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Ng, Vincent C.K Introduction Schizophrenia is a serious form of mental illness that has a debilitating effect on both the patients and their families. In essence, schizophrenia is understood as a form of psychosis, where patients suffering from the syndrome often experience considerable distress from a myriad of symptoms such as hallucinations, delusions, and bizarre thought processes. Most of the time, these patients will experience a distortion of their thought processes and perceptions, leading to a loss of boundaries between the person and the external world (Chong, 2001). The illness schizophrenia has become so pervasive that approximately 1% of the individuals in western countries can be expected to be labelled schizophrenic, at some point in their lives (Torrey, 1987). The prevalence of schizophrenia in Singapore is estimated to be 0.75% of the population (Institute of Mental Health, 2003). The exact cause of schizophrenia is not entirely understood. The general consensus amongst mental health professionals is that there is no single cause, and rather, a constellation of biological, psychological, and social factors that produce the schizophrenia illness (SAMH, 1988). Early empirical evidence had suggested that the family environment plays a crucial part in influencing the onset, as well as course of mental illness, particularly that of schizophrenia and other related psychotic disorders (Brown, Birley, & Wing, 1972; Vaughn & Leff, 1976). Similar studies were replicated to find out the extent in which family criticism, hostility, and emotional over-involvement affect the relapse of psychiatric patients. This level of family relationship is measured in terms of family expressed emotion, where patients returning to high expressed emotion environment were more likely to relapse than those returning back to family environment with low expressed emotion. The family’s level of emotional involvement and criticism are the two major aspects of the family’s level of expressed emotions, which has been consistently found to be a reliable predictor of relapse amongst psychiatric patients (Hooley, 1998; Hooley & Hiller, 2000; Dixon, King, Stip, & Cormier, 2000; Jarbin, Grawe, & Hansson, 2000). The relationship of expressed emotion to psychiatric relapse raises the question about how psychosocial factors affect the treatment outcome of an illness. With the current global trend of deinstitutionalization of care for the schizophrenic patients, vast majority of them are expected to return to live with the family, after receiving treatment for a psychotic relapse (Stirling, Tantum, Thonks, Newby, & Montague, 1991). Hence, the Singaporean family too is expected to play an increasingly significant role in the care and rehabilitation of the schizophrenic patient in the long-term. (Ng & Low, 2003). Families of schizophrenic patients often encounter a range of problems impacting on the well-being of the family life, as a result of providing care for the patient. These problems include coping with the psychotic symptoms of a relapse, impaired social skills from the patient, strained social relationship and isolation, and behavioral excesses from the patient, for example, aggression and restlessness. It is widely documented that considerable stress has afflicted families of patients suffering from schizophrenia (Brown et al., 1972; Doll, 1976; Falloon, Boyd, & McGill, 1982). Generally, the burden of care can come in the forms of financial, physical, and psychological strain (Grad & Sainsbury, 1968; Hatfield, 1978; Fadden, 1998; and Seng & Bentelspacher, 2001). Jackson, Smith, and McGory (1990) had suggested a link between the burden of care and expressed emotions in such families. Boye and his colleagues had also reported consistently high stress scores among relatives of patients with high level emotional involvement (Boye, Munkvold, Bentsen, Notland, Lerbryggen, Oskarsson, Uren, Ulstein, Lingjaerde, & Malt, 1998). It appears that psychiatric relapse, the burden of care, and expressed emotions in the family are inter-related. Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
Research Objective and Questions The main objective of this study was to find out the extent to which our local schizophrenic patients’ relapse was affected by their families’ level of expressed emotion, which is operationalized in the forms of emotional over-involvement and criticism. The primary aim of this study was to investigate the relationship between families’ level of emotional involvement and their level of criticism, in relation to the patient’s readmission into Woodbridge Hospital, Singapore’s state mental hospital. Although the study on family expressed emotion and schizophrenia has been around for more than four decades, the researcher has not been able to identify any of such study locally. To date, Azhar and Varma’s (1996) study in Malaysia provide the slightest clue to how the expressed emotion concept may have a relevance on our local schizophrenic patients. Yet, their non-representative sample also suggested that their attempt too were exploratory. Moved by the lack of local research in this area, it has motivated the researcher to pioneer an exploration on the phenomenon of expressed emotion and its effects on the relapse of schizophrenia patients in Singapore. In view of the research objective mentioned, this study therefore aimed to shed light on the following research questions: 1. 