by Michael D. Anestis, M.S.
Few people would disagree that living with bipolar disorder is extremely difficult. Even though most individuals experience manic episodes as exhilarating while they last, the repercussions of these episodes tend to result in extremely negative emotions and significant problems once the mania recedes. Additionally, the depressive episodes experienced by many bipolar individuals can be debilitating and dangerous. That being said, less attention is generally paid to the fact that living with somebody else who has bipolar disorder is also a difficult experience. For the spouses and families of an individual with bipolar disorder, the consequences of bipolar symptoms can be painful, costly, and disheartening. Some individuals are able to maintain a positive outlook in such situations and remain close to their ailing loved one. Others, however, find such outcomes more difficult to attain.
One of the most important variables to consider when discussing the relationship between a mentally ill individual and his or her loved ones is expressed emotion (EE). EE is defined as critical, hostile, or emotionally overinvolved attitudes towards and interactions with a relative diagnosed with a mental illness (Hooley, Rosen, & Richters, 1995). This definition is admittedly broad; however, a substantial amount of research has been conducted on EE and results have consistently indicated that high levels of EE predict poorer outcomes for a host of mental illnesses, including schizophrenia and mood disorders (Barrowclough & Hooley, 2003; Butzlaff & Hooley, 1998). In other words, the more critical family members are towards a mentally ill relative, the more likely that individual is to relapse and exhibit a negative outcome.
With respect to bipolar disorder, EE has been shown to be unrelated to manic relapse, but significantly related to depressive relapse. In fact, even when controlling for symptom severity, high levels of EE predicted a five-fold increase in the likelihood of depression relapse in individuals with bipolar disorder (Yan, Hammen, Cohen, Daley, & Henry, 2004). So, while EE does not appear to have any impact on manic episodes, high levels of EE in family members predicts subsequent relapses of depression for individuals with bipolar disorder.
In 2008, Lori Eisner and Sheri Johnson of the University of Miami published a study in Behavior Therapy that looked at the utility of an intervention aimed at reducing EE in individuals with a family member diagnosed with bipolar disorder. They noted that, despite the negative outcomes associated with EE, it persists in large part due to prominent misconceptions regarding the nature of mental illness in general and disorders such as bipolar disorder in particular. Individuals with high levels of EE tend to believe that the symptoms of mental illness are within the control of the mentally ill individuals (Barrowclough, Johnston, & Tarrier, 1994) and, as such, become highly angered when their loved one fails to prevent him or herself from exhibiting those symptoms. This viewpoint leads the high EE individual to make frequent judgmental, critical comments to the loved one and to become emotionally overinvolved in their loved one's life.
Eisner and Johnson further noted that prior attempts to develop interventions based on psychoeducation have succeeded in increasing relatives' understanding of mental illness, but have failed to actually reduce EE (Fristad et al., 2003; Simoneau et al., 1999). As such, their goal was to create an alternative approach that not only emphasized psychoeducation, but also sought to diminish EE directly by teaching high EE individuals acceptance skills capable of disarming the intense surges of emotions that likely lead to critical comments and interactions. The authors based this component of their intervention on Christensen and Jacobson's (2000) integrative behavioral couple therapy (IBCT), which works to reduce bitter interactions between romantic couples.
The study sample consisted of 42 adults from 32 different families. All participants had at least one relative who had a lifetime history of at least one full manic episode as determined through a semi-structured diagnostic interview (SCID-IV; First, Spitzer, Gibbon, & Williams, 1997). Participants had the option of attending one full-day seminar (9am - 4pm) or two evening seminars (5:30pm - 9pm). Only the family members themselves attended the workshop(s). The family members with a history of manic episodes did not attend, as prior research has indicated that this can have negative effects on participants' willingness to openly share information and engage in the treatment (Reilly, Rorbaugh, & Lackner, 1988). The intervention itself consisted of modules focusing on the following material:
- Providing education on the nature of bipolar disorder
- Helping family members understand and contextualize the responses of their relatives
- Addressing the impact of criticism on the course of bipolar disorder
- Defining acceptance and discussing its relevance to bipolar disorder
- Discussing ways to implement acceptance in their lives and practicing these skills in session
The rationale for this study was strong and the intervention itself seemed promising; however, the results were not consistent with what the authors anticipated. In the end, the clients were very happy with the intervention and exhibited an increased knowledge regarding bipolar disorder. The intervention was less successful in its other aims though, as levels of anger and criticism did not decrease post-treatment. Unfortunately, this is consistent with prior work and seems to indicate that EE is very difficult to change. Obviously, given the strong negative impact of EE on the course of bipolar disorder and other mental illnesses, it is pivotal that other researchers and clinicians work to develop empirically supported interventions capable of actually reducing EE. Given that the entire treatment consisted of either one full day or two half-day sessions, the brevity of the intervention may have had an impact on the outcome. Perhaps if the intervention included brief follow-up sessions in which the participants could problem solve regarding areas in which they have had a difficult time integrating material into their daily lives, the treatment would be more effective.
So what does all of this mean? First of all, the anger, frustration, and sense of being overwhelmed experienced by individuals with relatives diagnosed with bipolar disorder is entirely understandable. The research on EE is not blaming family members for their loved ones' illnesses nor are they saying that they are not entitled to their feelings. Instead, the research on EE simply tells us that frequent critical, harsh interactions with individuals diagnosed with mental illnesses can have a highly negative impact on outcomes. Consequently, maintaining the viewpoint that mentally ill individuals have complete control over their symptoms seems counterproductive and unlikely to result in desired outcomes. Whether or not an individual wants harsh criticism to be effective in changing behaviors, the evidence indicates that it is not. The acceptance-based approach tested by Eisner and Johnson (2008) seems philosophically appealing; however, the results of their study indicated that is not an effective solution either, at least as the intervention is currently packaged.
If you would like to learn more about expressed emotion or other relevant topics, we encourage you to consult our online store, which provides a long list of resources based on rigorous scientific studies.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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