducted in Great Britain (Strachan,

Leff, Goldstein, Doane, & Burtt, 1986), these findings were rep-

licated even though the schizophrenia in this study was of recent

onset and the interactional behavior was assessed from dyadic

rather than triadic interactions between patients and relatives.

A further suggestion that high EE and low EE relatives differ

behaviorally came from a study by Kuipers, Sturgeon, Berko-

witz. and Leff (1983) in which the rate of relatives' talking and

the duration of looking were used as dependent variables. Al-

though patients did not differ on these variables, high EE rela-

tives spent more time talking and less time looking at the patient

than did low EE relatives. This study did not examine the con-

tent of the verbal interactions.

These studies indicate that, when data are aggregated over a

total interaction, high EE families with a mentally ill member

are characterized by criticism, intrusion, and high verbal out-

put, whereas low EE families interact in a more neutral fashion.

Interestingly, none of these studies have reported that low EE

relatives use more positive or supportive statements than high

EE relatives during the family discussion (Strachan, Leff, et al.,

1986). This finding may be due to the task itself because it was

developed to examine conflictual issues, or it may reflect limita-

tions in the AS coding system, which was specifically designed

to capture negative communication behaviors. However, it

seems unlikely that the protective value of low EE behavior de-

rives simply from an absence of negative behavior. Thus, the

question of whether low EE families are more positive than high

EE families (e.g., show acceptance of the patient or have a more

constructive approach to solving family problems) remains

open.

Although the associations reported to date between relatives'

EE ratings during an interview and during family interaction

have been congruent with the EE construct and consistent

across studies, there are notable limitations in the previous

work. First, these studies have compared the CFI rating system

for EE, which is based on both the verbal and nonverbal behav-

ior of a respondent during an interview, with behavior in a di-

rectly observed family discussion coded by a system that relies

solely on verbal content (the AS system is used with verbatim

transcripts exclusively). In the present study, another coding

system was applied to the same interactional data. The Kategor-

iensystem fuer Partnerschaftliche Interaktion [Category Sys-

tem for Partners Interaction] (KPI; Hahlweg, Reisner, et al.,

1984) codes both verbal and nonverbal behavior on a unit-by-

unit basis. It was hypothesized that, with both verbal and non-

verbal behaviors coded, a clearer picture of the association be-

tween EE attitudes and interactional behavior would be re-

vealed.

Second, previous research has not examined the role and

contribution of the schizophrenic patient to the interactional

process. In the present study, the KPI was applied to the behav-

ior of both relatives and patients in the direct interactional task

to determine whether interactional behavior in patients was

correlated with the EE level of their relatives.

Third, because previous studies have aggregated the relative's

data over the whole interaction and have not considered the pa-

tient's behavior, it has not been possible to study the processes

of family interaction as they emerge over time. Whereas the AS

method is a critical-incident coding system, the KPI codes all

units of interactional behavior in sequential order. It is, there-

fore, possible to apply techniques of sequential analysis to these

data to measure the relative contributions of patients and rela-

tives to the observable family processes and to document

whether patterns of interaction discriminate high EE from low

EE families. Thus, a major objective of this article was to ana-

lyze the sequential interaction patterns of both relatives and pa-

tients as a function of the EE level of the family unit.

The present study was therefore designed to investigate five

questions:

1. Do the relatives of schizophrenic patients differ in their

interactional behavior as a function of their EE status?

2. Do the interactional patterns of relatives observed in high

EE family units vary according to whether the high EE status is

based on criticism or overinvolvement criteria?

3. Do low EE relatives simply show a low rate of negative

interactional behaviors, or do they also emit more positive and

supportive behaviors than high EE relatives defined by either

criticism or overinvolvement criteria?

4. Does the interactional behavior of patients correlate with

the EE status of their relatives?

5. Does sequential analysis of the interactional data reveal

distinctive patterns of relative and patient behavior in high EE

and low EE families?

