Families in Psychiatry

The Critical Question


Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

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