Vol.:(0123456789)1 3
Contemporary Family Therapy
https://doi.org/10.1007/s10591-019-09525-6
ORIGINAL PAPER
Family Functional Formulations as Guides to Psychological Treatment
Rudi Dallos1
   · Patricia M. Crittenden2
   · Andrea Landini3
   · Susan Spieker4
   · Arlene Vetere5
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
This paper proposes that clinical practice based on psychiatric diagnoses and categories of harmful behavior may be inadequate
at best and harmful at worst. An alternative model of functional family formulations is proposed based on exposure
to danger, developmental processes around danger, information processing regarding danger, and strategies for coping with
danger. These are encompassed by the dynamic-maturational model of attachment and adaptation (DMM). DMM theory
is outlined, then four types of harmful behavior that have resisted treatment are described, each with a case and treatment
outcomes: physical abuse, disruptive child behavior, psychosis, and autism. We conclude by describing how these four cases
address both children’s and parents’ need for safety and developmental progress in representing and responding to threats,
and also professionals’ need for a treatment-relevant nosology of human suffering.
Keywords  Assessment/diagnosis · Treatment · Adaptation · Attachment · Developmental psychopathology · DMM
Systemic family therapists have long pursued the Holy Grail
of being able to identify how family dynamics are causally
related to different types of problems and consequent
implications for improving treatment (Minuchin et al. 1978;
Bowen 1971). These efforts have diminished because they
came to be seen as being overly ‘expert’ and blaming of
parents for causing their children’s problems (Dallos 2019).
However, there is a resurgence of interest, for example
Kaslow and Patterson (2006) describe attempts to develop
a systemic model of relational diagnosis for inclusion in
DSM and struggles for this to gain any acceptance. Generally,
psychological treatments are less effective than would
be expected and have shown little or no improvement in
outcomes in the recent three decades (Insel 2014; Kaslow
and Patterson 2006; Wampold 2015). Lack of clarity about
how and why different treatments work or fail has resulted
in a pragmatic approach to treatment in which eligibility for
psychological services has been tied to psychiatric diagnoses.
These, however, are inconsistent theoretically and lack
clarity about the causes of problems and whom to target for
intervention. In systemic therapy the problem is not simply
the identified patient, but also the functioning of the individual’s
family. However, if the problem is in the family, then
there is the issue of who receives the treatment—everyone
altogether or different family members separately. Despite
this relational view, most family therapy is nevertheless conducted
in terms of currently predefined symptom-based categories,
which are assigned to an identified patient despite
the fact that no case fits perfectly, the categories lack empirical
validity, and cases of child maltreatment and criminality
fit very poorly.
Three core issues arise: defining the problem, who defines
it, and who should receive treatment; these problems may
reflect gaps in the conceptual knowledge base. There has
been a tradition in systemic family therapy of attempting to
address these issues by the therapist developing functional
formulations to link family typologies to different clinical
presentations (Minuchin et al. 1978; Dallos and Draper
2010). Contemporary family therapy, in contrast, emphasizes
a collaborative process whereby therapists together
with family members define these three issues. We think
that both approaches are necessary because the medical illness
discourse inevitably permeates the relationship between
*	 Patricia M. Crittenden
	crittenden@patcrittenden.com
1
	 Department of Clinical Psychology, University of Plymouth,
Plymouth, UK
2
	 Family Relations Institute, 9481 SW 147 St, Miami,
FL 33176, USA
3
	 Family Relations Institute, Reggio Emilia, Italy
4
	 Child, Family, and Population Health Nursing, University
of Washington, Seattle, WA, USA
5
	 VID Specialized University, Oslo, Norway
	 Contemporary Family Therapy
1 3
therapist and family. Family members, including the ones
seen as ‘having’ the problem, define themselves and their
difficulties in terms of diagnostic categories. This is compounded
by the fact that entry to services and payments of
health insurance typically require a diagnostic label.
Formulation
Formulation has been advocated as an alternative to diagnosis
in that it offers a detailed analysis and explanation of
problems leading to specific intervention strategies (Flåm
and Handegård 2015; Johnstone and Dallos 2013). In family
therapy, the earliest versions of formulation were the
functional theories regarding family typologies of problems.