Method

Subjects

Forty-three families with a schizophrenic patient were included in thestudy. All patients (and families) were participants in the Developmen-tal Processes in Schizophrenic Disorders Project (Nuechterlein, Edell,Morris, & Dawson, 1986; Nuechterlein, Snyder, et al., 1986), which isan ongoing longitudinal study of the early course of schizophrenia. Pa-tients were recruited in a psychotic state during an index hospitalization

SPECIAL SERIES: EXPRESSED EMOTION AND SCHIZOPHRENIA 13

from public hospitals in the western and San Fernando Valley regions

of the Los Angeles metropolitan area. Schizophrenic subjects were re-

quired to have a diagnosis of definite schizophrenia or schizoaffective

disorder, mainly schizophrenic, according to Research Diagnostic Cri-

teria (RDC; Spitzer, Endicott, & Robins, 1978) and based on an ex-panded version of the Present State Examination (PSE; Wing, Cooper, &

Sartorius, 1974), which was administered to the patient, with additional

data gathered from relatives. The PSE interviewers had all completed a

training course on the instrument and were certified as reliable to diag-

nose schizophrenia on the basis of their ratings of a series of standard-

ized training tapes. Interrater agreement between the PSE interviewers

and a criterion rater for PSE items relevant to distinguishing schizo-

phrenia from other psychiatric disorders had to exceed 85% for an inter-

viewer to participate in this study. The reliability of each diagnostician

was assessed each year to minimize rater drift and, in each case, reliabil-

ity did not fall below this criterion. Because the longitudinal study fo-

cuses on predictors of the early course of schizophrenia, patients were

required to have had a first psychotic episode not longer than 2 years

before their contact with the project. Subjects were excluded if they

showed evidence of an organic central nervous system disorder, signifi-

cant or habitual drug or alcohol abuse in the 6 months prior to the

current episode, past drug or alcohol abuse that clouded the diagnostic

picture, or mental retardation.

This schizophrenic sample (n = 43) was young, with an average age

of 22.3 years (SD = 3.5; range = 18-32). The mean educational level

was 11.9 years (SD - 1.8; range = 9-16). Ninety-one percent of the

patients were White, 7% were Hispanic, and 2% were of mixed race.

Eighty-four percent of the patients were men. In total, 64 relatives were

included in the study. Twenty-one families had two parents and 20 fa-

milies had one parent (primarily mothers). The remaining 2 families

contained either a spouse or a sibling paired with the patient.

Eleven additional schizophrenic patients had been entered into the

longitudinal study and their family members had been given CFIs by

the time of these analyses, but they were not available for the subsequent

direct interaction session. According to multiple / tests with adjustment

for nonindependence, these patients did not differ from the included

patients in age, sex, educational level, ethnicity, social class, age at onset

of psychosis, or EE level of family based on the CFI. A tendency for the

excluded patients to have had more total months of illness than included

patients was not significant (/) = .06).

Procedure

Expressed emotion: Camberwell Family Interview. Once the patient

had met study criteria, his or her closest relatives were administered the

CFI as soon as possible, generally within I month of hospital admission

while the patient was in the hospital. The CFI is a 1 Vi hr, semistructured,

audiotaped individual interview conducted with the patient's key rela-

tives. The interview is conducted with each relative individually and

focuses on the most recent schizophrenic episode and on the behavior

of the patient in the 3 months prior to admission. A relative is ratedhigh on expressed emotion if he or she makes six or more critical com-

ments about the patient (high EE-critical) or has a rating of 4 or 5 on a

global rating scale of emotional overinvolvement (high EE-overin-

volved). The CFI audiotapes were rated by trained raters who had pre-

viously been certified as reliable in administering and rating the CFI for

EE by obtaining interrater reliability coefficients of at least .85 (p <

.001). Periodic checks completed by an independent rater showed that

little rater drift occurred. The raters were not aware of the hypotheses

being tested in the present study.Expressed emotion: Short form. After the patient was discharged, the

family was asked to participate in a family assessment session con-

ducted 5-6 weeks after hospital discharge. At the session, each relativewas interviewed individually and was asked to speak for 5 min (5-min

speech sample; FMSS) about the patient. Utterances were coded later

from the audiotapes using the guidelines for coding EE from a FMSS

(MagaSa et al., 1986). Previous research by Magana et al. (1986) re-

vealed a substantial relation between EE classification on the basis of

the CFI and the FMSS system when the data sets were collected within

2 weeks of each other. The nature of the association between the CFI

measure of EE and that derived from the FMSS is not known when

the time period between administrations is longer. Interrater reliability

coefficients in the present sample for the FMSS were adequate, with

kappas ranging from .70 to .80 for the distinctions between low EE, high

EE, and high EE subtypes (critical vs. overinvolved). The kappas were

identical when computed for the first and last half of the sample, indicat-

ing no rater drift.

