Expressed emotion in couples facing breast cancer in women is associated with psychological distress in the first year after surgery

Abstract

The aim of this study was to assess the links between partners’ and women’s expressed emotion with the distress of one another during the first year after surgery for breast cancer in women. The design was longitudinal. A sample of 61 couples participated in the study at 2 weeks, 3 months, and 12 months after the surgery. Expressed emotion was assessed with the Five-Minute Speech Sample. Psychological distress was assessed with a self-reported questionnaire. Mixed-model analyses showed that partners’ expressed emotion is associated with heightened psychological distress in women during the first year after surgery, even after medical data were controlled for.

Keywords

breast cancer in women expressed emotion partners postsurgery period psychological distress

Introduction

Breast cancer is a stressful situation that affects women and their partners emotionally (Cairo Notari et al., 2017; Kayser and Scott, 2008; Schmid-Büchi et al., 2008). A supporting couple relationship, at the emotional and instrumental levels, is a major resilience factor that helps both individuals in the relationship to deal with the demands of the illness. Two relational processes play a central role in this regard: on one hand, the ability of the couple to face adversity as a team, and, on the other hand, their ability to prevent all areas of their lives from being invaded by the illness (Giese-Davis et al., 2000; Kayser, 2005; Manne et al., 2004; Miller-Day, 2011). When the relationship is tense or when both individuals are emotionally overloaded, non-supportive behaviors may appear, which in themselves may result in higher levels of psychological distress (Figueiredo et al., 2004; Manne et al., 2005, 2014; Rottman et al., 2015). Heightened distress, in turn, may lead to psychological disturbances (e.g. depression, anxiety, body image disturbances, and sexual dysfunctions) that develop independently of the course of the illness (Silva et al., 2012; Stenberg et al., 2010; Wagner et al., 2011). It is thus crucial for practitioners to be able to identify indexes of relational deterioration in order to support at-risk couples and to set up interventions to prevent the emergence of co-morbid psychopathological disorders (Ruddy and McDaniel, 2008).

In medical settings, expressed emotion (EE) is a construct that has been extensively used to describe the emotional attitudes of close relatives of individuals with a medical condition (among whom partners are first in line), be it a psychiatric disorder for which EE was first developed (Brown et al., 1958, 1962; Brown and Rutter, 1966) or a somatic condition, such as traumatic brain injury, Type 1 diabetes, rheumatoid arthritis, chronic pain, or chronic fatigue syndrome (for a review, see Wearden et al., 2000). EE refers, in particular, to negative statements, such as criticism or hostility: criticism refers to critical comments showing dissatisfaction or disapproval with the patient’s actions and behaviors; hostility refers to critical comments toward the personality of the patient (and not only toward actions and behaviors). High EE—the relative formulation of numerous negative statements—has been shown to impair coping aptitudes in patients and hence lead to a greater likelihood of relapse in psychiatric patients (Butzlaff and Hooley, 1998; Hooley, 2007) and to psychological disorders in somatic patients and their partners, such as depression and anxiety (Alway et al., 2012; Wearden et al., 2006; Weddell, 2010). Despite its importance in the detection of relational difficulties in couples facing various health conditions, EE has never been studied in the context of cancer. We therefore previously conducted an exploratory study to assess the presence of EE in a sample of women with breast cancer and their partners. First results showed that although EE was not present in this situation as much as it is in other somatic diseases, it was nevertheless observed in women and their partners as early as the immediate postsurgery period. Moreover, we highlighted the role of attachment tendencies and marital satisfaction as predictors of EE: partners who were insecurely attached and dissatisfied relationally were more likely to show EE (Favez et al., 2017). In order to assess the role of EE in partners’ adaptation to the stress of the illness, we aimed in this study to examine the extent to which EE observed in the immediate postsurgery period is still present in the following months, and whether it is linked with psychological distress.

