Page 1 of 15http://spider.apa.org/ftdocs/ccp/1999/october/ccp675658.html 8/30/2000Expressed Emotion and Behavior Therapy Outcome A Prospective Study With Obsessive—Compulsive and Agoraphobic Outpatients Dianne L. ChamblessDepartment of Psychology University of North Carolina at Chapel Hill Gail SteketeeSchool of Social Work Boston University ABSTRACTThe relationship of expressed emotion (EE) to behavior therapy outcome for obsessive—compulsive disorder ( n = 60) and panic disorder with agoraphobia ( n = 41) was investigated. Relatives' emotional overinvolvement and hostility predicted higher rates of treatment dropout. Higher hostility, as assessed by the Camberwell Family Interview (CFI), was related to poorer outcome for target ratings and for the Social Adjustment Scale; higher perceived criticism was also predictive of worse response on target ratings. In contrast, nonhostile criticism on the CFI was associated with better outcome on the behavioral avoidance test. In general, the relationship of EE to outcome was not moderated by type of relative, diagnosis, amount of contact with the relative, or use of psychotropic medication. This work was supported by Grant R01-MH44190 from the National Institutes of Health. We thank statistical consultant Leona Aiken; expressed emotion consultant Jill Hooley; therapists Leslie Shapiro, Elaine Williams, Ulrike Feske, and Judy Lam; Camberwell Family Interview (CFI) interviewers Marty Gillis, Cheryl Sheffler Rubenstein, Hope Warden, Sheila Woody, and Whitney Wycoff; CFI coders Henry Chung, Delphine Mattison, Scott Maynard, Brian McCorkle, and Maureen Patten; and data analysts Giao Tran, Kimberly Wilson, Tom Rodebaugh, and Carol Woods for their important contributions to this research. Correspondence may be addressed to Dianne L. Chambless, Department of Psychology, University of North Carolina, Chapel Hill, North Carolina, 27599-3270. Electronic mail may be sent to [email protected] Received: May 13, 1998 Accepted: February 8, 1999 Although the development of exposure-based treatment marked a breakthrough in treatment for people with agoraphobia or obsessive—compulsive disorder (OCD), the results of this treatment are not consistently satisfactory. The majority of patients completing treatment may improve ( Jacobson, Wilson, & Tupper,1988 ; Stanley & Turner, 1995 ), but only a minority recover normal functioning (e.g., Jacobson et al.,1988 ). Consideration of treatment dropout and refusal further lowers the apparent success rate ( Jansson &Ost, 1982 ; Stanley & Turner, 1995 ). Thus, it is important to identify variables associated with poor treatment response that may point to additional interventions to improve outcome. In the present investigation, we examined the utility of expressed emotion (EE) as such a predictor. Journal of Consulting and Clinical Psychology © 1999 by the American Psychological Association October 1999 Vol. 67, No. 5, 658-665 For personal use only--not for distribution.Page 2 of 15http://spider.apa.org/ftdocs/ccp/1999/october/ccp675658.html 8/30/2000EE refers to family members' feelings about an identified patient and includes emotional overinvolvement (EOI), criticism, and hostility. In a meta-analysis of EE research, Butzlaff and Hooley (1998 ) determined the average effect sizes for EE prediction of relapse for patients with affective disorder and with schizophrenia to be substantial and statistically significant ( r s = .39 and .30, respectively). Similar findings were observed in the few studies on eating disorders ( r = .51). EE's relationship to treatment outcome has been infrequently examined for patients with anxiety disorders. In a sample of 31 patients with posttraumatic stress disorder (PTSD), Tarrier, Sommerfield, and Pilgrim (inpress ) reported that higher criticism and hostility (but not EOI) predicted less change at posttest after treatment with imaginal exposure. Most relatives were spouses. Assessing the role of EE in spouses of agoraphobic patients, Peter and Hand (1988 ) reported unusual findings: Higher criticism tended to predict better outcome 1 to 2 years after behavior therapy; posttest findings were not significant. The authors proposed that more critical spouses might tolerate less dependency in their agoraphobic partners and pressure them to improve more. Although these findings are intriguing, their interpretation is made difficult by the small sample ( N = 20) and questionable data-analytic strategies. Two prospective studies of predictive factors in OCD have included measures that directly or indirectly assessed EE-related constructs. Using unvalidated interview measures, Steketee (1993 ) examined patients' and relatives' perceptions of familial interactions in relation to outcome 9 months after behavior therapy. Poor family functioning assessed before treatment, as well as negative household interactions (especially anger and criticism), predicted fewer gains at follow-up. In a study of children with OCD treated with pharmacotherapy, Leonard et al. (1993 ) found that children living with high-EE parents had poorer global adjustment at 2- to 7-year follow-up compared with children in low-EE households, but EE failed to predict OCD symptoms per se. Because only one third of the children received exposure and response prevention, no clear conclusions can be drawn about family factors as predictors of outcome for behavior therapy from this research. These few reports provide a mixed picture of the association of EE to outcome for anxiety disorders. Findings for agoraphobic patients do not accord with those for OCD and PTSD patients, but too little data from studies conducted with sound methodology and standard measures of EE are available to permit solid conclusions. To further this research, in the present study we examined the effects of EE on treatment outcome in a prospective study of response to outpatient behavior therapy for agoraphobia and for OCD. In addition, we examined the effects of two possible moderators of EE's relationship to outcome drawn from prior research on other patient populations: medication use and number of hours of contact with the relative weekly (see review by Hooley, 1985 ). Like Tarrier et al. (in press ) and Peter and Hand (1988 ), we used the benchmark EE measure, the Camberwell Family Interview (CFI; Vaughn & Leff, 1976 ). This measure is derived from an interview with the relative in the patient's absence and coded by trained raters for
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