Amy G. Weisman

Expressed emotion, attributions, and schizophrenia symptom dimensions

Using a sample of 40 Anglo American family members of schizophrenic patients, the present study replicates and lends cross-cultural support for an attribution-affect model of expressed emotion (EE). Consistent with attribution theory, the authors found that highly critical relatives (high-EE) viewed the illness and associated symptoms as residing more within the patients personal control as compared with less critical relatives (low-EE). A content analysis classified the types of behaviors and symptoms most frequently criticized by relatives. Symptoms reflecting behavioral deficits (e.g., poor hygiene) were found to be criticized more often than symptoms reflecting behavioral excesses (e.g., hallucinations). In line with an attribution-affect framework, relatives may be less tolerant of behavioral deficits because they are viewed as intentional, whereas behavioral excesses are easily recognized as core symptoms of mental illness.

An Attributional Analysis of Expressed Emotion in Mexican-American Families With Schizophrenia

In this study we tested an attributional model of expressed emotion (EE) among Mexican-American families. A sample of 46 key family members of schizophrenic patients were measured on three dimensions: affect toward patient, controllability attributions, and level of EE. Consistent with an attributional model, we found that high EE families (defined on the basis of critical comments) viewed the illness and associated symptoms as residing within the patients personal control, more so than did low EE families. We also found that attributions held by family members are related to their affective reactions. Specifically, family members who perceived the patient as having control over the symptoms of schizophrenia tended to express greater negative emotions such as anger and annoyance toward the patient than did family members who viewed the symptoms as beyond the patients personal control. An examination of the types of affects found and their relationship to EE status is discussed, along with implications for this research.

Shifting blame away from ill relatives: Latino families' reactions to schizophrenia.

The present study examined attributions, emotions, and help-giving of 24 relatively unacculturated Latino-Americans toward a family member with schizophrenia. Ninety-one percent of participants had been rated as low in expressed emotion (low-EE) in an earlier study using a sample that overlaps with the present study. Low-EE refers to relatives who express few critical attitudes when talking about a mentally ill family member. Study findings indicate a link between relatives’ emotions and their reported help-giving behavior. In support of attribution-affect theory, relatives who reported feeling more compassion toward an ill family member also reported exerting more effort to help their relative cope with the illness. A qualitative analysis of relatives’ views, values, and behaviors was also conducted with the aim of better understanding low-EE relatives’ perceptions, which may serve to buffer schizophrenia relapse. We observed the following three main categories of attributions: (1) most participants accepted the patient as having a legitimate illness, (2) the majority of participants viewed interpersonal problems or other external environmental stressors as causing or exacerbating the disorder, and (3) many participants implicated God in their causal attributions and also reported turning to religion as a source of hope and comfort in coming to terms with the patient’s illness. Together, the quantitative and qualitative data suggest that efforts to augment positive or favorable emotions in key family members may be most important in establishing a low-EE family environment.

Integrating culturally based approaches with existing interventions for Hispanic/Latino families coping with schizophrenia

Evidence suggests that schizophrenia is highly responsive to the sociocultural and emotional atmosphere of the family. Therapies have shown an improvement in schizophrenia symptoms following family-oriented interventions. However, most programs are developed and offered in English only, and few are culturally informed. Existing programs may fail to meet the needs of minorities, particularly Hispanics/ Latinos, the largest minority group in the United States. In this article, a broad literature is reviewed, which strongly supports the integration of culturally based treatment approaches with existing psychoeducational familyfocused interventions to enhance treatment programs for Hispanic/Latino patients and families coping with schizophrenia. On the basis of this conceptual integration, an intervention titled “culturally informed therapy for schizophrenia” is described.

Understanding cross-cultural prognostic variability for schizophrenia

Research suggests that critical and negatively charged family environments correlate with poor prognosis for schizophrenia across cultures. International research also suggests that the increasing industrial status of a country is associated with a less favorable outcome for the disorder. This article reviews the literature on culture and schizophrenia. An argument is made for using an attribution-affect model to help identify factors that may lead to unfavorable emotional reactions toward individuals with schizophrenia. In addition, specific sociocultural values and beliefs are proposed that are hypothesized to contribute to a favorable clinical course for schizophrenia in less industrialized countries.

