Article
Reference
Attachment and couple satisfaction as predictors of expressed emotion in women facing breast cancer and their partners in the
immediate post-surgery period
FAVEZ, Nicolas, et al.
Abstract
To investigate expressed emotion (EE) in couples facing breast cancer in the immediate post-surgery period. EE may be predictive of psychological disturbances that hinder both partners' capacities to cope with the stress of the disease. Severity of the disease, attachment tendencies, and couple satisfaction were tested as predictors of EE.
FAVEZ, Nicolas, et al. Attachment and couple satisfaction as predictors of expressed emotion in women facing breast cancer and their partners in the immediate post-surgery period. British Journal of Health Psychology, 2017, vol. 22, no. 1, p. 169-185
DOI : 10.1111/bjhp.12223 PMID : 27882634
Available at:
http://archive-ouverte.unige.ch/unige:93310
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Attachment and couple satisfaction as predictors of expressed emotion in women facing breast cancer and their partners in the immediate postsurgery period
Nicolas Favez, Sarah Cairo Notari, Tania Antonini, Linda Charvoz
Author Note
Nicolas Favez, Sarah Cairo Notari, and Tania Antonini, Faculty of Psychology and Educational Sciences, University of Geneva, Switzerland ; Linda Charvoz, University of Applied Sciences and Arts Western Switzerland, Social Work, Lausanne, Switzerland
This project benefited from the support of the Swiss National Centre of Competence in Research LIVES – Overcoming vulnerability: life course perspectives, which is financed by the Swiss National Science Foundation, and of the Swiss Cancer League, grant KLS 3396-02- 2014
Correspondence concerning this article should be addressed to Nicolas Favez, Faculty of Psychology and Educational Sciences, University of Geneva, Boulevard du Pont d’Arve 40, 1211 Geneva 4, Switzerland. E-mail: [email protected]. Tel.: +41 22 3799403. Fax:
+41 22 3790639.
Word count (excluding abstract, references, and tables): 5240
Abstract
Objectives. To investigate expressed emotion (EE) in couples facing breast cancer in the immediate postsurgery period. EE may be predictive of psychological disturbances that hinder both partners' capacities to cope with the stress of the disease. Severity of the disease,
attachment tendencies, and couple satisfaction were tested as predictors of EE.
Design. The design was cross-sectional. Couples (N = 61) were interviewed 2 weeks after the women’s breast surgery.
Methods. EE was assessed in women and in partners with the Five Minute Speech Sample, with a focus on overt and covert criticisms. Self-reported EE, attachment tendencies, and couple satisfaction were assessed with questionnaires. Hierarchical regression analyses were performed to test the predictors and possible interactions between them.
Results. Both partners expressed overt and covert criticisms; women expressed more overt criticisms than did their partners. Cancer stage was inversely related to the number of overt criticisms in women and to the number of covert criticisms in partners. Regression analyses showed that in women, higher attachment anxiety and lower couple satisfaction were positive predictors of overt criticisms; in partners, a higher cancer stage was a negative predictor of overt and covert criticisms.
Conclusions. Practitioners should pay attention to the couple relationship in breast cancer. EE is most likely to appear when the cancer stage is low, showing that even when the medical prognosis is optimal, relational and emotional disturbances may occur.
Attachment and couple satisfaction as predictors of expressed emotion in women facing breast cancer and their partners in the immediate postsurgery period
Breast cancer is a major stressful event. Women have to cope not only with the somatic symptoms related to the disease and its treatment, but also with its emotional consequences (Manne et al., 2004; Northouse et al., 2002; Schmid-Büchi, Halfens, Dassen, & Van Den Borne, 2008). Unsuccessful coping with the stress of this situation may result in elevated levels of psychological distress, which may, in turn, be predictive of psychological disturbances in the following years (e.g., depression, anxiety, body image, and sexual disturbances), independently of the evolution of the cancer (Rottman et al., 2015; Silva, Crespo, & Canavarro, 2012). Similarly, partners have to face a highly challenging situation.