Studies on the couple relationship have shown that negative attitudes and communication between individuals end up altering the relation if negativity is chronic and repeated (Elridge and Christensen, 2002; Gottman et al., 2002). The process unfolds over time as follows: as long as the couple considers their relationship as “positive” (most often defined as a “satisfying” relationship in the scientific literature), the expression of negative affects is transient and quickly regulated. Disagreements are discussed and an issue can be negotiated; if one individual is angry and negative, the other tends to deactivate the conflict by expressing positive affect in order to prevent negative escalation (Bodenmann, 1995; Gottman, 1998). However, when negativity is frequent, or when one or both parties are on emotional overload (for reasons internal to the couple relationship, such as sexual dissatisfaction, or due to external circumstances such as illness), the processes of deactivation may no longer work. Over time, negativity increases, with an escalation in negative communications: complaints turn into criticisms (targeting the personality of the other), individuals adopt a defensive attitude, and in the end they show contempt or a complete ignorance of one another (the “four horsemen of the Apocalypse”; Gottman and Levenson, 2002). Over time, the initial positivity turns into a negative “sentiment override” that makes the couple think about the relationship as globally negative and adopt a negative emotional attitude toward the other, which is related to a greater likelihood of relationship dissolution (Gottman and Levenson, 1992), and, at an individual level, to negative psychological outcomes such as depression (Davila, 2001; Heene et al., 2007; Rehman et al., 2008).

By analogy with what has been observed in studies on the couple relationship, we expected the links between EE and psychological distress to become stronger over time. The aims of this study were thus to (1) describe EE at several points during the first year after surgery and (2) to test the longitudinal links between EE and psychological distress in women and their partners. We specifically hypothesized that the more one individual in the couple relationship shows EE, the higher the psychological distress of the other across the year.

Materials and methods

The design of this study was longitudinal, with three time points: 2 weeks (T1), 3 months (T2), and 12 months (T3) after the women’s breast surgery.

Sample

Women diagnosed with non-metastatic breast cancer and their partners were recruited at the Senology Unit of the University Hospital of Lausanne (Switzerland). Criteria for study inclusion were as follows: (1) The patient had a diagnosis of non-metastatic breast cancer, (2) the patient and partner were 18 years of age or older, and (3) the patient and partner were French speaking. A total of 97 women agreed to participate in the study and to ask their romantic partner to participate. In all, 61 partners (62.9%) agreed to enter the study at T1. Attrition was high between time points: nine couples left the study between T1 and T2, and six more couples left between T2 and T3. The main reasons for refusal to participate and/or for leaving the study were as follows: no desire of the partner to participate, too much stress, and lack of energy. On the other hand, post hoc analyses showed that attrition was not linked to distress or to EE. The sample was thus N = 61 at T1, N = 52 at T2, and N = 46 at T3. At T1, 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).

In all, 11 patients had in situ breast cancer and 22 had stage I, 18 stage II, and 10 stage III. Regarding surgical treatments, 33 women underwent mastectomy, 28 lumpectomy, and 18 axillary lymph node dissection. Nine women underwent a neoadjuvant treatment. Concerning adjuvant treatments, 7 women underwent chemotherapy at T1, 6 at T2, and 0 at T3; 13 underwent radiotherapy at T1, 6 at T2, and 1 at T3; and 16 underwent hormonal therapy at T1, 29 at T2, and 36 at T3.

Procedure

Recruitment took place between September 2011 and December 2013. The referent nurse of the Senology Unit proposed that a patient take part in the research 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 (2 weeks after surgery), 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. At 3 and 12 months, the procedure was repeated. Participants received, at each time point, compensation of CHF 30, for their participation. This procedure and its protocol received approval from the Ethical Committee of the State of Vaud (Switzerland), where the University Hospital is located.

Five-minute speech sample

EE was assessed with the FMSS (Magaña et al., 1986). In this method, each participant is asked to talk about her or 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 recorded and the verbal content coded for EE. We used a standardized coding grid that combined the original coding tool with a review of the tool for the coding of covert criticisms (Leeb et al., 1991). We focused on two categories of the coding system, coded on a frequency basis: (1) overt criticisms (e.g. “My partner never helps me with housework”) and (2) covert criticisms (e.g. “My mother thinks that my partner doesn’t help me enough with housework”).