These were succeeded by the notion of ‘progressive
hypothesizing’ which contained the idea of formulation as a
dynamic and evolving process and also opened formulation
to being a progressive and collaborative process with family
members who, together with the therapist, defined the meaning
of their difficulties (Selvini et al. 1980; Perkins et al.
2019). However, lacking a developmental and evolutionary
model, these attempts were largely unsuccessful. Moreover,
complex and non-transparent situations, such as symptoms
in one family member serving functions for other family
members, might not be discernable or emotionally acceptable,
especially if they lead to a sense of feeling blamed. In
such circumstances, families may retreat to the perceived
safety of diagnostic labels.
DMM Family Functional Formulations
We suggest building on systemic functional formulations by
adding ideas from DMM attachment theory. The central idea
is the function of family relationships to promote survival of
each individual and their children. The DMM is an integrative
expansion of the Bowlby–Ainsworth theory of attachment.
A crucial contribution of DMM theory to understanding
harmful behaviour is highlighting humans’ capacity to
adapt to a wide range of threatening conditions. The DMM
treats danger as a near universal aspect of life (Centers for
Disease Control and Prevention 2016; Felitti 2009). Early
on, when children cannot protect or comfort themselves,
parents or other attachment figures do so, helping children
to learn to protect and comfort themselves. The importance
for individual and species survival of progressive adaptation,
based on a slow maturing and plastic brain, cannot be
over-emphasized. Of course, near universal endangerment
does not result in near universal maladaptation. The difference,
we think, is parents’ ability to protect and comfort their
children in each child’s zone of proximal development during
the event and later, as the children mature. For example,
studies of people diagnosed in adulthood with chronic PTSD
(Heller 2002) and eating disorder (Ringer and Crittenden
2007) have shown that they display on-going psychological
trauma from unprotected and uncomforted danger in childhood.
The point is that the DMM places the developing mind
between dangerous events and their outcomes.
The central DMM ideas that are relevant to increasing the
effectiveness of psychotherapy are:
	1.	 Safety and sex. Placing survival of self and progeny
as the evolutionary basis for adaptation/maladaptation
(Bowlby 1969/1982), thus including sex and reproduction
as part of attachment (Crittenden 1997), gives a
focus to formulation.
	2.	 Unprotected and uncomforted danger. Finding the
roots of maladaptation in unprotected and uncomforted
danger experienced early in life (before the brain is
fully mature) clarifies parents’ roles as including protecting
themselves sufficiently to promote survival of
their children.
	3.	 Influences on individual and family functioning. DMM
theory integrates information about functioning from
many sources. These range from genes that regulate
maturation to neurological structures that apply
matured possibility to actual experience, to psychological
processes involving primed neural networks
that predispose behavior, to relationships that give
meaning to behavior, to cultures that promote or discourage
various styles of behavior. See Fig. 1. These
influences are dynamically interactive; for adaptation/
maladaptation they converge on individual psychology
in attachment relationships.
	4.	 Intra-personal information processing and inter-personal
protective strategies. Individual differences in
response to threat consist of patterns of interpersonal
behavior and of intrapersonal psychological information
processing. This is crucial to combining intrapersonal
psychology with interpersonal relationships.
Fig. 1  The dynamic interplay of influences on adaptation. (Used with
permission, Crittenden 2016)
Contemporary Family Therapy	
1 3
	5.	 Functional definitions of behavior. Recognizing that
specific behaviors can serve different functions and
functions can be fulfilled by different behaviors is
crucial to moving beyond symptom-based diagnoses.
Further, the function of a behavior or symptom at one
point in development might not be the same at another
developmental period.
	6.	 Multiple sources of information. Recognizing that
information comes from different sources, including
at least the body, external contingencies with the self,
and associated feelings can focus therapists on the full
range of available information. This information can be
derived from a life-span set of assessments of attach-
ment.
	7.	 Brain maturation and transformations of information.
Neurological maturation affects how information can
be transformed, beginning with simple omission of
information from further processing and continuing,
at progressively older ages, to falsification, distortion,
denial and, by late adolescence, self-delusion. Transformations
provide an empirical basis to hypothesis
building, with strategies being seen as strengths when
they are organized (thus moving away from a deficit
model of maladaptation).