On the one hand, they find themselves in the role of an ‘informal caregiver’, with the duties of helping the women and taking over some (if not all) household chores; on the other hand, they have to cope with their own stress and fear of losing their loved ones (Cairo Notari, Favez, Notari, Charvoz, & Delaloye, 2016; Stenberg, Ruland, & Miaskowski, 2010; Wagner, Tanmoy Das, Bigatti, & Storniolo, 2011). A supporting couple relationship, at the emotional and instrumental levels, is a major factor of resilience in these situations (Giese-Davis, Hermanson, Koopman, Weibel, & Spiegel, 2000; Manne et al., 2004). It is thus crucial to identify signs of deterioration in the relationship as soon as possible, as couple dissatisfaction will have detrimental consequences on the ability of both partners to cope with the stress of the disease, and may in itself be predictive of anxiety and depression (Kayser & Scott, 2008).
Expressed emotion (EE) is a construct that has been designed to describe the emotional attitudes of close relatives of individuals with a medical condition (Brown & Rutter, 1966).
The EE construct was originally developed in order to understand the impact of family relationships on the clinical outcomes of patients with psychiatric disorders, principally schizophrenia (Brown, Carstairs, & Topping, 1958). EE refers in particular to negative
statements, such as criticism or hostility, and to emotional overinvolvement. Criticism refers to critical comments showing dissatisfaction or disapproval with the patient’s actions and behaviours, hostility refers to critical comments toward the personality of the patient (and not only actions and behaviours), and overinvolvement refers to exaggerated emotional responses in the relatives or markedly overprotective behaviours. Numerous studies have shown
associations between EE in the family and the worsening of the psychological functioning of patients (especially in terms of likelihood of relapse). High EE – the formulation of numerous overprotective and negative statements – has been shown to impair coping aptitudes in
patients, and hence lead to an increase in symptoms (for reviews, see Butzlaff & Hooley, 1998; Hooley, 2007). The predictive value of EE has induced researchers to investigate its effect on the aptitude to cope with the stress of medical and health conditions other than psychiatric conditions, such as traumatic brain injury, Type 1 diabetes, rheumatoid arthritis, chronic pain, or chronic fatigue syndrome (for a review, see Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). In these cases, EE has been shown to be a significant predictor of increased symptoms and of negative psychological outcomes such as depression, anxiety, and couple dissatisfaction (Alway, McKay, Ponsford, & Schönberger, 2012; Band, Barrowclough,
& Wearden, 2014; Weddell, 2010). While some studies have taken into account EE in the patient’s family (e.g., parents, children), several studies have specifically pointed out the role of romantic partners (Ballús-Creus, Rangel, Peñarroya, Pérez, & Leff, 2014; Burns et al., 2013; Wearden, Tarrier, & Davies, 2000; Wearden, Ward, Barrowclough, Tarrier, & Davies, 2006). Studies have also shown that the impact of EE is mutual: not only does EE in partners affect the patients, but EE in patients affects the psychological well-being of the partners (Benazon, Foster, & Coyne, 2006; Möller-Leimkühler & Jandl, 2011). In general, independently of the medical context, individuals with low couple satisfaction tend to be
more critical (Gavazzi, McKenry, Jacobson, Julian, & Lohman, 2000; Gottman, 1998;
Rogosch, Cicchetti, & Toth, 2004).
The presence and possible impact of EE in couples facing breast cancer has not yet been assessed. There are, however, clues indicating the relevance of considering EE in this context.
Studies assessing couple’s support in breast cancer have, for example, shown that partners’
critical comments are at the core of behaviours tagged as ‘unsupportive’ by patients and that they are linked to higher levels of psychological distress (Figueiredo, Fries, & Ingram, 2004;
Manne, Ostroff, Winkel, Grana, & Fox, 2005; Manne et al., 2014). The application of EE in the context of breast cancer could thus provide a powerful screening tool for relationships at risk.
Although the medical or psychiatric condition of a patient and the satisfaction in the couple relationship are among the predictors of EE, other psychological characteristics of individuals also play a role. EE is, for example, linked with the attributional style of the individual (Barrowclough & Hooley, 2003; Wearden et al., 2006): the more the partner tends to consider that the patient should be able to control her symptoms (or even more, is
responsible for them), the more he is likely to formulate criticisms and to show hostility.
However, a partner is unlikely to consider breast cancer as being controllable by the patient;
this variable should therefore not be central in this disease. Studies in the field of coping with aversive events have recently shown the importance of attachment tendencies in everyday life in general and in medical settings in particular (Mikulincer & Shaver, 2007). Attachment tendencies are indeed related to individual differences in the regulation of interpersonal emotions, in particular in situations of separation or possible loss of the attachment figure, that is, the partner in couple relationships (Bowlby, 1988). Attachment tendencies are thus likely to operate in breast cancer because individuals have to face a life-threatening disease.