2. 3. Does expressed emotion, in the form of emotional involvement and criticism, by family members have an effect on the schizophrenic patient’s readmission to Woodbridge Hospital? In terms of expressed emotion, what is the relationship between the family’s level of emotional involvement and level of criticism on the schizophrenic patient? Is there a difference in the level of family emotional involvement and level of criticism between schizophrenic patients with varying length of illness history? Research Hypotheses Specifically, the following research hypotheses were then tested as part of the attempt to provide tentative answers to the research questions. They were namely: 1. There is a relationship between the level of family emotional involvement on the schizophrenic patient and the length of time he stayed well at home before being readmitted to Woodbridge Hospital for treatment; There is a relationship between the level of family criticism on the schizophrenic patient and the length of time he stayed well at home before being readmitted to Woodbridge Hospital for treatment; There is a relationship between the level of family emotional involvement experienced by the schizophrenic patient and his length of illness history; There is a relationship between the level of family criticism experienced by the schizophrenic patient and his length of illness history; and There is a relationship between the level of family emotional involvement and the level of family criticism experienced by the schizophrenic patient.
3. 4. 5.
Methodology Research design Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
This study employed a Static-Group Comparison design, where the subjects were not randomly assigned to the level of independent variables, as compared to the experimental group design. Instead, the subjects were assigned according to their independent and mediating variables under natural occurring setting, for example, level of family emotional overinvolvement, level of family criticism, and length of illness history. The reason of employing such a research design is that the subjects were non- equivalent in nature. A major consideration of such a design is the threats to its internal validity. Rubin and Babbie (1993) define internal validity as the confidence in which the results of a study accurately depict whether a variable is causally linked to another. As the subjects were not randomly assigned to the groups, selection bias is an obvious threat to the internal validity of this research design. However, as the current study is primarily exploratory in nature where the results are not generalizable, considerations about internal validity are of little relevance. Operationalization of terms For the purpose consistency in approach in this study, the researcher referred to the diagnostic criteria of ICD-10 in classifying the mental disorder of schizophrenia. The current guidelines used in ICD-10 in diagnosing schizophrenia are: "A minimum requirement is one of the following symptoms: thought echo, insertion, withdrawal, broadcasting, passivity phenomena, delusional perception, third person hallucinations, and persistent delusions - all in clear consciousness. Other symptoms used to make the diagnosis (2 must be present) include persistent hallucinations in any modality, thought blocking, thought disorder, catatonic behaviour, negative symptoms, loss of social function." (WHO, 1992:325) The first independent variable of this study was the level of family emotional involvement on the patient. It was operationalized as the level of intrusiveness from the family members, which was perceived and reported by the patient. The second independent variable of this study was the level of criticism experienced by the patient from his family. It was operationalized as the family’s critical attitudes directed at the patient, and were measured by the perceived frequency of critical comments the patient received while at home. For the dependent variable of this study, it was operationalized as the patient’s readmission to Woodbridge Hospital for treatment, as a result of a psychiatric relapse. Psychiatric relapse refers to the re-manifestation of symptoms described in the ICD-10 criteria of schizophrenia. Patients readmitted to the hospital due to reasons other than psychiatric relapse, such as lack of shelter and abode, social misconduct, and family respite were not included in the study. The mediating variable of this study was operationalized as the patient’s length of illness history. It referred to the period between the time when the patient was first diagnosed with schizophrenia and his current readmission. The patient’s illness history was measured in months and rounded to the