Relatives' responses to psychosis: An exploratory investigation of low expressed emotion relatives

Objective. Expressed emotion (EE) refers to the emotional climate within a family. High EE significantly increases the risk of relapse in people with psychosis. The focus of research to date has largely been on understanding mechanisms underlying high EE. A greater understanding of low EE would help guide family interventions to build strengths within the family. The aim of this study was to understand how low EE relatives respond to having a close family member with psychosis. Design. A subsample of eight low EE relatives, from a larger study investigating relatives' adaptation to recent onset psychosis, was interviewed. Transcripts were analysed following the principles of interpretive phenomenological analysis (IPA). Method. Semi-structured interviews were carried out with each relative covering broad areas of their experience, including their awareness of the development of mental health problems and relationship with their relative. Results. Four core themes emerged: witnessing the distress; empathy through acceptance and understanding; a broad range of coping strategies to reduce distress; and realistic optimism for the future. Conclusions. The study highlights that, although relatives described distressing experiences and feelings of frustration and anger, they showed empathy and commitment to support the person. They demonstrated psychological mindedness about the psychosis and related behaviours, had developed coping strategies, and had adjusted their expectations for the future. Further research is warranted to investigate the findings in larger samples, with a view to informing the development of more effective ways of supporting families. Practitioner Points When working with low EE families practitioners should recognize that, despite the low EE rating, these relatives may have witnessed distressing and frightening experiences. Practitioners should support relatives to develop a cognitive model to understand the illness, including illness identity, cause and consequences, with particular attention paid to the illness appraisals. Family interventions may helpfully focus on working with relatives to develop proactive coping strategies and move towards a recovery-focused model of the illness with realistic expectations for the future. ©2011 The British Psychological Society.