Research into expressed emotion (EE) is now wellinto its fourth decade with a large body of workcontinuing to emphasise a robust association of high

EE in carers and relatives with poor outcome in pat-ients for numerous organic and psychological healthproblems [1–3]. Despite this understanding, compar-atively little emphasis has been placed on tracing theseparate developmental pathways of criticism andemotional over-involvement (EOI) for the purposesof targeting early intervention and support. AlthoughEE is taken to reflect fairly stable qualities in indi-viduals for intervention purposes, the high percent-age of change in EE status over relatively shortperiods of time reported in many studies [4] doesprovide cause for thought. This phenomenon can be

Preventing the entrenchment of highexpressed emotion in first episode psychosis:early developmental attachment pathways

Paul Patterson, Max Birchwood, Ray Cochrane

Objective: As part of a strategy to consider the options for preventing the develop-mental entrenchment of expressed emotion (EE), we examine the early ontogeny ofEE in a first-episode sample of individuals with psychosis and its links with theprocess of adaptation to change.Methods: The key relatives of 50 first-episode psychosis patients from two locationswere interviewed soon after patient referral and again 9 months later using measuresof expressed emotion and loss.Results: The developmental pathways of components of expressed emotion, par-ticularly criticism and emotional over-involvement, were independent despite havinga similar effect on outcome for patients. Initially, high levels of emotional over-involvement were reduced by follow up, with 37% resolving into high criticism. Overallexpressed emotion status changed in 28.2% of key relatives (all parental), predomi-nantly from high to low. High emotional over-involvement and low criticism are asso-ciated with significantly high levels of perceived loss in relatives. The metamorphosisof emotional over-involvement to criticism was linked to a reduction in perceived loss.Conclusions: Expressed emotion is not a stable index in relatives of first-episodepsychosis samples. Appraisals of loss by relatives may be driving high emotionalover-involvement with implications for family intervention programs. Attachmenttheory may help to explain some of the processes underlying resistance to changein some of the high-EE behaviours measured by expressed emotion.Key words: attachment, expressed emotion, family environment, first-episodepsychosis, loss.

Australian and New Zealand Journal of Psychiatry 2000; 34 (Suppl.):S191–S197

Paul Patterson, University of Birmingham and Research Fellow(Correspondence); Max Birchwood, Professor of Clinical Psychologyand Director

Early Intervention Service, Northern Birmingham Mental HealthTrust, Harry-Watten House, 97 Church Lane, Aston, BirminghamB6 5UG, UK. Email: pjsp60@hotmail.com

Ray Cochrane, Professor

School of Psychology, University of Birmingham, Edgbaston,Birmingham, UK

partly explained by noting that most of the EE studieshave assessed relatives while the patient was either inthe midst of or had very recently been in a state ofpsychosis, and the prevailing reactions at this timemay reflect some enduring characteristic of relatives’coping responses to a breakdown in a family member.

Expressed emotion as a clinical concept has threecomponents that are predictive of outcome: (i) emo-tional over-involvement, a breakdown of the naturalboundaries in the family situation; (ii) critical com-ments (CC), critical attitudes and condemnation ofbehaviours in the patient by carers; and (iii) hostility(H), which involves a generalisation of criticism ofthe patient’s personality and/or elements of rejectionon the part of carers. Family intervention studieshave shown that if the frequency of critical, over-involved and hostile interactions can be reduced, thisleads to a secondary reduction of the risk of relapseover time [4,5]. To assume that high EE is a stablefactor built into families would allow us to directstandard interventions at ‘critical periods’, however,the evidence suggests that EE is unstable, particu-larly during the early phase [4,5]. For this reason it istherefore important not to simply see EE as a riskfactor in itself, but rather as the outcome of anadjustment and adaptation process, which needs to beappropriately modelled.