nearest. Setting This study was set in Woodbridge Hospital, Singapore’s state mental hospital. Patients are generally admitted for inpatient treatment at the hospital via its emergency department, or from the psychiatric outpatient clinic at the Institute of Mental Health, located within the same vicinity, adjacent to the hospital. All admissions are transferred to acute wards, where treatment is rendered on a daily basis, by the multidisciplinary team comprising psychiatrists, nurses, medical social worker, psychologist, and occupation therapist. The patients receiving the inpatient treatment are segregated by their gender, where patients of the same gender are treated in the same ward. Sampling frame A sampling frame is defined as the actual list of the study population in which the sample is selected (Rubin & Babbie, 1993). As this study is exploratory in nature, where the gender difference was not a target of investigation and the results are not generalizable to the study population, the researcher had narrowed the sampling frame to include only all the male schizophrenic patients admitted into the acute Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
wards of Woodbridge Hospital. Basically, the patients eligible for this study must have at least one previous episode of admission to the hospital for psychiatric treatment. Selection of subjects A sample of 60 subjects was drawn from the sampling frame utilizing a systematic sampling method, where every 3rd patient found to be eligible for the study was recruited over a period of 6 months. This extended period of subject recruitment was necessary to address the possibility of selection bias due to seasonal effects on readmission. Based on informal observation by long-serving hospital staff, it was noted that the number of admissions for Chinese patients actually increased during the traditional “hungry ghost” month, and similarly observed for Malay patients during the Islamic holy month of Ramadan. Although the reliability of their observation has not been established, there were many literature that informed about the influence of cultural factors on the psychiatric condition of the patient (Cochrane & Singh, 1987; Leff, Berkowitz, Shavit, Strachan, Glass, & Vaughn, 1990). In order to control for gender and cultural specific influences, as well as other extraneous variables, the following exclusion criteria were applied in order to prevent confounding effects on the variables in this study. They included: • Dual diagnosis of substance abuse/dependence and schizophrenia; • Newly diagnosed schizophrenia with no prior admission to Woodbridge Hospital; • Schizophrenia patients with secondary diagnosis, such as depression, mental retardation, etc; • Patients who did not live with their family or relatives before their readmission; • Patients who were illiterate in English, as the instrument used in this study would be administered in English. Data collection Eligible patients were sampled and recruited after they have being assessed to have remitted in their psychotic symptoms by their consultant psychiatrist-in-charge. Selected patients were briefed individually by the researcher regarding the purpose of the study. The briefing included an overview of the study, and a description of the method of data collection, that is, via administration of the instrument in the form of a questionaire. Subsequently, informed consent was obtained from the subjects before they were officially recruited into the study. After recruitment, the patients were allotted an interview time and date, which was dependent on the projected date of discharge. They were also informed that at any stage of the study, their right to withdraw their participation from the study remained intact. As a rule of thumb, patients were interviewed one week before their projected discharge. This was necessary so as to minimize the disruption to the full-course of treatment regime administered during the patients’ hospitalization period. Typically, the average treatment period of a schizophrenic relapse ranged between two-to-three weeks of hospitalized treatment depending on the severity of relapse and the patient’s response to pharmacotreatment. This was followed by a week of inpatient rehabilitation programme, such as the ward-based occupational therapy, patient-education programme, and family-based interventions conducted by the various members of the multi-disciplinary team. At the designated time-slot, the researcher met and administered the instrument to the selected subjects in the ward, on a one-to-one basis. The researcher maintained objectivity throughout the administration of the instrument by not making any interpretations to the questions asked. The subjects were encouraged to provide their responses to what they had deemed to be most appropriate from their perspective, based on their understanding. The responses were subsequently scored by the researcher. After the whole data collection period was over, the subjects were individually debriefed by the researcher either via telephone or in person, depending on their availability.
Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
Traditionally, the most widely used instrument for assessing the level of expressed emotion in the family was the Camberwell Family Interview (CFI). Expressed emotion was measured by the coding the audiotapes of a 45 minute – 2 hour semi-structured interview with significant family members (Vaughn & Leff, 1976). However, the administration of the CFI was very time-consuming, requiring the use of skilled observers. Even when the interview was shortened to a 5-minute speech sample (Gift, Colle, & Waynne, 1985; and Magana, Goldstein, Karno, Miklowitz, Jenkins, & Falloon, 1986), it still required a considerable time to code the audiotapes (Shields, Franks, Harp, McDaniel & Campbell, 1992). The limited utility of the CFI due to resource constraints in this study’s setting, which essentially is an institution for treatment, led to the researcher to look for more efficient instruments to measure the level of expressed emotion in the subjects’ families. Two self-reporting instruments were identified to be potentially suitable for this study. The Level of Expressed Emotion Scale (LEE) is a scale administered to schizophrenic patients to report on his perception of family affective environment (Cole & Kazarian, 1988). Although the LEE has excellent internal consistency, with a KR-20 coefficient for the overall scale of 0.95 with its subscales ranging from 0.84 – 0.89, its main weakness was that correlations of the scale and its subscales with criterion measures were not reported (Corcoran & Fischer, 2000). The second instrument identified was the Family Emotional Involvement and Criticism Scale (FEICS) developed by Shield et al. (1992). There are 14 items measured on a 5-point Likert-scale in the FEICS, in which the items are allocated into two subscales, namely, the intensity of Emotional Involvement and Perceived Criticism. The two factors are analogous to emotional over-involvement and critical comments, the two main factors measured in the Camberwell Family Interview. The reliability of the two subscales yielded a Cronbach’s alpha of 0.74-0.82 and confirmatory factor analysis indicated that each item loaded on its proposed factor and not with the other (Shields et al., 1992). In terms of construct validity, the subscales exhibited significant correlations with the Family Adaptability and Cohesion Evaluation Scales (Olson, Portner & Lavee, 1985). Emotional Involvement positively correlates with cohesion and adaptability in the family, which means that families that are perceived to be intensely emotionally involved have higher cohesion and adaptability. On the other hand, Perceived Criticism negatively correlates with cohesion and adaptability in the family. This means that families that are perceived to be critical towards individuals, have less cohesion and are less adaptable. At the same time, the FEICS have reported partial correlations with various scales, such as Interpersonal Support Evaluation List (Cohen & Hoberman, 1983). Hence, after taking into account the good level of reliability, concurrent validity, and criterion-related validity reported in the development of the FEICS, the researcher chose to utilize it over the LEE as the primary instrument for this study. Data analysis The primary goal of data analysis in this study is to make statistical inferences on about measurements based upon the information contained in the sample. However, prior to the analysis, the researcher examined the data using descriptive statistics, such as the sample mean, and sample variance. Such descriptive efforts were important for presenting the essential features of the data in easily interpretable terms. Following such examination, statistical inferences were made through the use of correlational and multiple regression analyses, where the relationship of one or more independent variables (level of emotional involvement and level of family criticism) is evaluated to a single continuous dependent variable (length of time the patient was able to stay free from psychiatric relapse). According to Baker (1994), such analysis procedures are most often used when the independent variables cannot be controlled in a sample survey.
