Research over about 30 years demonstrates a strong relationship between Expressed Emotion [EE] and relapse in many disorders, such as schizophrenia, anxiety disorders, substance use disorders, childhood psychiatric disorders, and depression.

EE seems to be a major factor in relapse and recurrence.  While EE affects the onset of these disorders and is high in families of children at risk of depression, it is not as robust a factor in the initial onset of these disorders as it is in relapse after remission.

High EE corresponds to a poorer prognosis.  The relapse rate for those living in a high EE environment is about 56%, 1.5 to 5x the rate for those in a low EE environment.

Professionals are high EE people.  Finally, professionals show a surprising degree of high EE.  We are sometimes a cause of relapse!  But with experience professionals learn to show lower EE and to be more successful with clients.

Three factors in high EE.   High EE does not mean all emotion, certainly not positive, supportive, encouraging, hopeful emotions.  But rather, high EE refers to three factors, Criticism, Hostility, and Over-involvement.


1. Criticism.  Criticism refers to critical attitudes and statements, negative remarks, antagonism, intolerance, opening conversations with harsh start-ups*.  Criticism reflects a negative relationship with the client and the client’s illness.  It also reflects the family’s disappointment and pain caused by the client’s illness.   For all its ineffectiveness, the family member(s) view criticism as a way to motivate the patient or to change the symptoms.  Because of the CRITICISM FALLACY**, High EE families think they are helping.  Note: EE can be verbal or non-verbal [eye rolling, making a sign for craziness, etc.].

Criticism may also be the result of mental disorders and sub-optimal functioning among caregivers.

2. Hostility.  Hostile behavior includes contempt, such as rolling one’s eyes, directly angry responses, blaming, dismissive language, or more severe criticism of the person, such as angry name-calling.  As with critics, hostile caregivers tend to believe all of the client’s problems are under the client’s control.  In their view, the patient selfishly chooses to remain ill. They do not see the problem as generated by attitudes, reactions, memories, and brain chemistry, which the patient cannot control.  So the family blames the client for other problems in the family.  They see the patient as a cause of their distress.

3. Over-Involvement.  Emotional over-involvement reflects intrusive over-concern about the client, and includes self-sacrifice or overprotectiveness, exaggerated emotional displays by the speaker, and over-identification with the child or adult client.  Over-involved parents tend to blame themselves for the client’s problems.  But the parents’ involvement stresses the patient with repeated expectations and messages of failure, and it serves to keep the presence of symptoms (rather than the islands of effectiveness and hope) in the forefront of the family’s attention.  The family is over-oriented to pathology rather than health.  The patient views over-involvement as being over-bearing and promotes feelings of helplessness.  Over-involvement is concern that is not productive.  At a deeper level, we see over-involvement is actually in part a species of criticism.

EE Is Circular.  Furthermore, EE is not merely a one-direction factor – EE causes relapses – but it is a circular systemic reaction in the family.

We see negative attitudes and critical parenting behaviors among depressed or mentally disordered caregivers TOWARDS children.  We see that with both internalizing or externalizing, behavior disorders.  But these critical parenting behaviors are in some ways the results of the aversive behaviors of the children.  Depressed children and their parents participate in cycles of criticism and negative emotions which are escalating and which they mutually reinforce.

These cycles are rooted in the child’s early vulnerability toward developing a behavior disorder, on the one hand – temperament, thinking, behaviors – and the parents’ psychiatric vulnerabilities on the other.  The latter produce a tendency to react not with patience towards the child, but rather with distress, frustration, punishment, power-struggles, and escalation of conflict.  Parents may view the expression of anger, frustration, and discipline as the proper realm of response to children.  They may not understand the behaviors of the child as an organized syndrome with many related behavioral manifestations.  They may see normal developmental behaviors in a negative way.

So then they also are precluded from finding positive motives in the child’s behavior.  Nor can they respond empathically.  Nor can they readily lead the child to more functional behaviors and thinking through positive reinforcement and shaping of effective responses.

