In the 1940s and 1950s, schizophrenia was always considered the mother’s fault. Clinicians such as Frieda Fromm-Reichmann and Harry Stack Sullivan saw schizophrenia as a flight from the pain of “maternal rejection.”
Blaming the Mother
It is only natural, they thought, that a child confronted with so much rejection would retreat to a private world of delusions and hallucinations.
Fromm-Reichmann coined the phrase “schizophrenogenic mother,” which quickly became a phrase for clinicians. Around the same time, autism researcher Leo Kanner coined the phrase “fridge-mom” to explain the social withdrawal he observed in children with autism.
In this intellectual climate, the patient’s mother, and even the family as a whole, often experienced unbearable guilt and pain.
During the “biological revolution” of the 1970s, many families and clinicians sighed a collective sigh of relief. The biological revolution was about the search for genetic and brain diseases that cause mental illness. We stopped blaming families for schizophrenia.
Fifty years later, the elusive “gene for schizophrenia” is still not found, and researchers are increasingly seeing the “chemical imbalance” theory of depression as, at best, one small piece of a puzzle.
Today, many researchers adopt a “double-hit” model of schizophrenia in which genes alone do not cause schizophrenia, but a complex interplay of genetic and environmental factors. But once we recognize the role of the environment, we are forced to reconsider the family. A pillar of this research is the investigation of “expressed emotion”.
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Expressed emotion
Expressed emotion is a measure of the emotional tone of the family environment. You may think “high expressed emotion” is a good thing, but in this research it is not. Three signs of high expressed emotion are criticism, hostility and emotional over-involvement:
- Criticism: when the vulnerable person is confronted with disapproval for what they are doing.
- Hostility: when the person feels despised for who they are.
- Emotional over-involvement: when the family shows excessive concern about the person’s well – being, which can send the message that they are unable to cope with the world.
Psychiatrist George Brown launched research into “expressed emotions” in England in the 1960s. His experiment was simple. About 100 patients with schizophrenia were discharged from a hospital, many to their families. Brown and his colleagues interviewed the family and the patient separately before discharge and then ranked the family’s’ expressed emotion »—high or low? His hypothesis was that patients returning to families with “high expressed emotions” were more likely to relapse, as measured in part by hospital readmissions.
Although their study was small and their dimensions were rather crude, Brown’s basic suspicion has been repeatedly confirmed for more than 50 years. Two meta-analyzes, published in 1994 and 1998 (see references) confirm that high expressed emotion is a “significant and robust predictor” of relapse.
Newer work, much of it led by Preethi Premkumar, a psychologist at London South Bank University, broadened our understanding of the impact of expressed emotion. It’s not just about relapse. Her work also shows a link between expressed emotion and schizotypy – a measure of one’s risk of schizophrenia. Highly expressed emotion can also affect levels of depression and anger in people with schizophrenia.
Expressed emotion and the blame game
Are these studies infallible? Like everything in science, people can challenge their merits. One concern is with measurement. Dividing families into “high” and “low” expressed emotions is surely too simplistic to capture the extent and complexity of family emotional ties.
Another concern is its cross-cultural validity. Most studies have been conducted on “WEIRD” populations (“Western, educated, industrialized, rich, democratic”). Trying to measure expressed emotion in other cultures creates interpretation problems.
For example, a study conducted in Chandigarh, India, found no correlation between “emotional over-involvement” and relapse. The authors suggest that the difference is due to cultural attitudes across personal boundaries. What counts as intrusive interrogation for a New Yorker may seem like friendly concern in Chandigarh.
Some may worry that the study of expressed emotion may promote more blame and shame among family members, rather than alleviate it.
Social scientists warn us about how the study of human development could lead to a “blame game” targeting women out of proportion. For example, research on the impact of maternal-fetal interactions on mental disorders can be interpreted as an attack on mothers.
But the point here is not to cause more guilt and shame. As I know from personal experience, having a loved one with schizophrenia or other severe mental disorder can be overwhelming, stressful. It can create a mixture of intense feelings such as pity, guilt and anger.
The key is no longer shame and blame, but counseling and education. Clinical practice guidelines recommend universal family counseling for the families of people with schizophrenia. Programs such as the New York-based group and family-based cognitive behavioral therapy program for early psychosis are specifically designed to work with individuals and their families to improve lives.
Basically, expressed emotion research is about acknowledging that the family is an integral part of recovery. It shows how families can improve how they communicate to make their loved ones feel valued and appreciated.
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