Limitations of study
Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
The current study being exploratory in nature suffers from certain pitfalls. The first limitation lies with its single gender sample in which only male schizophrenic patients were studied. This made it impossible to explore and compare gender-specific issues that might inform on future treatment and research. The second limitation stems from the fact that the study was conducted only in one setting in Woodbridge Hospital, although there were other psychiatric treatment facilities in Singapore’s other hospitals. The final limitation was due to the research’s instrumentation. This meant that only patients who were literate in English were sampled, as there is no other translated version of the FEICS. The above three limitations implied that the findings of the current study would not be generalizable to the study population of schizophrenic patients in Singapore. Nonetheless, it does hope to raise the interest of future research into the studying gender-differences in patients’ recovery and relapse, environmental issues such as and caregivers’ burden, and expressed emotion. Results Subjects’ profile Basically, the patient sample was middle-aged with a mean age of 38.53 (s.d + 9.28 years). The youngest in the sample was aged 22 and the oldest was age 60. In terms of illness history, the mean time since the debut of the illness was 12.68 years (s.d + 7.98), where the most recently diagnosed was 1 year ago, and the most chronic having suffered from schizophrenia for 30 years. The sample has a varied length of symptom-free period where they were able to live in the community without having to be admitted to hospital for treatment. The shortest period between the current readmission and the previous one was 1 month, and the longest being 240 months, which is the equivalent of 20 years. On average, the subjects were able to maintain stability in their illness management and live in the community for 20.87 months (s.d + 39.29). The number of admissions to Woodbridge Hospital in the past 12 months for the sample ranged from 0 to 4, with an average of 1.40 (s.d + 1.17). The sample was fairly well represented by the various major ethnic groups found in Singapore. The Chinese accounted of the majority of 68.3%, followed by Malay 15%, and Indians 13.3%. As for marital status, the subjects were predominantly single (88.3%). Most subjects received some form of education. Only 11.7% did not have any formal education, while nearly 63.4% successfully completed at least secondary education. Yet, only 31.7% of the subjects were engaged in some form of employment. The rest were either unemployed or attending rehabilitation programs. Caregivers’ profile As all the patients were staying with their families, primary caregivers were mainly immediate family members, comprising parents (51.7%), siblings (36.7%), and spouse (6.7%). However, there were 2 subjects (3.3%) who identified their relatives as the primary caregivers, and another (1.7%) who was taken care off by his fiancee, technically listed in the category of spouse. The mean age of the primary caregiver was 50.83 (s.d + 12.68), and they were rather evenly distributed across the genders (females 55%, males 45%). In terms of marital status, a vast majority of the primary caregivers were married (78.3%), while the rest were either single (8.3%), separated/divorced (6.7%), or widowed (6.7%). Many of the primary caregivers received up to primary education (41.7%), while 36.7% managed to complete at least secondary education. However, there were 20% who did not have any formal education. Moreover, although they were identified by the subjects as their primary caregivers, a majority of them were engaged in some form of gainful employment (55%). There were only 5% who were listed as unemployed, while 26.7% had to balance between multiple roles of being the homemaker and serving their National Service (23.3% and 3.4% respectively). The rest were retirees (13.3%).
Association between family expressed emotion and psychiatric relapse
Oral Communication at 4thInternational Social Work Conference on Health & Mental Health, Quebec City Canada, 23-27 May 2004.