	8.	 States of conscious awareness. Recognizing that information
can be pre-conscious, verbal, or reflective,
dependent upon maturation of the brain and transformations
of information, opens hypothesis-building to
both family members’ conscious information and also
non-conscious processes that influence behavior.
	9.	 A categorical and dimensional classificatory system.
Expanding Ainsworth’s classificatory system of individual
differences for responding to threat in both
categorical and dimensional ways moves hypotheses
regarding protective functioning beyond forced-choice
categories to a relational system that is open to both
clustering and unique specification for each family
(Crittenden and Spieker 2018).
	10.	 Adaptation versus maladaptation. Defining adaptation/maladaptation
as an interaction of threat with
the availability of effective personal and interpersonal
strategies for coping with threat, in which unprotected
and uncomforted children develop age-defined ‘psychological
short-cuts’ using transformed information
(Crittenden 1992, 2016), moves family functional formulation
away from an illness model.
DMM attachment theory defines the role of therapists
as transitional attachment figures to family members,
thereby giving therapists expertise to work reciprocally (a)
in each family member’s zone of proximal development,
for the purposes (b) of expanding each person’s array
of possible protective strategies (recognizing that some
transformations of information block out new information
therefore impeding change processes), and (c) of seeking
both individual strategies appropriate for the person’s age
and maturation and also the set of family relational strategies
that provide the maximum benefit to the family, and
(d) guiding family members to repair breaches in relationships
and incorporate new information into existing psychological
processes, i.e., how to constantly update their
protective strategies to fit changing contexts.
These ideas require considerable expertise if they are to
be addressed consciously by therapists. Ironically, parents
are ordinarily expected to do this without conscious awareness
or professional labels for daily family interactions.
We think that these ideas from DMM attachment theory
can inform therapeutic responses to harmful behavior and
that the process is best described as a family functional
formulation.
DMM Family Functional Formulations
and Harmful Behavior
DMM family functional formulations (FFFs) provide
an alternative to psychiatric diagnoses or categories of
harmful behavior. DMM FFFs combine careful description
of problematic behavior with hypotheses about its function
for each person (thereby addressing why the harmful
behavior is maintained) with suggestions for how to
modify the need for the behavior (thereby suggesting treatment
approaches). Unlike treatment that addresses only
one person’s needs, the needs of all family members are
considered—even if family members do not participate in
the treatment.
We distinguish between DMM general functional formulations
(GFFs) that synthesize many families’ experience
and DMM FFFs that are specific to a particular family.
Although GFFs are helpful in illuminating aspects of
family functioning, they should not override attention to
differences among similar families. Further, families with
the same harmful behavior should not be assumed to fit
the same GFF. To the contrary, we expect equifinality,
with more than one developmental and psychological process
underlying psychiatric diagnoses and harmful behaviors,
e.g., PTSD (Crittenden and Heller 2017) and eating
disorders (Ringer and Crittenden 2007). We also expect
multifinality, with different symptom diagnoses and harmful
behaviors leading to similar functional outcomes (von
Bertalanffy 1968). GFFs can be validated in comparative
research designs whereas FFFs are validated and modified
through treatment actions, feedback, and reformulation.
	 Contemporary Family Therapy
1 3
Four Examples of DMM FFFs
To illustrate our model of family functional formulation
using the DMM, we examine four clinical issues, in order of
transparent versus transformed information: physical abuse,
behavioral disorder, psychosis, and autism. Each is discussed
in terms of GFFs, with an example of an FFF for which the
implications for treatment are outlined. Treatment, for each
case, is described in the final section of this paper.
1. Physical Abuse (Omitted Feelings
and Images with Acquired Prescriptive
Sematic Rules)
Child abuse seems inconsistent with parents’ protective
role. However, when families’ circumstances and interpersonal
dilemmas are formulated through a family functional
formulation, clinicians can often understand why parents
behaved as they did, thus becoming able to assist parents
to prevent violent behavior. In cases of physical abuse, we
look for predisposing conditions such as attachment threats
and injuries and extra-familial threats (e.g., debt, work problems,
isolation). We also seek the trigger that precipitated
the instance of violence; this trigger is often tied to a past
dangerous experience and is known only in a preconscious
imaged way. Protective resources, such as times when problems
were resolved or protective family members, can support
the treatment (Flåm and Handegård 2015).