Coding strategy

An expert in the coding system trained the three coders who were involved in this study. To establish inter-rater reliability, two coders rated all the FMSSs independently at each time point (a different pair of coders each time). Intra-class correlation coefficients for the coding of overt criticisms of women and their partners were between 0.60 and 1.00; for the coding of covert criticisms of women and their partners, they were between 0.66 and 0.90. These indexes were considered good to excellent according to Cicchetti (1994). Disagreements were discussed and consensus was found in order to establish the final coding used for the analyses.

Questionnaires

A questionnaire specifically designed for the study was used to collect the sociodemographic and medical data. The Brief Symptom Inventory (BSI-18; Derogatis, 2001) was used as an index of psychological distress. In all, 18 items assess symptoms on 5-point Likert scales along three dimensions: somatization, depression, and anxiety (six items per dimension). A total score of psychological distress, the Global Severity Index (GSI), is computed as the sum of the 18 items (α = 0.91). The GSI can be reported as a T-score; beyond a T-score of 63, the individual is considered as a “case,” that is, a “positive risk.” For women who are oncology patients, the equivalent of a T-score of 63 is a GSI of 23; for men, the equivalent is a GSI of 18.

Statistical analyses

A full set of descriptive statistics was computed for the main variables of the study. We then performed mixed-model analyses to study the links between time as an independent variable and psychological distress as a dependent variable, with overt and covert criticisms at each time point entered as a covariate, as well as the interaction terms time × overt criticisms and time × covert criticisms. Specifically, two models were tested, the first with women’s psychological distress as a dependent variable and partners’ EE as a covariate, the second with partners’ psychological distress as a dependent variable and women’s EE as a covariate. In addition, to control for the influence of medical variables, we first performed correlational analyses to select the relevant variables to be included as control variables in the analyses. Cancer stage was also introduced as a control variable, as we have previously shown its links with EE in a cross-sectional study at T1 (Favez et al., 2017). There were missing data for seven variables at T1 (3.7% on average; minimum 1.6%, maximum 6.6% for chemotherapy), for two variables at T2 (1.9% for chemotherapy, 3.8% for partners’ distress), and for one variable at T3 (6.5% for partners’ distress). Data were missing completely at random. Missing data were not replaced. All statistical analyses were performed with IBM SPSS Statistics for Windows, version 24.0.

Results

Description of EE and distress

Table 1 shows the descriptive data for the study variables. Regarding criticisms, the number of covert criticisms was higher than the number of overt criticisms at each time point for women and for partners (t-tests all significant at p < 0.01).

Table 1.

Descriptive data for study variables.

Variable	N	Women			Partners
Variable	N	N “positive case”	M (SD)	Min-Max	N “positive case”	M (SD)	Min-Max
Expressed emotion (FMSS)
Overt criticisms T1	61	–	0.4 (0.8)	0–4	–	0.2 (0.6)	0–4
Overt criticisms T2	52	–	0.1 (0.6)	0–4	–	0.0 (0.2)	0–1
Overt criticisms T3	46	–	0.2 (0.5)	0–2	–	0.1 (0.6)	0–4
Covert criticisms T1	61	–	1.1 (1.3)	0–6	–	0.9 (1.2)	0–5
Covert criticisms T2	52	–	1.1 (1.3)	0–6	–	0.9 (1.3)	0–5
Covert criticisms T3	46	–	0.8 (1.4)	0–6	–	0.6 (1.1)	0–5
Distress (BSI-18; score range: 0–72)
GSI T1	61	17	18.3 (12.5)	1–58	7	8.4 (7.7)	0–38
GSI T2	52	16	16.4 (14.8)	0–64	2	4.3 (4.7)	0–21
GSI T3	46	12	14.2 (11.0)	0–42	2	4.4 (5.1)	0–18

FMSS: Five-Minute Speech Sample; BSI-18: Brief Symptom Inventory—18-item version; GSI: Global Severity Index; T1: 2 weeks; T2: 3 months; T3: 12 months after surgery.