Pearson Correlation Tests were employed to establish whether there were any relationships between the various variables in this study. As expected, there was a significant positive relationship between the patient’s age and the number of years he had been diagnosed with schizophrenia (r = 0.677, p< 0.01). Not surprisingly too, there was a significant negative correlation between the number of months the patients had managed to stay symptom-free and the number of readmissions to the hospital for psychiatric treatment (r= -0.403, p < 0.01). The composite expressed emotion score was positively correlated with its subscales of emotional involvement and critical comments, at r = 0.528 (p < 0.01), and r = 0.612 (p < 0.01) respectively. In addition, the subscales of emotional involvement and critical comments were negatively correlated with each other, at r = -0.349 (p< 0.01). This was consistent with the findings from Shield et al’s original study (1992). However, associations between the independent variables and the dependent variables of the study yielded non-significant results. The correlation between the level of emotional involvement of the patient’s family and the length of time in which the patient was able to stay at home without a psychiatric relapse was at r = -0.59, p = 0.65 (N.S). Similarly the correlation between family’s level criticism on the patient and the number of months in which he was able to stay at home without a psychiatric relapse was at r = -0.12, p = 0.38 (N.S). Additional attempts to explore for associations between the level of family’s emotional involvement on the patient, as well as the level of criticism on the patient, on his number of readmission to hospital in the past 12 months found no significant relationship. Correlation of between the former was at r = -0.11, p = 0.40 (N.S) and the latter at r = 0.22, p = 0.09 (N.S) When investigating the association between the mediating variable and the dependent variables, the findings too yielded non-significant results. In essence, the length of the patient’s illness history, that is, the number of years in which the patient has been diagnosed and treated for schizophrenia, was not related to the level of family emotional involvement (r = -0.02, p = 0.42; N.S), nor the level of family criticisms (r = 0.19, p = 0.15; N.S ). The researcher therefore attempted further investigations to establish whether there was any association between the dependent variables and the subjects’ other variables. It was found that the subject’s, as well as his caregiver’s age had no significant correlation to the level of emotional involvement, criticisms, and overall expressed emotion experienced at home. There were also no significant correlations between the subject’s, and his caregiver’s age, with the number of months the subject was able to live in the community without having to be readmitted for psychiatric treatment. Variability between caregiver types Since it was established in the earlier section that there were no significant relationship between the dependent, independent and mediating variables, it was therefore not necessary to proceed with regression analysis. However, as all the subjects were living with their families, it would be important to investigate whether the typology of patient’s main caregiver does result in the differences reported in the level expressed emotion, as well as number of months in which the patients were able to live in the community without a psychiatric relapse. One-way ANOVA (Analysis of Variance) tests were conducted and the researcher found that there were generally no significant differences in the level of emotional over-involvement reported by the subjects, across the different caregivers’ type (F = 0.88, p = 0.48). However, in terms of the level of critical comments and overall level of expressed emotion, there were significant differences across the caregiver types (F= 4.39, p = 0.004; and F = 3.27, p = 0.018 respectively). For the former, subjects reported the level of critical comments to be highest from sibling caregiver type (M = 23.09, s.d + 3.07), followed by parents (M = 21.39, s.d + 3.52), and spouses (M = 18.25, s.d + 4.50). Subjects who were living with relatives experienced the lowest level of criticisms (M = 17.50, s.d + 2.12). For the latter, subjects reported highest level of expressed emotion from siblings caregiver type (M = 44.32, s.d + 3.75), followed by relatives (M = 43.00, s.d + 4.24), parents (M = 42.52, s.d + 3.71), and spouses (M = 40.25, s.d + 5.68).
As for the differences in terms of the number of months in which the subjects were able to live at home without having to be admitted to the hospital for psychiatric treatment as a result of a relapse, the ANOVA tests found significant variability between the caregiver types (F = 5.28, p < 0.01). It was found that subjects who were living with relatives were the most stable and were able to stay free from admission for 126 months (s.d + 161.22). This was followed by subjects who were living with their parents (M = 21.23, s.d + 35.35). In comparison, subjects who were staying with their spouses and siblings managed only 14.50 months (s.d + 8.54) and 10.73 (s.d + 9.97) months free from admission respectively. In view of the significant differences in the length of time in which the subjects were able to stay free from psychiatric relapse, as manifested by the number of months they were able to stay well at home prior to their current readmission, the researcher attempted one further test to find out whether the gender differences in the subjects’ primary caregiver accounted for the number of months in which the subject was able to stay free from psychiatric relapse. Results indicated that subjects who were staying with male caregivers were able to live in the community without having to be readmitted to the hospital for psychiatric treatment, longer than those who were staying with female caregivers (M = 27.04 months versus 15.82 months). However, the ANOVA results indicated that the differences observed were likely chance occurrences as they were statistically non-significant (F = 1.22, p = 0.28; N.S). Reliability of instrument Results from the internal consistency analysis tests revealed that the Emotional Involvement