Study of Family Expressed Emotion and Relapse of Male Schizophrenia Patients in

Singapore
Ng, Vincent C.K

Introduction

Schizophrenia is a serious form of mental illness that has a debilitating effect on both the
patients and their families. In essence, schizophrenia is understood as a form of psychosis, where
patients suffering from the syndrome often experience considerable distress from a myriad of symptoms
such as hallucinations, delusions, and bizarre thought processes. Most of the time, these patients will
experience a distortion of their thought processes and perceptions, leading to a loss of boundaries
between the person and the external world (Chong, 2001). The illness schizophrenia has become so
pervasive that approximately 1% of the individuals in western countries can be expected to be labelled
schizophrenic, at some point in their lives (Torrey, 1987). The prevalence of schizophrenia in Singapore is
estimated to be 0.75% of the population (Institute of Mental Health, 2003).

The exact cause of schizophrenia is not entirely understood. The general consensus amongst mental
health professionals is that there is no single cause, and rather, a constellation of biological, psychological,
and social factors that produce the schizophrenia illness (SAMH, 1988). Early empirical evidence had
suggested that the family environment plays a crucial part in influencing the onset, as well as course of
mental illness, particularly that of schizophrenia and other related psychotic disorders (Brown, Birley, &
Wing, 1972; Vaughn & Leff, 1976). Similar studies were replicated to find out the extent in which family
criticism, hostility, and emotional over-involvement affect the relapse of psychiatric patients.

This level of family relationship is measured in terms of family expressed emotion, where patients
returning to high expressed emotion environment were more likely to relapse than those returning back to
family environment with low expressed emotion. The family’s level of emotional involvement and criticism
are the two major aspects of the family’s level of expressed emotions, which has been consistently found
to be a reliable predictor of relapse amongst psychiatric patients (Hooley, 1998; Hooley & Hiller, 2000;
Dixon, King, Stip, & Cormier, 2000; Jarbin, Grawe, & Hansson, 2000).

The relationship of expressed emotion to psychiatric relapse raises the question about how
psychosocial factors affect the treatment outcome of an illness. With the current global trend of
deinstitutionalization of care for the schizophrenic patients, vast majority of them are expected to return to
live with the family, after receiving treatment for a psychotic relapse (Stirling, Tantum, Thonks, Newby, &
Montague, 1991). Hence, the Singaporean family too is expected to play an increasingly significant role in
the care and rehabilitation of the schizophrenic patient in the long-term. (Ng & Low, 2003).

Families of schizophrenic patients often encounter a range of problems impacting on the well-being of
the family life, as a result of providing care for the patient. These problems include coping with the
psychotic symptoms of a relapse, impaired social skills from the patient, strained social relationship and
isolation, and behavioral excesses from the patient, for example, aggression and restlessness. It is widely
documented that considerable stress has afflicted families of patients suffering from schizophrenia (Brown
et al., 1972; Doll, 1976; Falloon, Boyd, & McGill, 1982). Generally, the burden of care can come in the
forms of financial, physical, and psychological strain (Grad & Sainsbury, 1968; Hatfield, 1978; Fadden,
1998; and Seng & Bentelspacher, 2001).

Jackson, Smith, and McGory (1990) had suggested a link between the burden of care and expressed
emotions in such families. Boye and his colleagues had also reported consistently high stress scores
among relatives of patients with high level emotional involvement (Boye, Munkvold, Bentsen, Notland,
Lerbryggen, Oskarsson, Uren, Ulstein, Lingjaerde, & Malt, 1998). It appears that psychiatric relapse, the
burden of care, and expressed emotions in the family are inter-related.

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 Research Objective and Questions

The main objective of this study was to find out the extent to which our local schizophrenic patients’
relapse was affected by their families’ level of expressed emotion, which is operationalized in the forms of
emotional over-involvement and criticism. The primary aim of this study was to investigate the relationship
between families’ level of emotional involvement and their level of criticism, in relation to the patient’s
readmission into Woodbridge Hospital, Singapore’s state mental hospital.

Although the study on family expressed emotion and schizophrenia has been around for more than four
decades, the researcher has not been able to identify any of such study locally. To date, Azhar and
Varma’s (1996) study in Malaysia provide the slightest clue to how the expressed emotion concept may
have a relevance on our local schizophrenic patients. Yet, their non-representative sample also
suggested that their attempt too were exploratory. Moved by the lack of local research in this area, it has
motivated the researcher to pioneer an exploration on the phenomenon of expressed emotion and its
effects on the relapse of schizophrenia patients in Singapore.

