Changes in maternal expressed emotion toward clinically anxious children following cognitive behavioral therapy

The aim of this study was to determine whether maternal expressed emotion (criticism and emotional overinvolvement) decreased across treatment for childhood anxiety. Mothers of 48 clinically anxious children (aged 6-14 years) were rated on levels of criticism (CRIT) and emotional overinvolvement (EOI), as measured by a Five Minute Speech Sample (FMSS) from mothers, prior to and following cognitive behavioral therapy (CBT) for their children’s anxiety. Results showed a significant decrease in the proportion of mothers who expressed high levels of criticism and emotional overinvolvement from pretreatment to posttreatment. This finding suggests that interventions aimed at reducing symptoms of child anxiety can also result in a decrease of maternal expressed emotion (criticism and emotional overinvolvement).     

Rating expressed emotion from initial family therapy sessions (a pilot study)

A small pilot study is described in which an attempt was made to rate expressed emotion (EE) from an initial family interview. It was found that ratings could be made and that all but one of the families were high EE. Both empirical and clinical implications are discussed.     

Parental expressed emotion toward children: prediction from early family functioning

Expressed emotion (EE), an index of family member criticism and emotional overinvolvement, predicts outcome among adults and children with mental disorders. However, limited research exists on factors contributing to EE. Aims of the current study were to (a) examine EE in mothers of young children; (b) assess relationships between demographic factors and EE in a diverse sample; and (c) investigate whether family stress and functioning, including quality of marital relationship, life events, maternal stress, and family environment, predict EE. In the current study, 276 mothers completed questionnaires when their children were between 1 and 3 years of age and a measure of EE when their children were in kindergarten. Results indicated that family expressiveness was the most consistent predictor of EE. Further research seems warranted to better delineate associations between family functioning and EE.     

A systemic view of family therapy ethics

A critical review of the literature on family therapy ethics is used to develop the proposition that a more systemic analysis is needed, one that includes the levels of therapist and society as well as patient (family). These ideas are discussed through reexamining the issues of family secrets, therapist deceptiveness, and therapist advocacy of personal (feminist) values.     

Personality and expressed emotion

Expressed emotion (EE) is an established psychosocial predictor of relapse in patients with schizophrenia and mood disorders; however, nothing is currently known about the personality characteristics of high- and low-EE relatives. A total of 45 relatives of schizophrenia patients completed the California Psychological Inventory, a widely used measure of common personality traits. Compared with low-EE relatives, high-EE relatives were more conventional in their behavior (higher norm-favoring) and less satisfied with themselves and their lives (lower self-realization). High-EE relatives were also less flexible, tolerant, and lower in empathy and achievement via independence than were low-EE relatives. Even with statistical control of potential demographic confounds, flexibility remained a significant predictor of EE status.     

Perceived intimacy of expressed emotion

Research on norms for emotional expression and self-disclosure provided the basis for two hypotheses concerning the perceived intimacy of emotional self-disclosure. The first hypothesis was that the perceived intimacy of negative emotional disclosure would be greater than that of positive emotional disclosure; the second was that disclosures of more intense emotional states would be perceived as more intimate than disclosures of less intense emotional states for both negative and positive disclosures. Both hypotheses received support when male students in Canada rated the perceived intimacy of self-disclosures that were equated for topic and that covered a comprehensive sample of emotions and a range of emotional intensities. The effects were observed across all the topics of disclosure examined.     

Evidence-based practice in family therapy and systemic consultationChild-focused problems

Evidence for the effectiveness of family therapy and family-based interventions from critical literature reviews and controlled trials is considered for families with children and adolescents who present with various difficulties. The evidence supports the effectiveness of family therapy as an effective treatment either alone or as part of a multimodal or multisystemic treatment programme for child abuse and neglect, conduct problems, emotional problems and psychosomatic problems. Implications for practice, training and continuing professional development in the field of family therapy are discussed.     

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.     

Ethnicity, expressed emotion, attributions, and course of schizophrenia: family warmth matters

The authors examined the role of family factors and the course of schizophrenia by carrying out additional assessments and analyses in 2 previously published studies of Mexican American and Anglo American patients and families. The authors found partial support for an attributional model of relapse for families who are low in emotional overinvolvement. Attributions of control, criticism, and warmth together marginally predicted relapse. The data also indicated that for Mexican Americans, family warmth is a significant protective factor, whereas for Anglo Americans, family criticism is a significant risk factor. These findings suggest that the sociocultural context shapes the pathways by which family processes are related to the course of illness. Moreover, the warmth findings suggest that families may contribute to preventing relapse.     

The end-of-session message in systemic family therapy: a descriptive study

A retrospective case note review was conducted with the aim of describing the end-of-session messages conveyed during Milan-style systemic family therapy. Fifty consecutive families treated in an adult family clinic were included. A classification of messages was developed; for each type of message the mean number per therapy session was calculated and the rates compared both within and between four systemic categories of family. 'Supportive/engaging' messages were given more frequently than 'hypothesis-related' messages in each systemic category and this difference was most marked in families with grief as the central issue. More 'acknowledgement' messages were used in the 'grief' group than in the 'separation/individuation' group. 'Hypothesis-related' messages were used more often in the 'separation/individuation' group than in the 'grief' group. We discuss possible reasons for the observed patterns and compare different ways in which the message can be conceived and implemented.     

