The expressed emotion of case managers of the seriously mentally ill: the influence of expressed emotion on clinical outcomes

Background. Expressed emotion (EE) measured from relatives and informal carers has been consistently demonstrated to be associated with clinical outcome in schizophrenic patients. There have also been published studies that have investigated EE in professional carers that have suggested that the quality of the relationship between staff and patient may also be associated with patient outcomes. A large controlled trial of the effectiveness of different intensities of case management provided the opportunity to assess the association between the EE of case managers, including the quality of the relationship they had with patients under their care, and later clinical outcomes.

Method. This was a prospective naturalistic study of EE present in a case manager–patient dyad and subsequent patient outcomes. EE was assessed from the Five Minute Speech Sample (FMSS) at least 3 months after the case manager became responsible for the patient's care and a range of clinical outcomes were assessed 6 to 9 months later. Assessment of clinical outcomes was made independent and blind of the EE ratings.

Results. High EE ratings were significantly associated with individual case managers and not to symptom or illness factors. High EE was not associated with later clinical outcome, however, the positive relationship between case manager and patient was. The absence of a positive relationship was significantly associated with poorer outcomes.

Conclusions. In spite of very low face-to-face contact between case managers and patients, compared with the amount of contact patients have with their informal carers and family, aspects of staff attitudes and behaviour did influence clinical outcome. There are potential implications of these results for staff training and clinical practice.