In the 1940s and 1950s, schizophrenia was always considered to be the mother’s fault. Clinicians such as Frieda Fromm-Reichmann and Harry Stack Sullivan saw schizophrenia as a flight from the pain of “maternal rejection.”
Blaming the Mother
It’s only natural, they thought, that a child faced with so much rejection would retreat to a private world of delusions and hallucinations.
Fromm-Reichmann coined the phrase “schizophrenogenic mother,” which quickly became a catchphrase for clinicians. Around the same time, the autism researcher Leo Kanner devised the phrase “refrigerator mother” to explain the social withdrawal that he observed in children with autism.
In this intellectual climate, the patient’s mother, and even the family as a whole, often experienced excruciating guilt and pain.
During the “biological revolution” of the 1970s, many families and clinicians breathed a collective sigh of relief. The biological revolution was about looking for genetic and brain diseases that cause mental illness. We stopped blaming families for schizophrenia.
Fifty years later, the elusive “gene for schizophrenia” still hasn’t been found, researchers and researchers see the “chemical imbalance” theory of depression as, at best, one small piece of a puzzle.
Today, many researchers accept a “dual hit” model of schizophrenia in which genes alone don’t cause schizophrenia, but a complex interplay of genetic and environmental factors. But once we admit the role of the environment, we’re forced to consider, once more, the family. A pillar of this research is the investigation of “expressed emotion.”
Expressed emotion is a measure of the emotional tone of the family environment. You might think “high expressed emotion” is a good thing, but in this research, it’s not. Three marks of high expressed emotion are criticism, hostility, and emotional overinvolvement:
- Criticism: when the vulnerable person is faced with disapproval for what they do.
- Hostility: when the person feels disparaged for who they are.
- Emotional overinvolvement: when the family shows excessive concern for the person’s well-being, which can send the message that they’re unable to cope with the world.
The psychiatrist George Brown launched “expressed emotion” research in the 1960s in England. His experiment was simple. Around 100 patients with schizophrenia were discharged from a hospital, many to their families. Brown and his colleagues interviewed the family and the patient separately before discharge and then ranked the family’s “expressed emotion”— high or low? His hypothesis was that patients who go back to “high expressed emotion” families are more likely to relapse, as measured in part by hospital readmissions.
Although their study was small and their measurements rather crude, Brown’s basic hunch has been repeatedly confirmed for more than 50 years. Two meta-analyses, published in 1994 and 1998 (see references) confirm that high expressed emotion is a “significant and robust predictor” of relapse.
Newer work, much of it spearheaded by Preethi Premkumar, a psychologist at London South Bank University, has broadened our understanding of the impact of expressed emotion. It’s not just about relapse. Her work also shows a link between expressed emotion and schizotypy—a measure of one’s risk for schizophrenia. High expressed emotion may also impact levels of depression and anger in people with schizophrenia.
Expressed Emotion and the Blame Game
Are these studies foolproof? Like everything in science, people can challenge their merits. One concern is with measurement. Surely, divvying families into “high” and “low” expressed emotion is too simplistic to capture the range and complexity of family emotional ties.
Another concern is its cross-cultural validity. Most studies have been performed on “WEIRD” populations (“Western, educated, industrialized, rich, democratic”). Trying to measure expressed emotion in other cultures creates problems of interpretation.
For example, a study conducted in Chandigarh, India, found no correlation between “emotional overinvolvement” and relapse. The authors suggest that the difference is due to cultural attitudes about personal boundaries. What counts as intrusive questioning for a New Yorker might seem like friendly concern in Chandigarh.
Some might worry that the study of expressed emotion could promote more blame and shame among family members, rather than alleviate it.
Social scientists warn us about how the study of human development can lead to a “blame-game” that disproportionately targets women. For example, research on the impact of maternal–fetal interactions on mental disorders might be interpreted as an attack on mothers.
But the point here isn’t to induce more guilt and shame. As I know from my own experience, having a loved one with schizophrenia or other serious mental disorder can be overwhelming, taxing, and uncertain. It can create a mix of intense feelings like pity, guilt, and anger.
The key isn’t more shame and blame, but counseling and education. Clinical practice guidelines universally recommend family counseling for the families of people with schizophrenia. Programs like the Group and Family Based Cognitive Behavioral Therapy Program for Early Psychosis, based in New York City, are specially designed to work with individuals and their families to improve lives.
At root, expressed emotion research is about recognizing that the family is an integral part of recovery. It shows how families can improve how they communicate to make their loved ones feel valued and appreciated.