According to the theory, attachment is a motivational system activated when individuals faces
danger. They build cognitive models derived from their attachment experiences (from infancy on), that is, from the extent to which their caregivers (who provided protection against
danger) were responsive when they requested protection; these models serve as templates for emotional regulation. Two dimensions have been described as underlying attachment models:
avoidance and anxiety. Avoidance refers to the tendency to repress emotional needs as a consequence of a history of attachment needs being rejected by the caregiver. Consequently, people with high avoidant tendencies tend to see the expression of needs as a manifestation of weakness; they ‘deactivate’ their attachment system so that they tend not to report distress when facing a negative event. Highly avoidant people should thus be less likely to be critical toward their partner when facing breast cancer. Anxiety refers to the tendency to feel
uncertainty and helplessness as a consequence of a history of unpredictability in the responses of the caregiver. People with high anxiety tendencies tend to ‘hyperactivate’ their attachment system by overemphasizing their inability to cope with threatening situations in order to
‘force’ the social environment to provide protection. They do this either by showing helplessness, or by showing increased negativity and hostility. It is thus likely that anxious tendencies will be linked with a tendency to be critical toward the partner in the situation of breast cancer (Maunder, Lancee, Nolan, Hunter, & Tannenbaum 2006; Mikulincer & Shaver, 2007, 2008). To date, the few studies that have assessed the impact of attachment in breast cancer have shown that women with anxious or avoidant tendencies have lower psychological adaptation indexes to the stress of the disease (Favez et al., 2015; Rodin et al., 2007; Tacón, Caldera, & Bell, 2001).
The first aim of this study was to investigate the extent to which EE is shown in couples facing breast cancer; its second aim was to test predictors of EE. We focused on the
characteristics of the disease (the cancer stage) and of the treatment (surgery and adjuvant treatments) – considered the source of stress that may trigger EE – on couple satisfaction and
on attachment tendencies as psychological predictors. We specifically hypothesized that the more that partners have anxious tendencies and the less they are relationally satisfied, the more they will show EE; conversely, the more they have avoidant tendencies, the less they will show EE. We considered EE in the women and their partners because it is likely that negativism is present in both partners in distressed couples (Benazon et al., 2006).
Methods
We adopted a strategy that combined two sources of information: on the one hand, an assessment of EE through an observational situation in which each partner was filmed while speaking about the other, and on the other hand, the administration of questionnaires to assess self-reported EE, as well as the other study variables.
Sample
Sixty-one women diagnosed with non-metastatic breast cancer and their partners were recruited at the Senology Unit of the University Hospital XXX. A total of 127 women were asked to participate in the study; of these, 97 (76.4%) agreed to participate and to ask their romantic partner to participate. Sixty-one partners (62.9%) agreed to enter the study. Criteria for study inclusion were as follows: (a) the patient had a diagnosis of non-metastatic breast cancer, (b) the patient and the partner were 18 years of age or older, and (c) the patient and partner were French speaking. The main reasons for refusal to participate were the following:
no desire to be filmed, no desire of the partner to participate, too much stress, and lack of energy. Women were on average 52.6 years old (SD = 11.2) and men were on average 54.3 years old (SD = 11.9). The mean duration of relationship was 24.6 years (SD = 16.5). Eleven patients had in situ breast cancer: 22 stage I, 18 stage II, and 10 stage III.
Treatment data were as follows: concerning surgery, 33 patients underwent
mastectomy, 28 lumpectomy, and 18 axillary lymph node dissection; concerning adjuvant treatments, 9 women underwent chemotherapy, 14 radiotherapy, and 18 hormonal therapy.
Procedure
Recruitment took place between September 2011 and December 2013. The proposal to take part in the research was done by the referent nurse of the Senology Unit during pre- hospital consultation (1-2 weeks before surgery). Patients and their partners received documentation on the research and signed an informed consent form. At the end of the first postsurgical consultation, the Five Minute Speech Sample (FMSS; see below) was proposed to both partners, who completed it separately. Debriefing was done after the FMSS with the referent nurse. Couples were then asked to complete a set of self-reported questionnaires at home. Two self-addressed stamped envelopes (one for the patient and one for the partner) were provided to participants with instructions to send the completed questionnaires to the referent nurse within a month. It was not possible to strictly standardize the time intervals between surgery and participation in the study, mainly because of practical constraints. On average, the interval was 3 weeks between surgery and the FMSS (range: 2–5 weeks).
