Contents
Abstract
​1
Introduction
2
Analysis
A study linking relapse to expressed emotion
Family intervention: What are the options?
The effects of family on the treatment of schizophrenia
Causal models used by Chinese caregivers: What do these demonstrate?
6
8
10
13
Discussion
Does the Camberwell Family Interview effectively measure
expressed emotion in family caregivers?
How must culture be considered when assessing expressed
emotion and constructing a psychoeducation plan?
15
Conclusion
18
References
19
17
Abstract
The aim of my research was determine whether family psychoeducation, an
interventional method in which families of people with schizophrenia are provided
knowledge regarding the disease itself as well as practical information regarding
patient care, could have a positive effect on the patient’s treatment by reducing the
incidence of expressed emotion. Expressed emotion is a phenomenon characterized
by criticism and hostility towards the patient based on a feeling that they are to
blame for their disease. Through secondary research, I collected a number of journal
articles investigating the effects of expressed emotion on rates of relapse or
readmission, as well as the link between psychoeducation and levels of expressed
emotion in family members. As an aspiring medical student, I am particularly
interested in the ways in which the patient’s social environment, alongside
medication, can aid in their recovery. I found that expressed emotion is indeed
heavily linked with high rates of relapse, but can be reduced with effective family
intervention. However, I realised that culture greatly affects family dynamics, and
therefore influences the extent to which expressed emotion as a concept can be
applied to differing populations. I concluded that psychoeducation is crucial in
reducing expressed emotion and consequently rates of relapse, but must be
considered with respect to the culture from which the family originates. However,
throughout the entire process, one message pervaded; both the patient and the
family must not feel blamed or antagonized. Instead of being seen as the cause of
the problem, they must be acknowledged as part of the solution.
1
To what extent is psychoeducation for relatives of
people with schizophrenia effective in improving
family interaction and preventing relapse?
Introduction
It has been known for many years that a person with schizophrenia has a 40%
chance of attempting suicide in their lifetime. 10-15% of people with schizophrenia
will die from suicide (Planansky and Johnston 1971). ​The Schizophrenia
Commission, an independent organisation founded to combat marginalisation faced
by schizophrenic individuals, found in 2012 that the life expectancy for an individual
with schizophrenia is 15-20 years below that of someone not suffering from the
illness (Murray 2012). This is a concerning issue that should have been addressed a
long time ago.
Schizophrenia is a psychological illness associated with a multiplicity of symptoms,
which are categorised in several ways. Positive symptoms are defined as additional
behaviour that was not present before the onset of the disease such as
hallucinations, whereas negative symptoms refer to the withdrawal of normal
behaviours, such as lack of emotion or mutism. Hallucinations are a perception of an
external stimulus when none exists. They can manifest in any sensory modality, but
common forms are auditory hallucinations such as voices, or visual hallucinations,
which may be the perceived presence of an individual oe character that does not
exist. Delusional behaviour relates to a strongly held belief that is maintained even
when presented with evidence that proves otherwise.
Health professionals rely heavily on the Diagnostic and Statistical Manual of Mental
Disorders (DSM) published by the American Psychological Association (APA) to
provide a set of criteria with which mental illness can be identified. The DSM-5,
published in 2013, eliminated the classic subtypes of schizophrenia (catatonic,
disorganised, paranoid, residual and undifferentiated). A research team stated that
2
the “clinical manifestations are extremely diverse...​with this heterogeneity being
poorly explained by the DSM-IV clinical subtypes and course specifiers.” (Tandon ​et
al. ​2013). In addition, it has been found that patients’ symptoms will often change
from one subtype to another. As a psychology student and aspiring medical
applicant, the diverse, dynamic nature of these symptoms proved particularly
fascinating.
Since this reform, schizophrenia is now diagnosed if the individual suffers from a
particular set of symptoms for at least a month which profoundly impacts their social
or work life for at least six months (Hoffman, 2014). Patients must firstly suffer from
hallucinations, delusions or disorganised speech. In addition to this, negative
symptoms will often be present.