Direct family interaction. Following the FMSS, each family member

was interviewed individually in order to generate problem issues that

focused on family conflicts. After an issue had been identified, the inter-

viewer directed the family member to pretend that the person to whom

the problem was directed was sitting in the room with him or her and

to verbalize the issue while the tape recorder was running. This audio-

tape was taken to the respective family member, who listened to the

statement and was asked to respond to it. Two issues for each member

were generated in this way.

The family members were then brought into the lab, where they lis-

tened to two audiotaped statements together. The family was directed

to discuss each problem for 10 min, to express thoughts and feelings

about it, and to try to solve the problem while the experimenter was out

of the room. After 10 min, the family was asked to discuss a second

problem. One of the issues was generated by the patient and one by a

relative. The order of problem presentations was counterbalanced

across families(see Miklowitz et al., 1984, fora more complete descrip-

tion of the procedures).

KPI coding system. The behavior of each family member during the

videotaped discussions was coded using the KPI (Hahlweg, Reisner, et

al., 1984). The aim of the KPI is to assess empirically the speaker and

listener skills that form the basis of behaviorally oriented communica-

tion and problem-solving treatments. The basic coding unit is a verbal

response that is homogenous in content without regard to its duration

or syntactical structure.

The KPI consists of 12 verbal categories that are derived primarily

from assumptions about effective communication. The categories are

(a) self-disclosure, consisting of direct expressions of feelings (e.g., "I'm

too angry to listen to you at the moment") and direct expressions of

wishes and needs (e.g., "I'd like to go fishing tomorrow"); (b) positive

solutions, consisting of specific, constructive proposals (e.g., "I'll do the

dishes") and compromises (e.g., "I'll sweep the floor if you play with

the kids"); (c) acceptance of the other, indicated by paraphrasing (e.g.,

"You're saying that the kids are too young to go to kindergarten"), open

questions (e.g., "Are you still unhappy?"), and positive feedback (e.g.,

"I liked the way you started the discussion"); (d) agreement, including

direct agreement (e.g., "Yes, that's right"), acceptance of responsibility

(e.g., "I know I started the fight"), and assent; (e) problem description,

including neutral descriptions of the problem (e.g., "I think we've got a

problem with the kids") or neutral questions (e.g., "Did the car break

down yesterday?"); (f) mela-communication, comprising clarification

requests (e.g., "Would you repeat that, please?") or meta-communica-

tion related to the topic (e.g., "We're really getting away from the is-

sue"); (g) other category, coded when a statement does not fit into any

other verbal code or is inaudible; (h) personal criticism (e.g., "You are

lazy!"); (i) specific criticism (e.g., "\bu did not clean the bathroom yes-

terday!"); (j) negative solution, coded when the speaker describes some-

thing he or she would like the other not to do in order to solve a problem

(e.g., "\bu shouldn't sleep all day"); (k) justification, consisting of ex-

cuses of one's own behavior (e.g., "I had a lot of things to do yesterday")

or denial of responsibility (e.g., "That's not my job"); and (1) disagree-

14 HAHLWEG ET AL.

men!, indicated by direct disagreement (e.g., "No, that's not true"),"yes, but. . ." responses (e.g., "Yes, you're right, but we can't have themoney"), short disagreeing statements (e.g., "No," or "What?"), and

blocking (e.g., "Stop it, I've had enough").All of the content categories receive a nonverbal rating as well (see

Gottman, 1979; Notarius & Markman, 1981). In a hierarchical order,

the facial cues of the speaker or listener are evaluated first as positive,

negative, or neutral. If the coder is unable to code the utterance as posi-

tive or negative, he or she scans the voice tone cues. If the coder is stillunable to code the utterance as positive or negative, the body cues arescanned until an appropriate rating can be applied. Full details of the

KPI are provided in Hahlweg, Reisner, et al, (1984).'Psychometric properties of the KPI. In reliability studies conducted

in Germany and England, kappas have been well over .80, showing satis-factory interobserver agreement for frequency and sequential analysis.

