Causal Attributions, Expressed Emotion, and Patient Relapse: Recent Findings and Application to Chinese Societies

For more than 30 years, a measure of the family environment termed expressed emotion has enhanced our understanding of how family psychosocial factors influence psychiatric relapse. This article reviews research addressing relatives' causal attributions, expressed emotion, and patient relapse, which support a model in which relatives' attributions are causally related to expressed emotion. A mediational model of attribution-expressed emotion outcome is evaluated as a theoretical framework to understand how attributions and expressed emotion contribute to patient relapse. Research addressing this topic in China, where relatives' behaviours towards patients differ greatly from their western counterparts, is reviewed. Relatives of patients with schizophrenia in China demonstrated a more situational attribution bias than relatives of patients from western cultures, yet Chinese relatives' controllable and personal attributions still related to high expressed emotion types of criticism and hostility. Expressed emotion partially mediated controllability attributions in predicting relapse. Contrary to expectations, personal attributions, particularly relatives' causal beliefs of 'xiao xin yan' ('narrow-mindedness'), protected against relapse in a manner unexplained by expressed emotion. These results further support the hypothesised causal relation between attributions and expressed emotion, and provide a new pathway to explore how relatives' behaviours ameliorate patient illness course. Future directions for research utilising attributions and expressed emotion in Chinese societies are provided.