Tuesday, June 25, 2013

Guest Post: Five Ways the Affordable Care Act will Change Mental Health Treatment

Today's guest post is by Michael Cahill, of the Vista Health Solutions blog. He describes the expected effects of “Obamacare” for patients of mental health practitioners. While a lot of it sounds pretty good, what remains to be seen are the reimbursement rates for psychiatrists, especially for psychotherapy, which are abysmally low under Medicaid. With a huge doctor shortage anticipated (there has been no increase in the number of residency training slots in almost twenty years), this could become a big issue. Having coverage does not do anyone much good if they can’t find a doctor who accepts their insurance. But those insurance company CEO’s can not afford any cuts to their multi-million dollar salaries!   ~ DA

By this point you’ve certainly heard about the Affordable Care Act, sometimes more commonly referred to as Obamacare.

The legislation is the Obama administration’s landmark attempt at reforming the American healthcare system. After surviving 37 repeal attempts, the most recent of which took place last month, and a Supreme Court challenge, the major parts of the law are still intact and set to go into effect next year on Jan. 1, 2014.

One group that stands to enjoy some of the best benefits of the Affordable Care Act are those individuals with mental illness. The law takes aim at the current pseudo separation of mental health and physical health. It tries to bridge that gap to improve treatment and make it more affordable, while also placing an emphasis on prevention and early detection.

Here are five ways that the legislation will change mental health treatment in America:

1. No more “pre-existing” conditions

People with a serious mental illness diagnosis have long been disproportionately affected the routine denial of health insurance coverage because of a “pre-existing” condition.

For years insurers in most states could deny coverage to anyone because of their medical history. Often this left people who needed coverage the most out in the cold with no way to pay for their medical care. In cases where they were actually sold health insurance their premiums were often much higher than a person’s without their history.

Because of these practices millions of people living with severe, debilitating diseases were unable to get the treatment and help they needed to get healthy and stay healthy.

Now that policy’s days are over.

Since the law's 2010 passage these folks with a pre-existing condition have been able to receive health insurance coverage through a state by state high risk insurance pool.

Come 2014 when the last big phase of the Affordable Care Act becomes law, insurance companies will no longer be able to deny coverage to people with pre-existing conditions or charge them more than they would a healthy person.

Respectively these policies are called guaranteed issue and commuting rating. States like New York and Massachusetts have had these policies on the books for a number of years, allowing medical coverage to expand to a great many people.

Critics have complained that these policies will raise rates nationwide to levels that still put insurance beyond the reach of many people. However many of those people will also be eligible to receive a premium tax credit if their yearly income falls between 133 and 400 percent of the federal poverty live.

More on how that tax credit works in a little bit.

2. More Access to Medicaid

As part of the Affordable Care Act the Obama administration passed legislation that would expand access to Medicaid. Medicaid is a federally subsidized health insurance program for low income and disabled individuals who are not insured through their spouse or employer and cannot afford to purchase health insurance.

Each state runs their own Medicaid program, and the eligibility requirements differ from state to state. Usually there is a minimum threshold of age and/or income. 

The Affordable Care Act legislation proposed to expand Medicaid eligibility to people at 133 percent and below of the federal poverty line. It also would allow single childless adults to apply for Medicaid.

After last summer’s Supreme Court ruling on the Care Act states were allowed to opt out of the Medicaid expansion if they so chose. So far 26 states have said they will accept the expansion, while 13 have said they will reject with. The other 11 states are still deciding about what to do.

Historically Medicaid has provided an array of mental health treatments and services that have been superior to many of the services offered by private traditional health insurance plans. It’s also an especially helpful program to those with a serious mental illness as many are unemployed and could not afford to pay for insurance.

3. Plans sold through the state health insurance exchanges have to cover mental health treatment.

All health insurance plans sold through the state public health insurance exchanges, or just exchanges for short, will have to include coverage for a list of essential benefits in 10 categories. One of those categories is mental health and substance abuse services.
The exact details of which treatments and services will be offered is left up to the states. Each state will have a slightly different list of exact services, which is still being finalized.