subscale yielded an overall Cronbach’s alpha of 0.63 (M = 3.05, s.d = 0.50), while the Critical Comments subscale had an overall alpha of 0.61 (M = 3.08, s.d = 0.54) and hence, within the acceptable range as a reliable instrument for measuring expressed emotion. Discussion Predictive value of expressed emotion on psychiatric relapse The most significant learning point from this study is the absence of association between the phenomenon of family expressed emotion and psychiatric relapse. Whilst many studies reported evidence of family expressed emotion as a predictor of psychiatric relapse among schizophrenia patients, our findings differ from those reported in the literature. Neither of the sub-constructs of expressed emotion, namely, emotional overinvolvement and criticism, was related to the patient’s psychiatric relapse. The lack of association between family expressed emotion and psychiatric relapse illuminates the contribution of other important factors that are not addressed or included in this study. In fact, MacMillan et al. (1986) provided evidence to suggest that high expressed emotion and high relapse rate were confounded by other factors such as compliance to neuroleptic medication; duration and severity of illness; and drug and placebo administration etc. When these factors were controlled for, the level of association between expressed emotion and relapse were reduced to the point of non-significance. In view of this, it was highly probable that in this study, the patients’ relapse could have been attributed to their poor compliance to medication, their severity of illness, and the quality of care and support received from the caregivers. A relook on the early evidence from Brown et al. (1972) and Vaughn and Leff’s (1976) studies had pointed out that two factors appeared to serve a protective function for patients living in high expressed emotion environment. These two factors were identified as maintenance of neuroleptic medication, and having a low face-to-face contact with their relatives.
Evidence to suggest averting ‘blame’ on the family The growing literature on family expressed emotion playing a role in resulting the psychiatric relapse in the patient were often criticized by opponents of the concept as a convenient attempt to place blame on the family for causing mental illness. Whilst it was generally accepted that the expressed emotion index was a reliable predictor for long-term course of schizophrenia, Falloon et al. (1984) warned that it would be a grave mistake to conclude that critical and overinvolved attitudes in the family are major causes of poor prognosis or relapse. In fact, Hatfield, Spaniol and Zipple (1987) too had suggested that families may have scored high on expressed emotion as a result of deteriorating mental condition of the patient, rather than vice versa. The results of non-relationship between the two provided tentative evidence to absolve the family from the culture of blame, and highlighting the concern on studying the direction of relationship between the two variables. Other non-supportive studies This current study was not an isolated case where no associations were found between family expressed emotion and the patient’s relapse. Other important studies too had failed to support the association between expressed emotion and relapse (Kottgen et al., 1984; Azhar & Varma, 1996). Most notably, the latter’s study was fairly recent and conducted in Malaysia, a country whose people have similar cultural experience and heritage with their Singaporean counterparts. Psychiatric disorders, pathological family-functioning, and expressed emotion are predominantly Western in conception. There is an extent to which cultural worldviews indigenous to the local population impact on the understanding and meaning attributed to the nature, causes, course, and management of an illness, as well as reactions to it. Various studies have identified this issue as central to the formation of express emotion attitudes (Vaughn, 1986; Hooley, 1987). Understanding expressed emotion as a threshold for caregiving stress Although the concept of expressed emotion is usually defined as an index to measure the emotional atmosphere in the family, Lefley (1996) has also described expressed emotion as the threshold of the family in dealing with the many demands of providing care to the patient. It may be plausible to suggest that the lack of association between expressed emotion and relapse in this study could be due to the difference in the threshold of local families for dealing with the stress of caregiving. One reason being that our local family caregivers tended to have a larger network of informal resources from extended families and kinsmen. Comparatively, the Western culture tends to emphasize more on individual freedom and responsibility. As a result, the family caregivers surveyed in most Western research may be more isolated and therefore having lower threshold to the patients’ disturbed behaviors. Closely related to this is the reliability and validity of the instrument in measuring expressed emotion in the Asian context. Although reliability tests showed that the instrument had achieved acceptable level of internal consistency in measuring both the emotional involvement and critical comments sub-phenomena, the Cronbach’s alpha was lower than that reported by Shields et al’s (1992) original study. The difference may be attributed to how critical comments, and emotional over-involvement are perceived differently, as a result of our cultural differences. Depathologizing family coping The advent of literature on family expressed emotion over the years have largely focused on the negative aspects of family coping with the care of a schizophrenic patient at home, and how family interactional patterns were detrimental to the patient’s stability in recovery. Falloon (2003) pointed out that despite Vaughn and Leff’s classic paper in 1976 (it was based on Vaughn’s doctorate thesis) highlighted the negative over-intrusive and critical attitudes of families as predictors of clinical relapse, it should be noted that Vaughn’s unpublished thesis had in fact, given more emphasis on better clinical outcomes associated with emotional warmth and supportive comments by family members.
