Exploring associations between mentalisation, expressed emotion, self-harm, and attachment: a research portfolio

Abstract

Background: Research indicates that both familial Expressed Emotion (EE) and attachment security are associated with mental health outcomes for children and young people. This research portfolio investigates the associations between EE and attachment. It aims to determine whether there is a relationship between the two constructs, and how they may be connected to adolescent self-harm, a common transdiagnostic behaviour which is a major public health concern given its associations with psychological disorder and attempted and completed suicide. Objectives: A systematic review was conducted to identify, collate, and appraise research reporting associations between parental EE and caregiver-child attachment. An empirical project was conducted to better understand the associations between adolescent self-harm and perceived EE, attachment insecurity, and reflective functioning (RF), each of which has been associated with self-harm in past studies. Methods: Systematic review: A thorough search of electronic databases was conducted to identify eligible studies which investigated the associations between parental EE and caregiver-child attachment. These studies were assessed for quality using a standardised set of criteria and a narrative synthesis was conducted to collate research findings. Empirical project: A cross-sectional design was used. Participants aged 16 to 24 years completed an online survey containing a series of self-report questionnaires. A hierarchical serial mediation model, whereby attachment insecurity and RF mediated the relationship between perceived EE and adolescent self-harm, was tested using path analysis in IBM SPSS Amos. Results: Systematic review: Nine studies were identified. From the extant evidence, no conclusive associations between parental EE and caregiver-child attachment have been established. Several studies reported that higher levels of parental EE were associated with attachment insecurity and disorganisation, but variability in measurement methods and study populations make comparisons challenging to draw. Empirical study: 377 participants aged 16 to 24 years gave full responses to the survey, reporting on one or two caregivers each. Responses were split into female and male caregiver databases. Statistical analyses revealed significant direct effects of perceived EE on attachment insecurity, and significant direct effects of RF on self-harm in both databases. A significant indirect effect of perceived EE on self-harm through attachment anxiety and RF was obtained in the female caregiver dataset only. Conclusions: Systematic review: Previous studies have not evidenced a robust association between parental EE and child attachment, and the current evidence base has several methodological issues. Empirical study: Both attachment anxiety and RF mediated the relationship between perceived EE and adolescent self-harm for female caregivers only, and direct effects on self-harm were obtained for RF only. This suggests that family-based approaches, attachment-focused interventions, and mentalization-based therapy may be useful interventions for adolescent self-harm.