Digging into the legislation, it requires that the mental health and substance abuse coverage be on par with medical/surgical coverage. For people with mental health disabilities this will be a big relief if they are searching for an insurance plan through the state exchange.

They won’t have to worry about slogging through pages of benefits summaries to see if the treatment they need is covered. The essential benefits in the exchange will also cover rehabilitative and habilitative services, as well as ambulance service, prescriptions, and inpatient services.

4. Tax credits

With a large majority those with a serious mental illness also unemployed many, especially with the Medicaid expansion, will qualify for government assisted health insurance. But for those who aren’t eligible and want an exchange plan they might get a nice tax credit to offset costs.

If an individual’s yearly income falls between 133 percent and 400 percent of the federal poverty line (FPL) then they’ll qualify for a premium tax credit. For states that did not accept the Medicaid expansion the qualifying range is between 100 and 400 percent of the FPL.

So let’s walk through how this tax credit work. Bear with me here it does get a little complicated.

The credit is calculated based off of a maximum contribution toward their health insurance of 9.5 percent of their annual income minus the price of the second lowest Silver tier plan offered in that person’s region.

If your annual income is less than 400 percent of the FPL the percentage of your annual income decreases accordingly. This percentage is based off of a sliding scale, so the less you make, the less you have to pay.

Still with me?

Insurance plans sold on the exchange come at four different levels each with its own price and level of coverage. Although they all cover the same mandated services, they have different cost sharing levels. They are:
     Bronze level - 60 percent coverage
     Silver level - 70 percent coverage
     Gold level - 80 percent coverage
     Platinum level - 90 percent coverage

Those percentages refer to the amount paid in premiums versus the out of pocket expenses. A Bronze plan for example will have low monthly premiums, but higher deductibles and copays. While a gold plan will cost more each month, but come with low deductibles and copays..

Lets take a look at an example for how the tax credit might work:

Chris is a 32-year-old individual earning $22,000 a year. Because of his income level he doesn’t qualify for Medicaid and his job doesn’t offer health insurance. He wants to purchase a health insurance plan at the state exchange. The yearly premium cost of the unsubsidized, second to lowest level Silver plan in Chris’ area is $3,570. John’s income puts him at 189 percent of the federal poverty line, making him eligible for a premium tax credit.

Because Chris’ income is 189 percent of the FPL his maximum premium contribution is 5.79 percent of his yearly income, which is $1,273. Now to determine his tax credit we subtract $3,570 (the amount of the unsubsidized second-lowest Silver plan) from $1,273 (his maximum premium contribution or 8.27 percent of his annual income).

This gives Chris an annual tax credit of $2,297, which is paid directly to the insurance company that Chris picks at the exchange.

Something to keep in mind though is that the cap only applies for the premium at the Silver level. Don’t forget that there three other levels of plans at the exchange. You can still get the tax credit for the other plans, but the credit amount doesn’t change.

Take for another example that Chris wanted to purchase the Gold level plan. The premium for that plan would be more expensive than the Silver level premium from which his tax credit was calculated. But he would still receive the $2,297 premium tax credit. The same goes if Chris opts for a lower cost Bronze level plan instead of the Silver.

5. Preventative Care

Part of the philosophy of the Affordable Care Act, so to speak, is a shift away from addressing just the symptoms of disease and heading more toward preventing disease in the first place or detecting it early on.

Which means that the Affordable Care Act requires all insurers to cover preventive care services with no cost sharing (AKA deductibles, co-pays, coinsurance, etc.). This preventative care coverage includes things like regular checkups, screenings for diabetes and cancer, and help losing weight for those who obese or at risk for becoming obese.

People with serious mental illness are at great risk for such preventable diseases. Also included will be access to smoking cessation treatment and aids. Studies have shown that those with a mental illness are up to 70 percent more likely to smoke than those without.