Many people who are aggressive use self-protective
strategies organized on the basis of prescriptive semantic
‘directives’ and omit information about their own feelings
from awareness, especially when they feel threatened. They
might up-regulate anxious arousal so as to perceive all possible
dangers (with the risk of mis-perceiving non-threats
as threats); alternatively, they might down-regulate arousal
and dismiss feelings (with the risk of sudden disinhibition
of overwhelming negative feelings) (Johnson 1995). Neither
set of transformations promotes reflective thinking that
could identify the transformations (Crittenden 2016). In our
example, treatment enabled ‘Pete’ to connect his childhood
experiences of fear when being bullied to his aggressive
behavior toward his older stepson.
Pete’s Violence to his Stepson
Pete was a stepfather to his wife’s sons (aged 11 and 13) and
biological father to their sons (aged 2 and 3). One morning
Pete went into the kitchen and found his 2-year-old crying,
with a red weal across his forehead; his stepson stood nearby.
Assuming that he had caused the wound, Pete jumped on the
older boy, injuring him severely. His wife heard the screaming,
came running, then called an ambulance and the police.
Pete’s stepson was taken to hospital; Pete was arrested and
sent to prison.
When Pete was released, he and his wife wanted to live
together as a family. Like most men released early for good
behavior, Pete accepted full responsibility for his own inappropriate
behavior, sometimes even excessively so, without
considering exonerating circumstances or others’ partial
responsibility. Pete said that the cognitive information
in CBT in prison had really helped with his ‘background’
anger, but, ‘My attack on my stepson was ‘explosive’ anger
and I do not understand that—so, hand on my heart, I cannot
promise I will not do that again’. Pete’s ‘back-story’, narrated
early in treatment, revealed more than he had expected.
An Olfactory Image of Forgotten Violence
Pete’s parents separated when he was three years old; he
had not seen his father since. He knew that his father had
been violent to his mother, but Pete said he had no memory
of this. Both Pete and his father were carpenters. After his
mother remarried, his older brother bullied him, and his
stepfather disciplined Pete very harshly. Pete learned to
inhibit his fear to avoid bullying and punishment, but he
had not learned what he should do until being in prison.
We had warned Pete that talking about the past was likely
to ‘stir the pot’ of memories that were not conscious and to
not be surprised if memories surfaced. One Saturday morning,
Pete had been in his workshop. He telephoned, sobbing
uncontrollably, hardly able to say what was happening. He
kept saying that it was ‘the smell of the sawdust.’ Together,
we speculated that Pete had been exposed to his own and
his mother’s fear as an infant, and that the smell of sawdust
was the imaged trigger for violent memories to emerge. This
helped Pete to understand ‘explosive anger’ and illuminated
the links between fear, bullying, and his violence to his stepson.
Pete described it as ‘bigger people beating up on littler
[sic] people’ and he was poignantly aware of the terrible
irony in this.
Formulating Pete’s Problem
The formulation revealed the impact of his ‘forgotten’ feelings
during childhood trauma on Pete’s protective strategies,
both as a child and in adulthood. The DMM notion
of safety and protection in close relationships clarified his
self-protective strategies and how his violent actions had
been intended to protect his son. Revealing non-conscious
imaged memories was crucial to integrating Pete’s intentions
with his behavior.
Contemporary Family Therapy	
1 3
2. Disruptive Behavioral Disorders
in Children (ODD and ADHD)
Complex family patterning: Parents: Denial of negative
affect plus substitution of external guides for denied feelings;
Older son: massive omission of ‘forbidden’ negative
affect with uncontrolled intrusions; Younger son: contingent
exaggerated distortions of negative affect.
About half of all children diagnosed with Oppositional
Defiant Disorder (ODD) also have a diagnosis of Attention
Deficit Hyperactivity Disorder (ADHD) (Barkley and Murphy
2006), a chronic condition of inattention and impulsive
behavior. There is concern that some therapists treating children
with disruptive behavior only target symptoms, often
with stimulant medications, without identifying parental
mental health and family issues associated with child disruptive
behavior (Sayal et al. 2015; Timimi et al. 2011).