Participants received compensation of XXX 30.- for their participation. This procedure and its protocol received approval from the Ethical Committee of the XXX, where the University Hospital is located.
Five Minute Speech Sample
EE was assessed with the FMSS (Magaña, Goldstein, Karno, Miklowitz, & Falloon, 1986). In this method, each participant is asked to talk about her/his partner and the couple relationship for 5 minutes. While one partner speaks, the other waits in an adjacent room. The instruction is as follows: ‘I’d like to hear your thoughts about your partner in your own words and without my interrupting you with any questions or comments. When I ask you to begin,
I’d like you to speak for 5 minutes, telling me what kind of a person your partner is and how the two of you get along together. After you have begun to speak, I prefer not to answer any questions. Are there any questions you would like to ask me before we begin?’
The speech is videotaped and the verbal content coded for EE. We used a standardized coding grid that combined the original coding tool (Magaña et al., 1986) with a review of the tool for the coding of covert criticisms (Leeb et al., 1991). Coding is performed in five
categories. The first two categories are given nominal labels: (i) The initial statement (i.e., the first statement of the speech) is coded according to its emotional valence as negative, neutral, or positive and (ii) each occurrence of a statement referring to the relationship is coded as negative, neutral, or positive; the most represented of the three valences in the number of statements gives the final label for this category. The other three categories are coded on a frequency basis: (iii) overt criticisms (e.g., ‘My partner never helps me with housework’), (iv) covert criticisms (e.g., ‘My mother thinks that my partner doesn’t help me enough with
housework’), and (v) overinvolvement statements (e.g., ‘Most of my life I had to take care for my partner’).
Coding strategy
An expert in the coding system trained the two coders who were involved in this study.
In order to establish interrater reliability, the two coders rated all the FMSSs independently.
Kappas were .75 and .62 for the coding of the initial statement of the women and that of the partners, respectively, and .30 and .46 for the coding of the relationship of the women and that of the partners, respectively. Intraclass correlation coefficients (ICCs) were .82 and .92 for the coding of the overt criticisms of the women and that of the partners, respectively, and .84 and .86 for the coding of covert criticisms of the women and that of the partners, respectively.
ICC could not be computed for overinvolvement statements, as this comment was almost
non-existent for both women and partners. Disagreements were discussed and consensus was found in order to establish the final coding used for the analyses.
Questionnaires
Self-reported EE was assessed with the Family Attitude Scale (FAS; Kavanagh et al., 1997; French version, Vandeleur, Kavanagh, Favez, Castelao, & Preisig, 2013). The FAS is a 30-item questionnaire assessing the informant’s EE through positive and negative attitudes and behaviours toward the partner (e.g., ‘He/she is a real burden’; ‘I enjoy being with him/her’). The instruction is ‘Please say how often each statement is true of your relative at the moment’. Each item is assessed according to its frequency: every day, most days, some days, very rarely, never. Answers are converted to scores from 4 to 0 for the negative items and to scores from 0 to 4 for the positive items. A total score of between 0 and 120 is
computed by summing the scores of the items ( = .97 for the patients and .92 for the partners in this study). The higher the score, the higher the EE.
Couple satisfaction was assessed with the Relationship Assessment Scale (Hendrick, 1988; French version Charvoz & Cairo, 2010). This questionnaire contains seven items that assess, on Likert scales from 1 (low) to 5 (high), couple satisfaction (e.g., ‘To what extent has your relationship met your original expectations?’). A total score of between 1 and 5 is
obtained by computing the mean of the seven scales (two items are reverse scored; = .93 for the patients and .85 for the partners in this study). The higher the score, the higher the
satisfaction.
Attachment was assessed with the Revised Experiences in Close Relationships questionnaire (Fraley, Waller, & Brennan, 2000; French version Favez, Tissot, Ghisletta, Golay, & Cairo Notari, 2016). This instrument consists of 36 items that assess, on Likert scales from 1 (disagree strongly) to 7 (agree strongly), the two dimensions of anxiety (18
items; e.g., ‘I'm afraid that I will lose my partner's love’) and avoidance (18 items; e.g., ‘I find it difficult to allow myself to depend on romantic partners’). A total score of between 1 and 7 was obtained for each dimension by computing the mean of the 18 items related to avoidance (12 items are reverse scored; = .88 for the patients and .82 for the partners in this study) and to anxiety (two items are reverse scored; = .91 for the patients and .86 for the partners in this study).