Although the number of criticisms tended to decrease with time, this effect was not significant (all repeated measures analyses of variance not significant). There was no difference in the number of criticisms expressed by women and partners (all t-tests not significant) at every time point. In women, there were two intra-individual correlations: for covert criticisms between T1 and T2 (r = 0.32, p = 0.023) and between overt and covert criticisms at T1 (r = 0.21, p = 0.034); there was no correlation for overt criticisms. In partners, there were intra-individual correlations for covert criticisms between all measurement points (all correlations, p < 0.05) and there was no correlation for overt criticisms and no correlation between overt and covert criticisms. There was only one inter-individual correlation between women and partners: for overt criticisms at T1 (r = 0.54, p < 0.001).

Regarding distress, the mean scores decreased for women and for partners from T1 to T3. The number of positive-risk individuals was already low at T1 (17 women, 7 partners). At T2, 16 women and 2 partners were still above the cut-off, and at T3, 12 women and 2 partners were above the cut-off and considered a positive risk for psychological distress. There were strong intra-individual correlations between distress scores at T1, T2, and T3 in women and in partners (all ps < 0.001). On the other hand, women’s distress was correlated with partners’ distress only at T2 (r = 0.33, p = 0.017).

At T1, there was no correlation between criticisms and distress, either intra-individually or inter-individually. At T2 and T3, partners’ covert criticisms were correlated with women’s distress (r = 0.36, p = 0.008 and r = 0.39, p = 0.008, respectively). Partners’ overt criticisms at T1 were linked to women’s distress at T2 (r = 0.038, p = 0.003).

Time and EE as predictors of psychological distress during the 12 months after surgery

We first correlated the variables related to medical treatment with the distress reported by the women and their partners: mastectomy at T1, neoadjuvant treatment, chemotherapy at T1 and T2, and hormonal therapy and radiotherapy at T1, T2, and T3. The only variable linked to women’s distress was chemotherapy at T1 (correlations with psychological distress at T1, T2, and T3 all ps < 0.05). We thus introduced this variable as a control in subsequent analyses.

Mixed models were then performed to test the links between EE and distress. The parameter estimates (Table 2) showed that women who underwent chemotherapy at T1 reported higher psychological distress, and their distress was higher when the partners expressed more covert criticisms at T3. For partners, psychological distress was significantly higher at T1 than it was at T2 and T3; there was a marginal effect of women’s covert criticisms at T1. None of the interaction terms between time and EE were significant; they are thus not presented in Table 2 for the sake of readability.

Table 2.

Estimates of the fixed effects of expressed emotion on women’s and partners’ distress (N = 61).

Parameter	Women’s distress			Partners’ distress
	b	SE	95% CI	b	SE	95% CI
	b	SE	LL, UL	b	SE	LL, UL
Intercept	13.48***	3.33	6.89, 20.08	2.84°	1.49	−0.10, 5.79
Time (reference: T3)
T1	2.69	3.31	−3.88, 9.25	6.32***	1.74	2.86, 9.77
T2	0.76	3.31	−6.49, 6.64	1.00	1.75	−2.47, 4.48
Partners’ overt high EE
T1	1.07	5.00	−8.86, 10.99	–	–	–
T2	−13.49	8.28	−29.90, 2.92	–	–	–
T3	2.04	5.12	−8.10, 12.19
Partners’ covert high EE
T1	−0.47	1.64	−3.73, 2.78	–	–	–
T2	−3.47	2.81	−9.04, 2.11	–	–	–
T3	6.64*	3.27	0.15, 13.12	–	–	–
Women’s overt high EE
T1	–	–	–	0.56	1.40	−2.21, 3.34
T2	–	–	–	3.18	6.57	−9.86, 16.22
T3	–			−3.43	2.36	−8.11, 1.24
Women’s covert high EE	–	–
T1	–			1.29°	0.73	−0.16, 2.74
T2	–			–0.50	0.78	−2.05, 1.05
T3	–	–	–	0.88	0.79	−2.45, 0.68
Cancer stage	−0.94	1.22	−3.36, 1.47	0.59	0.58	−0.57, 1.74
Chemotherapy	8.64**	3.13	2.43, 14.86	1.67	1.84	−1.97, 5.32

T1: 2 weeks; T2: 3 months; T3: 12 months after surgery; CI: confidence interval; EE: expressed emotion; LL: lower limit; UL: upper limit; dashes: not included in the model.