In view of the research objective mentioned, this study therefore aimed to shed light on the following
research questions:

1. Does expressed emotion, in the form of emotional involvement and criticism, by family members
have an effect on the schizophrenic patient’s readmission to Woodbridge Hospital?

2. In terms of expressed emotion, what is the relationship between the family’s level of emotional
involvement and level of criticism on the schizophrenic patient?

3. Is there a difference in the level of family emotional involvement and level of criticism between
schizophrenic patients with varying length of illness history?

Research Hypotheses

Specifically, the following research hypotheses were then tested as part of the attempt to provide
tentative answers to the research questions. They were namely:

1. There is a relationship between the level of family emotional involvement on the schizophrenic
patient and the length of time he stayed well at home before being readmitted to Woodbridge
Hospital for treatment;

2. There is a relationship between the level of family criticism on the schizophrenic patient and the
length of time he stayed well at home before being readmitted to Woodbridge Hospital for
treatment;

3. There is a relationship between the level of family emotional involvement experienced by the
schizophrenic patient and his length of illness history;

4. There is a relationship between the level of family criticism experienced by the schizophrenic
patient and his length of illness history; and

5. There is a relationship between the level of family emotional involvement and the level of family
criticism experienced by the schizophrenic patient.

Methodology
Research design

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 This study employed a Static-Group Comparison design, where the subjects were not randomly
assigned to the level of independent variables, as compared to the experimental group design. Instead,
the subjects were assigned according to their independent and mediating variables under natural
occurring setting, for example, level of family emotional overinvolvement, level of family criticism, and
length of illness history.

The reason of employing such a research design is that the subjects were non- equivalent in nature. A
major consideration of such a design is the threats to its internal validity. Rubin and Babbie (1993) define
internal validity as the confidence in which the results of a study accurately depict whether a variable is
causally linked to another. As the subjects were not randomly assigned to the groups, selection bias is an
obvious threat to the internal validity of this research design. However, as the current study is primarily
exploratory in nature where the results are not generalizable, considerations about internal validity are of
little relevance.

Operationalization of terms

For the purpose consistency in approach in this study, the researcher referred to the diagnostic criteria
of ICD-10 in classifying the mental disorder of schizophrenia. The current guidelines used in ICD-10 in
diagnosing schizophrenia are:
"A minimum requirement is one of the following symptoms: thought echo, insertion, withdrawal,
broadcasting, passivity phenomena, delusional perception, third person hallucinations, and persistent
delusions - all in clear consciousness. Other symptoms used to make the diagnosis (2 must be present)
include persistent hallucinations in any modality, thought blocking, thought disorder, catatonic behaviour,
negative symptoms, loss of social function." (WHO, 1992:325)

The first independent variable of this study was the level of family emotional involvement on the
patient. It was operationalized as the level of intrusiveness from the family members, which was
perceived and reported by the patient. The second independent variable of this study was the level of
criticism experienced by the patient from his family. It was operationalized as the family’s critical attitudes
directed at the patient, and were measured by the perceived frequency of critical comments the patient
received while at home. For the dependent variable of this study, it was operationalized as the patient’s
readmission to Woodbridge Hospital for treatment, as a result of a psychiatric relapse. Psychiatric relapse
refers to the re-manifestation of symptoms described in the ICD-10 criteria of schizophrenia. Patients
readmitted to the hospital due to reasons other than psychiatric relapse, such as lack of shelter and
abode, social misconduct, and family respite were not included in the study. The mediating variable of this
study was operationalized as the patient’s length of illness history. It referred to the period between the
time when the patient was first diagnosed with schizophrenia and his current readmission. The patient’s
illness history was measured in months and rounded to the nearest.

Setting

This study was set in Woodbridge Hospital, Singapore’s state mental hospital. Patients are generally
admitted for inpatient treatment at the hospital via its emergency department, or from the psychiatric
outpatient clinic at the Institute of Mental Health, located within the same vicinity, adjacent to the hospital.
All admissions are transferred to acute wards, where treatment is rendered on a daily basis, by the multi-
disciplinary team comprising psychiatrists, nurses, medical social worker, psychologist, and occupation
therapist. The patients receiving the inpatient treatment are segregated by their gender, where patients of
the same gender are treated in the same ward.

