Part 19 of The Mental Health Workers' Guide looks at High Expressed emotion (HEE) in mental health care. Don't forget that you can download the podcasts and video clips that accompany this series here.

Buy the entire series as an Ebook here

Remember the three types of High Expressed Emotion (HEE) we identified in the last session. These are…

1.       Criticism

2.       Hostility and Aggression

3.       Over Emotional Involvement

It can be difficult to challenge these often deeply ingrained patterns of behaviour and yet recovery is much more likely in low expressed emotion environments than in high expressed emotion households or units. A good rule of thumb is to approach the subject from the perspective of normal reactions to extremely difficult circumstances.

Some practitioners see HEE as a way to blame families for their relative’s problems which is rarely helpful and almost never entirely true. Even when it is true (let’s face it sometimes familial trauma really is the cause of the problem) it rarely helps to go around accusing people. Very few people respond well to being blamed and I’ve never met anyone who was encouraged to change for the better by somebody else treating them badly.

I am talking as much about care workers here as I am about families by the way. There are many people at all levels in mental health care who carry extremely judgemental attitudes and seem quite happy to criticise, threaten and even physically hurt their service users, patients and clients. This is High Expressed Emotion (HEE) at its most destructive.

I’ve made this point before but I think it bears repeating:

If you work with mentally disordered people, don’t get angry with

them when they behave like mentally disordered people.

To do so says much more about you and your unsuitability for this line of work as it does about the people you are pretending to care for.

Let’s look briefly at these three categories of destructive behaviour in turn…

Criticism: Success breeds success. If you want to help someone to do better then don’t catch them doing it wrong – catch them doing it right. By acknowledging and commenting positively upon people’s successes, however small, you encourage then to strive for even greater achievement. Little by little even the most debilitating mental disorders can be alleviated and even overcome completely in time.

Criticism has the opposite effect. Criticism demoralises people. Criticism encourages people to give up, to stop risking failure and when that happens growth and coping skill development ceases too. Criticism is not the way to move people on – it is the way to trap them in their disorder and to ensure that they never overcome it. They never overcome your critical attitude.

If you really must criticise – do so elsewhere. This is not the job for you.

Hostility and aggression: You catch more bees with honey than with vinegar. People are unlikely to respond positively to you if you are hostile or aggressive. On the contrary their defences will go up, they will avoid you – or worse fight back – and you will lose any opportunity you might have had for constructive work.

You also become a major source of stress for that person. We have already covered the stress and vulnerability model so it should come as no surprise to learn that stressful relationships with relatives or workers can cause relapse and prevent mental health recovery. This does not mean that relatives who are hostile are ‘bad’ people – they are responding like ordinary people faced with extraordinary problems.

Unlike mental health workers, relatives didn’t ask for this situation – they had it thrust upon them and are doing the best they can with the resources they have available.

But all that aside the fact remains – if they are to remain in contact with their relative then they need to know how to respond to them and hostility isn’t helpful.

Workers who use hostility and aggression might deserve a little less sympathy and understanding. They have chosen to do this work and they have accepted a duty of care to do their work appropriately. My own view is that hostile workers should not be allowed to continue working in this way and if they refuse to change they should be removed from their positions altogether. That may seem a little uncompromising but let’s face it – mental health work is about working for the benefit of patients, clients and service users.

It’s not about us.

Emotional over involvement: This one is far more common and far more insipid than the other two categories of expressed emotion. It’s something that many mental health workers and relatives are guilty of. It’s the result of caring too much and of trying too hard.

Life involves risk and it involves experiencing and learning to cope with a range of problems and a range of distressing emotions too.

We only learn to cope with emotional or practical problems by facing them – and sometimes we fail. If we are ‘protected’ from that process we never develop. We don’t learn coping skills. We don’t learn emotional management. We don’t ‘improve’.

The same is true for service users. If workers and relatives protect them from problems and distress; if we protect people from the realities of life then they will never learn to deal with them and so they will never overcome their present problems – we prevent them from learning how.

This is called over ‘emotional’ involvement because it tends to be emotionally driven.

People get scared that others will think badly of them if their service user doesn’t succeed. They have an emotional fear of being judged as incompetent or unsupportive and so they remove the risk by becoming over protective. But it’s not the service user they are protecting, it’s their own emotional security.

Until we come to understand that progress involves distress and learning involves short-term failure we will never be able truly to overcome emotional over involvement. And neither will our service users.

I’ll end this section with a parable…..

A young man with psychosis wanted to go on a day trip to Blackpool. His support worker (this could equally be relative or other carer) was worried that he may get lost or ‘led astray’ in a strange town. So she prevented him from doing so. She used every ploy she could think of before eventually becoming direct and simply insisting that he didn’t go. She explained that she was worried that something terrible might happen to him if he went.

The trouble is that something terrible has already happened to him.

This overly emotionally involved support worker has happened to him.