Expressed Emotion

Origins and Measurement

More than 50 years ago, a British sociologist named George Brown made a surprising observation. Brown and his colleagues noted that male patients who were suffering from chronic schizophrenia did much better after they were discharged from the hospital if they went to live in lodgings, or with siblings, rather than returning home to live with their wives or their parents. The finding that patients did better when they did not live with their families was unexpected. At the time, there was little in the British psychiatric literature that might have led anyone to think that social experiences might play a role in the course of schizophrenia. The unusual finding led Brown and his collaborators to begin systematic research designed to explore the possible role that family relationships might play with respect to clinical outcome in schizophrenia.

A major insight here was that it was the more everyday aspects of family relationships that were thought to be important, not relationships that were pathological or extremely disturbed. Brown and his colleagues began a series of studies designed to measure the emotional climate that existed in the family. This work resulted in the development of the expressed emotion (EE) construct.

The most accepted way of measuring EE is through an interview with the patient's key relative (usually a parent or a spouse); this is conducted in the absence of the patient. The interview is known as the Camberwell Family Interview (CFI). It is semistructured, and it takes about 1 to 2 hours to complete. Although the CFI contains specific questions about the development of the patient's psychiatric difficulties and asks about specific symptoms, it is also designed to provide the relative with an opportunity to talk and tell his or her story. There is a focus on how the relative deals with difficult situations involving the patient. Other questions concern the relationship between the relative and the patient and how they get along on a day-to-day basis.

Ratings of EE are derived from the relative's tone of voice when speaking about the patient as well as from what he or she says during the CFI. Because of this, the CFI must always be recorded for later coding. Training to rate EE is time-consuming and sometimes difficult to obtain. However, after approximately 2 weeks of training, coders are able to rate the elements of EE quite reliably. Coding EE takes approximately 4 hours per recorded interview.

Three key elements are used in rating EE: criticism, hostility, and emotional overinvolvement. The most important of these is criticism. Critical remarks are remarks that indicate clear dislike or disapproval of some aspect of the patient's behavior (e.g., “He stays up late watching TV and makes a lot of noise when the rest of us are trying to sleep. It's so frustrating and annoying.”). Critical remarks are rated as such either because they contain critical content or because the relative uses a negative voice tone when speaking about the patient.

...