1. INTRODUCTION

The concept of expressed emotion (EE) was first developed by the team at the Medical Research Council Social Psychiatry Unit in the late 1960s. The original investigators (Brown, Birley and Wing 1972) decided to investigate how some patients suffering from schizophrenia appeared to steer a better course of the illness when staying in a hostel instead of going home. The Camberwell Family Interview (CFI) was devised after an extensive series of interviews with patients, parents (either singly or jointly) and parents and patients together. Briefly, the most predictive sub-scales of the CFI are relative criticism, hostility and emotional over-involvement. Criticism is defined as unfavorable comments on the patient; hostility is defined as either generalization of criticism or hostility and emotional over-involvement consists of over-protective behavior, devoted behavior and exaggerated emotional response. If one relative is classified as high EE relative, the family is classified as a high EE family. It was found that ratings based on interviewing parents singly had the most predictive value. The original CFI lasted about two to three hours. In the early 1970s, the second generation of EE investigators (Vaughn and Leff 1976) shortened the original CFI to about an hour. It is this short CFI that has been used for the robust findings of EE predicting how patients suffering from schizophrenia fare (Kuipers and Bebbington 1988, Kavanagh 1992).

Despite thirty years of research, EE remains an empirical construct whose origin and course are not understood. It also does not contribute much to our understanding of the etiology of schizophrenia. Moreover the label of high EE has a value-judgement connotation to it. Families also worry that the burden of caring for a mentally ill person will mostly fall on them if they are singled out as the target of intervention. Despite these concerns, the past fifteen years have witnessed a major advance in the care of schizophrenic patients living with their families. EE has influenced the development of intervention packages for families with a member suffering from schizophrenia. Studies published in the last decade include a few purely educational studies as well as the more intensive family interventions lasting up to 9 months or more (See Lam, 1991 for a detailed review) . In England, this innovative work was initially carried out by Leff at the Medical Research Council Social Psychiatry Unit in London (Leff et al. 1982, 1985) and replicated by Tarrier's team (Tarrier et al. 1988, 1989) in Salford near Manchester.

In this paper I shall start by stating the common assumptions of the psycho-education family intervention in schizophrenia. I shall limit my review to studies carried out in the United Kingdom. I shall first review three brief interventions with education as the main component. The more intensive family interventions are reviewed next. The efficacy of both types of studies is examined. There is one report of family interventions, which had no impact on patient's relapse rates. The characteristics of this non-effective study are examined and suggestions of what we can learn from it are made.

2. Common assumptions

The types of psychosocial family intervention reviewed here share the following common assumptions:

1. Schizophrenia is regarded as an illness with a biological component. Patients suffering from schizophrenia are particularly vulnerable to environmental stress, including relative criticisms, hostility and emotional over-involvement. Therapists advocate a disease model that carries implications for rehabilitation and avoidance of stress.

2. Families are not blamed for causing the illness in the first place or subsequent relapses. There is no assumption that the origin of the illness lies in the pathological interaction in the family. In fact high EE behavior is relevant to other medical conditions and possibly exists in 'normal' families.

3. There is a clear message that families are not ill or needing treatment. Instead, relatives' burden in caring for a deeply disturbed or disabled person is acknowledged. EE is regarded as a barometer of how much stress the families are under. In fact family members are enlisted as therapeutic agents.

4. Psychosocial family intervention is offered as part of a treatment package in conjunction with drug treatment and outpatient clinical management. The aims of family intervention are broadly prevention of relapse and promotion of the patient's level of functioning.

3. EDUCATIONAL STUDIES

Brown et al. (1972) speculated quite early on that high EE is due to a relative's lack of understanding of the illness. Leff and Vaughn (1985) also suggested that high EE relatives tend to believe patients had control over their symptoms whereas low EE relatives believe that patient were genuinely ill and had very little control over their disturbed behavior. It was hoped that better understanding on the part of the relatives as a result of education would attenuate their critical behavior of the patients.

Three published studies (Berkowitz et al. 1984; Barrowclough et al 1987; Smith and Birchwood 1987) of brief educational packages are reviewed below. The studies by Berkowitz et al. (1984) and Barrowclough et al. (1987) were part of their more intensive family intervention studies. However, Smith and Birchwood's (1978) study was designed specifically to compare the effect of oral presentation using audio-visual aids, booklets and homework assignment with booklet through the post and home work assignment. These studies also differed in the length of family education packages, from two sessions in a single family situation (Berkowitz et al. 1984; Barrowclough et al. 1987) to four sessions in a multi-family setting (Smith and Birchwood 1987).