Here we consider two cases in which disruptive behavior
symptoms emerged because of their interpersonal function
within the family, whether or not there was also an underlying
biological vulnerability for ADHD. We propose that
disruptive behavior can be a child’s attempt to elicit attachment
responses from the threat of parents who are inconsistently
available (Marvin and Stewert 1990). The symptoms of
ADHD can hold parents’ attention or distract their attention
from spousal problems. Either way, parents’ inconsistent
responses can lead to escalating demands by the child that
frustrate the parents, leading to a cycle of ineffective interactions.
Such a familial explanation might fit many cases of
comorbid ADHD and ODD; the Doyle family is an example.
Because the parents sought treatment for their children, as
competent parents do, and had been approved to adopt the
children by the child welfare system, the therapists accepted
the assumption that the problem resided in the children.
The Doyles
Pavi, age 6, had been in therapy for 2 years and Stefan, age
4, for more than a year when their therapists, seeing little
improvement, sought a consultation. By this time, the parents
each had a therapist for themselves, making four therapists
working with the family. Mrs. Doyle was the primary
caregiver and Mr. Doyle worked long hours.
Pavi’s problems (biting, hitting, attacking Stefan, and
dangerous behavior such as running into the street) began
after a cross-country move far from relatives. Some months
after Pavi’s treatment had begun Stefan’s teacher reported
he had become uncooperative, aggressive, and had difficulty
calming down after being agitated or aggressive. The teacher
urged the Doyles to have Stefan evaluated for medication.
Mrs. Doyle reported being exhausted with managing the
boys’ aggression toward each other and, occasionally, to her.
Assessment of Attachment
The family members participated in individual DMM
attachment assessments and a whole-family interview. Mrs.
Doyle’s protective attachment strategy was idealizing her
parents, not doing the wrong thing (i.e., inhibit before acting),
and trying to do the right thing (according to her parents
and parenting books). Mrs. Doyle openly missed her
family, but denied feeling any anger. Mr. Doyle’s protective
attachment strategy was similar: idealizing his parents, putting
himself down, and trying to say and do the right thing.
He distanced himself from sadness, fear, grief or anger by
omitting them from awareness.
As the older son, Pavi’s self-protective strategy was to
comply with instructions, be good, and care for his mother
if needed. Pavi rigidly inhibited anger, sadness and fear until
he could not—and then he exploded in angry aggression.
Stefan used the opposite strategy; he alternated coercive
displays of vulnerability and disarming coyness with sudden
displays of intense anger. Especially after Pavi entered
treatment, Stefan openly challenged his parents. Nevertheless,
both parents maintained modulated, even pleading,
demeanors, such that their responses to Stephan became
non-contingent and unchanging, whether he was calm and
cooperative or defiant.
Formulating the Family’s Problem
Both parents tried to do the right thing from the perspective
of others, including their sons, which required omitting their
negative feelings from awareness. They felt inadequate when
their children were angry, could not assert their hierarchical
authority, and instead often deferred to their children. This
imbalance was the critical cause of the family’s problems.
Stefan filled the resulting power vacuum with a coercive
strategy. For him, acting emotionally was more effective in
the competition for parental attention than Pavi’s inhibition.
When Pavi’s inhibitory strategy broke down explosively, it
frightened his parents. They also were trapped into Stefan’s
frequent and sudden alternation of aggressive and disarming
behavior. These two different uses of aggression left them
uncertain of what to do, afraid of the boys, and even more
unwilling to display anger themselves. The family was in a
self-maintaining downward spiral of distress.
Three problems with individual treatment of children are
highlighted by the Doyle family: (a) Both boys would qualify
for psychiatric diagnoses of ‘ADHD’ or possibly ‘ODD’, but
the basis for each boy’s behavior was very different. (b) Individual
treatment of one boy had been followed by escalating
problems until all family members were in treatment; this
suggested that Pavi’s treatment had destabilized the family.
(c) With treatment focused on inhibiting disruptive behavior
rather than on its function, the basis of the problems
	 Contemporary Family Therapy
1 3
had been overlooked all together. Indeed, the therapists had
accepted the parents’ premise that the problems resided in
the boys; this prevented anyone from seeing the larger family
situation in which the parents’ inhibition of anger and
abdication of parental authority generated and maintained
the distressing behavior.
