The present study investigated expressed emotion among adolescents with NSSI, CC, and NC adolescents. To date, this is the first study including both maternal expressed emotion toward adolescents with NSSI, CC, and NC as well as adolescent expressed emotion toward their mothers.
We found that adolescent high expressed emotion was more common in the NSSI and CC groups than in the NC group, cautiously supporting the findings that high expressed emotion is associated with psychopathology (21, 31). Adolescents with NSSI expressed significantly more covert criticism and critical tone toward their mothers than CC and NC adolescents. This is in line with previous studies showing that mother–child interactions of adolescents with NSSI are characterized by anger and conflict (9). Referring to Crowell et al. (9)impulsive and emotionally sensitive adolescents may experience difficulty inhibiting extreme emotions when faced with high expressed emotion by family members. The greater difficulties with impulse control of adolescents with NSSI compared to CC adolescents (32) may explain the higher level of covert criticism and critical tone toward mothers among adolescents with NSSI. Further, adolescents with NSSI reported less emotional clarity than CC adolescents, underlining the positive relationship between difficulty in identifying emotions and NSSI (33).
As expected, the concordance between adolescent and maternal expressed emotion status in the present study was moderate. This is in line with several studies indicating that informants reports correlate at low-to-moderate magnitudes (34, 35). Nevertheless, the significant correlation between adolescent and maternal high expressed emotion in the present study suggests a reciprocal relationship between maternal and adolescent expressed emotion in NSSI. Expressed emotion research on bulimia nervosa indicated that the match in parent and adolescent expressed emotion status may impact treatment outcome. The smallest symptom reduction was reported for the group in which patients showed high expressed emotion and parents low expressed emotion (20). Therefore, future studies should analyze different family profiles (high expressed emotion mother/high expressed emotion adolescent, high expressed emotion mother/low expressed emotion adolescent, high expressed emotion adolescent/low expressed emotion mother, and low expressed emotion mother/low expressed emotion adolescent) and their impact on the course of NSSI and treatment outcome. Longitudinal studies are needed to understand the direction of the association between maternal and adolescent high expressed emotion and NSSI.
According to the comprehensive model of NSSI (5, 36), maternal high expressed emotion reflects a distal risk factor for NSSI, while high expressed emotion exhibited by adolescents can be understood as a result of adolescent emotion regulation difficulties and poor communication and problem-solving skills. However, a child’s psychopathological symptoms may also elicit expressed emotion from their parents. Results from a longitudinal study examining perceived expressed emotion showed that both internalizing and externalizing symptoms in adolescents predicted adolescents’ perception of maternal expressed emotion, as well as mothers’ self-rated criticism over time (37). In accordance with previous research (25, 38), adolescent and maternal high expressed emotion status in the present study referred primarily to criticism and only to a small extent to emotional overinvolvement. Self-report data showed that adolescents with NSSI indicated higher parental intrusiveness than adolescents without NSSI (17). As suggested by Rienecke (38), current measures of emotional overinvolvement may assess different components of emotional overinvolvement.
Limitations and Strengths
Given the small sample size and the uneven distribution of groups, especially in the sample of mothers, the results of the present study must be interpreted with caution. The results are further limited that expressed emotion was only assessed in female adolescents and mothers and not in male adolescents and fathers. Future studies should include all genders since previous research has found gender differences in the association between maternal criticism and NSSI (12, 16). The use of a cross-sectional design further limits the conclusions about the direction of the effects between adolescent symptomatology and adolescent/maternal high expressed emotion.
The strengths of this study include the use of the FMSS as a reliable and valid measure for expressed emotion, the bidirectional approach, including adolescent and maternal expressed emotion levels and the inclusion of a clinical and a nonclinical control group.
The definition of emotional overinvolvement in the FMSS, also used in the present study, differs from the definition in the Levels of Expressed Emotion Scale used by Ammerman and Brown (2018). Emotional overinvolvement in the FMSS is defined by self-sacrificing and overprotective attitudes of mothers as well as nonverbal signs of overinvolvement during the monologue (e.g., crying), while the intrusiveness subscale of the Levels of Expressed Emotion Scale primarily refers to controlling parenting behaviors and intrusions of privacy. Furthermore, perceived parental emotional overinvolvement may not correspond with interviewer-rated emotional overinvolvement; this should be addressed in further studies. Therefore, it remains to be clarified if emotional overinvolvement is influential in the engagement and maintenance of NSSI. Further research is needed to examine the validity of the FMSS and especially the operationalization of emotional overinvolvement in samples of adolescents with expressed emotion.
Reciprocal processes between adolescents and parents (e.g., high expressed emotion) as well as parental (e.g., heightened stress) and child (e.g., impulsivity) contributors leading to insufficient parent–child interactions should be considered in the maintenance of NSSI. The burden of caring for an adolescent with NSSI (39, 40) and changes in parenting behavior as reactions to NSSI, for example, more controlling behavior and rule setting (8, 41) may affect parent–child interactions.
NSSI can be conceptualized as a high-cost communication behavior when other behaviors have failed to elicit a response from the family environment (36). Considering the three ways in which caregivers can affect child adjustment (42), high levels of expressed emotion represent an interaction style that negatively reinforces emotional arousal. Therefore, the findings suggest that it is important to examine adolescent expressed emotion in addition to parental expressed emotion, to gain a better understanding of the reciprocal parent–child interactions in families of adolescents with NSSI.
Effective treatments for NSSI, such as the dialectical behavior therapy for adolescents (DBT-A) 43–45 or the emotion regulation individual therapy for adolescents (ERITA) (43, 44), target emotion regulation and interpersonal functioning, especially within the family, and offer the possibility of including the family or parents in the adolescent’s treatment. Breaking a vicious cycle between adolescents and parents characterized by frustration and criticism and reestablishing more functional family patterns can reduce high expressed emotion (45). Given that adolescents with NSSI reported fewer positive aspects in the mother–child relationship than NC adolescents, interventions should not focus merely on the reduction of negative relationship aspects but also on the enhancement of positive relationship quality.