Alongside antipsychotic medication, individuals diagnosed with schizophrenia will
almost invariably undergo some form of social intervention. Perhaps surprisingly, a
particularly contentious aspect of social support is the level of involvement
appropriate for close relatives.
Family interventions attempt to educate relatives acting as caregivers, so as to
create a patient-caregiver relationship lower in expressed emotion. Expressed
emotion is the manifestation of thoughts or beliefs that would negatively affect a
patient’s treatment. Expressed emotion can be broken down into three dimensions;
hostility, emotional overinvolvement (EOI) and critical comments (CC). Hostility is
signified by negative emotions towards the patient and beliefs that the patient could
control their symptoms if they wanted to. Emotional overinvolvement refers to
over-protective, intrusive behaviors. Critical comments tend to be unconstructive and
may cause other family members to behave similarly.
Psychoeducation sessions aim to reduce levels of expressed emotion in caregivers
by ​equipping them with knowledge about the disease itself, as well as practical
information regarding patient care. This may be in the form of written instructions, or
guided practice, aiming to inform both the family members and the patient
3
themselves of the patient’s practical and emotional needs, while advising against
hostile, critical behaviour.
This essay attempts to assess the effectiveness of psychoeducational family
interventions through secondary research and the analysis of journal articles. Using
secondary allowed me to study research conducted over many months or even
years, as well as well as combining investigations from all over the world, giving me
a wider understanding of the family considerations for patients with schizophrenia.
Collecting first-hand data from families and patients through interviews may provide
more rich, detailed findings, but the lack of sufficient training and professional insight
would make it difficult for me to conduct the research in an ethical manner.
Initially I sought to understand the effect of expressed emotion on relapse, and found
a study by Barrelet which monitored the levels of expressed emotion in family
caregivers, concluding that expressed emotion increases the likelihood of relapse
(Barrelet ​et al.​ 1990). I progressed to look at the effect of psychoeducation in
reducing relapse by examining the findings of Tarrier’s study (Tarrier​ et al.​ 1988),
which revealed that a long term psychoeducation scheme greatly benefited the
family and subsequently the patient by reducing levels of expressed emotion.
However, I felt that it was important to understand the beliefs behind the caregivers’
actions in order to combat expressed emotion, and found that Philips’ study into the
causal beliefs of caregivers (Philips ​et al. ​2000) demonstrated how misconception of
that causes of schizophrenia can be detrimental to the patient’s recovery. Finally, I
was interested in effect of culture on expressed emotion and relapse, and found
Garcia’s paper on the effect of expressed emotion on relapse in Mexican-American
people with schizophrenia (Garcia ​et al.​ 2006) to be contradictory to Barrelet’s
findings. Having analysed these sources and evaluated their research methods
carefully, I concluded that psychoeducation and support for families of patients with
schizophrenia is imperative in reducing the likelihood of relapse, but must be
approached with consideration to the culture in which the family and the patient lives.
Additionally, throughout the research process it became clear that in order to
4
diminish the effects of expressed emotion and encourage psychoeducation, it was
crucial that family members do not feel blamed or antagonised in any way. The
family must not feel that they are the cause of the problem, but instead part of the
solution.
5
Analysis
A study linking relapse to expressed emotion
Barrelet ​et al.​’s study of Expressed Emotion and First-Admission Schizophrenia
found that certain aspects of expressed emotion did correlate with relapse (Barrelet
et al. ​1990). Using readmission within 9 months following the first admission as a
measure of treatment success, the results suggested that both family support and
expressed emotion affect relapse in the months following the initial hospitalisation.