The National Alliance on Mental Health estimates that one in four adults experience a mental illness during the course of a year. Altogether that’s 55.7 million people. For a nation of 350 million that’s a pretty startling number. 

Right now it’s probably too early to tell what the ultimate impact of the Affordable Care Act will be on mental health treatment in America. But because of legislative items like expanding Medicaid and requiring coverage for mental health in the exchange, things are looking pretty positive.

Michael Cahill is Editor of the Vista Health Solutions blog. He has a degree in Journalism from SUNY New Paltz and previously worked as a reporter for the Poughkeepsie Journal and an editor for the Rockland County Times. Follow him on Twitter at  @VistaHealth and @ElectronicMike

Tuesday, June 18, 2013

The Historical Backdrop of Family Dysfunction

Victorian's Secret

In a new and fascinating book, Family Secrets: Shame and Privacy in Modern Britain, professor of history Deborah Cohen traces the historical development of the current concepts of, and attitudes towards, shame and family secrets in Britain over the last two hundred years. As described in a press release about the book, the author explores what families in the past chose to keep secret and why, and how privacy eventually came to be viewed as a sacred right, while at the same time a contradictory idea developed that family secrets are destructive. 

Deborah A. Cohen, Ph.D.

So why am I reviewing this book in a blog on family dysfunction?  Allow me to explain.

In my experience using my family systems-oriented psychotherapy model of treatment for repetitive and ongoing self-destructive and self-defeating behavior in individual patients, I without exception find repetitive and ongoing problematic interpersonal relationship patterns in the families of origin of the patient that both trigger and reinforce the patient’s ongoing difficulties.  

These so-called dysfunctional families are characterized by chronic conflict, inability to perform and fulfill family responsibilities, ongoing tension, and even abuse and neglect of children, domestic violence, and/or substance abuse.

Saying that self-destructive behavior is caused by family dysfunction of course just raises another question: Why are the family members all compulsively behaving in ways that make both themselves and one another miserable? Are they just mad, bad, blind, or stupid?

I do not believe they are any of those things. My patients and I are often able to trace back the history of their family's dysfunction through the use of a genogram or emotional family tree. As we look back over at least three generations, we find family members of varying abilities and propensities experiencing various individual traumas and interacting with their cultural milieu and historical trends. In the process they develop habits that are adaptive to their situation at that time. 

However, as times change, these habits become maladaptive, while the original reasons for their existence are obscured. For reasons that I will not go into here, some families get stuck in the past with these once useful but now counterproductive attitudes and rules of behavior – a phenomenon anthropologists call cultural lag. This “stuckness” often makes their otherwise horrific and inexplicable behavior more understandable, even as we do not necessarily condone it.  

Gaining this type of insight into one’s family dynamics is, in my opinion, the past way to gain insight about oneself. It also helps my patients develop empathy for both themselves and their problematic relatives, paving the way for discussions about family dynamics that do not cause fight, flight, or freeze reactions in members of the group.  Problem solving can then take place in a constructive atmosphere, and dysfunctional patterns can be significantly attenuated and even stopped.  My patients then feel free to give up their own self-destructive behavior.

Now of course the complete family history is not always available, as relatives who might know what happened to family members in the past die off. Sometimes the development of dysfunctional patterns goes back several generations, and my patient and I lose the historical scent, so to speak.

So what to do?

One possibility is geneological research. This has become very popular of late, and often is related to a quest to understand the behavior of one’s family over time. This popularity can be seen in the frequency of visits to the web archive, and with television shows like Who Do You Think You Are? and Finding Your Roots with Henry Louis Gates.

The information in historical records, such as dates of immigration and census data about who composed the various related families during certain times, may at times be fruitful for trying to understand family dynamics, but they often do not really help a lot. They do not say anything about such things as why a family emigrated, or tell us that grandpa had a mistress, or that grandma was a suffragette. They certainly do not really tell us a lot about how various members related to one another.