It has been found that, even within chronic popu-lations, EE is not stable over time. Kuipers andScazufca found that 36% of patients had changed EEstatus over 9 months and even more over a longerperiod of time [6]. Examining the ontogeny of EE,they also found that changes in EE were linked tochanges in subjective burden and perception ofclients’ functioning. The idea that EE is not a traitcharacteristic but a thermometer of patient and rela-tive transactions at a particular point in time is impor-tant for what happens after the onset of the firstpsychotic symptoms and, therefore, also for whathappens before the first presentation [7].

Existing family intervention methods, designed asthey were for use with families experiencing longer-term psychosis in a relative, appear less useful infirst-episode samples. A study of behavioural familytherapy in first-episode psychosis found no impact onrelapse and for some families it actually increaseddistress [8]. Expressed emotion in first-episodesamples seems to be particularly mutable and thismay be considered to be a critical period for adjust-ment before EE response styles are established,which makes it an ideal period to prevent theentrenchment of high-EE behaviours.

Emotional over-involvement and criticism

Hooley has suggested that emotional over-involve-ment and criticism are both strategies reflecting acommon need to control the home situation [9].Critical and hostile statements, often directed atbehaviours thought to be under the control of thepatient rather than illness-caused [10], are perhapsmore clearly understood than the processes under-lying high EOI. Criticism is seen in both spouses and parents of patients with schizophrenia, whileEOI is more often seen in parents. Emotional over-involvement has been more often linked to poor premorbid functioning [11,12] and burden. Bentsenet al. found that anxiety and depression were moreprevalent in households where there are high levelsof EOI displayed [13]. Stirling et al., looking at afirst-episode psychosis sample, contradict many of theprevious findings concerning the association of highEE with relapse rates, but are in agreement with amodel that takes reactive components of the patient/illness/relative dynamic into account [14,15]. Theyfound that a very large proportion of their high EEgroup reached threshold in EOI (14/16) at index butthis was greatly reduced by follow up. Kavanaghwrites:

In an interactive model, patients’ symptoms andother problem behaviours elicit frustration, distressand concern from other people, and prompt attemptsto cope. Unfortunately, these attempts at copingsometimes involve critical or intrusive interactions.The resultant negative emotions exacerbate patients’symptoms and make it more difficult for them tofunction effectively. [3]

Loss and grief as a response to severemental illness

Miller examined the role of loss in relatives of indi-viduals with serious mental illness and found thatgrief is a key reaction, with many relatives longingfor a return of the quality of their former relationshipwith their ill relative [16,17]. Miller used a modifiedversion of the Texas Revised Inventory of Grief [18]to measure levels of grieving that relatives of indi-viduals with severe mental illness were experiencing.He found levels of grief similar to those displayed byrecently bereaved individuals even years after thefamily member had first become mentally ill. Millerspeculated that such high levels of grief may be due to

PREVENTION OF HIGH EXPRESSED EMOTION IN PSYCHOSISS192

. . . the difficulty some relatives had in identifyingand openly talking about their loss either because ofthe stigma of mental illness or because of theabstract nature of ‘psychic loss’ in which the personlives on but the relationship changes profoundly [16]

and suggests that the grief that needs to be addressedin this population is resulting ‘from the loss of specifichopes and aspirations rather than loss through death’.Clearly, the perception of loss will interact with theprior level of attachment or bonding between relativeand patient.

Birchwood has argued that the perception of lossand change may be a prime motivator of criticismand EOI, starting before the formal onset of positivesymptoms [4,5]. The longitudinal links between crit-icism and EOI observed by Stirling et al. mightsuggest that criticism is a coping strategy to deal withthe pain of loss [16]. This explanation is entirely con-sistent with attachment theory. Bowlby argued thatcriticism is an ego-involving response to bring theerrant individual ‘back into line’ through an acti-vation of attachment behaviours [19,20].