For example, the child who feels emotionally displaced when mother remarries, then starts to be hostile and defiant, is seen in mainly negative ways that escalate the behavior.  The child’s fear, hurt, and anxiety are not noticed and the child’s ways of trying to restore the relationship with mother are not perceived as being behind the child’s behavior.  The parents react to the child’s problem behaviors with high EE and a vicious cycle sets in.

Repetition of these patterns strongly influences the parents’ concept of the child and shapes the child’s schemas, automatic beliefs, coping skills, emotional regulation, and social skillsOnce these patterns are institutionalized in the family, they maintain the child’s disorder.

High EE family members tend to believe symptoms are within the control of the patient.  So they are angry when the patient doesn’t prevent the expression of the symptoms.  Then they are judgmental, critical, and over-involved.  They do not know another way to help; they believe they are helping by their reactions.

So disruptions in the family environment may serve as precursors OR as sequelae of child and adolescent disorders and other problems.  As a precursor, low warmth and high criticism/rejection are sometimes due to parental depression or other parental disorders.

Interestingly, Brown et al (Lancet, 2,1958; Brit J Preventive & Social Medicine, 16, 1962) reported some years ago that the lowest relapse rate was among those who live alone or with siblings, doubled for those living with parents, but tripled amongst those living with spouses.  The former are less exposed than the latter to cycles of blame and criticism.

EE is a significant factor.  The effect size for EE (Butzlaff and Hooley, Archives of General Psychiatry, 55, 1998) is around .39 to .51.  This is consistent with the finding that EE is a major factor in relapse, but not the only one.  Incidentally, an effect size of .39 is the same as the effect of aspirin in preventing heart attacks, enough to lead us to recommend paying particular attention to this phenomenon. It is nearly as robust an effect as that of anti-depressants, which we recommend for so many cases of depression.  So the effect is considerable.

EE and Youth Depression.   EE is associated with poor recovery from depression.  Depression in youth is frequent and recurring.  Youth depression can disrupt emotional, social, and occupational functioning well into adulthood.  It is associated with increased rates of attempted and completed suicides.  Both High EE and previous depressions are risk factors for recurrent episodes of depression.  Depressed youth have on-going social impairments between episodes.

While both the development and the maintenance of youth depression involves the interaction of inherited factors, acquired biological characteristics, thought processes, emotional reactions, and painful or traumatic experiences, the family environment seems to have a significant role as well.  EE is an important part of that constellation.

Research shows that mothers of children who are depressed and even of those at a high risk for depression (but who have not had an episode to date) rate higher on criticism than mothers of non-depressive children.  A rejecting, critical environment is often present before MDD takes place.  The higher the level of critical emotion, the higher the risk of future depression.  Not only are negative comments more frequent in these families, positive comments are less frequent than in controls.   However, positive comments tend to lower the risk of relapse.

Think of it this way.  Let’s just assume in a well functioning family a child hears 12 positive or complimentary comments in a day with 4 criticisms; but in a family prone to raising a depressed teen, the ratio is reverse, 4 positives to 12 negatives.  In the course of a month, the former received 360 positives to 120 negatives, 240 more positives.  The latter received 120 positives to 360 negatives, 240 more negatives.  That is a tremendous tilt toward high EE.  That is a difference of 480 fewer helpful remarks in the depression-prone case, a combination of fewer positives and more negatives.  In a year, that is 5760 fewer helpful remarks.  Remarkable.

Puig-Antich, et al. (Archives of General Psychiatry, 42, 1985) found that moderate interpersonal problems appear to improve on recovery, but that more severe interpersonal problems, including those in the family environment, persist during recovery and remission.  So a negative family environment may continue to exert pressure towards relapse.

Other research shows high EE predicts poorer outcomes for psychotic disorders and mood disorders, though mainly for depression, not mania.  For bipolar disorder, high EE is associated with 5x more likelihood of relapse on the depressive side (Yan, et al. Journal of Affective Disorders, 83, 2004).

