Family therapy for schizophrenia

Expressed emotion

Expressed emotion (EE) describes the emotional climate in a family, measured in an interview with relatives. It has two main parts: critical comments and emotional over-involvement. A relative is usually rated high-EE if they make six or more critical comments, show hostility, or show marked emotional over-involvement.

Studies since the 1960s found high EE predicts relapse. Kavanagh's (1992) review found median relapse rates (mostly over 9 to 12 months) of about 48% in high-EE homes versus 21% in low-EE homes.

What family therapy involves

Family interventions (developed in the 1980s) include the person with schizophrenia and their family. Common elements:

• a non-blaming, empathic approach based on the vulnerability-stress model
• psychoeducation about schizophrenia and medication
• training in communication and problem-solving to lower stress
• planning for crises.

The NHS describes sessions over about 6 months; NICE (2014) recommends 3 months to 1 year, combined with antipsychotics for an acute episode.

Evaluation

• Evidence of effectiveness: in controlled studies, year-one relapse was about 50% with standard care versus about 10% with family intervention; effect sizes in guideline reviews are low to moderate.
• Holistic: it treats the social environment, not just biology, and supports carers.
• Practical problems: it needs families to attend; scheduling, transport and cost are barriers, and it is under-used in services.
• Not for everyone: some people have no close family or do not want them involved.
• Risk of blame: families may feel blamed, which is why modern approaches stress a non-blaming stance.
• Compare with drugs: drugs act faster on positive symptoms, but family therapy addresses relapse triggers; the two together are recommended.

Worked example

Explain why family therapy might reduce relapse in schizophrenia.

1. High expressed emotion (criticism, over-involvement) is a source of stress.
2. Under diathesis-stress, stress can trigger relapse in a vulnerable person.
3. Family therapy teaches communication and problem-solving, lowering expressed emotion and stress at home.
4. With less stress, relapse is less likely.

Answer: It lowers expressed emotion and family stress, a known relapse trigger.

Check yourself

1. Which are the two main components of expressed emotion?
   • Hallucinations and delusions
   • Psychoeducation and medication
   • Dopamine and glutamate
   • Critical comments and emotional over-involvement
   Show answer

   Critical comments and emotional over-involvement. EE = criticism plus over-involvement.

2. Kavanagh (1992) found median relapse rates of about 48% in high-EE homes and 21% in low-EE homes. What is the difference in percentage points?
   Show answer

   27 percentage points. 48 - 21 = 27 percentage points.

3. How many times greater was the relapse rate in high-EE homes? Give your answer to 1 decimal place.
   Show answer

   2.3. 48 / 21 = 2.3.

4. What is psychoeducation in family therapy?
   • Teaching the family about schizophrenia and its treatment
   • Giving the family medication
   • Hospitalising the patient
   • Blaming the family for the illness
   Show answer

   Teaching the family about schizophrenia and its treatment. Psychoeducation provides information.

5. Which is a practical limitation of family therapy?
   • It always works faster than drugs
   • It has no evidence base
   • It depends on family members being able and willing to attend
   • It increases expressed emotion
   Show answer

   It depends on family members being able and willing to attend. Attendance barriers limit its use.

6. Explain how family therapy can be linked to the diathesis-stress model of schizophrenia.
   Show answer

   Family therapy reduces stress in the home, such as criticism from relatives, and under the diathesis-stress model lower stress makes relapse less likely in a vulnerable person.. Reducing environmental stress lowers relapse risk in a vulnerable person.

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Sources

• Pearson Edexcel International Advanced Subsidiary/Advanced Level in Psychology specification (issue January 2026)
• Pearson IAL Psychology component guide: WPS04 (Issue 2, November 2024)
• Hahlweg and Baucom (2023), Family therapy for persons with schizophrenia: neglected yet important, European Archives of Psychiatry and Clinical Neuroscience
• Kavanagh (1992), Recent developments in expressed emotion and schizophrenia, British Journal of Psychiatry 160
• NHS: Schizophrenia, treatment

Last updated 8 November 2026. Spotted a mistake? Tell us.