Statistical analyses
We first computed a set of descriptive statistics in order to describe EE in the FMSSs of the women and their partners for the entire sample (N = 61). The following variables of the coding system were not considered beyond this descriptive phase: the initial statement, as there was almost no variance in the results; the valence of the relationship, as interrater reliability was very low; and overinvolvement statements, as they were almost non-existent.
We consequently focused on the frequencies of overt and covert criticisms. We then
computed correlations between criticisms in the FMSSs and the self-reported EE in the FAS questionnaire in order to perform cross-method validation of the EEs in our sample.
Second, we tested the predictors of EE. Ten patients and partners were excluded from this phase, as they did not completely fill out the questionnaires (the a priori criterion for exclusion was any missing answer, but in the 10 cases, one or more questionnaires were entirely missing). The sample size was thus smaller for this second part of the analyses (N = 51). To avoid common-method bias, we used data from the questionnaires as predictors and data from the FMSSs as dependent variables. We first investigated the bivariate links between variables by computing a correlation matrix. We then computed regression analyses by using the characteristics of the disease and of the treatment, attachment tendencies, and couple satisfaction as predictors and the overt and covert criticisms as dependent variables. As the dependent variables were count variables, we computed Poisson regression models. We used
the corrected Akaike information criterion (AICC) for small sample sizes to compare the relative likelihood of the models. All statistical analyses were performed with IBM SPSS 23 software.
Results Description of EE
Descriptive statistics showed that 13 women and 6 partners expressed one or more overt criticisms, while 38 women and 30 men expressed one or more covert criticisms (see Table 1).
Only one woman made an overinvolvement statement; partners did not make such a
statement. Few participants began the FMSS directly with a negative statement (4 women and 3 partners), showing that criticisms were more likely to emerge at a later time. Finally, only 3 women and 1 partner qualified their relationship as negative.
- Insert Table 1 about here -
Comparisons of patients and partners showed that women expressed significantly more overt criticisms than did their partners, t(60) = 2.43, p = .018; there was no difference
regarding covert criticisms. The correlations between the FAS total scores and criticisms in the FMSSs showed that there were strong positive links between observed and self-reported EEs. The higher the FAS score in women, the more they expressed overt criticisms (r = .49, p
< .001); the higher the FAS score in partners, the more they expressed overt and covert criticisms (r = .35, p = .008 and r = .33, p = .013, respectively). There was no link between FAS and covert criticisms in women.
The content of the criticisms mainly concerned personality in general and were rarely focused on the disease per se, as illustrated by the following examples of criticisms made by partners: ‘She doesn’t see that I am accompanying her’ (overt); ‘She says that I am
responsible for all the problems we have to face; this is a worry’ (overt); or ‘To be calm and
quiet is difficult. One has to be constantly in action, doing something’ (covert). The criticisms made by the women were similar: ‘He lives for himself only’ (overt); ‘He is doing things for himself’ (overt); ‘He used to live as if he was alone; that’s bothering me if it goes on like that’
(overt); or ‘He is very impulsive, he talks before thinking, it bothers me’ (overt).
Predictors of EE
Preliminary analyses (t-tests) showed that neither the type of surgery nor the type of adjuvant treatment was linked with EE (each variable was used as a binary present/absent independent variable for group comparisons). As shown in Table 2, however, the cancer stage was linked with criticisms in both partners (the higher the stage, the less the women expressed overt criticisms and the less the partners expressed covert criticisms).
- Insert Table 2 about here -
The correlation matrix shows that there were several bivariate links between
attachment, couple satisfaction, and overt and covert criticisms. The more the women had anxious tendencies, the more they expressed overt criticisms, while the more the partners had avoidant tendencies, the more they tended to express covert criticisms. The more that women and partners were satisfied with their relationship, the less they expressed overt criticisms. It is of note that there is a strong correlation between the overt criticisms of women and their partners, showing that overt criticisms tend to be mutual in couples.