The Camberwell Family Interview (CFI) was used as the method of gathering data
relating to expressed emotion (Vaughn and Leff 1976), conducted with a family
caregiver without the patient present. The questions address the onset of the
symptoms, tension within the home of the patient and the caregiver, and daily rituals
carried out by the family. The interview lasts 1-2 hours and produces ratings on five
scales. A family member’s level of expressed emotion is assessed using the three
scales of Critical Comments (CC), Hostility and Emotional overinvolvement (EOI).
More than six critical comments or at least one hostile comment rates a family
member as “high in expressed emotion” (Venkatasubramanian & Amaresha 2012).
Patients who had relapsed experienced a much higher level of CC and EOI from
their caregivers (​CC median score=​15.0, ​EOI median score=​2.0) than the patients
who did not relapse (​CC median score=​4.5, ​EOI median score​=1.0), suggesting the
presence of a parent may not always be beneficial.
The researchers found that “the use of CC plus EOI in [their] population introduced
“noise” in the EE ratings”. This means that the consideration of EOI in addition to CC
creates meaningless data that does not contribute to the findings. Barrelet ​et al.
therefore found that CC alone predicted relapse rates more accurately than when
combined with EOI. If these findings are valid, then family interventions must be
engineered in such a way as to eliminate CC in particular.
6
There may be uncertainty as to the level of intervention required to limit expressed
emotion. It is important to acknowledge the considerable expense of designing and
carrying out a family intervention plan, and whether this will continue indefinitely.
Finding a less expensive, simpler alternative may be appropriate. Tarrier ​et al​.
(1988) examined the effects of routine treatment, a short educational program, and
two versions of family intervention programs.
7
Family intervention: What are the options?
Tarrier ​et al. ​(1988) carried out a study comparing the differing effects of two types of
family behavioural intervention for patients with schizophrenia, as well as assessing
the effect of education alone, yielding promising results regarding the reduction in EE
levels and relapse rates. Families, each containing at least one high-EE relative,
were assigned to one of four conditions. One group received routine psychiatric
treatment, which did not include any education or intervention for family members.
The second condition consisted of two sessions designed to inform the participants
of the pathology of schizophrenia as well as home-management of the disease. The
final two conditions introduced a behavioural intervention for family members. Both
interventions aimed to teach the same content, but were different in that Behavioural
Enactive intervention demonstrated behaviors and required the participants to learn
through “role-playing, guided practice and record keeping”, whereas Behavioural
Symbolic intervention involved providing verbal instructions.
Tarrier found that patients who received routine treatment alone had higher relapse
rates than patients receiving education alongside their relatives. These rates
dropped dramatically when family behavioural intervention was offered. Within the
Enactive intervention group, 2 out of 13 (17%) participants relapsed, and only 1 out
of 12 (8%) participants receiving Symbolic behavioural intervention relapsed within 9
months of discharge. The difference between the two behavioural intervention
groups was shown not to be significant.
It is important to question the measure of treatment success used in this study.
Readmission is arguably greatly affected by culture. For example, many of the Swiss
citizens Barrelet ​et al.​’s study and American citizens in Tarrier ​et al.​’s study would
have been paying a significant healthcare insurance premium, and would be eligible
for the high quality of healthcare provided. However, schizophrenic individuals in
developing countries may not be a priority within the healthcare system, and will not
be admitted to a hospital as readily. Furthermore, countries may not always use the
8
same diagnostic criteria for identifying schizophrenia. This again poses a validity
problem in that rates of readmission may depend partly on the wealth of the country
as well as the criteria for diagnosing a relapse.
One must be careful when applying findings and the subsequent family treatment
plans to numerous cultures. In a study of Mexican-Americans with schizophrenia, it
was found that expressed emotion may not be linked to failed treatment as expected
when assessing family interactions across different cultures.
9
The effects of family on the treatment of schizophrenia
Garcia ​et al. ​used the Camberwell Family Interview (CFI) to assess levels of
expressed emotion in family caregivers Mexican American schizophrenic patients, in
conjunction with the nature of support the family members provided (emotional or
instrumental support). The research team assessed the patients’ treatments by their
medication use 9 months following discharge from a psychiatric hospital, categorised
as either “regular” or “irregular”. The findings showed that expressed emotion did not
correlate with irregular medication use. However, it was found that higher levels of
instrumental support were associated with regular medication use.