This current research’s lack of significant finding on how pathological family communication patterns have a direct impact on the clinical outcome of the patient is a timely reminder for mental health practitioners and researchers to revisit the search for positive and non-pathologizing attributes of families coping with mental illness, a stance that has been neglected for a substantive period of time.
Conclusion The concept of expressed emotion informs one aspect of family functioning and vaguely implies a particular style of family coping (Vaughn, 1989). Generally, research on family coping with mental illness is sparse when compared to those attempting to link family dynamics to patient’s recidivism. Bland (1998) identified four main focuses on research of families with mental illness. They were namely, the family as aetiological agents; family as a source of environmental stress; family as a bearer of burden; and family as suffering from the impact of the illness. Social workers have been an integral part of the mental health system since its profession’s early years. Our chief operating framework of person-in-environment augments well for future research and investigation away from the traditional deficit and medical oriented model of disease and chronicity, to explore on individual and family strength, resilience, and coping, within a recovery model of mental health. This current research had operated from the earlier premise and found gaps with many unanswered questions. Moving into the latter’s paradigm may trigger more questions in a positive direction, those that may help to solidify social work profession’s values of client empowerment, advocacy, and selfdetermination. Reference Azhar, M.Z., & Varma, S. (1996). Relationship of expressed emotion with relapse of schizophrenia patients in Kelantan, Singapore Medical Journal, 37(1), 82-85. Baker, T.L. (1994). Doing Social Research. Singapore: McGraw-Hill Inc. Bland, R. (1998). Understanding grief and guilt as common themes in family response to mental illness: Implications for social work practice, Australian Social Work, 51(4), 27-34. Boye, B., Munkvold, O.G., Bentsen, H., Notland, T.H., Lerbryggen, A.B., Oskarsson, K.H., Uren, G., Ulstein, I., Lingjaerde, O., & Malt, U.H. (1998). Pattern of emotional overinvolvement in relatives of patients with schizophrenia: A stress syndrome analogue? Nordic Journal of Psychiatry, 52(6), 493-499. Brown, G.W., Birley, J.L.T., & Wing, J.K. (1972). Influence of family life on the course of schizophrenic disorders: A replication. British Journal of Psychiatry, 121, 241-258. Brown, G.W, Bone, M., Dalison, B., & Wing, J.K. (1966). Schizophrenia and Social Care (Maudsley Monographs, No. 17). London: Oxford University Press. Chan, P. (1992). Schizophrenia and psychotic disorders. In E.H. Kua (Ed), Understanding Mental Illness: A Guide for Family Carers. Singapore: National University of Singapore. Chong, S.A. (2001). Schizophrenia. In E.H. Kua (Ed), Psychiatry for Doctors. Singapore: National University of Singapore. Cochrane, R., & Singh, B.S. (1987). Migration and schizophrenia: An examination of five hypotheses. Social Psychiatry, 22, 181-191.
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