3. Psychosis (Displaced, Denied,
and Delusionally Transformed Information)
Psychotic disorders are disabling for patients and their
families and require extensive treatment resources. They
are relatively frequent: a 12-month prevalence of 0.4% has
been estimated (Moreno-Küstner et al. 2018). The symptoms
include delusions, hallucinations, thought disorders (“positive”
symptoms), inhibition of initiative (“negative” symptoms),
and anomalies of cognitive functioning (American
Psychiatric Association (APA) 2013). Nevertheless, there is
lack of consensus regarding the diagnostic criteria, etiology
and pathophysiology of these disorders (Patel et al. 2014).
Psychotic episodes can recur, become chronic, or remit completely
(Crismon et al. 2014). We note the similarity between
the symptoms of psychosis and DMM inhibitory strategies
when these are accompanied by explosively disinhibited
negative affect.
Formulating Psychosis
Understanding psychosis requires looking outside the family
system to understand how a family problem is not resolved
and, instead, may be maintained by professionals. Because
developmental transitions (for example, the birth of a child
or the transition to adulthood) require a radical re-shaping
of family attachment structures, such periods can threaten
families when their structure is rigid and based on denied
information, particularly information tied to trauma. In
these cases, a family member behaves as if they would be
destroyed if the transition were allowed to occur. Because
transitions are unavoidable and culturally regarded as normal
and desirable, these fears cannot be expressed openly, nor
even thought about clearly. Instead, the person in transition
behaves in seemingly irrational ways that function to halt
the transition. Sometimes diagnosing a psychotic state in
that person and ‘protecting’ everyone by hospitalizing the
‘psychotic’ person or prescribing medication (that restores
inhibition of the forbidden ‘psychotic’ behavior) functions
to maintain the family dysfunction.
The DMM GFF for psychotic disorders considers them to
be a response to irresolvable developmental conflict between
the approaching context that requires new behavior and
the ‘old’ context that requires incompatible behavior. The
inability to resolve the conflict precipitates the ‘psychotic’
crisis. For example, older adolescents need to leave home
to start their own families while some parents need them to
remain at home. Or a woman might believe that she cannot
meet both her current life demands and also those of being
a mother, with the outcome being postnatal psychosis. The
family member whose behavior must both change and not
change can experience extreme peaks of arousal, displayed
either as explosive forbidden behavior or somatic anomalies.
This signals that the family system has exhausted its
resources, and needs help from professional systems to manage
the crisis. As we noted, professional help might maintain
the problem.
Giovanni and his Family
Twenty-four-year-old Giovanni and his two older siblings
lived with their parents; Giovanni appeared learning disabled,
only one adult child had a job, and none had a romantic
relationship. At age 15, Giovanni had first attracted professional
attention when he was seen having sex with older men
near the local graveyard. His parents arranged psychiatric
care for him. Giovanni told his psychiatrist that he was in
daily contact with his paternal grandfather (dead before his
birth) who was protecting him by telling him what to do.
Giovanni was diagnosed with schizophrenia. Both Giovanni
and local rumors hinted at sexual abuse in and out of the
family by Giovanni’s father (possibly involving his sons), but
nothing was substantiated. When asked, all family members
denied sexual abuse with outrage. The family terminated
the psychiatric support for Giovanni without professional
agreement.
After several years of relative stability, Giovanni came
to professional attention again with gait anomalies indicative
of a possible neurological dysfunction; in hospital, no
neurological problems were found, but Giovanni considered
hospitalization one of the best experiences in his life. A few
years later, Giovanni’s parents complained that he refused
to leave his bedroom, had an inverted circadian rhythm, ate
very little and barely spoke to anyone. During a two-month
psychiatric hospitalization, Giovanni’s mother was tender
and affectionate to him, unlike at home. On his return home,
the family reported that all was well.
Formulating the Family’s Problem
Giovanni’s AAI showed evidence of delusional repair of
family problems (his dead grandfather advising him to
avoid people from the community) and of his arousing
anger (which was displaced to hostile people who spread
defamatory lies about his family). This crisis was formulated
as Giovanni’s recurrent need to say and not to say
that he and his brother had been sexually abused by their
father while continuing to live at home. This information
Contemporary Family Therapy	
1 3
was transformed somatically in ways that elicited external
support for him and the family while not revealing the problem.
Attempts to address the sexual abuse generated further
‘psychosis’ by threatening the family with dissolution rather
than facilitating alternative developmental pathways.