On the television shows that I mentioned, subjects must turn to historians to help them understand what was going on culturally at relevant times and places, and this knowledge often sheds a lot of light on the experiences of early generations.

So, a knowledge of history, when combined with a knowledge about typical ethnic group norms (subject of a later post), can be extremely useful in making an educated guess about how and why certain family behavior patterns may have developed. These patterns were then transferred to succeeding generations through a process known as the intergenerational transfer of dysfunctional behavior (which will also not be discussed in this post. It’s described in detail in my first book, A Family Systems Approach to IndividualPsychotherapy). 

When I use the term history, I am not talking about the boring stories about the names of kings and dates of wars - those things which pass for history in American schools - but the history of societal forces affecting different cultures. In particular, the evolution of individualism from originally traditional, collectivist ethnic groups is a crucial and central theme.

So this is where a book like Dr. Cohen’s comes in handy. She focuses on England rather than America, despite the fact that she is an American professor, because she was able to obtain previously sealed documents from various archives in that country that shined a light on important historical cultural trends. She is therefore able to tell stories of how major historical developments affected the fortunes of specific individuals and families, which helps us to understand cultural trends from a very personal perspective.  

Fortunately, while there were and are many differences between the British and the Americans, the countries across the pond from each other do share many commonalities as well.

One example from the book of how cultural attitudes might affect the relationship between parents and their children was the prevalent attitude towards adopted children. Although widespread for a long time, adoption was not even legal in Britain until 1926. Adopted children were often seen as inferior. This was to a large degree a product of the widespread belief in the pseudo-science of eugenics (which is present in only slightly disguised form in many of today’s attitudes towards behavioral problems). 

Eugenicists believed that traits such as promiscuity or “loose morals” were genetically determined.  Since many adoptees were the product of unwed pregnancies, these children were presumed to be prone to “degenerate” behavior themselves. 

Another source of children for prospective adoptive parents came about during the World Wars. Apparently, in spite of the persistence of Victorian attitudes towards female sexualtiy, women whose husbands were overseas for extended periods of time often had paramours. If they became pregnant, they would often want to adopt out the baby in order to hide it from their husbands.

Causing childless couples keen to adopt children further grief - and a need to keep the facts of the situation secret from their social circle - were certain peculiarities of English law. For a long time, the natural parent could theoretically reclaim her child at any time. Furthermore, “The intent of England’s harsh bastardy laws was to inflict the sins of the parents upon their children; the stigma of illegitimacy was to follow a child through life" (page 126).

Because of societal attitudes such as these, adopted children were often never told that they were adopted. (Inquisitive children might nonetheless know based on the presence of clues such as their hair color or hush-hush conversations between their parents). Anxiety about the child making an embarrassing discovery led adoptive parents to want as few people to know about the adoption as possible – keeping the secret even from the child’s adoptive siblings. Birth certificates were routinely altered. 

Both the parents’ fear of discovery and the fear that the child would turn out badly because of his or her heredity almost certainly had a negative effect on the relationship between many adopted children and their parents. This in turn may have led adopted children to develop any number of problematic attitudes which later on might affect their relationships with their own children. For example, adopted children might have thought that the parents had no confidence in them, creating a self-fullfilling prophecy that they would become failures in life.

In a similar manner, Dr. Cohen uses fascinating examples of how families were affected by historical trends in societal and governmental attitudes toward factors such as race, divorce, developmental disability, and homosexuality. One interesting subject she discusses that I had never heard about was that, when India was a colony of Britain and a lot of British men (but not women) were there making their fortunes, many had mixed race children with native women. British law allowed the Brits to take these children to England over the objections of the children’s mothers. Various ruses were then used to hide the child’s Eurasian heritage from prying eyes.

