Attributions and expressed emotion: a review.

This review examines the contribution of an attribution-based framework to our understanding of both expressed emotion (EE) and the process of patient relapse. It considers all published studies that have assessed the attributions of high- and low-EE relatives and carers. Across these studies, a great deal of consistency is apparent. Critical relatives are more likely to hold patients responsible for their difficulties. On the other hand, attributions made by emotionally overinvolved relatives are similar to the attributions made by those who are low EE. In reviewing the association between attributions and patient relapse, it is concluded that carers' beliefs may play a role in the relapse process in a variety of ways. These include mediating controlling behavior, which may serve to increase patient stress or decrease patients' sense of self-worth. A major limitation of research in this area is the cross-sectional and correlational nature of the data. This makes it impossible to draw conclusions about directions of effect in the association of EE and attributions. Nonetheless, an argument can be made for the development and evaluation of interventions designed to help relatives adopt less blaming and more flexible beliefs about the nature of patients' problems. Particularly helpful in this regard may be interventions that use verbal and behavioral reattribution techniques similar to those described in the cognitive behavioral treatment of emotional disorders.