Part 18 of The Mental Health Workers' Guide looks at High Expressed emotion (HEE) in mental health care. Don't forget that you can download the podcasts and video clips that accompany this series here.

Today’s topic will be High Expressed Emotion (part 1)

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Many people who work in mental health services have heard of, or even used the Camberwell assessment protocols. Many service users and their relatives have found themselves the subjects of these assessments. However few people know where they came from.

The story starts over half a century ago with a social worker (then known as mental health officer) called George brown. In the 1950s George worked in the London borough of Camberwell and had a large number of people on his caseload who were described rather uncharitably at the time as ‘revolving door’ patients. This meant that they seemed to exist on a continuous cycle of admission, treatment, discharge, relapse and readmission. They represented the hospital equivalent of the equally uncharitably named ‘heartsink’ patients who attend GP surgeries with alarming regularity causing the GP’s heart to ‘sink’ whenever their name is seen on the appointments list.

But not everyone followed this pattern. Some patients returned only rarely to the ward and still others seemed to be discharged and never return at all. So old George developed a hypothesis. He speculated that patients who went home to supportive families would do better than those who returned to live alone in the community. A reasonable assumption to make – but it was only an assumption.

George knew better than to rely purely upon assumption and hypothesis – he had a truly scientific way of thinking – and so he tested his hypothesis. He went back through the hospital records to test his hypothesis about supportive families, expecting to find that the most vulnerable ‘revolving door’ patients would be those who lived alone after discharge. But that’s not what he found.

It was true that some of those without support did poorly but by no means all. He also found that some patients who returned to families did well but also, by no means all. In reality the bulk of the hospital’s ‘revolving door’ patients were discharged to the care of their families – a finding that genuinely surprised mental health officer Brown and his team. And that generated another question to be answered.

What was the difference between the few families where people did well and the majority of families where people did very badly?

The ensuing research lasted several years – in fact different versions of it have been repeated across the developed world ever since. The results of that research have been very consistent and they tell us a lot about the effect of families’ (and also workers’) attitudes upon mentally ill service users.

I should be absolutely clear at this point. Brown’s research on Expressed emotion within families is not to be interpreted as supporting the tired old notions of the ‘schizophrenogenic mother’ championed by RD Laing or any other overly simplistic attempt to throw blame onto relatives.

That’s not what it’s about. As a rule, relatives do the best they can with what they’ve got. They may not be perfect but they’re not supposed to be.

 Almost any of us, when faced with the care of a mentally disturbed relative will make mistakes and there is nothing to be gained by blaming them for behaving no better than we would ourselves. The famous native American proverb about walking a mile in someone else’s moccasins springs irresistibly to mind at this point.

Rather, the value of this research is in helping us to understand how to help ordinary people (relatives, carers or workers) to do better. It is not about blaming them for behaving like almost anyone would in those particularly trying circumstances.

Living with a mentally disordered person is stressful. Many people find the stress of their situation difficult to cope with and this puts them at risk of mental disorder themselves. Remember that the stress and vulnerability paradigm works for relatives too.

Whether they develop mental disorders or not family members and carers often find themselves reacting in less than positive ways to their mentally disordered relatives. Unfortunately these essentially normal, human responses tend to make relapse more likely and so mitigate against recovery.

There are essentially three distinct types of interaction that seem to encourage relapse. These are known collectively as High Expressed Emotion or HEE.

The three types of High Expressed Emotion are:

1.       Criticism

2.       Hostility and Aggression

3.       Over Emotional Involvement

In the next episode we’ll look at these three types of High Expressed emotion in a little more detail.