The author goes on to discuss today’s culture in which the concept of privacy has been turned on its head to encompass the individualistic idea that individuals should be free to openly live their lives in almost any way that they please, and express their feelings and opinions openly without fear of retaliation. 

Some families have not received this message and, as I mentioned earlier, unknowingly remain trapped by the rules of the past. Being stuck in between two worlds can often lead to problems for the children of immigrants to the United States - a subject of post coming in the near future.

Tuesday, June 11, 2013

Guest Post: Writing About Your Family: Lessons I Have Learned

Today’s guest post is written by Sharon Hicks, author of How Do You Grab a Naked Lady, a memoir about her life with her bipolar mother. I reviewed the book here. The best way to gain insight into yourself, in my opinion, is by learning about your family, even if what you learn is somewhat painful.

Sharon Hicks

A few years ago, I met with Mother’s psychiatrist, Dr. Amjadi, to ask him a few questions about my mother. I was writing Mother’s story. I wanted to know more about her. Why did he tell me years ago that she was obsessed with knowing the truth? Aren’t we all?  Is obsession a symptom of bipolar? She was diagnosed as manic-depressive with schizophrenic tendencies. What does that mean? Another psychiatrist told me: “Can’t be both.” Could it?

After a few hours of discussion, he said he was amazed that I was writing her story rather than entering a field like psychology or social work that might help me understand mental illness better. Many of the family members of mentally ill patients he had previously encountered had done that. Then, he suggested I make it my memoir: showing the differences between mother and daughter, mentioning the things I had done that mother couldn’t, describing our roles as mother/daughter, etc.

My story! Impossible. She was the colorful, sexy, crazy one; the one arrested over thirty-three times mainly for parading around town naked, in and out of mental hospitals, multiple shock treatments and meds. For Pete’s Sake! She drove around the island in her yellow GS Buick convertible (she named Goose Shit) with the top down, naked. Well, okay, she did wear a yellow Gucci scarf around her neck, but only to blow in the wind. She especially loved coming to a stop sign next to a truck or bus so they could look at her, naked. “Those people can be so stupid. Haven’t they seen a naked body before? Wow, the stop light; ever see anything so fucking red as a blinking red stop light!”  

But, now it was my story. Well, my life with mother: how she was crazy and I was perfect. Heck! I had proof. Mother’s police records, documentations, her audiotapes. And, my senior class voted me Most Ideal and Homecoming Queen. We were clearly opposites! I was determined to prove it.

I wasn’t prepared for the agonizing writing process. The crazy ride on the roller coaster of emotions. Laughing and crying. Pacing, fidgeting and then exhaustion.

I wasn’t prepared for the ending. After the writing, I loved her and connected with her in a way I never did before. After the writing, I learned that the best parts of me were also my mother’s best parts: her inquiring philosophical mind, her raw honesty, her free spirit. And I learned I was not perfect! 

Today, I wish I could reach out, hug her and whisper in her ear: “I can’t possibly understand, but I want you to know I am your biggest ally. I love you.” 

Mother would quote Erhard: “Understanding is the booby prize.” Then she would snicker: “Who gives a shit?”   

Then we both would laugh and eat her “fart” cookies.


Others ask me to share lessons I learned in writing my memoir. I don’t think any are hazardous, but some may be considered dangerous and scary, like diving into the deep end of a dark lagoon where the monsters live. You really don’t know what lurks in the darkness or crevices of your mind. Give up the fight to be right and know that “What you resist persists.” (Carl Jung) Once you face honesty in the face, humility bathes your body. And, you can shake hands with authenticity.

Lessons I have learned:

Be honest. With each event: what were you doing? Wearing? Thinking? Feeling? Be as honest as you can with each episode. Re-live it!  During the writing I paced, cried, panted, took deep breaths and ate dark chocolate. With your honesty, readers will relate whether they share the same experience or not, much like The Glass Castle by Jeanette Walls, The Liars’ Club by Mary Karr or Running with Scissors by Augusten Burroughs.