Sample characteristics

Descriptive characteristics of patients and relativesare shown in Table 1. Patients and relatives wereselected at the time of the patient’s first presentationfor acute psychosis conforming to ICD-10 schizo-phrenia or a related disorder. Patients were recruitedfrom acute hospital admissions and direct referrals tohome-treatment teams in the North Birmingham andGloucestershire health regions. Inclusion in the studywas requested if they had lived with or had been in

regular contact with their relatives for one of the 3 months prior to admission; had engaged with thehealth services for the first time for the treatment ofpsychosis; and had no comorbid major neurologicaldisorders. Fifty patients and 50 key relatives wereinitially recruited, with six relatives refusing to participate in the follow up, two patients and one relative having left the area and a further two patientsnot returning to the relatives’ household, leaving 39relative/patient pairs. The drop-out group did notdiffer significantly from the remainder on demo-graphic measures or symptom indices.

As shown in Table 1, 30 of the relatives wereparents (77%), of whom 17 represented single-parenthouseholds. The remaining relatives were six partners(15%) and three siblings (8%). The patient sampleincluded white (28; 72%), Asian (6; 15%) andblack/mixed race (5; 13%) individuals.

Assessment

The EE levels of the relatives were assessed byusing the Camberwell Family Interview (CFI) [21].All interviews were carried out either in the familyhome or in a mental health centre and relatives wererated as high in EE if they scored 6 or higher in thecriticism (CC) subscale; 3 or higher in the emotionalover-involvement (EOI) scale or had any score forhostility (H). Follow-up interviews were carried out 9 months after first testing (median = 9.5 months).The expressed emotion ratings of the relatives wereassessed by a researcher trained to reliability in ratingthe CFI. A sample of interviews were also ratedblindly by another trained CFI rater with acceptablelevels of reliability.

P. PATTERSON, M. BIRCHWOOD, R. COCHRANE S193

Table 1. Descriptive characteristics of patients and relatives (n = 39)

Female Male TotalPatients

Sex 15 24 39Age at onset 24.1 (3.72) 22.0 (6.7) 23.1 (6.7)Untreated illness (days) 216 (377.8) 223.5 (322) 219.7 (339.6)Untreated psychotic symptoms (days) 25.2 (22.6) 45.5 (68.8) 35.3 (56.1)

RelativesSex 27 12 39Age 45.4 (10.95) 39.8 (11.5) 43.9 (11.7)Parent 25 5 30Partner 3 3 6

Sibling 2 1 3

Values in parentheses are SD.

Loss was assessed in relatives and patients by usingthe mental illness version of the Texas Inventory ofGrief [16,18], a two-part questionnaire measuringinitial reactions at the time of loss and levels ofongoing grieving. Demographic data were collectedby using standard forms at interviews for bothpatients and relatives. Several other instruments wereemployed in the assessment procedure.

The majority of patients (34, 86%) returned to livein the family household for the duration of the follow-up period, with the other five remaining in high(several times weekly) contact with their key relative.

Results

Ontogeny of expressed emotion

Expressed emotion status at index and follow-upwere significantly but moderately correlated (r = 0.48,P < 0.01), as were CC (r = 0.55) and EOI (r = 0.66)but not H (r = 0.13), suggesting considerable intra-individual change. The period of untreated psychoticsymptoms for patients differentiated high and lowCC relatives at first testing, with high CC relativeshaving longer reported exposure to untreated symp-toms prior to medical intervention (low CC = 26.4days, high CC = 75.4 days, F1,37 = 5.99, P < 0.05).No other differences were found in EE or subscalestatus for this or untreated illness measures.

There was a considerable change in overall EEstatus over the follow-up period, with 28% of therelatives obtaining a different EE rating from theinitial measure (Fig. 1) and 42% of the initially highEE relatives resolving to low EE. The individual sub-scales of the CFI show clear differences in the reso-lution of EOI and CC over time. The rate of high EOIat first testing was 41% (n = 16) while 9 months laterthis had reduced to 18% (7) (Fig. 2).

The number of participants rating above thresholdfor criticism also changed markedly over the 9 monthswith an initial group of 9 (23%) increasing to 12(31%) over the follow-up period (Fig. 3).