The discriminant validity of the KPI has been established using crite-rion groups of distressed and nondistressed couples (Hahlweg, Reisner,

et al., 1984) and groups of depressed patients with high EE relatives andlow EE relatives (Hooley, 1986b). The results of another study investi-gating the effects of behavioral marital therapy on couples' communica-

tion skills showed that the KPI is also a sensitive instrument for moni-toring change after treatment (Hahlweg, Revenstorf, &Schindler, 1984).

For the present study, the first author trained six raters in the use of

the KPI. Training was extensive and lasted for about 50 hr. At the endof the training, the raters independently coded five family discussions.

Interrater agreement between pairs of the six coders ranged from 71%to 95.3%. Kappa values were 0.83 (p < .001) for the verbal and 0.84(p< .001) for the nonverbal codes. To evaluate rater drift, the sixth to

eighth minute in each videotape was coded by a second rater blind tothe original coding. A 91% agreement rate was found between the twosets of codes, indicating minimal rater drift.

Three different teams of raters worked independently of each other,one for the CFI, one for the FMSS, and one for the KPI. Each team was

blind to the data available to the others.

Results

Base Rate Analyses

Because there was notable variation in the number of codable

behaviors emitted by each participant in the interaction, it was

necessary to correct the raw frequency for each coding category

by the total number of codable behaviors emitted. Therefore,

the score for each KPI code was expressed as a proportion of

codable units for that person. To restrict the number of signifi-

cance tests and the problem of ipsative data produced by the

use of proportions derived from a constant denominator, only

positive and negative KPI codes were used in the analysis, and

neutral codes were omitted (problem description, meta-com-

munication, other category, and neutral nonverbal).

Initially, multivariate analyses of variance (MANOVAS) were

applied to these proportions to test for group differences be-

tween high EE and low EE relatives based on the CFJ and on his

or her behavior during both family interactions as coded by the

KPI. The results were disappointing because no significant

differences were found. Because the CFI was conducted approx-

imately 2 months before the family interaction, it was decided

that a second analysis should be completed using the EE status

of each relative as assessed by the FMSS. As mentioned pre-

viously, this measure was taken just before the family discussion

took place.

In Table 1, the means and standard deviations for the verbal

Table 1Relation Between FMSS, EE, and Interactional Data

for Relatives of Schizophrenic Patients

KPI code Low Overinvolved Critical

Self-disclosureMSD

Positive solutionMSD

Acceptance ofother

MSD

AgreementMSD

Criticism, specificMSD

Criticism, personalMSD

Negative solutionMSD

JustificationMSD

DisagreementMSD

Negative nonverbalMSD

Positive nonverbalMSD

2.72.9

1.91.8

7.17.0

10.46.9

3.54.6

0.10.5

0.20.5

0.51.4

6.65.3

4.58.0

34.527.2

2.94.8

1.72.3

7.87.5

9.27.6

3.45.1

0.00.0

0.10.4

0.00.0

7.97.6

5.89.0

41.032.1

2.42.6

0.40.5

2.24.0

10.89.8

11.75.6

5.56.5

0.71.1

0.71.4

10.26.5

35.831.1

11.425.3

0.08

3.75

2.99

0.11

14.58

17.31

3.14

0.75

1.81

19.85

4.23

.92

.03

.05

.89

.000

.000

.05

.47

.17

.000

.02

Note. EE = expressed emotion; FMSS = five-minute speech sample;KPI = Kategoriensystem fuer Partnerschaftliche Interaction [CategorySystem for Partners Interaction]. Low = low EE (n = 42); overin-volved= high EE-overinvolved (n = 9); critical = high EE-critical(n = 13).

and nonverbal KPI codes of individual relatives (N = 64) are

shown. Family members were classified as either low EE, high

EE-overinvolved, or high EE-critical on the basis of their

FMSS rating.

