Understanding Expressed Emotion mechanisms : an investigation of behavioural control, attributions and distress in relatives of people with psychosis

The University of Manchester Candidate: Débora Antoniotti de Vasconcelos e Sá A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Medical and Human Sciences in December 2013 Thesis title: Understanding Expressed Emotion mechanisms: An investigation of behavioural control, attributions and distress in relatives of people with psychosis Research indicates that certain family environments can impact negatively on psychosis. Expressed Emotion (EE) in relatives is a reliable measure of the individual’s interpersonal family environment that has been shown to predict relapse. However, the factors contributing to the development of EE in this condition and the mechanisms by which EE leads to relapse are still poorly understood. Relatives’ control attributions and behaviours have been linked to EE, and controlling behaviours have been found to be predictive of relapse. This thesis investigated the role of behavioural control, controllability and self-blame attributions in highand low-EE relatives of individuals with psychosis, and explored the impact of these cognitions and behavioural responses on patient’s symptom outcomes and on relative’s distress. The first empirical study (Study 1) utilised a cross-sectional design to compare types of behavioural control attempts (direct influencing vs. buffering) in high-EE-critical/hostile and high-EEoverinvolved relatives of patients with recent-onset psychosis; and examined whether behavioural control attempts and controllability attributions differed for the highand low-EE relatives. The links between relatives’ behavioural control and patient relapse were also explored. Results confirmed that types of behaviours (direct influencing and buffering) were associated with different sets of beliefs (about controllability) and with different types of EE (criticism and EOI). However, EE, controllability attributions, nor behavioural control predicted patient relapse. Study 2 used a cross-sectional design to explore the links between self-blame attributions and distress, and self-blame attributions and behavioural control in recent-onset relatives. Results showed that selfblame attributions predicted relatives’ controlling behaviours towards the patient. Relatives who blame themselves did so for not overseeing their family member’s mental health problems properly or for perceiving themselves generally as poor carers. However, self-blame was not predictive of distress. The final empirical study (Study 3) examined temporal associations between contact with high/low EE relatives, behavioural control, affect and symptom experiences in the daily life of patient-relative dyads experiencing psychosis, using experience sampling methodology. Findings revealed that contact with high/low-EE relatives per se did not impact on patient’s symptom experiences or affect, but behaviourally controlling interactions did, suggesting that the measure of behavioural interactions rather than the EE status of the relative may be more sensitive to momentary fluctuations in patients’ symptoms. Momentary self-reports of relatives’ behavioural responses were also linked with their negative affect. This thesis evidenced that relatives’ controllability and self-blame attributions and behavioural control are associated in significant and meaningful ways with psychosis experiences and can impact both patient and relative outcomes, shedding some light into the EE mechanisms that relate to relapse and to the development of EE responses in relatives. However, more work is needed to further understand how these mechanisms operate, particularly in high-EE-overinvolved or low-EE relatives, in order to increase our knowledge about relapse prevention. The findings highlighted that the concept of behavioural control should be considered in future clinical work with families experiencing psychosis.