A memoir (non-fiction) is written as a novel (fiction). Fiction has three parts: The Set Up/Climax/Resolution. A movie producer interested, asked me quickly: “What is Act 1?” I answered: “Growing up with crazy/manic Mother.”  “Act 2?” “Marrying squeaky clean proving I am nothing like Mother.” “Act 3?”  “Discovering I am like my mother. Her best qualities are my best qualities.” He then said he was interested and wanted to read my memoir.

He did offer a movie option. But wait, not so easy: How was my life resolved?  Who am I?  Who is my authentic self? Part 3 was the most difficult to write. To resolve. Oh shit…Mark Twain to the rescue: “It's no wonder that truth is stranger than fiction. Fiction has to make sense.” Then I relaxed with the understanding that Part 3 is a work in progress.

Focus on what your memoir is about. Write a couple of sentences or what is called an elevator pitch. Write a synopsis of one page to indicate the three parts as described above. Focus.

Legal advice may be needed when writing about others. Does writing about this particular incident/person contribute to my story? Will it damage my relationship with this person or harm this other person unduly?

Do your research. Attend Writers Conferences, Storytelling and Writing Workshops. Read. Learn. The best work I read is On Writing by Stephen King.

Focus on writing to one person. I focused writing to my only sibling, my brother who is four years older. David says my book answers many questions in his life and he has a deeper understanding why he does certain things a certain way. And, the biggest bonanza: he now knows me at a deeper level.

Know that there will be questions. I thought after I wrote my memoir, I would feel relief and satisfaction. It was over. The burning desire inside me to write “mother’s story” was finally completed. Published. I could relax. Oh no! The questions keep coming. I am reliving it over and over: painful, yet cathartic, exhausting and consuming. No end to the story.


My dad told me I broke his heart when I was ten years old. I asked him the most difficult question: “Will I grow up to be like Mother?”  We were driving to the mental hospital to see Mother. I noticed him gripping the steering wheel until his knuckles were white and, looking straight ahead answered in a low voice: “no.”

The question lingered. Others continually asked me the question. Friends, husbands, lovers. “Are you anything like your mother?”  Anger would boil inside me as I answered with a loud “NO. Absolutely not!”  I broke off relationships. He doesn’t even know me. I am perfect. Mother was the crazy one. Screw him.

Today, after publication of How Do You Grab a Naked Lady? I am asked again at book signings, meetings, and interviews; in emails; on face book and twittering, “Are you anything like your mother?”  I answer calmly and proudly:  “I hope so.”   

Sharon L. Hicks is a retired executive living in Honolulu, Hawaii. She is the daughter of businessman and community leader Harold E. Hicks, whose company, Hicks Homes, built over 20,000 affordable pre-designed homes in Hawaii. How to Grab a Naked Lady is her first book, inspired by her mother.  It is available at Amazon and Barnes and Noble.

Sunday, June 9, 2013

DSM Jive

After all the hoopla, looking through the new DSM-5, it's incredible how few substantive changes there really are from DSM-IV. 

My personality disorders research group argued back and forth for years about radically changing that section, taking out certain disorders, adding "dimensions," etc. Turned out that the DSM left the section pretty much completely unchanged! 

They did put another chapter in the back of the book for anyone interested in the suggested "new" paradigm. No clinicians will be interested. They already "defer" personality disorder diagnosis as it is.

My prediction: The DSM 5 will lead to precisely NO changes in the way psychiatry is practiced today by anyone, myself included.

Tuesday, June 4, 2013

Strategies for Initiating Discussions of Family Dysfunction, Part II

In Part I of this post, I discussed two possible initial strategies for beginning discussions about highly charged, difficult family relationship patterns with the goal of putting a stop to them (metacommunication). Here in Part II I will discuss three more.