What About Low EE?  1) In one type of low EE, families are more reserved emotionally.  They do not try to control the client and the disorder.  These family members believe the client does not have control over the disorder.  They tend to be more educated about the disorder.  They may experience negative emotion, but they tend to suppress criticism.  They tend to interact with the client to problem-solve the client’s symptoms and problems.  2) In another type, families are resigned that the client may not improve.  They do not want to put up with the problems.

From the perspective of the patient, those who rated their parents with high PROTECTION (controlling, intrusive, infantilizing), but low CARE (indifferent, rejecting), felt parents do not trust their judgment or ability to be independent.  But, high in CARE (concerned, accepting) and low PROTECTION (respectful, supportive of independence) led to a less severe course of illness (Warner and Atkinson, British Journal of Psychiatry, 153, 1988).  High EE is experienced by the patient as intrusive and intolerant, but with high expectations for the client.  Think of how a patient might worry about how parents may view him or her and the anxiety that may cause.

What Does EE Do to the Client?   These are some of the ways EE has been hypothesized to work.

  • Causing the patient to be resigned, unmotivated to work at recovery.  If one’s improvement is not appreciated, the appearance of symptoms is criticized, and successes receive lessor notice, the client is less able to sustain improvement and treatment.  Another way to say it as that hope, effort, and success are not reinforced; so they wane.
  • Causing the patient to believe the family does not like him/her or blames him/her.  The patient is monitoring family reactions and connecting them with feelings of guilt, shame, and self-reproach.
  • Causing the client to feel like an outsider who cannot be accepted or normal.
  • Causing excessive attention to fall upon the client, making him/her feel uncomfortable and deviant.
  • Causing the client to internalize negative identity.  In the case of over-protectiveness and over-involvement, the message is that parents do not value the patient’s independence, competence, self-development, and judgment.
  • Causing the client to feel watched, that every thing he/she does is observed and judged.
  • Causing escalation of conflict.  When conflicts escalate, unpleasant words are almost always spoken.  The client is likely to internalize these conflicts as negative self-esteem, hopelessness, etc.

In essence, relapse is a form of escape from the family environment.

EE and Schizophrenia.  Extensive research during the past three decades has indicated a strong association between EE and poor clinical outcome in adult schizophrenic patients and relapse in adult depressives (Butzlaff & Hooley, Archives of General Psychiatry, 55, 1998).  Marom et al (Schizophrenia Bulletin, 31, 2005) reported psychiatric symptoms occur in high EE families (criticism, over-involvement) more often than in low EE families.  Hospitalizations occur more often and last longer.

EE and Alcoholism. Tim O’Farrell’s studies (e.g., Treating Alcohol Problems: Marital and Family Interventions, 1993) with couples show that spouses have an important role in prognosis.  High EE is associated with likelihood of relapse.  The drinking provokes a reaction, often critical towards the drinker, which triggers relapse.  The spouse is angry the drinker cannot be depended upon, for instance.  The drinker loses motivation and may drink in some part to escape from the criticism.  While relapse in alcoholism occurs with high likelihood anyway, high EE causes more rapid progression toward relapse.  Reduced criticism tends to correlate with longer periods of sobriety.

EE and Learning Disabilities.  Somewhat more than half of parents with disabled children tend to focus on tasks the child cannot successfully do.  Imagine trying to learn a skill while being told (or it is implied) you are a disappointment, failure, or incompetent for not being able to do it!  With LD, often over-involvement occurs, which is stressful for the child by creating an environment of expectations and failure (Lam, et al, Journal of Intellectual Disability Research, 47, 2003)

EE and Anxiety Disorders.   Chambless and Steketee (Journal of Consulting and Clinical Psychology, 67, 1999) and Chambless et al (Journal of Family Psychology, 15, 2001) found that EE was associated with relapses in OCD and Panic Disorder, and that most of the moderator variables one might expect to influence outcome were not predictive — type of relative, diagnosis, amount of contact with relative, and even the presence of medication.  For PTSD, EE is associated with less change in treatment.  In OCD, EE is associated with fewer gains in treatment.  Anxious children with high EE parents had poorer global adjustment at follow up (Leonard et al, Archives of General Psychiatry, 50, 1993).