Loss appraisals

The present findings show a significant differencein loss perceived by relatives high or low in EOI (Fig. 4). Conversely, it was also found that those highin criticism had a lower appraisal of loss (Fig. 5). Inthose relatives where initial high EOI changed tohigh criticism (n = 6), loss appraisal has reduced sig-nificantly over time (t = 8.84, P < 0.001).

Discussion

The present findings suggest that, in the early stageof a psychotic episode, a significant proportion ofkey relatives will experience an emotional reaction to

PREVENTION OF HIGH EXPRESSED EMOTION IN PSYCHOSISS194

Figure 1. Stability and change in expressedemotion in first-episode psychosis

Figure 2. Ontogeny of relatives initially high inemotional over-involvement over 9 months

Figure 3. Ontogeny of relatives initially high incritical comments over 9 months

the appraisals of loss that can best be described as aprocess of grieving. This may generate some of theover-involved behaviours found in relatives high inEOI and may be particularly resistant to certainforms of family intervention. Miller suggests that, forthese relatives, interventions containing specific griefwork such as reminiscence and loss-accommodationmay be more appropriate and beneficial in preventing

long-term denial and distancing that, for a proportionof relatives, is likely to lead to the later entrenchmentof critical attitudes [16,17]. Relatives experiencinginitially high levels of grief in response to psychosismay be at a particular risk of ‘sealing-over’ [22]affective elements of the relationship with the patientand remaining distant. The other potential pathwaywould appear to be an ‘integrating’ response, wherethe loss is acknowledged but no distancing occurs.That the EOI response would seem to be specific tofamilial experiences of loss is supported by theobservation that no above-threshold EOI was foundin studies of EE in key workers of mentally illpatients in institutional settings [23,24]. Some ofthese processes can be understood from research thathas examined the evolution of loss appraisals inresponse to illness, such as Burke et al., who differ-entiate chronic sorrow from pathological grief [25].Chronic sorrow, a pervasive sadness, which, how-ever, allows for functional behaviour and good realitytesting, has been found in parents of mentallyretarded children. This is occasioned by the chronicnature of the losses experienced and differs fromacute grief, which is time-limited. The experience ofpsychosis within a family holds many similarities tothis as the cycle of relapse and wellness generate acontinuing cycle of grieving. Eakes, in a small study,found that eight of ten parents of seriously mentallyill children suffered from chronic sorrow [26]. Thiswould suggest a partial integration and acceptance ofthe loss leading to a capacity to function as well aspossible under the circumstances and may mirror thelevel of functioning stability found in low-EE familymembers.

Bowlby has drawn attention to the pervasiveness of angry coercive behaviour acting in the service ofan affectional bond, describing it as the behaviourseen when a mother, whose child has run foolishlyacross the road, berates and punishes him with ananger born of fear, or, in some families, when amember becomes angry whenever his approaches toanother family member are met by an unresponsivesilence [20]. If angry coercion is seen as a ‘natural’adaptive response to discourage individuals from‘stepping out of line’, it may help to explain some ofthe origins of high levels of criticism in studies ofEE. Highly critical attitudes toward family memberswith psychosis have been associated with attributionsof patients’ responsibility for symptoms from rela-tives [10] as well as subjective burdens experiencedby the caregiver [6]. If the patient does not recoverover time, the coercive criticisms may be employed

P. PATTERSON, M. BIRCHWOOD, R. COCHRANE S195

Figure 4. Comparison of present grief levels inrelatives high or low in emotional over-involvement

[t(1,37) = –3.571, P < 0.001]

Figure 5. Comparison of present grief levels inrelatives high or low in criticism [t(1,37) = 3.543,

P < 0.001]

as an attempt to establish more normative behav-iours. These can soon escalate into hostility if thehoped-for improvements do not occur. Bowlby sug-gests that dysfunctional anger occurs whenever people(children or adults) become so intensely and/or persistently angry with their partner that the bondbetween them is weakened instead of strengthenedand the partner is alienated. Anger with a partner alsobecomes dysfunctional whenever aggressive thoughtsor acts cross the narrow boundary between beingdeterrent and being revengeful. It is at this point, too,that feeling ceases to be the ‘hot displeasure’ of angerand may become, instead, the ‘malice of hatred’ [20].Family interventions may need to take these critical‘default’ mechanisms into account when attemptingto reduce EE in family relationships. Perhaps thelow-criticism relatives have simply reached theinsight, either through empathy or experience, thatcoercive criticism does not work for the behavioursassociated with psychosis.