All three studies (Berkowitz et al. 1984; Barrowclough et al. 1987 and Smith and Birchwood 1987) demonstrated some gain in knowledge about the illness. Brief education packages did not seem to have much impact on relatives' knowledge of the etiology of the illness (Berkowitz et al 1984; Barrowclough et al. 1987). There was very little evidence of change in the family members, belief systems and attitude (Smith and Birchwood 1987). However there was evidence of increased optimism in relatives about the patient's future (Berkowitz 1984) and the family’s role in treatment (Smith and Birchwood 1987) which unfortunately was not maintained at six months. Furthermore, Tarrier's team showed that family education showed no impact on patients' relapse rates whether they came from high or low EE families (Tarrier et al.1988). However, there was some evidence of relief of burden and distress from Smith and Birchwood (1988). Unfortunately the beneficial effect was not maintained when families were followed up at six months.

As a whole, the studies reviewed did not show any substantial benefits of brief educational packages. However, one can argue that telling families about the illness is a moral obligation. Families are entitled to know more about the illness once a diagnosis is made. Moreover, Berkowitz et al (1984) commented that the initial educational sessions were a good way to engage families. Therapists worked in an open and honest way and shared what they knew with families. The finding of temporary relief from distress is also important. When highly distressed, families may not be able to work effectively with therapists.

4. FAMILY INTERVENTION

In contrast, three more intensive family interventions from different geographic sites by two different research teams demonstrated a robust effect of delaying relapse (Leff et al. 1982, 1985; Tarrier et al 1988, 1989; Leff et al. 1988, 1989). Leff’s team carried out two of these studies. In their second study, Leaf’s team compared the effect of relatives' groups with family intervention.

On the whole the effect of delaying relapse has been impressive, ranging from 9 to 17% in the family intervention group compared with about 50% in the high EE comparison groups at 9 or 12 months. At 24 months the relapse rate was about 40% in the family group compared with 59 to 78% in the high EE comparison groups.

In addition to relapse rates, Tarrier et al. (1990) reported significant gains in the patients' social functioning. Leff et al. (1990) also reported an improvement in the patients' negative symptoms in their two-year follow-up.

Most teams also reported a reduction of EE in the family intervention groups. However, it was also observed that a reduction of EE was not necessary to prevent relapse. Leff's team managed to reduce relapse rates in families, which remained as high EE, by reducing the amount of face-to-face contact. There was some evidence that intervention worked independently of increases in the amount of medication (Tarrier et al .1988). One of the purposes of the study by Tarrier's group was to compare Enactive (role-plays in sessions and homework to change behavior actively) and Symbolic (discussion only) Behavioral Treatments. There was no statistically significant difference in relapse rates at one-year follow-up. In Leff's second study (Leff et al. 1988, 1989) the number of families was very small. There was no statistically significant difference in relapse rate between the family intervention group (8%) and the relatives' group (33%). However, this can simply be due to the lack of statistical power.

One study (McCreadie et al. 1991) in Scotland did not show any effect of psycho-social family intervention in delaying relapse when compared to routine treatment groups. McCreadie et al.'s (1991) failure to replicate Leff's findings is baffling. The authors stated that their approach to family education, relatives' groups and family meetings was similar to Leff et al.'s (1982, 1985) approach. However, the treatment manual of Leff's team has only just been published (Kuipers, Leff and Lam 1991). It was not clear to what extent the two approaches were similar. Furthermore, the Scottish team did not offer family intervention at a crisis point. The high refusal rates for acceptance of help offered by McCreadie's team confirmed that help should be offered at a crisis point when it is needed most.

Finally, with the successful interventions, there are common components even though the approaches are known by different names (Lam 1991). These include genuine working relationships with families; providing structure and stability by adopting a behavioral approach, focusing on the here and now; education about the illness; cognitive behavioral approaches which include assessing families' strengths and needs, setting up small but achievable goals; widening social networks and improving communication.

5. Recent development of EE and Psycho-education

Since the favorable outcome of psycho-social family work had been reported and replicated not only in Britain but also in the United States (Lam 1991), the next stage is to train clinicians to carry out interventions. There are two British reports of training psychiatric nurses to carry out psychosocial family work with schizophrenic patients: from London (Lam et al. 1992) and from Manchester (Brooker et al. 1992). Both studies had some tentative findings of nurses picking up knowledge and attitudinal changes as a result of training (Lam et al. 1992) and some indication of favorable outcomes in patients (Brooker et al. 1992). Leff's team is currently running a randomized controlled trial of psychosocial family interventions using psychiatric nurses who are trained by them as therapists.

Recently Ball, Moore and Kuipers (1992) reported findings of expressed emotions in care staff of two hostels. At the nine-month follow-up, it was found that the needs of residents in the more critical hostel were not met and more patients were discharged to other settings. The next logical step is to develop training programs to help change staff's critical behavior.

References

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