Causation Is Complex.  Clinicians should look at etiology and relapse as a complex interaction of multiple factors.

  • Congenital Factors – temperament, underlying tendency toward anxiety, genetic loading for various disorders, birth weight, parental drug use
  • Cognitive-Affective Factors – schemas, automatic thoughts, past experiences which shape emotional reactions, unresolved and un-mastered emotional experiences, defense and coping patterns, internalized self-image and self-esteem
  • Contextual Factors – family reactivity, poor support for autonomy and individuation, over-protectiveness or under-protectiveness, high levels of rejection, blame, hostility, over-involvement; low levels of warmth, support, and communication.

Note, EE shows some cross-cultural predictive power.  But remember that the expected or ambient level of emotional expression does vary with culture.

Treatment.  As it turns out, EE and its association with relapses is not easily influenced. The family’s interactional style is so over-learned and their response to the client’s accumulating difficulties can be so profound that effecting serious change is a laborious process.  But we must make the effort.

  • Educate the family about the disorder.  Help the family understand the patient’s behavior and responses.  It is important that the family can see all the behaviors that are connected to the disorder as related to each other.
  • See the behavior as a legitimate disorder in which the symptoms do not appear and vanish at will.
  • Educate families on the challenges the patient faces having depression, schizophrenia, OCD, PTSD, ADHD, etc.
  • Educate about EE and explain impact of criticism.  Map out alternative ways to respond.
  • Support the client’s efforts toward autonomy, independence, and problem solving.
  • Acceptance of the disorder is not the same as understanding it intellectually.  So educating alone is an intervention that does not always reduce EE.  Increasing understanding of symptoms and disorder does not seem to reduce EE.  So work on acceptance skills.  Practice acceptance.  Show compassion towards the client.
  • Reduce emotional reactivity.  Help family members de-escalate conflict.
  • Help the family learn compassion towards every member.  Clients should not be exposed to critical language.
  • View the problem as circular, so no one is to blame. Parents are as much reacting to the client as they are affecting the client.
  • Re-label or connote behaviors as having positive purposes, such as protectiveness.

EE and Health Care Professionals.

EE is surprisingly common in professionals, often highest in nurses.  Professionals with high EE show high expectations, often imply unattainable goals.  They tend to focus on client deficits and weaknesses.  Their behavior implies the patient is doing or likely to do something wrong.  High EE professionals tend to be less objective, to lack distance.  They also tend to let personal emotions penetrate the treatment setting.  More than one study shows that EE is higher in less educated professionals.  (Van Humbeeck & Van Audenhove, Social Psychiatry and Psychiatric Epidemiology, 12, 2003)

Low EE professionals tend to focus on setting reasonable boundaries before there are problems, defining the treatment situation for the patient.  This creates a more objective framework.  They focus on strengths.  They control their feelings, show consistent warmth.  But they are not passive and sometimes do lead and confront, but with consistent compassion and empathy.  They try to see the world through patient’s eyes.  They suppress their own negative reactions.  Low EE in therapy is associated with openness, flexibility, and tolerance of behavior that does not conform to rules.

Van Audenhove and Van Humbereck (2003) suggest EE is a good tool for observing family interaction and that successful professional teams show low EE.

While not researching EE per se, John Gottman, the prolific researcher on marriage, found that the predictors of divorce include criticism and contempt.   Doesn’t that seem to be related?  Criticism maintains dysfunction and descent into more dysfunction.

In conclusion, high EE is an important focus for treatment intervention and a useful filter for understanding family interaction.  No less important is monitoring treatment professionals for avoiding high EE and learning the skills associated with low EE.


© Don D Rosenberg 2011


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