Expressed Emotion in Families of Adolescents with Obsessive–Compulsive Disorder

The term “Expressed Emotion” (EE) in mental health is used to describe the way in which family members or close members of the support network express their emotions toward a person with mental health difficulties. EE may take on a negative form (negative expressed emotion), when hostility, intense criticism, or excessive emotional involvement predominate, or a positive form (positive expressed emotion), when it is manifested through care, understanding, a supportive attitude, and positive remarks.

During adolescence, when OCD often presents with intense symptoms, negative expressed emotion can exert a particularly detrimental impact on family relationships.

Negative Expressed Emotion: Criticism and Hostility

Criticism and hostility represent one of the most characteristic forms of negative expressed emotion in families of adolescents with OCD.

Examples of criticism and hostility may include phrases such as: ““Don’t you have any sense of responsibility?”“…,” which convey disapproval and anger toward the adolescents’ compulsions. Similarly, nonverbal reactions such as a heavy sigh or a sarcastic smile reinforce the same negative message, even in the absence of words.

Although parents often believe that by acting in this way they are “shaking” the adolescent into recognizing the seriousness of the situation, in reality criticism and hostility further burden the child with guilt, anxiety, and disappointment, fostering a negative climate in family relationships. Research evidence supports this view: in the study by Hibbs et al. (1991), parents of adolescents with OCD expressed higher levels of critical comments and emotional overinvolvement compared to parents of children without an OCD diagnosis, while according to Valleni-Basile et al. (1995), adolescents with OCD reported receiving less emotional support and warmth from their families compared to peers without the disorder.

Emotional Overinvolvement

An equally important form of negative expressed emotion is emotional overinvolvement, which often manifests as an overprotective stance. Driven by excessive worry, parents may find it difficult to tolerate their child’s distress and therefore intervene constantly in an effort to alleviate it. As a result, the adolescent is not encouraged to develop autonomy or to cultivate psychological resilience.

Examples of such attitudes include:

– the constant effort to protect the child from situations that cause them distress

– excessive worry about even the slightest discomfort or failure of the adolescent

– the neglect of parents’ own personal needs, as their entire daily routine often revolves around their child’s disorder

Although such behaviors stem from care and concern, in practice they reinforce adolescents’ dependence on their parents and undermine the effectiveness of treatment. This is particularly evident in Exposure and Response Prevention (ERP), where the goal is for the adolescent to learn to tolerate distress without resorting to compulsions. In this context, an overprotective parental stance acts as an obstacle to the effectiveness of the therapeutic process.

Positive Expressed Emotion

In contrast, positive expressed emotion is associated with more positive outcomes in the course of the disorder. It is manifested when parents and other family members demonstrate acceptance, understanding, and encouragement toward the adolescent.

Examples of positive expressed emotion include:

– expressions of understanding

– recognition of effort

– an attitude of support and warmth

A family climate characterized by high levels of positive expressed emotion reduces the pressure experienced by the adolescent, strengthens self-esteem, and facilitates the therapeutic process.

In summary

Expressed emotion constitutes a key factor in the course of OCD during adolescence. Excessive criticism, hostility, and overprotectiveness—despite parents’ good intentions—exacerbate symptoms, hinder the adolescent’s autonomy, and limit the effectiveness of treatment. In contrast, positive expressed emotion, conveyed through acceptance, understanding, and encouragement, contributes to therapeutic progress and strengthens the adolescent’s psychological resilience.

Psychoeducation and family guidance can play a crucial role in this process. When parents gain a clearer understanding of the nature of OCD and the importance of how they express their emotions, they learn to reduce criticism and overprotectiveness, to tolerate their child’s distress without constant interventions, and to set boundaries with respect. In this way, they foster the adolescent’s autonomy and contribute not only to the course of treatment but also to the overall quality of family relationships.

Sources:

Χαλιμούρδας, Θ., Ματσούκα, Ε., Ευστρατιάδου, Σ., & Βαιδάκης, Α. (2023). Οικογένεια και ιδεοψυχαναγκαστική διαταραχή: Η αξιοποίηση της οικογένειας στη διαχείριση της συμπτωματολογίας και στη θεραπεία της ΙΨΔ. Αθήνα: Εκδόσεις Βήτα.

Hibbs, E. D., Hamburger, S. D., Lenane, M., Rapoport, J. L., Kruesi, M. J., Keysor C. S., & Goldstein, M. J. (1991). Determinants of expressed emotion in families of disturbed and normal children. Journal of Child Psychology and Psychiatry, 32(5), 757–770. https://doi.org/10.1111/j.1469-7610.1991.tb01900.x

Valleni-Basile, L. A., Garrison, C. Z., Jackson, K. L., Waller, J. L., McKeown, R. E., Addy, C. L., & Cuffe, S. P. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 33(6), 782–791. https://doi.org/10.1097/00004583-199407000-00002