Journal of Community & Public Health Nursing
Open Access

The ‘family’ is among the most important institutions in Indian society. The family provides shelter and nurture to children till they become independent. All families are not the same in society; they differ in terms of family dynamics. However, families do share few common features, particularly when phase changes and certain processes pertaining to health and disease occur in the family. In the Indian scenario families are the primary social resource for help for a psychiatrically ill person. A psychiatric patient must be seen in relation to family, relatives and community at large.

Mental illness causes disturbed relationships in the family, in terms of roles the members of the family need to adjust. Unpredictable bizarre behavior of the patient has a negative impact on family functioning. The negative attitudes and disturbed communication pattern have negative impact in patient’s recovery and prognosis [1].

The EE attitude and behaviors expressed by a caregiver towards a person diagnosed with mental disorder vary from criticism and hostility to emotional over involvement [2]. Various studies have concluded demonstratively [3,4] that patients in families having high EE are more likely to experience relapse than patients living in households with low level of EE [5,6].

The term EE originated in England in research on the role of the family environment in schizophrenia patients. The patient who experiences critical and over involvement by the family in patient care are those more likely to have relapsed [7]. They subsequently drew the concept of EE and introduced a semi structured interview. The EE [8] has two major components viz. critical comments and emotional over involvement. Many studies have established EE as a high reliable psychosocial predictor in relapse of psychiatric patients. When family environment is highly critical, hostile, emotionally over involved or intrusive those are the cases at high risk of relapse as compared to those who do not live in such a family environment [9,10].

The connection between high level of EE and clinical relapse has been studied and well established in disorders of schizophrenia and depression. [11,12]. The other psychiatric disorders including anxiety disorders, substance use disorders and eating disorders have shown predictive validity of high EE [13,14].

Major mental disorders like schizophrenia cause stress to the patient and also to family caregivers. Between 50% to 80% of schizophrenia patients live together with their family having regular contact and are also dependent on housing, emotional and financial support on their family. Studies demonstrated that caregivers undergo significant stress in coping with a person with schizophrenia [15,16].

Development and basic concept of expressed emotion

The development of the concept of EE emerged in 1950 with innovative work by George Brown. In 1956 George Brown joined the Medical Research Council Social Psychiatry in London, which originated in 1948, under Sir Aubrey Lew’s directorship. In this era, the chlorpromazine drug was widely being used in the treatment of schizophrenia. This resulted in symptomatically stable patients functionally recovered who could be discharged from the long stay at a hospital. However, most of the patients had to be rehospitalized due to symptoms relapsing. To understand the basic relevance of the symptoms relapsing a research was commissioned under George Brown and his colleagues with 229 men who were discharged from psychiatric care among whom 156 were diagnosed with schizophrenia [17]. The home where patients stayed after being discharged was a major factor for relapse and subsequent readmission. The patients who stayed with their parents or wives had a higher chance of relapse requiring hospitalization than those who lived in a hospital or with their siblings. It was also observed that if the mother went out for work, the patient had a reduced risk of relapse and showed better prognosis [18,19]. The probable conclusion drawn could be an adverse effect of prolonged stay of the patient with their family caregiver. This prolonged stay may reflect the degree of disability and level of functioning of the patient [2].

George Brown felt that there was a need to develop a scale of measuring emotional relationship between patient and their family caregivers. Michael Rutter extended his support to Brown who was interested in the study of the emotional impact of neurotic parents. An audio-taped interview method was introduced to measure the emotions and the relationship between the patient and their family caregivers. In the early stage they focused only on married couples and at a later stage it was extended to parents of schizophrenia patients [2]. Many studies have demonstrated links between mechanism of EE, clinical outcome and family interactive pattern [20]. The families that exhibit high level of EE are those that are more critical and intrusive in a face-to-face interaction and found to be more emotionally enmeshed [21].

The five types of EE as listed by George Brown include critical comments, hostility, positive remarks and warmth [22].

Hostility

Hostility is a type of EE that consists of negativity towards the person with mental disorder. The caregivers blame the person with the mental disorder while assuming that the person is in control of the course of the illness. The family member feels that the patient is being selfish by choosing not to get better assuming the illness is an internal conflict. The family member, i.e. the patient is held accountable for any kind of negative incident that occurs within the family and is constantly blamed for the problems of the family. Problem solving skills within the family are minimal because most of the problems are considered to be caused by the disorder [23].

Criticalness

This is basically ascertained at the time of assessment. Hostility and emotional over-involvement are the combination of critical comments. The negative symptoms of schizophrenia or any other psychotic disorder like inability to wake up in the morning, failing to attend to personal hygiene and not involving oneself in household activities are criticized thinking that the patient is lazy and selfish. More often than not these potentially lead to physical violence and 70% of critical comments are seen on negative symptoms of schizophrenia [24].

Emotional over involvement

Relatives of the patient may over involve themselves in the mental illness and display excessive emotion, blaming themselves for everything involving the patient. These people are seen to be more intrusive. These families believe that the patient cannot overcome problems due to external causes. This thinking leads them to choose over involvement strategies to control the fate of the patient and do things for him or her [25]. In this scenario the patient is found to be very anxious and frustrated while interacting with the family caregiver. This reflects on the whole family with high EE and they might have poor communication patterns with the patient, talking more and listening less effectively. Emotional over involvement is nothing but family members trying to be excessively intrusive, selfscarifying, and holding extreme over protective behaviors towards the patient.

Positive Regards

The caregiver provides verbal and nonverbal reinforcement towards the patient to support or promote positive behavior.

Warmth

Warmth is regarded as one of the significant characteristics of low EE in the family environment. It is the kindness, concern, empathy of the caregivers during the course of treatment.

The existence of psychosocial factors, like high EE in the family results in pathological family interaction and induces anxiety and frustration on the part of the patient which has a significant effect on the prognosis and outcome of treatment. Conversely warmth and positive regards in the household fosters improvement. Therefore, mental disorders may first require the overcoming of a high level of EE otherwise there is a risk for relapse.