***

p < 0.001; **p < 0.01; *p < 0.05, p < 0.10.

These results show that the predictors of psychological distress are not the same for women and for their partners; EE seems to play a role mainly for women.

Discussion

The goals of this study were to describe EE in women and their partners during the first years after surgery and to longitudinally test the links between EE and the psychological distress of women and their partners. We assessed EE through the coding of overt and covert criticisms expressed in the FMSS procedure.

First, our results show that EEs are present throughout the first year in women and in their partners; however, overt criticisms were scarce and EEs were expressed mainly through covert criticisms (such as “She is very perfectionist”; “To be calm and quiet is difficult. One has to be constantly in action, doing something”; “I would like him to be more emotionally open”).

Second, we tested the longitudinal links between EE and distress. Regarding women’s distress and partners’ EE, we found that, in accordance with our hypothesis, distress was significantly higher in women whose partners expressed more covert criticisms at T3. The fact that it is only at T3 that criticisms are linked to distress is in line with the results of studies on couple relationships, which have shown a cumulative effect on the relationship of negativity repeated through time (Gottman and Levenson, 2002). Partners’ EE was not the only predictor of women’s psychological distress: women who underwent chemotherapy at T1 were those who reported the most distress; this can be a consequence of the side effects of chemotherapy that in itself causes important distress (in particular alopecia; see, for example, Lemieux et al., 2008). Time itself was not linked with women’s psychological distress. Taken together, these results show that, even when women have to face a life-threatening disease and treatment with important side effects, psychosocial variables such as EE related to the couple relationship may still be linked with the distress they feel. Although the effect of psychological distress on the illness itself is a controversial issue (Coyne et al., 2007), it is well established that additional distress (i.e. distress that is not caused directly by the illness and the treatment) plays a role in post-treatment recovery and in the occurrence of co-morbid psychopathological troubles (Silva et al., 2012).

Regarding partners’ distress and women’s EE, we found that time is the only significant predictor of distress in partners: distress is the highest in the immediate postsurgery period and decreases over time, as early as 3 months after surgery. Elevated distress in the immediate postsurgery period may be explained on one hand by the initial shock of the illness and by fear of the consequences of the surgery itself. Most partners in our study were at that time active caregivers and the feeling of taking control of events that this role allows may explain why distress decreases. On the other hand, women’s EE was not linked with partners’ psychological distress. This does not necessarily mean that partners are not affected by the emotional attitudes of the women in the long run; it may well be that the time frame we have chosen in this study is too short to highlight a link between these variables in relation to partners. During the first year, partners are indeed highly engaged in their role as an informal caregiver; they may interpret a possible negative emotional state of the women as a natural reaction to a highly stressful situation and hence, they may not be immediately affected by their negativity. However, a possible “rebound effect” should be investigated after the importance of the role of the informal caregivers diminishes and if the negative attitude of the women persists for a longer period. Overall, little is known about the evolution of the distress of caregivers through time and across the stages of the illness (Stenberg et al., 2010).

The link between partners’ EE and women distress points to the importance of preventive actions as early as during the months following surgery to prevent relational distress that arises in addition to the distress generated by the illness and the treatment. Assessment of the relationship before the illness was not possible and so we cannot ascertain that EE is a direct response to the stress of the illness; in some couples, EE may have been present beforehand and the illness could be a precipitating factor that amplified the distance between the pair (Burton and Watson, 1998). However, it does not make our approach less relevant: couples who were in a tense situation even before facing the illness are all the more likely to not be able to cope with the situation so that they are even more at risk of elevated distress. They are therefore in more critical need of help.