Because the KPI variables are intercorrelated, a MANOVA

was first conducted to test for overall group differences. The

FMSS EE subgroup was used as the independent variable, and

the 11 KPI variables (9 verbal, 2 nonverbal) were used as depen-

dent variables, resulting in a significant overall test, f\22,96) =

2.78, p < .001. As seen in Table 1, significant one-way analyses

of variance (ANOVAS) were found for the following codes: posi-

tive solutions, acceptance of other, specific criticism, personal

criticism, negative solution, and negative and positive nonver-

bal behavior. Three planned comparisons were completed to

examine pairwise differences between the three groups: low vs.

1 The coding manual is available from the first author.

SPECIAL SERIES: EXPRESSED EMOTION AND SCHIZOPHRENIA 15

Table 2

Relation Between FMSS, EE, and Interactional Data

for Schizophrenic Patients Across Family Types

KPI code Low Overinvolved Critical F* p

Self-disclosureMSD

Positive solutionMSD

Acceptance of partnerMSD

AgreementMSD

Criticism"MSD

Negative solutionMSD

JustificationMSD

DisagreementMSD

Negative nonverbalMSD

Positive nonverbalMSD

5.33.5

1.41.9

0.91.4

28.516.1

1.23.3

O.I0.2

0.71.2

9.84.6

12.620.2

20.621.1

6.05.4

0.20.5

0.40.6

22.514.8

2.53.4

0.10.4

1.93.2

20.012.3

16.114.1

22.222.9

5.24.8

0.50.8

1.22.9

17.711.4

5.17.0

0.30.7

4.04.5

16.69.1

33.729.4

11.315.1

0.11

2.39

0.48

2.11

2.87

1.89

5.35

6.42

3.48

0.96

.89

.10

.62

.14

.08

.16

.009

.004

.04

.39

Note. EE = expressed emotions; FMSS = five-minute speech sample;KPI = Kategoriensystem filer Partnerschaftliche Interaktion [CategorySystem for Partners Interaction], Low = low EE (n = 24); overin-volved - high EE-overinvolved (n = 8); critical = high EE-critical(«=11).' df= 2,40. " Sum on specific and personal criticisms.

overinvolved, low vs. critical, and critical vs. overinvolved. In

none of the planned comparisons did the high EE-overinvolved

relatives differ from the low EE relatives. High EE-critical rela-

tives did differ significantly from the two other groups on all of

the variables for which the univariate tests were significant (see

Table 1). These differences were all in the expected direction of

high EE-critical relatives expressing more negative and fewer

positive behaviors than relatives in the other two groups.

In Table 2, the means and standard deviations for the verbal

and nonverbal KPI codes of patients from low and high EE fam-

ilies are shown. Unlike the previous analyses in which data ob-

tained from the individual relative were used as the unit of anal-

ysis, questions pertaining to KPI codes of patients utilized the

EE status of the family as the unit of study. Family units were

classified as high EE-overinvolved or high EE-critical when-

ever at least one family member was rated as high on the respec-

tive criterion. The MANOVA was nonsignificant, F(20, 58) =

1.7, p < .07, probably because of the relatively small sample

sizes in the high EE groups. Using univariate ANOVAS, the

groups differed significantly in the following variables: for justi-

fication, F(2,40) = 5.46, p < .01; for disagreement, F(2, 40) =

6.43, p< .01; and for negative nonverbal behavior, F(2,40) =

3.57, p< .05. With regard to justification and negative nonver-

bal behavior, patients from low EE and high EE-overinvolved

homes made fewer of these statements than did those from high

EE-critical homes, whereas patients in both high EE family

groups differed significantly from those in low EE families in

their greater frequency of disagreements (all ps < .05, planned

comparisons). Because of the nonsignificant MANOVA, these

analyses of patient KPI variables must be viewed with caution.

Sequential Analysis

Base-rate analysis of family communication behaviors does

not allow the investigation of the structure of the familial com-

munication process. Here, the best method is to look for proba-

bility rules using sequential analysis.