Sampling frame

A sampling frame is defined as the actual list of the study population in which the sample is selected
(Rubin & Babbie, 1993). As this study is exploratory in nature, where the gender difference was not a
target of investigation and the results are not generalizable to the study population, the researcher had
narrowed the sampling frame to include only all the male schizophrenic patients admitted into the acute

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
wards of Woodbridge Hospital. Basically, the patients eligible for this study must have at least one
previous episode of admission to the hospital for psychiatric treatment.

Selection of subjects

A sample of 60 subjects was drawn from the sampling frame utilizing a systematic sampling method,
where every 3rd patient found to be eligible for the study was recruited over a period of 6 months. This
extended period of subject recruitment was necessary to address the possibility of selection bias due to
seasonal effects on readmission. Based on informal observation by long-serving hospital staff, it was
noted that the number of admissions for Chinese patients actually increased during the traditional “hungry
ghost” month, and similarly observed for Malay patients during the Islamic holy month of Ramadan.
Although the reliability of their observation has not been established, there were many literature that
informed about the influence of cultural factors on the psychiatric condition of the patient (Cochrane &
Singh, 1987; Leff, Berkowitz, Shavit, Strachan, Glass, & Vaughn, 1990). In order to control for gender and
cultural specific influences, as well as other extraneous variables, the following exclusion criteria were
applied in order to prevent confounding effects on the variables in this study. They included:
• Dual diagnosis of substance abuse/dependence and schizophrenia;
• Newly diagnosed schizophrenia with no prior admission to Woodbridge Hospital;
• Schizophrenia patients with secondary diagnosis, such as depression, mental retardation, etc;
• Patients who did not live with their family or relatives before their readmission;
• Patients who were illiterate in English, as the instrument used in this study would be administered in
English.

Data collection

Eligible patients were sampled and recruited after they have being assessed to have remitted in their
psychotic symptoms by their consultant psychiatrist-in-charge. Selected patients were briefed individually
by the researcher regarding the purpose of the study. The briefing included an overview of the study, and
a description of the method of data collection, that is, via administration of the instrument in the form of a
questionaire. Subsequently, informed consent was obtained from the subjects before they were officially
recruited into the study. After recruitment, the patients were allotted an interview time and date, which was
dependent on the projected date of discharge. They were also informed that at any stage of the study,
their right to withdraw their participation from the study remained intact. As a rule of thumb, patients were
interviewed one week before their projected discharge. This was necessary so as to minimize the
disruption to the full-course of treatment regime administered during the patients’ hospitalization period.

Typically, the average treatment period of a schizophrenic relapse ranged between two-to-three weeks
of hospitalized treatment depending on the severity of relapse and the patient’s response to pharmaco-
treatment. This was followed by a week of inpatient rehabilitation programme, such as the ward-based
occupational therapy, patient-education programme, and family-based interventions conducted by the
various members of the multi-disciplinary team.

At the designated time-slot, the researcher met and administered the instrument to the selected
subjects in the ward, on a one-to-one basis. The researcher maintained objectivity throughout the
administration of the instrument by not making any interpretations to the questions asked. The subjects
were encouraged to provide their responses to what they had deemed to be most appropriate from their
perspective, based on their understanding. The responses were subsequently scored by the researcher.
After the whole data collection period was over, the subjects were individually debriefed by the researcher
either via telephone or in person, depending on their availability.

Instrument

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 Traditionally, the most widely used instrument for assessing the level of expressed emotion in the
family was the Camberwell Family Interview (CFI). Expressed emotion was measured by the coding the
audiotapes of a 45 minute – 2 hour semi-structured interview with significant family members (Vaughn &
Leff, 1976). However, the administration of the CFI was very time-consuming, requiring the use of skilled
observers. Even when the interview was shortened to a 5-minute speech sample (Gift, Colle, & Waynne,
1985; and Magana, Goldstein, Karno, Miklowitz, Jenkins, & Falloon, 1986), it still required a considerable
time to code the audiotapes (Shields, Franks, Harp, McDaniel & Campbell, 1992).

