The Role of Metacognitions in Expressed Emotion and Distress: A Study on Caregivers of Persons with First-Episode Psychosis Jens Einar Jansen, 1,2 * Susanne Harder, 2 Ulrik Helt Haahr, 1,4 Hanne-Grethe Lyse, 1 Marlene Buch Pedersen, 1 Anne Marie Trauelsen 3,4 and Erik Simonsen 3,4,5 1 Early Psychosis Intervention Center, Zealand Region Psychiatry Roskilde, Roskilde, Denmark 2 Department of Psychology, University of Copenhagen, Copenhagen, Denmark 3 Psychiatric Research Unit, Zealand Region Psychiatry Roskilde, Roskilde, Denmark 4 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 5 Department of Psychology and Educational Studies, Roskilde University, Roskilde, Denmark Background: In first-episode psychosis, the family is considered an important part in the recovery process. This is often accompanied by significant distress, which is acknowledged in numerous studies. However, little is known about the psychological factors involved. Method: One hundred and twenty-seven caregivers of persons with first-episode psychosis completed a series of questionnaires aimed at investigating the contribution of expressed emotion and metacognitions to caregiver distress. Results: Linear mixed model analysis found that emotional over-involvement and metacognitions independently predicted caregiver distress. Mediation analysis using bootstrapping showed that emotional over-involvement could be seen as mediating the effect of metacognitions on distress. Conclusion: The current study is a first step towards understanding the role of metacognitions in caregiver distress, thus opening up for the possibility of using interventions from ‘contextual behaviour therapies’. Implications and future studies are discussed. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message: • This study is the first attempt to address caregiver concerns from the perspective of contextual cognitive behavioural therapy. • The metacognitive framework for caregiver distress in first-episode psychosis may help develop new therapeutic interventions to better support families. • The study proposes a psychological understanding of emotional over-involvement and caregiver distress. Keywords: Caregivers, Distress, Emotional Over-involvement, Metacognition, First-episode Psychosis, Contextual Behaviour Therapies INTRODUCTION In first-episode psychosis, the family is considered an important part in the recovery process, and many relatives go to great lengths in supporting their ill family member (Glynn, 2012; Szmukler et al., 2003). Unfortunately, this often involves a great deal of distress including anxiety, depression and economic strain (Addington, Coldham, Jones, Ko & Addington, 2003; Kuipers, Bebbington & Barrowclough, 2005; Szmukler, Burgess et al., 1996). Traditionally, studies on caregivers have been concerned with the relationship between caregiver behaviour and relapse (Pilling et al., 2002), but recently, there has been an increased focus on the psycho- logical well-being of caregivers themselves (Breitborde, López & Kopelowicz, 2010; Kuipers et al., 2005). The concept of expressed emotion (EE)—defined as caregiver criticism, hostility and over-involvement—has been the cornerstone of research on caregivers and is con- sidered as a robust predictor of relapse in schizophrenia (Brown, Monck, Carstairs & Wing, 1962; Kuipers et al., 2006; Pilling et al., 2002). Recently, however, the concept has been questioned from a number of sources. First, it has been argued that the components of EE are related to different variables and are best studied separately. Alvarez-Jimenez and colleagues (Alvarez-Jimenez et al., 2012; Álvarez-Jiménez et al., 2008) found that only *Correspondence to: Jens Einar Jansen, Early Psychosis Intervention Center, Region Zealand Psychiatry Roskilde, Smedegade 10, 4000 Roskilde, Denmark. E-mail: jenj@regionsjaelland.dk; jens.einar@gmail.com Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. (2014) Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1907 Copyright © 2014 John Wiley & Sons, Ltd.