As a semi-structured interview, the procedure is standardised, allowing results to be
compared as well as coded into objective data and assessed statistically. However,
the CFI was designed with the express purpose of assessing levels of expressed
emotion. As such, the interviewer must avoid closed questions directed towards the
caregiver. Researcher triangulation may be effective at diminishing interviewer
effects, which involves using multiple researchers to assess the biases within the
interview process and minimise the effect of individual interviewers’ expectations.
The measurement of family support is limited in this study to emotional and
instrumental, two of four functions within family support (Wills 1991). Emotional
support refers to the expression of compassion and warmth. Instrumental support is
the direct assistance given to an individual in need of care​. ​An example provided of
instrumental support was ​“I helped him fill out an employment application”, whereas
“I told her that I love her” would be considered emotional support. Garcia ​et al.​ found
that instrumental support correlated with regular medication use, whereas emotional
support did not seem to have an effect on whether the participants adhered to their
medication plan.
The relationship between instrumental support and medication use is unclear.
Although the research team concluded that instrumental support has a positive effect
on medication usage, it could be argued that a patient displaying motivation towards
10
their medication may subconsciously encourage a higher level of hands-on support
from family members. This introduces bidirectional ambiguity to the results, meaning
it is not possible to determine whether instrumental support caused regular
medication use, or instrumental support was caused by regular medication use.
It is important to question the measures used to assess the success of the patient’s
treatment within the study. Arguably, readmission or non-readmission is a more valid
measure of treatment that medication usage. Cessation of regular medication may
suggest that the patient feels stable enough to discontinue medication altogether, as
opposed to being unsupported in their care. In contrast, readmission is
comparatively unambiguous in its implications. This is important in that the perceived
level of success in the treatment would not only affect the direction of treatment in
the future, but also influence levels of optimism in both family members and the
patient themselves, which could greatly affect levels of expressed emotion within the
household.
The categorisation of medication use as either “regular” or “irregular” hinders the
results, in that specific details regarding the personal circumstances of each patient’s
treatment are lost. Regular medication use was defined as “patients who took their
medications at least 75% of the time with no 4-week or longer interval of
discontinued use”. Anyone outside of this was considered an irregular medication
user. One could argue that the criteria for regular medication use do not reflect
successful treatment. For example, although discontinued medication use for longer
than 4 weeks was considered irregular, any discontinuation for a period shorter than
that would still be considered regular medication use, calling into question the
accuracy of the dependent variable.
In addition, the qualitative reasons behind the participants’ medication usage are lost
in the results. An important factor that should be considered when encouraging
compliance to a medication plan is the individual’s potential reasons for not taking
their medication regularly. Whereas simply forgetting to take medication can be
easily resolved through reminders, feelings of helplessness or futility that precipitate
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a cessation of medication use may be harder to address. Without this information it
is extremely difficult to deduce the reasons for regular or irregular medication use,
and therefore difficult to determine the effect of family support for individuals with
schizophrenia.
Although Garcia ​et al.​’s study found a correlation between family support and
compliance to a medication plan, the motivations and beliefs behind the caregiver’s
behaviour were not clear. Philips ​et al. ​conducted a study of causal beliefs among
Chinese family members of people with schizophrenia, which provides a clearer idea
of the causal models for schizophrenia used by caregivers.
12
Causal Models used by Chinese Caregivers: What do these demonstrate?
This study elucidates the reasons family attribute to their relative’s onset of
symptoms. This is important in tackling the development of expressed emotion. If the
fundamental beliefs behind the expressed emotion exhibited by the relative are
understood, then the expressed emotion can be addressed through an effective
educational intervention.