We then performed regression analyses in order to test the different predictors of overt and covert criticisms in women and in partners. In order to gain statistical power, we used only those variables that were significantly linked with EE either in women or in partners. A first check confirmed that the data were Poisson-distributed (one-sample Kolmogorov-
Smirnov tests all non-significant). We then tested two models for each dependent variable, the first model with cancer stage as a disease- and treatment-related predictor and the second with
cancer stage as a disease- and treatment-related predictor, but adding attachment anxiety and avoidance, as well as couple satisfaction, as psychological predictors. A third model that included interaction terms was tested, but because none of the interaction terms was a
significant predictor, these results are not presented. The same models were tested for women and for partners.
Regarding the women (see Table 3), the first model was significant, cancer stage being a significant negative predictor of overt criticisms. The predicted rate was a 49% decrease in overt criticisms for each higher level of cancer stage. The second model was also significant, although cancer stage was no longer a significant predictor: the more the women had
attachment anxiety tendencies, the more they expressed overt criticisms toward the partner (the predicted rate was 93%), and the more they were satisfied with their relationship, the less they expressed overt criticisms (the predicted rate was -54%). The AICC index was smaller for this model than for the first one. Moreover, the relative likelihood of model 1 is 1.44E-06, showing that model 2 should be preferred. There was no significant predictor for covert criticisms.
- Insert Table 3 about here -
Regarding the partners (see Table 4), the first model was significant, cancer stage being a significant negative predictor of overt criticisms. The predicted rate was a 62% decrease in overt criticisms for an increase in cancer stage. The second model was also significant, cancer stage being the only significant predictor. The AICC index was, however, smaller for this second model. The relative likelihood of model 1 is 0.0085, showing that model 2 should be preferred. The results were alike for covert criticisms: the first model was significant, cancer stage being a significant negative predictor of covert criticisms (predicted rate of - 38%), and the second model was also significant, cancer stage still being the only significant
predictor (predicted rate of -40%). The AICC index was smaller for the second model. The relative likelihood of model 1 is 0.0015, showing that model 2 should be preferred.
- Insert Table 4 about here - Discussion
The goals of this study were to examine the presence of EE among couples facing breast cancer in the immediate postsurgery period and to test their predictors among disease- and treatment-related variables, couple satisfaction, and attachment tendencies. We
specifically focused on two components of EE: overt and covert criticisms. They are at the core of the construct of EE, as they have been shown to be especially detrimental to the couple relationship and predictive of negative psychological outcomes in both partners in medical contexts.
First, EE was observed in several women and partners, showing the validity of this construct to screen for possible relational distress in couples facing breast cancer. This is a confirmation that EE may be present in both partners in medical settings, as has been shown in other diseases such as chronic heart failure (Benazon et al., 2006). One of the most
noteworthy results was the fact that the women expressed significantly more overt criticisms than did the partners, showing that in the case of a somatic illness, the balance may tip to the other side compared with psychiatric illnesses, in which EE was described mainly in partners (or in other relatives of the patients). We validated the observational assessment of EE in the standardized situation of the FMSS by self-reported questionnaires; in both women and partners, the number of EEs in the speech sample (and assessed by an external informant) was correlated with the self-reported negative behaviours and attitudes toward the partner, with the exception of covert criticisms in women.
Second, assessing the predictors of EE, we saw an inverse relationship between cancer stage and the number of criticisms, overt in women and overt and covert in partners: the more severe the disease, the less both partners tended to express criticisms toward one another.
There is thus an impact of the disease on EE in that its severity tempers the production of criticisms. This may reveal that, when facing a more acute situation, both partners focus their attention on the disease and less on their relationship. For women, the reasons might be that they have an interest in not scaring their partners away by being critical – and hence losing their support. Partners, on the other hand, might attribute much of the women’s behaviours (also those they would be critical of under different circumstances) to women’s burden from the disease and treatment. Partners might also refrain from expressing their negative feelings, as they feel that they have a duty to be ‘perfect’ in order to help the women (Blum &
Sherman, 2010). However, even after the cancer stage has been taken into account, psychological variables are still important predictors of criticisms, but only in women.
According to our hypotheses, higher attachment anxiety and lower couple satisfaction are both predictive of more overt criticisms. Regarding attachment, women with higher anxiety tendencies may be more vulnerable to the situation; attachment anxiety has been shown to be directly linked to the psychological distress reported in the postsurgery period (Favez et al., 2015), and our results show that it may, in addition, have a negative impact on the attitude toward the partner, which in turn increases the likelihood of emotional disturbances.