If, as attachment theory suggests, a normal reactionto loss involves coercive anger or criticism, we mightexpect a resolution of EOI behaviour to criticismover a period of time, once some issues of guilt andinsecurity [27] in the carer had been worked through.Using this model, we would expect that in mostcases, the high EOI of relatives should graduallyresolve into high-CC or low-EE responses and weshould seldom see a low-EE relative change status toa high-EOI relative except where there is an acutedeterioration in the patient’s condition.

Contributing issues to the grieving process

The length of time over which grief processes maybe occurring in families with an ill member can bevast. Davis and Schultz [28] detected grief in olderparents of children with schizophrenia, for 43% ofwhom the duration of diagnosed schizophrenia wasmore than 10 years. Grief was conceptualised here asa cognitive, behavioural and emotional reaction toloss. This shows that the intensity of this process maybe contributing to other family dynamics such as sub-jective burden and EE for much greater periods oftime than previously realised. In a small qualitativestudy exploring the experience of caring for an adultchild with schizophrenia, Tuck et al. suggest that thechanged dynamics involve both the loss of an imag-ined, idealised child and a transformation of thephysically present child into a needy stranger [29],which is emphasised by a finding that parents displaysignificantly more warmth to well children and EOI

to a schizophrenic child [30]. This may give someclue as to the protracted nature of the grievingresponse in carers, as it is not just the loss of a healthychild with associated loss of positive aspirations forthe future but also, in periods of psychosis, the intru-sion of a demanding ‘stranger’ who must complicatethe intensity of the already traumatic experience.

Conclusion

An examination of the ontogeny of EE in first-episode samples with emphasis on the subscales ofcriticism and EOI can provide a deeper understand-ing of the processes involved in the development ofhigh-EE behaviours in the relatives of individualswith psychosis. An appreciation of the influence thatappraisals of loss and associated grief reactions canplay in the establishment of new patterns of behav-iour with the patient may help in the design and tar-geting of specific interventions for this period inorder to prevent the entrenchment of high-EE behav-iours in carers. Attachment theory allows us to recog-nise coercive criticism as an adaptive mechanism inresponse to an errant family member and mayexplain the lack of long-term effectiveness of someof the previous family intervention trials. Early inter-vention at this crucial stage is likely to show thegreatest benefit for individuals with psychosis andtheir relatives in terms of long-term improvements inoutcome.

References

1. Hooley JM, Orley J, Teasdale JD. Levels of expressedemotion and relapse in depressed patients. British Journal ofPsychiatry1986; 148:642–647.

2. Flanagan DA, Wagner HL. Expressed emotion and panic-fear in the prediction of diet treatment. British Journalof Clinical Psychology1991; 30:231–240.

3. Kavanagh DJ. Recent developments in expressed emotionand schizophrenia. British Journal of Psychiatry1992;162:601–620.

4. Birchwood M, Spencer E. Psychotherapies forschizophrenia: a review. In: Maj M, Sartorius N, eds.Schizophrenia. Chichester: Wiley, 1999:139–241.

5. Birchwood M. Family factors in psychiatry. CurrentOpinion in Psychiatry1992; 5:295–299.

6. Scazufca S, Kuipers E. Links between expressed emotion andburden of care in relatives of patients with schizophrenia.British Journal of Psychiatry1996; 168:580–587.

7. Birchwood M, Cochrane R. Families coping withschizophrenia: coping styles, their origins and correlates.Psychological Medicine1990; 20:857–865.