Philips ​et al. ​conducted a study assessing the causal beliefs of Chinese
schizophrenia patients and their families (Philips ​et al.​ 2000), using a causal model
questionnaire derived from a Chinese version of the CFI conducted in urban and
rural communities. The team sought to determine whether causal beliefs in
caregivers would have an effect on the nature of the care they provided. 245
principal caregivers of 135 schizophrenia patients answered the CMQS, and it was
found that “personality problems” were attributed in 60% of cases and “stress” in
48.9% of cases, making psychosocial factors the most attributed causes by
caregivers. However, “brain disease” was not stated as a perceived cause in any of
the patients, and “alcohol and drug misuse” were attributed in only 1.5% of patients.
The results suggest an urgent need for improved education in Chinese caregivers
regarding their perceived causes of schizophrenia. “Brain disease” was not
recognised by any caregiver as having caused the patient’s symptoms, suggesting a
low level of education surrounding mental illness. Interestingly, in 15.6% of
caregivers, “Spiritual/mystical factors” were believed to be a contributing factor to the
patient’s schizophrenia, suggesting a propensity among Chinese family caregivers to
use supernatural explanations over evidence grounded in scientific understanding.
Qualitative data collected following the questionnaire suggested that participants
may not be willing to alter their causal models. The researchers found that
“[caregivers’] ideas about the causes of illness changed little after contact with
psychiatrists.”​ ​It is possible that the qualitative data was low in validity, and the
participants’ apparent inflexibility was due to the fact that they were feeling pressured
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by researchers from an unfamiliar culture. A more informal interaction with a Chinese
social worker may prove more successful in altering causal models for
schizophrenia.
It is vital to consider the generalisability of this study. Due to the high level of
ethnocentricity, meaning participants originate a single specific culture, the causal
beliefs held by Chinese caregivers may differ greatly from other cultures. Much of
Chinese culture maintains an element of spirituality, and as a result caregivers may
attribute schizophrenia to supernatural causes. If compared to a country with a
generally lower level of superstition such as the U.K., causal models of
schizophrenia may appear starkly different.
Garcia ​et al.​ (2006) and Philips ​et al. ​(2000) both make clear the cultural
considerations necessary when approaching the treatment of schizophrenia. Both
suggest that if a successful intervention scheme is to be established, every culture
must have a version designed specifically to target the principal causes of expressed
emotion in that culture.
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Discussion
Does the Camberwell Family Interview effectively measure expressed emotion
in family caregivers?
The Camberwell Family Interview was the main source of data regarding levels of
expressed emotion in the family caregivers in all four studies. The CFI is a
semi-structured interview conducted with close family relatives of the patient without
the patient present. The interview focuses on the patient’s symptoms in the months
prior to hospitalisation, as well as the level of stress in the household, irritability in
both the patient and the caregiver, and the daily household routines of the patient
and the caregiver. This normally lasts 1-2 hours, and is recorded for coding later.
The CFI is the most commonly used method of assessing expressed emotion in
family caregivers for patients with schizophrenia. The same questions are used
every time the interview is performed, allowing for standardisation of procedure. This
means data from different studies can be more effectively compared because they
have used very similar methods for collecting data. A strong rapport between the
caregiver and their interviewer will allow them to disclose more sensitive, personal
information that could be important in assessing the dynamic between the patient
and their caregiver. That said, if the researcher cannot build rapport with the
interviewee then their answers to the questions may be less detailed.
Furthermore, the preconceptions of the researcher may alter the findings. The
purpose of the CFI is to measure levels of expressed emotion, a phenomenon that is
widely believed to negatively affect patient care. For this reason, the researcher must
be careful not to appear judgemental towards the caregiver. If the interviewee feels
antagonised, they will not yield informative data. As such, the researcher should
consider interviewee’s concerns and demonstrate a high level of reflexivity, by
considering the ways in which their personal beliefs, as well as the design of the
experiment, may limit the acquisition of rich, thick data. Asking participants whether
15
they agree with the results may also ensure that the researcher’s biases have not
affected findings.