Regarding couple satisfaction, we do not have the necessary data to evaluate whether lower satisfaction was caused by the disease or was pre-existing. The latter seems plausible, however, as the content of the criticisms formulated by women were mainly focused on the general relationship and not on relational events concerning the disease per se. Finally, contrary to our hypothesis, attachment avoidance was not predictive of less EE.
If these results were to be confirmed, they might have clinical implications. The mere presence of EE shows in itself that relational negativity could be present in the breast cancer situation. A vicious circle could then be triggered: lower satisfaction would increase the likelihood of displaying EE, which in turn might aggravate couple dissatisfaction; as a
consequence, partners could lower the support they bring to each other. As has been shown in studies on couple relationships, negativity is an ‘absorbing’ state in dissatisfied couples, each negative act by one partner making the emergence of a negative act by the other partner more likely – a process that has been called ‘negative reciprocity’ (Gottman, 1998). Although this may seem at first paradoxical, the couple relationship could be all the more under stress when the cancer stage is low, showing that even in this situation (and especially in this situation), practitioners should pay attention to the relation between the patient and partner. Moreover, our study highlights the fact that negative communication can occur in both partners of the same couple and that the women – that is, the patients – are even more likely to address criticisms than are their partners. In the long run, the partners could finally counter-attack and thus break their helping role, with all the known negative consequences for the women. It would thus be all the more important to take care of the couple relationship and of its
relational dynamics as early as in the immediate postsurgery period. Structured interventions targeting communication in couples facing cancer throughout the different phases of
treatment have indeed shown their efficiency in reducing distress and increasing coping skills (Kayser, 2008).
Several limitations have to be mentioned. An important one is the small sample size.
Although recruitment ran for a 2-year period, it was difficult to enrol couples, as partners were often reluctant to participate, and being video recorded in the FMSS was an
unacceptable condition for some patients. Another limitation is the fact that although criticisms were observed, they were few, especially in partners. Several explanations are
possible. The first is that, as mentioned earlier, the nature of the disease may attenuate the expression of criticisms (Benazon et al., 2006). One variable triggering EE is the extent to which relatives think that the patient is responsible for the symptoms; this kind of attribution is much less likely to happen in a somatic disease such as breast cancer than in psychiatric conditions. The specificity of the disease is also one of the reasons we chose to treat the data as continuous variables, and not to categorize the participants as being ‘high’ versus ‘low’ in EE, as is the standard procedure in EE studies; we preferred to have a more process-oriented perspective, taking into account variability even within participants who expressed several criticisms. A second explanation for the few EEs is the methodological strategy we used:
compared to the Camberwell Family Interview, the FMSS is known to underestimate EE tendencies (Hooley & Parker, 2006). The original situation of observation allows an in-depth assessment of EE, but takes several hours to be administered and analysed (Rutter & Brown, 1966). Another limitation is that the predictive direction between psychological predictors and EE outcomes cannot be ascertained, only assumed, because of the cross-sectional nature of the data. Further studies with longitudinal designs are needed to test the causality between these variables. Finally, as we have focused on individual data and not considered the
interdependence between partners’ data, EE in a given couple is also the result of its relational history and reflects a process of mutual (mal)adjustment between partners. A further step would be to consider not only the extent to which the predictors explain the absolute number of EEs in each partner, but also the extent to which they explain partners’ relational dynamics (the ‘negative reciprocity’ mentioned earlier, for example). The FMSS could thus be
complemented with a situation of observation aimed at assessing couples while they are interacting.
Despite its limitations, this study has allowed us to highlight the presence of EE and some of their predictors in couples facing breast cancer. The next step will be to evaluate the
extent to which EEs are predictive of individual psychological distress in women and their partners.
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Table 1. Descriptive data for study variables (N = 61)
Women Partners
Variable Theoretical range N M (SD) Min-Max N M (SD) Min-Max
Expressed emotion (FMSS)
Overt criticisms - 13 0.36 (0.80) 0-4 6 0.15 (0.57) 0-4
Covert criticisms - 38 1.11 (1.34) 0-6 30 0.90 (1.22) 0-5
Overinvolvement statement - 1 0.02 (0.12) 0-2 0 0.00 (0.00) -
First sentence negative - 4 - - 3 - -
Relationship negative - 3 - - 1 - -
Expressed emotion (FAS)
Total score 0-120 22.15 (18.63) 1-79 14.92 (11.32) 0-48
Attachment (ECR-R)
Avoidance 1-7 2.38 (1.07) 1.00-5.83 2.25 (0.87) 1.00-4.53
Anxiety 1-7 3.04 (1.19) 1.00-5.78 2.46 (0.86) 1.00-4.67
Couple satisfaction (RAS)
Total score 1-5 4.27 (0.79) 1.43-5.00 4.48 (0.57) 3.00-5.00
Note. FMSS = Five Minute Speech Sample; FAS = Family Attitude Scale; ECR-R = Experiences in Close Relationships – Revised; RAS = Relationship Assessment Scale.