Competences and occupational standards for systemic family and couples therapy

This article reports on the recent government initiative of 2007–2010 to delineate, for the major forms of psychological therapy, expected professional standards of practice and conduct in workplaces (the national occupational standards) and to specify expected levels of competent practice (the competences). The article focuses on the processes and outcomes of this initiative for systemic therapy and its clinical and political relevance. The rationale, research and consultation processes by which these formulations were achieved are described and the outcomes of the work are reported. We also discuss their wider implications, including the various ways in which these achievements might be used and their potential value for the field of systemic family and couples therapy.     

The state of the art of training in systemic family therapy in Switzerland

This article presents a training program in systemic therapy with families and couples. Our training institute was founded by an interdisciplinary group of psychologists, psychiatrists, sociologists, and social workers in 1987 in Meilen (Zürich), Switzerland, and has from the beginning been connected to the field of family therapy in Europe and the United States. The specific organization of our institute, our training program, and the theoretical base of the training concept are highlighted. Our multidimensional treatment and training model is grounded in a variety of conceptual frameworks and inspired by the tradition of Enlightenment in European philosophy. We pay special attention to the personal and professional development of the emerging family therapist.     

Milan systemic family therapy: a review of ten empirical investigations

Ten empirical investigations of Milan Family Therapy (MFT) are reviewed in this paper. The studies include both single and comparative group outcome trials; investigations of therapeutic process; clinical audit and consumer satisfaction surveys. Substantive findings and methodological issues are discussed in the light of family therapy and individual psychotherapy research generally. Findings indicate that MFT may lead to symptomatic change in two-thirds to three-quarters of cases and to systemic change in half the treated cases. Engagement of fathers may be important for positive outcome. Technical aspects of MFT, such as the use of screens and teams, may lead to client dissatisfaction in some cases. MFT-based consultation may be effective in resolving therapeutic impasses. Coupled with short-term residential placement, MFT may reduce the risk and complexity of cases as rated by referring social workers.     

The effectiveness of family therapy and systemic interventions for child-focused problems

This review updates a similar paper published in the Journal of Family Therapy in 2001. It presents evidence from meta-analyses, systematic literature reviews and controlled trials for the effectiveness of systemic interventions for families of children and adolescents with various difficulties. In this context, systemic interventions include both family therapy and other family-based approaches such as parent training. The evidence supports the effectiveness of systemic interventions either alone or as part of multimodal programmes for sleep, feeding and attachment problems in infancy; child abuse and neglect; conduct problems (including childhood behavioural difficulties, ADHD, delinquency and drug abuse); emotional problems (including anxiety, depression, grief, bipolar disorder and suicidality); eating disorders (including anorexia, bulimia and obesity); and somatic problems (including enuresis, encopresis, recurrent abdominal pain, and poorly controlled asthma and diabetes).     

The effectiveness of family therapy and systemic interventions for adult-focused problems

This review updates a similar paper published in this Journal in 2000. It presents evidence from meta-analyses, systematic literature reviews and controlled trials for the effectiveness of couples and family therapy for adults with various relationship and mental health problems. The evidence supports the effectiveness of systemic interventions, either alone or as part of multimodal programmes, for relationship distress, psychosexual problems, domestic violence, anxiety disorders, mood disorders, alcohol abuse, schizophrenia and adjustment to chronic physical illness.     

Family expressed emotion prior to onset of psychosis

This study compared components of expressed emotion (EE; rejection, warmth, protectiveness, and fusion) across three samples: two in which the subjects had an established schizophrenic or mood disorder, and a third in which the subjects were at high risk for an initial psychosis. METHODS: Family members rated themselves on the Social Adjustment Scale-III and, in the prodromal sample, estimated the duration of the prodrome. RESULTS: Scores were all but identical in the two established-disorder samples but were markedly higher than scores in the prodromal sample on all four factors. In mothers, warmth (decreasing), rejection, protectiveness, and fusion (increasing) were significantly correlated with duration of prodrome, whereas for fathers, warmth and protectiveness were similarly correlated. CONCLUSION: These data suggest that expressed emotion is largely reactive to deterioration manifested by the young person developing a psychotic disorder, rather than a trait of family members.     

Family therapy without the family: a framework for systemic practice

This paper contrasts the basic tenets of systemic thinking with some guiding principles of the psychodynamic approach, and outlines specific techniques which family therapists can use when seeing individuals. It is argued that a useful systemic framework can be maintained if the therapist aims to keep the therapy system 'open' for relevant others to join at any time.     

A diathesis-stress conceptualization of expressed emotion and clinical outcome

A sizeable body of research has demonstrated that expressed emotion (EE) predicts clinical relapse in a number of distinct psychiatric disorders. These findings have provided the impetus for the development of interventions that attempt to reduce patients' relapse rates by modifying aspects of the family environment believed to be associated with high levels of EE. Despite the efficacy of these treatments, however, we know little about how EE develops in relatives of psychiatric patients or about the mechanisms through which high EE leads to relapse. Moreover, there is not a coherent theory that attempts to integrate findings concerning the impact of high EE on relapse in different disorders. The purpose of this article is to elucidate a diathesis-stress conceptualization of EE to explain both the development and manifestation of high EE in relatives of disordered patients and the impact of high EE on the course of patients' disorders. In this context, we use a diathesis-stress perspective to examine why EE predicts symptom relapse and poor clinical outcome in schizophrenia, depressive disorders, and borderline personality disorder. We conclude by discussing treatment implications of the diathesis-stress perspective and by outlining what we believe are fruitful directions for future research.