To analyze the data sequentially, the K-Gramm method was

used (Revenstorf, Hahlweg, Schindler, & Vogel, 1984).2 This

method computes the conditional probability of a particular

behavior as a function of the behavioral sequence that preceded

it. The K-Gramm analysis is only possible when dyadic data

are available. For triadic families, it is therefore necessary to

combine the responses of both parents so that parent-patient

dyads are analyzed sequentially. Because the number of obser-

vations for each family is rather small, results are based on ag-

gregate data. Data were summed across families in each EE

group. Unfortunately, when analyzing larger sequences with

any form of sequential analysis, statistical evaluations of the

difference between groups are not possible because of the aggre-

gation (see Revenstorf et al., 1984). The results must therefore

be interpreted descriptively and the data regarded as explor-

atory. For purposes of illustration, we present the sequential

pattern only for the nonverbal codes. Similar tendencies were

observed for the verbal data when a three-category grouping of

positive, neutral, and negative codes was used.

In the following, negative escalation patterns were defined as

a sequence of negative nonverbal communication (NC) behav-

iors. Figure 1 shows the escalation process for negative nonver-

bal behavior in low EE, high EE-overinvolved, and high EE-

critical families. The conditional probability (in percentages) is

given on the ordinate and the sequence length is shown on the

abscissa. Sequence Length 1 represents the base rate of negative

nonverbal behavior. Examination of Figure 1 shows that about

31 % of all nonverbal behavior emitted by high EE-critical fami-

lies was negative. In contrast, about 10% and 11% of the behav-

ior of low EE families and high EE-overinvolved families, re-

spectively, was negative. To explain this, let us consider the high

EE-critical families. If partner a shows negative behavior

(probability = 31%), the conditional probability that partner b

will respond negatively is 60% (Sequence Length 2). Given that

partner b responds in that way, the probability is .80 that part-

ner a will again be negative (Sequence Length 3) and .81 that

partner b will again reciprocate (Sequence Length 4). This pat-

tern of negative escalation continues and ends at a sequence

length of 20 due to lack of further occurrences.

2 The sequence analysis program, written in FORTRAN, is availablefrom the firet author.

HAHLWEG ET AL.

O LOW

A £01

m CRIT

Sequence

15 16 17 18 19 20

Figure 1. Generalized interaction pattern of negative nonverbal escalation. (Ordinate indicates the condi-tional probability of the response after the foregoing sequence [«—!]. Low EE - low expressed emotion;EOI = high expressed emotion-overinvolved; CRIT = high expressed emotion-critical. BR = base rate for

negative nonverbal behavior over the whole interaction.)

In contrast, low EE families escalate only briefly up to a se-

quence length of 6. The escalation process stops because of the

lack of data, that is, partner b then emits either a positive or a

neutral statement. In high EE-overinvolved families, the pro-

cess continues up to a sequence length of 7.

Discussion

The aim of this study was to compare the communication

behavior of high EE and low EE relatives as they interacted face-

to-face with their schizophrenic family members. To summa-

rize the results, high EE-critical relatives were characterized by

a negative interactional style in that they showed more negative

nonverbal affect, more criticism, and more negative solution

proposals than either low EE or high EE-overinvolved relatives

when discussing an emotionally loaded family problem with the

patient. Both of the latter groups not only showed a lower rate

of negative behaviors but also showed a higher rate of positive

and supportive statements than did the high EE-critical rela-

tives.

Patients who had high EE-critical relatives showed more neg-

ative nonverbal affect and more self-justifying statements than

patients with either low EE or high EE-overinvolved relatives.

Patients living with high EE members, irrespective of subgroup,

expressed more disagreements than patients living with low EE

relatives.

The results for negative behavior are even more apparent

when the findings of the sequential analysis are taken into ac-

count. High EE-critical families showed long-lasting negative

reciprocal patterns in the nonverbal domain, whereas low EE

and high EE-overinvolved families had much shorter negative

patterns.

The failure to find the kinds of correlates of EE, based on the

Camberwell Family Interview, that have been found in previous

studies (Miklowitz et al., 1984; Strachan, Leff, et al., 1986)

raises two possibilities. First, the time between CFI and direct

interaction was longer here than in previous studies so that the

affective attitudes of relatives may have changed by the time the

FMSS and direct interaction were conducted. This would have

reduced the association between the CFI EE measure and the

subsequent direct interaction data. Second, the longer interval

may have allowed more opportunity for patients to change in

clinical state so that the nature of relatives' interactions with

the patient was altered from what it presumably may have been

at the time of the CFI. Efforts are currently underway by our

research group to examine these alternatives.

