Expressed emotion (EE), is a qualitative measure of the amount of emotion displayed, typically in the family setting, usually by a
family or care takers. Expressed emotion was introduced in England in the 1960s by Brown and his associates (Kanter et al., 1987). The
Lancet (Brown, Carstairs & Topping, 1958) looked at the social environment into which long-stay psychiatric patients returned after discharge from the hospital. Theoretically, a high level of EE in the home can worsen the prognosis in patients with mental illness,
(Brown, Birley & Wing, 1972) or act as a potential risk factor for the development of psychiatric disease (Butzlaff and Hooley, 1998) . The Expressed Emot ion (EE) is considered to be an adverse family environment which includes the quality of interaction pattern and nature of family relationships among the family caregivers and patients with schizophrenia and other psychiatric disorders. The ability of the family caregiver to provide quality care and contribute to the management of chronic disease is a vital health care resource. Brown & Rutter (1966) found that the Expressed Emotion (EE) is considered to be an adverse family environment which includes the quality
of interaction pattern and nature of family relationships among the family caregivers and patients with schizophrenia and other
psychiatric disorders. It is a significant characteristic of the family milieu that has been found to predict symptom relapse in a wide range of mental disorders. Relative of patients experience a range of emotions from loss and grief to guilt and anger. Like the patient, they also feel isolated and stigmatized. Their lives are disrupted by providing more care than would normally be appropriate for someone of the patients age. The addition of the care giving role to already existing family roles becomes stressful-psychologically
as well as economically.

The three dimensions of high EE shown are hostility, emotional over-involvement and critical comments.

Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient
is choosing not to get better. Problems in the family are often blamed on the patient and the patient has trouble problem solving in the family. The family believes that the cause of many of the family’s problems is the patient’s mental illness, whether they are or not.

Emotional Over-involvement
It is termed emotional over-involvement when the family members blame themselves for the mental illness. This is commonly found in
females. These family members feel that any negative occurrence is their fault and not the disorders. The family member shows a lot of concern for the patient and the disorder. This is the opposite of a hostile attitude and a show that the family member is open minded about the illness, but still has the same negative effect on the patient. The pity from the relative causes too much stress and the patient relapses to cope with the pity.

Critical Comments
Critical attitudes are combinations of hostile and emotional over-involvement. It shows openness that the disorder is not entirely in the patients control but there is still negative criticism. Critical parents influence the patient’s siblings to be the same way. Family
members with high expressed emotion are hostile, very critical and not tolerant of the patient. They feel like they are helping by
having this attitude. They not only criticize behaviours relating to the disorder but also other behaviours that are unique to the
personality of the patient. High expressed emotion is more likely to cause a relapse than low expressed emotions.

Low expressed emotion is when the family members are more reserved with their criticism. The family members feel that the patient doesn’t have control over the disorder. When the family is more educated and doesn’t have to put up with the patient and his/her
disorder they are more likely to have low expressed emotion. Low expressed emotion causes a different stress and it is directed at
the patient less. The attitudes of family members with high expressed emotion are too strong for the patient and the patient now
has to deal with the mental illness and the criticism from those that they need support from in their time of recovery. The stress from high expressed emotion may cause the patient to relapse. The patient falls into a cycle of rehabilitation and relapse because the stress
builds up too much so the only escape is relapse and then the disorder is unsustainable and rehabilitation is required. The only way
to escape this cycle is for the family to go through therapy together. This will greatly lower family conflicts and the stress level of
the household.

Locus of Control Model
Studies show that locus of control and EE has significant associations, especially with
internal locus of control. Individuals with a high internal locus of control view themselves as accountable for the consequences of their actions and believe that they have control over reinforcements (Rotter, 1954). Those with a high internal locus of control are more likely to believe that their efforts will be successful and they are more active in seeking information and knowledge regarding their circumstances. Those with a high external locus of control believe that powerful others, fate, or chance primarily determine events. It is said to be the people with high external control who have no hold over the situation and they are reported to be inactive, have decreased self-esteem, and not trusting of others (Silvester et al. 2002; Loosemore & Cam, 2004). High EE caregivers, particularly those who are high in criticality, have been shown to have a more internally based locus of control than do low EE caregivers (Hooley, 1998) and to be more self-blaming (Hooley, 1998; Docherty, Cutting & Bers, 1998) also found that highly critical caregivers are more likely than low-critical caregivers to have an internal locus of control.

Stress-Diathesis Model (Stress Vulnerability Model)
Stress-diathes is model combines both biological and ecological factors to explain the manifestation of mental disorders and it is one
of the most significant models to understand the development of psychopathology (Zubin & Spring, 1977; Monroe and Simons, 1991;
Rosenthal, 1970). In this model, the degree of vulnerability to a given psychiatric episode is determined by each person’s tolerance to
traumatic or stressful life events. As EE appears to accurately determine relapse among patients, the research suggested that
family environment may be a major contributing factor to critical stress levels among persons with schizophrenia. Stressdiathesis
approach facilitates the view that both patients and caregivers are involved in a system of mutual influence in which each
contributes to the stress that acts on the intrinsic vulnerabilities of the other; this perspective emphasizes upon interactions between vulnerability and stress variables.

Expressed Emotions is important elements in assessing family dynamics. Health care providers such as psychiatric social workers, clinical psychologist and psychiatrist, etc should be supportive of family caregivers and help them acquire knowledge and problem
solving, organizational and communication skills in order to maximize quality care. Some caregivers are able to carry out care giving
tasks better than others because of their knowledge about the disease , their experience, level of involvement and skills.
Expressed Emotions is of interest to researchers and clinicians because it predicts symptom relapse in patients with psychological problems and because family based interventions that seek to reduce expressed emotions have had success in decreasing patients’relapse rates (Hogarty et al., 1986; Leff et al., 1982). High or low expressed emotion makes the patient feel trapped, out of control and
dependent upon others. The patient may feel like an outsider because of the excessive attention received. In bipolar patients relapse from manic to depressed can be triggered by a family member’s comments. Expressed emotion affects everyone in the home, raising the stress level for everyone. This is bad for the patient’s recovery and for the family as a whole. The behaviour of everyone around the
patient influences the patient to relapse or progress with their illness. Criticism of the patient is hard to stop once it has started.


There are many psychological disorders that everyone has heard of through readings, experiences with the disorders, or interactions
with people diagnosed with one. A common disorder is alcoholism, is the addiction to and consumption of too much alcohol. Many people
go through rehabilitation to stop the addiction because it has taken control of their lives. When they are released, the toughest part is getting back into the world, where alcohol is available and the influence of familiar people and places. In a study by O’Farrell et al. (1998) it was shown that a relapse is more likely to occur with patients that have spouses of high expressed emotion more than those that have low expressed emotion. A cycle forms because of the constant criticism of past experiences of drinking which causes a relapse. A spouse of high expressed emotion is likely to complain about the drinking before the rehabilitation which causes the start of drinking again. This creates more criticism toward the spouse and in addition causes a set back where the person does not care to get better again. This cycle creates problems between the spouse and patient that could easily be avoided with less critical comments and complaints. Again, the high expressed emotion causes relapse quicker than those with lower expressed emotion because they are less verbally critical of the spouse’s drinking problem. The fewer negative comments a spouse makes, the longer time there is before a relapse (O’Farrell et al., 1998).

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