The limited utility of the CFI due to resource constraints in this study’s setting, which essentially is an
institution for treatment, led to the researcher to look for more efficient instruments to measure the level of
expressed emotion in the subjects’ families. Two self-reporting instruments were identified to be
potentially suitable for this study. The Level of Expressed Emotion Scale (LEE) is a scale administered to
schizophrenic patients to report on his perception of family affective environment (Cole & Kazarian, 1988).
Although the LEE has excellent internal consistency, with a KR-20 coefficient for the overall scale of 0.95
with its subscales ranging from 0.84 – 0.89, its main weakness was that correlations of the scale and its
subscales with criterion measures were not reported (Corcoran & Fischer, 2000).

The second instrument identified was the Family Emotional Involvement and Criticism Scale (FEICS)
developed by Shield et al. (1992). There are 14 items measured on a 5-point Likert-scale in the FEICS, in
which the items are allocated into two subscales, namely, the intensity of Emotional Involvement and
Perceived Criticism. The two factors are analogous to emotional over-involvement and critical comments,
the two main factors measured in the Camberwell Family Interview.

The reliability of the two subscales yielded a Cronbach’s alpha of 0.74-0.82 and confirmatory factor
analysis indicated that each item loaded on its proposed factor and not with the other (Shields et al.,
1992). In terms of construct validity, the subscales exhibited significant correlations with the Family
Adaptability and Cohesion Evaluation Scales (Olson, Portner & Lavee, 1985). Emotional Involvement
positively correlates with cohesion and adaptability in the family, which means that families that are
perceived to be intensely emotionally involved have higher cohesion and adaptability. On the other hand,
Perceived Criticism negatively correlates with cohesion and adaptability in the family. This means that
families that are perceived to be critical towards individuals, have less cohesion and are less adaptable.
At the same time, the FEICS have reported partial correlations with various scales, such as Interpersonal
Support Evaluation List (Cohen & Hoberman, 1983). Hence, after taking into account the good level of
reliability, concurrent validity, and criterion-related validity reported in the development of the FEICS, the
researcher chose to utilize it over the LEE as the primary instrument for this study.

Data analysis

The primary goal of data analysis in this study is to make statistical inferences on about measurements
based upon the information contained in the sample. However, prior to the analysis, the researcher
examined the data using descriptive statistics, such as the sample mean, and sample variance. Such
descriptive efforts were important for presenting the essential features of the data in easily interpretable
terms.

Following such examination, statistical inferences were made through the use of correlational and
multiple regression analyses, where the relationship of one or more independent variables (level of
emotional involvement and level of family criticism) is evaluated to a single continuous dependent variable
(length of time the patient was able to stay free from psychiatric relapse). According to Baker (1994), such
analysis procedures are most often used when the independent variables cannot be controlled in a
sample survey.

Limitations of study

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 The current study being exploratory in nature suffers from certain pitfalls. The first limitation lies with its
single gender sample in which only male schizophrenic patients were studied. This made it impossible to
explore and compare gender-specific issues that might inform on future treatment and research. The
second limitation stems from the fact that the study was conducted only in one setting in Woodbridge
Hospital, although there were other psychiatric treatment facilities in Singapore’s other hospitals. The final
limitation was due to the research’s instrumentation. This meant that only patients who were literate in
English were sampled, as there is no other translated version of the FEICS. The above three limitations
implied that the findings of the current study would not be generalizable to the study population of
schizophrenic patients in Singapore. Nonetheless, it does hope to raise the interest of future research into
the studying gender-differences in patients’ recovery and relapse, environmental issues such as and
caregivers’ burden, and expressed emotion.

Results
Subjects’ profile

Basically, the patient sample was middle-aged with a mean age of 38.53 (s.d + 9.28 years). The
youngest in the sample was aged 22 and the oldest was age 60. In terms of illness history, the mean time
since the debut of the illness was 12.68 years (s.d + 7.98), where the most recently diagnosed was 1 year
ago, and the most chronic having suffered from schizophrenia for 30 years. The sample has a varied
length of symptom-free period where they were able to live in the community without having to be
admitted to hospital for treatment. The shortest period between the current readmission and the previous
one was 1 month, and the longest being 240 months, which is the equivalent of 20 years. On average,
the subjects were able to maintain stability in their illness management and live in the community for 20.87
months (s.d + 39.29).