Table 2. Correlations between FMSS expressed emotion and predictors (N = 61)
Variables 1 2 3 4 5 6 7 8 9 10
1. Cancer stage -
2. EE Overt criticisms, women -.27* -
3. EE Covert criticisms, women -.12 .27* -
4. ECR-R Anxiety, women -.05 .45*** .15 -
5. ECR-R Avoidance, women -.09 .22 .09 .39** -
6. RAS Satisfaction, women .05 -.45*** -.14 -.36** -.55*** -
7. EE Overt criticisms, partners -.21 .54*** .24 .26 .18 -.28 -
8. EE Covert criticisms, partners -.32* -.01 -.07 .03 -.06 .14 .09 -
9. ECR-R Anxiety, partners -.07 .21 -.09 .55** .57*** -.46*** .08 -.08 -
10. ECR-R Avoidance, partners .09 .34* .07 .34* .57*** -.64*** .25 .01 .42** - 11. RAS Satisfaction, partners .14 -.45*** -.18 -.31* -.26 .52*** -.28* -.07 -.43** -.41**
Note. FMSS = Five Minute Speech Sample; EE = expressed emotion; ECR-R = Experiences in Close Relationships – Revised; RAS = Relationship Assessment Scale.
*p < .05; **p < .01; ***p < .001.
Table 3. Predictors of FMSS overt and covert criticisms in women (N = 51)
Overt Covert
Predictors χ2 AICC β Exp(β) 95% CI PR χ2 AICC β Exp(β) 95% CI PR
Model 1. Disease-
related data 7.79** 99.23 1.31 182.98
Cancer stage -.67** .51 .31-.84 -49% -.15 .86 .67-1.11 -14%
Model 2. Adding
psychological variables 31.11*** 72.34 4.21 166.93
Cancer stage -.34 .72 .41-1.24 -28% -.12 .89 .69-1.14 -11%
ECR-R Avoidance -.29 .75 .37-1.50 -25% .00 1.00 .75-1.33 00%
ECR-R Anxiety .66** 1.93 1.19-3.13 93% .14 1.15 .90-1.46 15%
RAS Satisfaction -.78* .46 .23-.92 -54% -.11 .90 .63-1.29 -10%
Note. FMSS = Five Minute Speech Sample; ECR-R = Experiences in Close Relationships – Revised; RAS = Relationship Assessment Scale; AICC = corrected Akaike Information Criterion; CI = confidence interval; PR = predicted rate of increase/decrease in the number of criticisms for every one unit increase in the predictor variable.
*p < .05; **p < .01; ***p < .001.
Table 4. Predictors of FMSS overt and covert criticisms in partners (N = 51)
Overt Covert
Predictors χ2 AICC β Exp(β) 95% CI PR χ2 AICC β Exp(β) 95% CI PR
Model 1. Disease- related data
6.08* 56.63 10.66*** 159.83
Cancer stage -.97* .38 .16-.89 -62% -.49** .62 .46-.83 -38%
Model 2. Adding
psychological variables
16.22** 47.10 11.77* 146.90
Cancer stage -1.01* .37 .15-.87 -63% -.52** .60 .43-.82 -40%
ECR-R Avoidance .81 2.24 .92-5.48 124% .14 1.15 .78-1.70 15%
ECR-R Anxiety -.75 .47 .14-1.60 -53% -.27 .76 .51-1.14 -24%
RAS Satisfaction -1.30 .27 .06-1.33 -73% -.12 .89 .48-1.66 -11%
Note. FMSS = Five Minute Speech Sample; ECR-R = Experiences in Close Relationships – Revised; RAS = Relationship Assessment Scale; AICC = corrected Akaike Information Criterion; CI = confidence interval; PR = predicted rate of increase/decrease in the number of criticisms for every one unit increase in the predictor variable.
*p < .05; **p < .01; ***p < .001.