The CFI is not the only way to assess levels of expressed emotion in family
caregivers. The Level of Expressed Emotion (LEE) scale is a self-report that
assesses the patient’s relationship and the emotions involved. It is composed of 60
items, categorised into four subscales, Intrusiveness, Emotional Response, Attitude
towards Illness, Tolerance and Expectations. The report asks for true or false
answers to statements and a score for the overall level of EE is produced, as well as
individual scores for the subscales. The LEE scale may be more beneficial to
researchers than the CFI in that both the patient and the caregiver are assessed
using this method. Furthermore, since it is a self-report measure, the LEE scale is
easier to administer than the CFI and the researcher bias within the CFI is not
present in the LEE scale.. However, the participant’s preconceptions about
themselves may affect the data. In addition, depending on the severity of the
patient’s schizophrenia symptoms, the data collected in their LEE scale may not be
applicable to their treatment, for example if they believe they are healthy and not in
need of treatment.
16
How must culture be considered when assessing expressed emotion and
constructing a psychoeducation plan?
In Garcia ​et al​.’s study (2006), 52% of patients were born in Mexico, as were 68% of
their family caregivers. As immigrants in the USA, they may be familiar with
discrimination at the hands of Americans born in the USA. Having a Mexican native
interviewer would have allowed for a deeper development of rapport through a
greater understanding of the culture from which the participants originate. Although
the research team did conduct the CFI using trained bilingual interviewers, there is
no evidence of the interviews being conducted by people familiar with the Mexican
culture. ​This means any conclusions drawn regarding symptoms, levels of expressed
emotion and plans for intervention may have been drawn through the sociocultural
lens of the American research team that performed the experiment. Any findings
must be interpreted by researchers that have either originated from Mexico, or have
spent considerable amounts of time within the culture, learning and understanding
the beliefs, values and attitudes of people within the culture.
These considerations are important within the investigation of family support for
schizophrenia due to the culture of family within Mexico, which differs from the
American concept of family. In Mexico, life revolves around family relationships and
is far more central to an individual’s identity than the American understanding of
family (Steidel and Contreras 2003). This could affect the assessment of expressed
emotion, in that a parent who seems emotionally over-involved to an American
analyst may fit perfectly with a Mexican understanding of a parent’s role in caring for
their child. A misguided interpretation of expressed emotion would lead to an
ineffective intervention strategy which may only increase levels of stress and hostility
in the household.
17
Conclusion
The studies examined have clearly demonstrated the detrimental effects of
expressed emotion on the recovery of patients with schizophrenia, as well as the
extremely positive effects of psychoeducational family intervention on the reduction
of expressed emotion, which in turn reduces rates of relapse.
However, questions have arisen as to the effect of culture when assessing
expressed emotion and creating a plan for intervention. Garcia ​et al. ​(2006) and
Philips ​et al. ​(2000) have identified factors that may greatly affect the levels of
expressed emotion within family units, such as the understanding of family within a
certain culture or the perceived cultural importance of psychosocial factors.
Questions that have arisen as the essay developed include the potential flaws within
the measurement of expressed emotion; Barrelet ​et al.​ (1990) found that only CC
correlates with relapse. Should more studies yield similar findings, there may be
cause to amend the CFI with regards to the separate dimensions measured. In
addition, Philips ​et al.​’s (2000) investigation into the causal models found that
caregivers were generally unwilling to alter their beliefs, suggesting that cultural
opinions are very firmly held. Researchers must exercise caution when planning
treatment, so as not to disregard cultural and personal beliefs.
Overall, the evidence suggests that expressed emotion and therefore future relapse
can be greatly reduced through effective family intervention and psychoeducation
that is tailored to the culture of the family itself.
Word count (inc. references) = 4043
Word count (not inc. references) = 3999
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