The number of admissions to Woodbridge Hospital in the past 12 months for the sample ranged from 0
to 4, with an average of 1.40 (s.d + 1.17). The sample was fairly well represented by the various major
ethnic groups found in Singapore. The Chinese accounted of the majority of 68.3%, followed by Malay
15%, and Indians 13.3%. As for marital status, the subjects were predominantly single (88.3%). Most
subjects received some form of education. Only 11.7% did not have any formal education, while nearly
63.4% successfully completed at least secondary education. Yet, only 31.7% of the subjects were
engaged in some form of employment. The rest were either unemployed or attending rehabilitation
programs.

Caregivers’ profile

As all the patients were staying with their families, primary caregivers were mainly immediate family
members, comprising parents (51.7%), siblings (36.7%), and spouse (6.7%). However, there were 2
subjects (3.3%) who identified their relatives as the primary caregivers, and another (1.7%) who was taken
care off by his fiancee, technically listed in the category of spouse. The mean age of the primary
caregiver was 50.83 (s.d + 12.68), and they were rather evenly distributed across the genders (females
55%, males 45%).

In terms of marital status, a vast majority of the primary caregivers were married (78.3%), while the rest
were either single (8.3%), separated/divorced (6.7%), or widowed (6.7%). Many of the primary caregivers
received up to primary education (41.7%), while 36.7% managed to complete at least secondary
education. However, there were 20% who did not have any formal education. Moreover, although they
were identified by the subjects as their primary caregivers, a majority of them were engaged in some form
of gainful employment (55%). There were only 5% who were listed as unemployed, while 26.7% had to
balance between multiple roles of being the homemaker and serving their National Service (23.3% and
3.4% respectively). The rest were retirees (13.3%).

Association between family expressed emotion and psychiatric relapse

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 Pearson Correlation Tests were employed to establish whether there were any relationships between
the various variables in this study. As expected, there was a significant positive relationship between the
patient’s age and the number of years he had been diagnosed with schizophrenia (r = 0.677, p< 0.01).
Not surprisingly too, there was a significant negative correlation between the number of months the
patients had managed to stay symptom-free and the number of readmissions to the hospital for psychiatric
treatment (r= -0.403, p < 0.01).

The composite expressed emotion score was positively correlated with its subscales of emotional
involvement and critical comments, at r = 0.528 (p < 0.01), and r = 0.612 (p < 0.01) respectively. In
addition, the subscales of emotional involvement and critical comments were negatively correlated with
each other, at r = -0.349 (p< 0.01). This was consistent with the findings from Shield et al’s original study
(1992).

However, associations between the independent variables and the dependent variables of the study
yielded non-significant results. The correlation between the level of emotional involvement of the patient’s
family and the length of time in which the patient was able to stay at home without a psychiatric relapse
was at r = -0.59, p = 0.65 (N.S). Similarly the correlation between family’s level criticism on the patient
and the number of months in which he was able to stay at home without a psychiatric relapse was at r =
-0.12, p = 0.38 (N.S).

Additional attempts to explore for associations between the level of family’s emotional involvement on
the patient, as well as the level of criticism on the patient, on his number of readmission to hospital in the
past 12 months found no significant relationship. Correlation of between the former was at r = -0.11, p =
0.40 (N.S) and the latter at r = 0.22, p = 0.09 (N.S) When investigating the association between the
mediating variable and the dependent variables, the findings too yielded non-significant results. In
essence, the length of the patient’s illness history, that is, the number of years in which the patient has
been diagnosed and treated for schizophrenia, was not related to the level of family emotional involvement
(r = -0.02, p = 0.42; N.S), nor the level of family criticisms (r = 0.19, p = 0.15; N.S ).

The researcher therefore attempted further investigations to establish whether there was any
association between the dependent variables and the subjects’ other variables. It was found that the
subject’s, as well as his caregiver’s age had no significant correlation to the level of emotional
involvement, criticisms, and overall expressed emotion experienced at home. There were also no
significant correlations between the subject’s, and his caregiver’s age, with the number of months the
subject was able to live in the community without having to be readmitted for psychiatric treatment.

Variability between caregiver types

Since it was established in the earlier section that there were no significant relationship between the
dependent, independent and mediating variables, it was therefore not necessary to proceed with
regression analysis. However, as all the subjects were living with their families, it would be important to
investigate whether the typology of patient’s main caregiver does result in the differences reported in the
level expressed emotion, as well as number of months in which the patients were able to live in the
community without a psychiatric relapse.