8. Linszen D, Dingemans P, Van Der Does JW et al.Treatment, expressed emotion and relapse in recent onsetschizophrenic disorders. Psychological Medicine1996;26:333–342.

PREVENTION OF HIGH EXPRESSED EMOTION IN PSYCHOSISS196

9. Hooley JM. Expressed emotion: a review of the criticalliterature. Clinical Psychology Review1985; 5:116–139.

10. Brewin CR, MacCarthy B, Duda K, Vaughn CE. Attributionand expressed emotion in relatives of patients withschizophrenia. Journal of Abnormal Psychology1991;100:546–554.

11. Brown GW, Birley JLT, Wing JK. Influence of family lifeon the course of schizophrenic disorders: a replication.British Journal of Psychiatry1972; 121:241–258.

12. Miklowitz DJ, Goldstein MJ, Falloon IRH. Premorbid andsymptomatic characteristics of schizophrenics from familieswith high and low levels of expressed emotion. Journal ofAbnormal Psychology1983; 92:359–367.

13. Bentsen H, Boye B, Munkvold OG et al. Emotional over-involvement in parents of patients withschizophrenia or related psychoses: demographic andclinical predictors. British Journal of Psychiatry1996;169:622–630.

14. Stirling J, Tantam D, Thomas P et al. Expressed emotionand early-onset schizophrenia: a one year follow-up.Psychological Medicine1991; 21:675–685.

15. Stirling J, Tantam D, Thomas P et al. Expressed emotionand schizophrenia: the ontogeny of EE during an 18-month follow-up. Psychological Medicine1993;23:771–778.

16. Miller F, Dworkin J, Ward M, Barone D. A preliminarystudy of unresolved grief in families of seriously mentallyill patients. Hospital and Community Psychiatry1990;12:1321–1325.

17. Miller FE. Grief therapy for relatives of persons withserious mental illness. Psychiatric Services1996;47:633–637.

18. Faschingbauer TR. Texas revised inventory of grief manual.Houston: Honeycomb, 1981.

19. Bowlby J. Attachment and loss.Vol. III. Loss. New York:Basic Books, 1980.

20. Bowlby J. Attachment and loss. Vol. I. Attachment. 2nd edn.New York: Basic Books, 1982.

21. Vaughn CE, Leff J. The measurement of expressed emotionin families of psychiatric patients. British Journal ofClinical and Social Psychology1976; 15:157–165.

22. McGlashan TH, Levy ST, Carpenter WD. Integration andsealing over: clinically distinct recovery styles fromschizophrenia. Archives of General Psychiatry1975;32:1269–1272.

23. Oliver N, Kuipers E. Stress and its relationship to expressedemotion in community mental health workers. InternationalJournal of Social Psychiatry1996; 2:150–159.

24. Moore E, Ball RA, Kuipers L. Expressed emotion in staffworking with the long-term mentally ill. British Journal ofPsychiatry1992; 12:802–808.

25. Burke ML, Hainsworth MA, Eakes GG, Lindgren CL.Current knowledge and research on chronic sorrow: afoundation for inquiry. Death Studies1992; 16:231–245.

26. Eakes GG. Chronic Sorrow: the lived experience of parentsof chronically mentally ill individuals. Archives ofPsychiatric Nursing1995; 2:77–84.

27. Bentsen H, Notland TH, Munkvold OG et al. Guiltproneness and expressed emotion in relatives of patientswith schizophrenia or related psychoses. British Journal ofMedical Psychology1998; 71:125–138.

28. Davis DJ, Schultz CL. Grief, parenting and schizophrenia.Social Science and Medicine1998; 3:369–379.

29. Tuck I, duMont P, Evans G, Shupe J. The experience ofcaring for an adult child with schizophrenia. Archives ofPsychiatric Nursing1997; 3:118–125.

30. Schreiber JL, Breier A, Pickar D. Expressed emotion trait orstate? British Journal of Psychiatry1995; 166:647–649.

P. PATTERSON, M. BIRCHWOOD, R. COCHRANE S197