Several limitations of this study may be mentioned, the main one being sample size. As mentioned in a previous paper, it was difficult to enroll couples: partners were often reluctant to participate, and being recorded in the FMSS was an unacceptable condition for some patients. Moreover, several couples left the study between time points; given the numerous medical appointments during the acute phase of treatment and the stress of the situation, taking part in the study was too much of a hassle. As a consequence of this small sample size, we were not able to test more complex models (e.g. mediational models) that could better explain our data. Another limitation is the fact that, for two reasons, we did not use the cut-off score of the BSI-18 to split our sample into negative and positive risks for psychological distress, which could have been a more straightforward way to indicate vulnerable participants. First, as stated by Derogatis (2001) in the BSI-18 manual, these cut-off points depend on community values and cannot be transposed from one context of research to the other without being validated. Second, we nevertheless performed a test using these data: our results were confirmed (the effects being even stronger), but up to a certain point they were meaningless, as the number of positive cases was low. As a consequence, we focused on within-group variability in women and in their partners and used the GSI data as a continuous variable.

Despite these limitations, this study shows that taking into account EE is a relevant strategy to detect couples who are at risk of increased psychological distress; not only is EE already present in the immediate postsurgery period, but its presence in partners throughout the first year is linked to heightened psychological distress in women.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Swiss National Centre of Competence in Research LIVES—Overcoming vulnerability: life course perspectives, which is financed by the Swiss National Science Foundation, under Grant IP11; and by the Swiss Cancer League, under Grant KLS 3396-02-2014.

References

Alway

McKay

Ponsford

, et al. (2012) Expressed emotion and its relationship to anxiety and depression after traumatic brain injury. Neuropsychological Rehabilitation 22: 374–390.

Bodenmann

(1995) A systemic-transactional conceptualization of stress and coping in couples. Swiss Journal of Psychology 54: 34–49.

Brown

Rutter

(1966) The measurement of family activities and relationships: A methodological study. Human Relations 19: 241–258.

Brown

Carstairs

Topping

(1958) Post-hospital adjustment of chronic mental patients. The Lancet 272: 685–689.

Brown

Monck

Carstairs

, et al. (1962) The influence of family life on the course of schizophrenic illness. British Journal of Preventive and Social Medicine 16: 355–368.

Burton

Watson

(1998) Counselling People with Cancer. Chichester: Wiley.

Butzlaff

Hooley

(1998) Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry 55: 547–552.

Cairo Notari

Favez

Notari

, et al. (2017) The caregiver burden in male romantic partners of women with non-metastatic breast cancer: The protective role of couple satisfaction. Journal of Health Psychology 22(13): 1668–1677. DOI: 10.1177/1359105316633285.

Cicchetti

(1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment 6: 284–290.

10.

Coyne

Stefanek

Palmer

(2007) Psychotherapy and survival in cancer: The conflict between hope and evidence. Psychological Bulletin 133: 367–394.

11.

Davila

(2001) Paths to unhappiness: The overlapping courses of depression and romantic dysfunction. In: Beach

SRH

(ed.) Marital and Family Processes in Depression: A Scientific Foundation for Clinical Practice. Washington, DC: APA Press, pp. 71–87.

12.

Derogatis

(2001) BSI 18, Brief Symptom Inventory 18: Administration, Scoring and Procedures Manual. San Antonio, TX: NCS Pearson.

13.

Elridge

Christensen

(2002) Demand-withdraw communication during couple conflict: A review and analysis. In: Noller

Feeney

(eds) Understanding Marriage: Developments in the Study of Couple Interactions. Cambridge: Cambridge University Press, pp. 289–322.

14.

Favez

Cairo Notari

Antonini

, et al. (2017) Attachment and couple satisfaction as predictors of expressed emotion in women facing breast cancer and their partners in the immediate postsurgery period. British Journal of Health Psychology 22: 169–185.

15.

Figueiredo

Fries

Ingram

(2004) The role of disclosure patterns and unsupportive social interactions in the well-being of breast cancer patients. Psycho-Oncology 13: 96–105.

16.

Giese-Davis

Hermanson

Koopman

, et al. (2000) Quality of couples’ relationship and adjustment to metastatic breast cancer. Journal of Family Psychology 14: 251–266.

17.

Gottman

(1998) Psychology and the study of marital processes. Annual Review of Psychology 49: 169–197.

18.

Gottman

Levenson

(1992) Marital processes predictive of later dissolution: Behavior, physiology, and health. Journal of Personality and Social Psychology 63: 221–233.

19.