In trying to figure out the best possible strategy for a given family member, I mentioned the process I use with my psychotherapy patients: 

In doing psychotherapy with patients, when I start to help them shape an initial approach, I usually try one or another of the five potential strategies in a role playing exercise to see what my patient is up against. I generally stick with a given strategy even if the target’s initial response is a negative one - such as evasive maneuver or a verbal invalidation of the patient. Such maneuvers can often be countered with specific responses that are employed as the conversation progresses.

However, if I seem to get in trouble with escalating negativity from the patient playing the targeted other even while employing the usual countermeasures, I know that I should stop, and try a different initial approach.

Of course, all the usual approaches may not work, so ingenuity is required. Every time I am foolish enough to think that I have heard every possible negative response, I am surprised. But where there is a will, there is definitely a way.

Here are the remaining three strategies for getting the ball rolling:

3. Initiation strategy #3 is used in cases in which someone has been sacrificing his or her idiosyncratic ambitions in order to overtly or covertly “look after” parents. Such individuals may have been “on call” to help mediate the parents’ disputes, take care of various chores or duties for one parent or the other, or to provide missing companionship for one of them. 

Alternatively in families with gender role problems, an adult may live with a widowed mother so that either the mother appears to be dependent on her adult child or vice versa. The latter situation is created by the dyad in order to avoid the violation of any family proscriptions against women being powerful enough to make it on their own. In this situation, the adult child also appears to be in some way dysfunctional, so that the mother partially discharges her repressed ambition by running the adult child’s life. In such cases, it is very difficult indeed to tell exactly who is taking care of whom.

"Who is Taking Care of Whom?" is a shell game

Metacomunicators begin strategy number three with a statement that they are worried about the parent’s well being in some way. They might say, “I’ve been really worried about you, Mom, you’ve looked so lonely and depressed.”  The patient brings this up without any suggestions or advice about how Mom should take care of this problem. The reason for doing so is that the parent will usually argue with any particular advice offered - which is usually something fairly obvious anyway - in order to avoid dealing with his or her underlying loneliness and depression. 

Any such behavioral prescriptions that are offered by the metacommunciator can be dissected and debated ad infinitum, and the conversation invariably deteriorates into a game of “why don’t you - yes but” ("Well try this."  "Yes, I could do that, but [here's why that won't work]").

The initial response of the parent to this recommended opening statement is usually something like, “You don’t have to worry about me, I’m doing fine.” Such statements are an invalidation of the metacommunicator’s worries, since in most of these cases the parent really is depressed or lonely - or may be drinking too much or behaving self-destructively in some other way as the case may be. 

The statement is also an invalidation of the metacommunicator’s caring and concern. The best response here is for the individual to reply, “I appreciate the fact that you don’t want me to trouble myself with your problems, but I really am concerned.” 

Predictably, the parent will then respond with a distancing remark such as, “No you don’t. You don’t care about anyone but yourself.”  The metacommunciator can answer this type of statement by saying: “I wish I knew of a way to convince you that I really do.” No point arguing about it, since there is really no way to prove it one way or the other.

In the case of a mother and, say, an adult son playing the game of “who is taking care of whom” as described above, the son might begin strategy number three with a statement such as, “I know that you are perfectly capable of taking care of yourself, but sometimes you seem to be afraid to for some reason.” With this opening gambit, the mother has an obvious comeback that she can use in order to avoid facing the dilemma that has been brought up - usually for the first time - by the metacommunicator.

She can point out that it is really the son who is the dependent one. After all, such individuals often have, up to that point, exhibited some apparent defect that has prevented them from going out and making their own life separate from Mom. In many of these cases Mom has bailed the adult child out of one financial bind after another. Who is he to be talking about the mother’s dependency problem? In this situation, the adult child should confess that he has not striven for independence thus far, but that one of the reasons for his not having done so is his continued worry about how the mother might feel if left alone and on her own.

If the metacommunicator is successful at getting the parent to talk frankly about his or her expressed areas of concern, the adult child and parent can then go on to discuss how they have been misreading one another’s intentions and about the past family history that has lead to the problem.