One-way ANOVA (Analysis of Variance) tests were conducted and the researcher found that there were
generally no significant differences in the level of emotional over-involvement reported by the subjects,
across the different caregivers’ type (F = 0.88, p = 0.48). However, in terms of the level of critical
comments and overall level of expressed emotion, there were significant differences across the caregiver
types (F= 4.39, p = 0.004; and F = 3.27, p = 0.018 respectively). For the former, subjects reported the
level of critical comments to be highest from sibling caregiver type (M = 23.09, s.d + 3.07), followed by
parents (M = 21.39, s.d + 3.52), and spouses (M = 18.25, s.d + 4.50). Subjects who were living with
relatives experienced the lowest level of criticisms (M = 17.50, s.d + 2.12). For the latter, subjects
reported highest level of expressed emotion from siblings caregiver type (M = 44.32, s.d + 3.75), followed
by relatives (M = 43.00, s.d + 4.24), parents (M = 42.52, s.d + 3.71), and spouses (M = 40.25, s.d + 5.68).

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 As for the differences in terms of the number of months in which the subjects were able to live at home
without having to be admitted to the hospital for psychiatric treatment as a result of a relapse, the ANOVA
tests found significant variability between the caregiver types (F = 5.28, p < 0.01). It was found that
subjects who were living with relatives were the most stable and were able to stay free from admission for
126 months (s.d + 161.22). This was followed by subjects who were living with their parents (M = 21.23,
s.d + 35.35). In comparison, subjects who were staying with their spouses and siblings managed only
14.50 months (s.d + 8.54) and 10.73 (s.d + 9.97) months free from admission respectively.

In view of the significant differences in the length of time in which the subjects were able to stay free
from psychiatric relapse, as manifested by the number of months they were able to stay well at home prior
to their current readmission, the researcher attempted one further test to find out whether the gender
differences in the subjects’ primary caregiver accounted for the number of months in which the subject
was able to stay free from psychiatric relapse. Results indicated that subjects who were staying with male
caregivers were able to live in the community without having to be readmitted to the hospital for
psychiatric treatment, longer than those who were staying with female caregivers (M = 27.04 months
versus 15.82 months). However, the ANOVA results indicated that the differences observed were likely
chance occurrences as they were statistically non-significant (F = 1.22, p = 0.28; N.S).

Reliability of instrument

Results from the internal consistency analysis tests revealed that the Emotional Involvement subscale
yielded an overall Cronbach’s alpha of 0.63 (M = 3.05, s.d = 0.50), while the Critical Comments subscale
had an overall alpha of 0.61 (M = 3.08, s.d = 0.54) and hence, within the acceptable range as a reliable
instrument for measuring expressed emotion.

Discussion
Predictive value of expressed emotion on psychiatric relapse

The most significant learning point from this study is the absence of association between the
phenomenon of family expressed emotion and psychiatric relapse. Whilst many studies reported
evidence of family expressed emotion as a predictor of psychiatric relapse among schizophrenia patients,
our findings differ from those reported in the literature. Neither of the sub-constructs of expressed
emotion, namely, emotional overinvolvement and criticism, was related to the patient’s psychiatric relapse.
The lack of association between family expressed emotion and psychiatric relapse illuminates the
contribution of other important factors that are not addressed or included in this study. In fact, MacMillan
et al. (1986) provided evidence to suggest that high expressed emotion and high relapse rate were
confounded by other factors such as compliance to neuroleptic medication; duration and severity of
illness; and drug and placebo administration etc. When these factors were controlled for, the level of
association between expressed emotion and relapse were reduced to the point of non-significance. In
view of this, it was highly probable that in this study, the patients’ relapse could have been attributed to
their poor compliance to medication, their severity of illness, and the quality of care and support received
from the caregivers. A relook on the early evidence from Brown et al. (1972) and Vaughn and Leff’s
(1976) studies had pointed out that two factors appeared to serve a protective function for patients living in
high expressed emotion environment. These two factors were identified as maintenance of neuroleptic
medication, and having a low face-to-face contact with their relatives.

