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Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters

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Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters Journal of Abnormal Psychology Copyright 2004 by the American Psychological Association 2004, Vol. 113, No. 3, 428–439 0021-843X/04/$12.00 DOI: 10.1037/0021-843X.113.3.428 Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters Steven Regeser Lo´pez Kathleen Nelson Hipke University of California, Los Angeles Wisconsin Psychiatric Institute and Clinics Antonio J. Polo Janis H. Jenkins University of California, Los Angeles Case Western Reserve University Marvin Karno Christine Vaughn University of California, Los Angeles Institute of Psychiatry Karen S. Snyder University of California, Los Angeles 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. Family factors are related to the course of schizophrenia. After (EE), is important for at least two reasons. First, it points out that discharge, patients who return to families characterized by high social factors are related to the course of schizophrenia—a disor- levels of criticism, hostility, or emotional overinvolvement are der with strong biological underpinnings. Second, this research has more likely to relapse than those patients who return to families significantly influenced the development of family interventions characterized by low levels of the same negative emotional/attitu- for schizophrenia. Family treatments based on psychoeducation, dinal attributes (Butzlaff & Hooley, 1998). This line of research, communication, and problem-solving skills training have been which is referred to as the study of families’ expressed emotion developed largely to reduce some families’ negatively charged emotional climate (e.g., McFarlane et al., 1995). Despite these important contributions, the study of families’ expressed emotion Steven R. Lo´pez and Antonio J. Polo, Department of Psychology, has significant limitations. Its conceptual foundation is underde- University of California, Los Angeles; Kathleen Nelson Hipke, Depart- veloped, and it has largely overlooked the role of prosocial family ment of Psychology, Wisconsin Psychiatric Institute and Clinics; Janis H. functioning and culture. Jenkins, Department of Anthropology, Case Western Reserve University; Marvin Karno and Karen S. Snyder, Neuropsychiatric Institute, School of Medicine, University of California, Los Angeles; Christine Vaughn, Insti- Conceptual Processes—An Attributional Perspective tute of Psychiatry, London, United Kingdom. This research was supported by Grants R03-MH53589 and K08- To examine one set of conceptual processes underlying EE, a MH01499 from the National Institute of Mental Health. Preparation of this small group of investigators has proposed and tested the applica- article was supported in part by a Minority International Research Training bility of attribution theory (e.g., Brewin, MacCarthy, Duda, & grant (TW00061) from the Fogarty International Center of the National Vaughn, 1991; Lo´pez & Wolkenstein, 1990). Hooley (1987) was Institute of Health awarded to UCLA–Instituto Mexicano de Psiquiatria. the first to suggest that family members’ attributions of the pa- We thank Tom Bradbury, Rena Repetti, and Bernie Weiner for their tient’s illness and behavior may be particularly important in un- input on earlier versions of this article. The work of the coders, Dorothy derstanding the household’s emotional climate. In her initial for- Black, German Hercules, and Jessica Serna is much appreciated. Also, the mulation, she focused on the family’s perception of the patient’s statistical consultation of Michael Mitchell and the Statistical Consulting Group of UCLA’s Academic Technology Service was most helpful. controllability of the symptoms. She stated, “High-EE attitudes are Correspondence concerning this article should be addressed to Steven R. hypothesized to develop when symptoms are perceived by family Lo´pez, University of California, Los Angeles, Psychology Department, members as being to some degree controllable by patients” 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563. E-mail: (Hooley, 1987, p. 191). Hooley and other investigators have since [email protected] drawn on attribution theory, which, in its most current rendition, 428 ETHNICITY, EXPRESSED EMOTION, AND SCHIZOPHRENIA 429 focuses on the closely related construct of attributions of respon- tional overinvolvement. Prior research has indicated that the attri- sibility (Weiner, 1993, 1995). Specifically, relatives’ perceptions butional processes underlying emotionally overinvolved (EOI) key that patients are either responsible or not responsible for their relatives may be different than that for other high EE families illness-related behavior are central to the relatives’ affective (Barrowclough et al., 1994; Brewin et al., 1991; Lo´pez et al., stance. Attribution theory proposes that those who judge the pa- 1999). Specifically, EOI family members may tend to perceive tient as responsible will tend to feel negative affect (anger, bother, their ill relatives as not responsible for their own behavior. A annoyance), whereas those who judge the patient as not responsi- recent measurement study further confirmed the significant differ- ble will tend to feel positive or supportive affect (sympathy, ence between emotional overinvolvement and criticism (Cham- compassion, concern).1 bless, Bryan, Aiken, Steketee, & Hooley, 1999). Therefore, con- The available studies provide some support for attribution the- sideration of families’ emotional overinvolvement is likely to be ory, but they are not conclusive. There is strong evidence that EE important in attributional studies of relapse. is related to attributions. Family members who are designated as high in EE judge their ill relatives as having more volitional Families’ Prosocial Functioning control (responsibility) over their behavior than do family mem- bers who are designated as low in EE (e.g., Hooley & Campbell, The study of EE has evolved over the years to focus largely on 2002; Weisman, Nuechterlein, Goldstein, & Snyder, 1998). These negative family factors, in other words, what family members do findings are consistent with the attribution–negative affect linkage, “wrong” that is associated with a negative outcome. Early on, given that most of the high-EE family members were so designated Brown and colleagues (e.g., Brown & Rutter, 1966) included because their views of their ill relative were found to be high in family warmth and positive remarks in their initial assessment of criticism or hostility, both reflecting negative affect. Studies that EE. In subsequent published studies, however, family warmth and more directly tested this attribution–affect linkage by examining positive remarks received little attention. For example, with regard the correlation of families’ attributions of control and specific to favorable emotions, Brown, Birley, and Wing (1972) reported indices of criticism and hostility, rather than the more global no findings for positive remarks and gave limited attention to notion of EE, also support this linkage (e.g., Lo´pez, Nelson, warmth. Snyder, & Mintz, 1999; Weisman, Lo´pez, Karno, & Jenkins, 1993). Thus, available evidence supports one linkage of attribution Warmth, which was formerly considered to be a component [of EE], theory, namely, family members’ attributions are associated with is now seen to be a complex variable. A high rating of warmth is often accompanied by a high rating on emotional over-involvement, while their negative affect, specifically criticism and hostility. a low rating in warmth usually implies a high level of critical com- Much less attention has been given to the other linkages of ments. Patients whose relatives showed marked warmth without also attribution theory, in particular the relationship between families’ expressing criticism or over-involvement had a significantly better attributions and positive affect, and the interrelation of attributions, outcome. Warmth was consequently not included in the index of affect—both positive and negative—and clinical outcome. On the expressed emotion. “Expressed emotion,” therefore, has a mainly basis of data from a treatment study, Barrowclough, Johnston, and negative connotation. (Brown, Birley & Wing, 1972, p. 253) Tarrier (1994) found that attributions of controllability reliably predicted relapse; more attributions of control were associated Thus, warmth was thought to be too complex and, as a result, with a greater likelihood of relapse. In addition, they found that dropped from the definition of EE. From 1972 to the present, the attributions were related to family members’ warmth toward the study of EE has focused primarily on risk factors, largely over- patient. The more family members judged patients’ behaviors to be looking protective factors against
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