Gottman

Levenson

(2002) A two-factor model for predicting when a couple will divorce: Exploratory analyses using 14-year longitudinal data. Family Process 41: 83–96.

20.

Gottman

Murray

Swanson

, et al. (2002) The Mathematics of Marriage: Dynamic Nonlinear Models. Cambridge, MA: The MIT Press.

21.

Heene

ELS

Buysse

ANN

Van Oost

(2007) An interpersonal perspective on depression: The role of marital adjustment, conflict communication, attributions, and attachment within a clinical sample. Family Process 46: 499–514.

22.

Hooley

(2007) Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology 3: 329–352.

23.

Kayser

(2005) Enhancing dyadic coping during a time of crisis: A theory-based intervention with breast cancer patients and their partners. In: Revenson

Kayser

Bodenmann

(eds) Couples Coping with Stress. Washington, DC: APA Press, pp. 175–194.

24.

Kayser

Scott

(2008) Helping Couples Cope with Women’s Cancers: An Evidence-Based Approach for Practitioners. New York: Springer Science & Business Media.

25.

Leeb

Hahlweg

Goldstein

, et al. (1991) Cross-national reliability, concurrent validity, and stability of a brief method for assessing expressed emotion. Psychiatry Research 39: 25–31.

26.

Lemieux

Maunsell

Provencher

(2008) Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: A literature review. Psycho-Oncology 17: 317–328.

27.

Magaña

Goldstein

Karno

, et al. (1986) A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry Research 17: 203–212.

28.

Manne

Kashy

Siegel

, et al. (2014) Unsupportive partner behaviors, social-cognitive processing, and psychological outcomes in couples coping with early stage breast cancer. Journal of Family Psychology 28: 214–224.

29.

Manne

Ostroff

Sherman

, et al. (2004) Couples’ support-related communication, psychological distress, and relationship satisfaction among women with early stage breast cancer. Journal of Consulting and Clinical Psychology 72: 660–670.

30.

Manne

Ostroff

Winkel

, et al. (2005) Partner unsupportive responses, avoidant coping, and distress among women with early stage breast cancer: Patient and partner perspectives. Health Psychology 24: 635–641.

31.

Miller-Day

(2011) Family Communication, Connections, and Health Transitions. New York: Peter Lang.

32.

Rehman

Gollanb

Mortimer

(2008) The marital context of depression: Research, limitations, and new directions. Clinical Psychology Review 28: 179–198.

33.

Rottmann

Hansen

Larsen

, et al. (2015) Dyadic coping within couples dealing with breast cancer: A longitudinal, population-based study. Health Psychology 34: 486–495.

34.

Ruddy

McDaniel

(2008) Couple therapy and medical issues: Working with couples facing illness. In: Gurman

(ed.) Clinical Handbook of Couple Therapy (4th edn). New York: Guilford Press, pp. 618–637.

35.

Schmid-Büchi

Halfens

RJG

Dassen

, et al. (2008) A review of psychosocial needs of breast-cancer patients and their relatives. Journal of Clinical Nursing 17: 2895–2909.

36.

Silva

Crespo

Canavarro

(2012) Pathways for psychological adjustment in breast cancer: A longitudinal study on coping strategies and posttraumatic growth. Psychology and Health 27: 1323–1341.

37.

Stenberg

Ruland

Miaskowski

(2010) Review of the literature on the effects of caring for a patient with cancer. Psycho-Oncology 19: 1013–1025.

38.

Wagner

Tanmoy Das

Bigatti

, et al. (2011) Characterizing burden, caregiving benefits, and psychological distress of husbands of breast cancer patients during treatment and beyond. Cancer Nursing 34: E21–E30.

39.

Wearden

Tarrier

Barrowclough

, et al. (2000) A review of expressed emotion research in health care. Clinical Psychology Review 20: 633–666.

40.

Wearden

Ward

Barrowclough

, et al. (2006) Attributions for negative events in the partners of adults with Type 1 diabetes: Associations with partners’ expressed emotion and marital adjustment. British Journal of Health Psychology 11: 1–21.

41.

Weddell

(2010) Relatives’ criticism influences adjustment and outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation 91: 897–904.