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 Evidence to suggest averting ‘blame’ on the family

The growing literature on family expressed emotion playing a role in resulting the psychiatric relapse in
the patient were often criticized by opponents of the concept as a convenient attempt to place blame on
the family for causing mental illness. Whilst it was generally accepted that the expressed emotion index
was a reliable predictor for long-term course of schizophrenia, Falloon et al. (1984) warned that it would
be a grave mistake to conclude that critical and overinvolved attitudes in the family are major causes of
poor prognosis or relapse. In fact, Hatfield, Spaniol and Zipple (1987) too had suggested that families
may have scored high on expressed emotion as a result of deteriorating mental condition of the patient,
rather than vice versa. The results of non-relationship between the two provided tentative evidence to
absolve the family from the culture of blame, and highlighting the concern on studying the direction of
relationship between the two variables.

Other non-supportive studies

This current study was not an isolated case where no associations were found between family
expressed emotion and the patient’s relapse. Other important studies too had failed to support the
association between expressed emotion and relapse (Kottgen et al., 1984; Azhar & Varma, 1996). Most
notably, the latter’s study was fairly recent and conducted in Malaysia, a country whose people have
similar cultural experience and heritage with their Singaporean counterparts. Psychiatric disorders,
pathological family-functioning, and expressed emotion are predominantly Western in conception. There
is an extent to which cultural worldviews indigenous to the local population impact on the understanding
and meaning attributed to the nature, causes, course, and management of an illness, as well as reactions
to it. Various studies have identified this issue as central to the formation of express emotion attitudes
(Vaughn, 1986; Hooley, 1987).

Understanding expressed emotion as a threshold for caregiving stress

Although the concept of expressed emotion is usually defined as an index to measure the emotional
atmosphere in the family, Lefley (1996) has also described expressed emotion as the threshold of the
family in dealing with the many demands of providing care to the patient. It may be plausible to suggest
that the lack of association between expressed emotion and relapse in this study could be due to the
difference in the threshold of local families for dealing with the stress of caregiving. One reason being that
our local family caregivers tended to have a larger network of informal resources from extended families
and kinsmen. Comparatively, the Western culture tends to emphasize more on individual freedom and
responsibility. As a result, the family caregivers surveyed in most Western research may be more isolated
and therefore having lower threshold to the patients’ disturbed behaviors.

Closely related to this is the reliability and validity of the instrument in measuring expressed emotion in
the Asian context. Although reliability tests showed that the instrument had achieved acceptable level of
internal consistency in measuring both the emotional involvement and critical comments sub-phenomena,
the Cronbach’s alpha was lower than that reported by Shields et al’s (1992) original study. The difference
may be attributed to how critical comments, and emotional over-involvement are perceived differently, as a
result of our cultural differences.

Depathologizing family coping

The advent of literature on family expressed emotion over the years have largely focused on the
negative aspects of family coping with the care of a schizophrenic patient at home, and how family
interactional patterns were detrimental to the patient’s stability in recovery. Falloon (2003) pointed out that
despite Vaughn and Leff’s classic paper in 1976 (it was based on Vaughn’s doctorate thesis) highlighted
the negative over-intrusive and critical attitudes of families as predictors of clinical relapse, it should be
noted that Vaughn’s unpublished thesis had in fact, given more emphasis on better clinical outcomes
associated with emotional warmth and supportive comments by family members.

Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City
Canada, 23-27 May 2004.
 This current research’s lack of significant finding on how pathological family communication patterns
have a direct impact on the clinical outcome of the patient is a timely reminder for mental health
practitioners and researchers to revisit the search for positive and non-pathologizing attributes of families
coping with mental illness, a stance that has been neglected for a substantive period of time.

Conclusion

The concept of expressed emotion informs one aspect of family functioning and vaguely implies a
particular style of family coping (Vaughn, 1989). Generally, research on family coping with mental illness
is sparse when compared to those attempting to link family dynamics to patient’s recidivism. Bland (1998)
identified four main focuses on research of families with mental illness. They were namely, the family as
aetiological agents; family as a source of environmental stress; family as a bearer of burden; and family as
suffering from the impact of the illness.

Social workers have been an integral part of the mental health system since its profession’s early
years. Our chief operating framework of person-in-environment augments well for future research and
investigation away from the traditional deficit and medical oriented model of disease and chronicity, to
explore on individual and family strength, resilience, and coping, within a recovery model of mental health.
This current research had operated from the earlier premise and found gaps with many unanswered
questions. Moving into the latter’s paradigm may trigger more questions in a positive direction, those that
may help to solidify social work profession’s values of client empowerment, advocacy, and self-
determination.

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