Controllability perceptions and reactions to symptoms of schizophrenia : A within-family comparison of relatives with high and low expressed emotion

In a sample of 35 family members of patients with recent-onset schizophrenia, attributions of control and the content of critical comments were compared for 2 relatives of the same household who held discrepant expressed emotion (EE) attitudes (1 high and 1 low) toward their mentally ill family member. Attributions and the content of critical comments were also compared for low-EE relatives from low-EE homes versus low-EE relatives from high-EE homes. Our results indicate that high-EE relatives tend to attribute more control over behavior to patients than do low-EE relatives of the same patient. In addition, low-EE relatives from high-EE homes attribute more behavioral control to patients than do low-EE relatives from low-EE homes. These findings suggest that EE status is linked to attributions of control over behaviors, but additional patient factors or influences among family members may also affect EE attitudes.

Religion: A Mediator of Anglo-american and Mexican Attributional Differences toward Symptoms of Schizophrenia?

This study examined the relationship of religiosity to attributions toward schizophrenia, within a cultural context. Previous research suggests that on self-report measures, Mexicans endorse holding greater moral-religious values than do their Anglo-American counterparts. Research also indicates that Mexicans, relative to Anglo-Americans, tend to hold fewer blameworthy attributions and are less likely to view patients with schizophrenia as responsible for the symptoms of the disorder. In an analog study of 88 Mexican and 88 Anglo-American college students asked to imagine that they have a brother with schizophrenia, this study assessed two competing hypotheses regarding the role of religion in shaping reactions to schizophrenia in a family member. For hypothesis 1, Baron and Kennys mediational model (1986) was used to assess whether moral religious values may play a direct mediating role between ethnicity and controllability attributions for schizophrenia. In other words, based on observations of previous researchers, this set of analyses assessed whether ethnic differences in controllability attributions might be explained by a religious or spiritual tendency in Mexicans to view negative events, such as mental disability, as rooted in divine factors beyond the patients personal control. In contrast, a second, competing, hypothesis was also assessed in this study: namely, that greater religiosity would be positively correlated with increasing perceptions of control over the symptoms of schizophrenia. This hypothesis stems from the premise of several investigators that religious individuals may be more likely to perceive anothers adversity (such as having schizophrenia) as a punishment for prior wrongdoings or for failure to try to help oneself. Results indicate support for the latter hypothesis. Implications of the paradoxical finding, that Mexicans were both more religious and more external in their attributions, are discussed.

Nonreligious coping and religious coping as predictors of expressed emotion in relatives of patients with schizophrenia.

Expressed emotion (EE) is a measure of the amount of criticism and emotional over involvement expressed by a key relative towards a relative with a disorder or illness. Research has established that living in a high EE environment, which is characterised by increased levels of critical and emotionally exaggerated communication, leads to a poorer prognosis for patients with a mental illness when compared to low EE environments. Despite evidence that EE is a strong predictor of the course of the illness, there continue to be questions concerning why some family members express excessive levels of high EE attitudes about their mentally ill relatives while others do not. Based on indirect evidence from previous research, the current study tested whether religious and nonreligious coping serve as predictors of EE. A sample of 72 family members of patients with schizophrenia completed an EE interview, along with questionnaires assessing situational nonreligious coping and religious coping. In line with the hypotheses, results indicated that nonreligious coping predicted EE. Specifically, less use of adaptive emotion-focused coping predicted high EE. Also consistent with predictions, maladaptive religious coping predicted high EE above and beyond nonreligious coping.

Examining Patients’ Perceptions of their Relatives’ Expressed Emotion

Numerous studies have demonstrated that critical or emotionally overinvolved attitudes on the part of family members can be a significant stressor for mentally ill patients (for review, see Butzlaff and Hooley, 1998). High levels of these attitudes, referred to as Expressed Emotion (EE), have been shown to predict both the development of schizophrenia (Goldstein, 1987) and a poorer course of illness in a variety of psychiatric disorders, including schizophrenia (Brown, Birley and Wing, 1972; Vaughn and Leff, 1976a; Vaughn, Snyder and Jones et al., 1984), bipolar disorders (Miklowitz et al., 1988), substance abuse (0’ Farrell, Hooley, Fals-Stewart, and Cutter, 1998), unipolar depression (Hooley, Orley and Teasdale, 1986; Vaughn and Leff, 1976a), and eating disorders (LeGrange, Eisler, Dare, and Hodes, 1992; Van Furth et al., 1996). While relatives’ attitudes may be viewed as a potential stressor for patients with psychiatric illnesses, the mechanism by which they exert their influence is still unclear. Measures of EE have traditionally been made by counting the number of criticisms and making ratings of emotional overinvolvement (EOI) based on the Camberwell Family Interview (Vaughn and Leff, 1976b), or more recently, by the Five Minute Speech Sample (Magana et al., 1986).