4. The fourth opening strategy is employed when mild to moderate distancing behavior by the parents is a primary obstacle to metacommunication. Distancing behavior is manifested when any attempt by an adult child to get close to the parent or to discuss important family issues is met with hostility, verbal abuse, or other provocative behavior. 

The metacommunicator begins strategy #4 by expressing a wish for more closeness with the parent. They say something like, “I really feel bad that we get along so poorly; I really wish that things were better between us.”

This statement often leads to an initial positive reaction by the parent for two reasons. First, many distancing parents do not like to admit that their behavior is purposely designed to drive their children away. In effect, they would have to do so if they were to blatantly reject this overture. Secondly, the statement appeals to the side of the parent’s ambivalence that really does desire a close relationship with their children. The adult child’s expressed desire for closeness in spite of the fact that the parents have been treating her or him horribly communicates such love for the parent that the parent’s hostility often seems to melt away.

Unfortunately, in more severely disturbed families this type of approach may lead to an even nastier rejection of the patient than had been the norm previously. The parent may respond with a statement that communicates the sentiment, "“Well, I do not want to be close to you; I wish you had never been born!”  If this kind of response seems likely, metacommunicators should usually not attempt to employ this strategy. 

I believe that it is highly doubtful that the parent really feels that way even if he or she says it and acts like it, but clearly some other strategy might work better. In rare cases, however, the parent’s nastiness is so transparently feigned that a metacommunicator can break through it by saying, “I don’t believe that for a second.”

If the parent responds to initiation strategy number #4 positively, adult children might then wonder aloud why they and the target are always fighting. This question can once again lead to empathic discussions of the nature and origins of mixed messages and misunderstandings within the relationship, which are in turn used as a basis for requesting concrete behavioral changes from the target.

5. The fifth opening gambit is useful in cases in which an adult child is following in a parent's footsteps in some way. Such individuals usually recreate the parent’s maladaptive behavior in order to shield the parents from feelings of envy. In these cases, the adult child usually tries but fails to achieve some goal that is desperately desired by, but forbidden to, the parent. For example, a daughter might appear to seek out nice men but, just like her mother, end up with a succession of abusive mates. This may happen after Mom has spent years trying to shield the child from this very outcome or warning her about the dangers of it.

The metacommunicator begins strategy number five by asking the target for advice on how to handle a difficulty that the patient is experiencing outside of his or her relationship with the target. The outside difficulty should parallel a difficulty that the target has also experienced within the family. For example, in a family in which a daughter’s father always gives in to the mother's unreasonable demands, the daughter may come to the mother with the following request for help: "Mom, I need your advice. My husband is following me around like a puppy dog. How do you think I should handle it?” 

The goal here is to establish a sense of commonality between the two women that allows for open discussion about how parallels in the family happened to have come about. Once again, this naturally leads to discussions of the nature and origins of mixed messages and misunderstandings within the relationship. 

In dysfunctional interactions, whenever one party brings up such parallels, the other party usually feels unjustly criticized, and therefore reacts negatively. This occurs for one of two reasons. First, the second party may feel that the first party is a hypocrite who is criticizing her for things the other party does herself. Alternately, one or the other party may feel that their situations though similar are not really the same at all.

Strategy #5 changes the valence of the interaction from negative to positive in two ways. First, it puts the daughter in the proper hierarchy with the mother. The patient is asking the mother for advice based on the mother’s experience and intelligence. Second, the mother usually will not feel criticized by the daughter for having the problem, because the daughter is admitting to having the very same or a similar problem herself.

All five initiation strategies, as well as any other creative approaches an individual is able to devise, are meant to soften up the target, so to speak, so that the family dynamics can be discussed and clarified. If an initial approach seems to work, the metacommunicator continues the conversation to the point where the goal of mutual understanding and a request for a concrete change has been achieved.