The finding that high EE-critical relatives, as defined by the

FMSS method, express more critical statements during the in-

teraction task than either low EE or high EE-overinvolved fam-

ily members replicates the results reported by Valone et al.

(1983), Miklowitz et al. (1984), and Strachan, Leff, et al. (1986).

However, two of these studies found that high EE-overinvolved

relatives manifested a higher rate of intrusiveness than high

EE-critical or low EE relatives (Miklowitz et al., 1984; Stra-

chan, Leff et al., 1986). This finding awaits further replication

because these behaviors are not assessed by the KPI.

The finding that low EE and high EE-overinvolved relatives

SPECIAL SERIES: EXPRESSED EMOTION AND SCHIZOPHRENIA 17

show more positive communication behavior than do high EE-

critical relatives contrasts with previous studies that did not find

such a difference using the AS coding system (Strachan,

Goldstein et al., 1986). This discrepancy may be explained by

the fact that the AS system was developed to capture predomi-

nantly negative behavior, whereas the KPI codes are balanced

with regard to negative and positive behaviors. It appears that

low EE relatives are not just more neutral than high EE-critical

members; in addition, they are actively supporting the patient.

They provide a positive nonverbal climate, show concern for the

patient, and try to find solutions to problems.

It is surprising that high EE-overinvolved relatives behave so

similarly to low EE family members. It is difficult to explain,

given this similarity to the low EE pattern, why, in previous

studies, patients from high EE-overinvolved homes have the

same risk of relapse as those from high EE-critical homes. The

finding that patients interacting with high EE-overinvolved as

compared with low EE family members express a higher rate of

disagreements suggests two possibilities. First, in the face of a

patient who disagrees frequently, the relatives may attempt to

counteract this with a high rate of positive supportive remarks.

Second, the precise nature of these positive supportive remarks

may not be experienced by the patient as they are intended by

the relative. It may be that the KPI codes are not sufficiently

subtle to discriminate between positive supportive statements

that are likely to be effective and those that are not.

To understand the high relapse rate of patients with high EE-

overinvolved relatives, it would be helpful to examine the be-

havior within these families in more detail, looking especially

at the intrusive communication styles identified in previous re-

search. This implies that coding systems like the KPI should be

broadened like the AS coding system to assess these behaviors

(Doaneetal., 1981). Similarly, the nature of the disagreements

expressed by patients needs further investigation to determine

what role these behaviors play in emotionally overinvolved fam-

ily interactions.

The assessment of the patient's as well as the relatives' inter-

actional behavior allows one to investigate more fully the pa-

tient's role in the development of the negative family climate,

especially when using sequence analysis. A more detailed inves-

tigation of a subsample of families used in the present study

revealed that it made no difference whether the patient or the

parents started a negative sequence. In both instances, the same

interaction pattern resulted (Hahlweg et al., 1987). However, it

may well be that there are subtle differences in the way in which

parents or patients contribute to the negative verbal communi-

cation patterns, which are masked by the necessity to summa-

rize the KPI codes for sequential analysis. One might infer from

the base-rate analysis that the negative patterns in high EE-crit-

ical families are characterized not only by attack-counterattack

(i.e., criticism by parents or patient followed by returned criti-

cism) but also by attack-justify (parent is criticizing, patient is

excusing himself or herself). Either criticism-countercriticism

or criticism-self-justification may raise family tension rather

than lead to conflict resolution.

Inspecting the magnitude of the effects identified in the pres-

ent study, especially in the positive domain, reveals that not all

high EE or low EE families show the respective interaction be-

havior patterns that have been described. A great deal of vari-

ability exists within each group, and substantial overlap occurs

between groups, suggesting the importance of observing each

family separately to learn more about individual differences.

Furthermore, the predictive utility of these interactional mea-

sures for identifying relapse-prone cases deserves exploration in

future research.

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Received March 7,1988

Revision received March 29,1988

Accepted March 29,1988 •