Expressed emotion

Expressed emotion

What is expressed emotion?

These are the hostile, emotionally over-involved or critical attitudes of carers/relatives towards a family member with a mental disorder. They are one of the main contributors to relapse of psychological disorders.


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 it is or not.

Emotional over-involvement

This reflects a set of feelings and behaviour of a family member towards the patient, indicating evidence of over-protectiveness, self-sacrifice or excessive use of praise.

Family members who show high emotional involvement tend to be more intrusive. They may believe that patients cannot help themselves and that their problems are due to causes external to them; thus high involvement will lead to strategies of taking control and doing things for the patients. In addition, patients may feel very anxious and frustrated when interacting with family caregivers with high emotional involvement due to such high intrusiveness and emotional display towards them.

Critical attitudes

These are combinations of hostility and emotional over-involvement. It shows that the disorder is not entirely in the patient’s control, but there is still negative criticism. Critical parents could influence the patient’s siblings to be the same way.

How can we measure expressed emotion?

Expressed emotion can be assessed in a taped interview with the patient’s key relatives (without the patient being present) called the Camberwell Family Interview (CFI); there is a scale that is used to categorise the three major expressed emotion scales: critical attitudes, hostility, and emotional over-involvement. In his original interview, Brown described five components of expressed emotion (Brown, 1985): emotional over-involvement, critical comments, hostility, positive remarks and warmth. All of the scales are taken into consideration while watching the tape of the relatives that are interviewed. The answers and reactions of the family members are carefully observed. Expressed emotion is best measured by a person from the same cultural group.

What are the effects on the family?

Everyone in a family is affected by the illness of one member because it changes their lifestyle. Relatives themselves become psychologically distressed because of all the stress from the illness.

Do cultural influences have an effect on expressed emotion?

It is a universally known fact that cultures vary greatly all across the world. These varying cultures include a variety of differences in almost an infinite number of areas. A considerable amount of data from Western cultures suggests that high expressed emotion can lead to relapse in vulnerable individuals, even when they are on medication. However, the data from other cultures are less solid, although the family’s expressed emotion has been shown to be predictive of outcome in mental and physical illnesses in a variety of cultural settings. Emotional over-involvement is seen in the West as pathological because it crosses the boundaries of individuals, whereas in other cultures such an approach may be the norm. For example, in the Indian context, mothers are over-involved with their sons and this over-involvement is not necessarily pathological. Similarly, in Jewish settings, critical comments and over-involvement on part of the mothers are culture-related and should not be perceived as pathological.

What are the consequences of expressed emotion?

Family members high in expressed emotions cause relapse in psychological disorders such as schizophrenia, alcoholism and bipolar disorder; they can also cause relapse in children with learning disabilities. The stress from negative criticism and pity becomes a burden on the person with a disorder, and the only way to cope is relapse. On the other hand, over-involvement causes the child to feel trapped because they feel like they cannot do anything independently. This adds onto the entrapment they have with the psychological disorder that they are trying to handle. 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 entire household.


Both criticism/hostility on one end of the spectrum and over-protectiveness on the other end are not good for patients. It is best to follow a ‘middle path’ of being hopeful, positive and understanding of their difficulties whilst offering support when required, and mostly behave as one would behave with any family member.


This article is for information only and should not be used for the diagnosis or treatment of medical conditions. myHealthSpecialist makes no representations as to the accuracy or completeness of any of the information in this article, or found by following any link from this article. Please consult a doctor or other healthcare professional for medical advice.

Dr Adil Jawad MBBS; DPM; MRCPsych
Dr Adil Jawad MBBS; DPM; MRCPsych

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