Several other conditions in the family made the situation
more complex. The parents’ marriage was fragile because it
was based on hiding the father’s homosexuality. The angry
mother attempted to keep the family together using coercion.
The father and sons sought comfort and connection through
physical closeness. The therapists understood the situation
as Giovanni experiencing conflict between establishing relationships
outside the family and maintaining the integrity of
the family, but displacing it on inappropriate extra-familial
sexuality.
The psychiatric diagnosis of psychosis relieved the immediate
crisis while maintaining, and further obscuring, the
underlying family problem. The children’s development was
frozen at the point of crisis. The resulting chronic cognitive
and somatic symptoms functioned to tie the family together
and periodically activated services as a ‘relief valve.’
The problem to be resolved by treatment was children’s
inability to leave home without harming their parents and,
possibly, exposing sexual abuse.
4. Autism (Two Generations of Multiple
Transformations, Including Falsification
and Denial)
Autism is described as a neuro-developmental disorder of
genetic origin. Nevertheless, the genetic evidence is lacking
(Crittenden 2017; Timimi et al. 2011) and rates of diagnosis
have risen faster than genes can change. High rates of occurrence
among extended family members could reflect either
genetic or familial influence, but there are very few studies
of family functioning in the last 50 years. Among the few
family studies, mothers of children with autism often manifest
dismissed psychological trauma for childhood events
(Roberts et al. 2013) and the children often display inhibitory
strategies (Brewerton et al. 2017; Crittenden et al. 2014,
2018). Like other psychiatric diagnoses, the central indicators
of autism (limited social and linguistic communication
and repetitive behaviors) overlap with many other conditions,
such as anxiety disorders, self-harm, and eating disorders.
Two points are central: (a) the diagnosis as now applied
probably refers to several different conditions (Timimi et al.
2011) and (b) severe cases of autism, with strong evidence
for neurological differences and inhibitory strategies, no
longer constitute the majority of samples (Stedman et al.
2018). This suggests the need to explore individual differences
among families with a child diagnosed with autism.
Formulating One Family with Autism
Penny (age 9 years) had diagnoses of autism and cerebral
palsy, which impeded her ability to play with other children.
The cerebral palsy was a result of a home birth in which
Penny had suffered brain damage from anoxia. Penny had a
younger sister; both parents were highly educated, meticulous,
and semantically-oriented. Penny’s mother sought
treatment because Penny had mood swings that included
‘meltdowns’ in which she attacked her younger sister. At
school, she refused to conform and was aggressive. Penny’s
mother believed that ‘autism’ explained Penny’s behavior;
this left her feeling helpless to change her daughter’s behavior.
She described Penny’s father as possibly autistic himself;
although he chose not to attend the family treatment,
his role in the family was considered as we developed the
DMM FFF.
Penny’s mother’s AAI revealed an inhibitory strategy of
compulsive self-reliance (with dismissed feelings and attachment
needs) along with dismissed psychological trauma
for her parents’ unavailability and consequent emotional
neglect. She described growing up in a commune with her
parents who had had very little time for her, using vivid
images of being left alone, staring out of a window into the
garden. A recurrent theme was her mother’s unreliability.
For example, she was sometimes stuck at school for hours
waiting for her mother to turn up, but she negated any blame
by laughing (thus transforming anger to false positive affect).
On the other hand, she repeatedly emphasized a corrective
semantic intention of being reliable and present for her own
daughters. She did not notice the discrepancy between her
laughter and her distress as a child.
Formulating the Family’s Problem
Penny’s mother constructed her model for raising her daughters
from explicit semantic ideas that reversed her parents’
behavior rather than from experienced sensory memories
of being cared for and comforted, by either her parents or
her husband. Strikingly, she expressed no emotion regarding
Penny’s birth and consequent cerebral palsy and saw
no similarity of it to her parents’ neglect of her. Her most
pressing concern was Penny’s meltdowns and she sought
advice about these.
Many family conditions contributed to Penny using a
coercive strategy that included tantrum meltdowns. Penny’s
mother had conflicting experiences and intentional representations
of parenting. She denied the trauma for Penny’s
birth and loss of the well child she had wanted, nevertheless
guilt made her unwilling to constrain Penny. As a result, she
became vulnerable to Penny’s attempt to get her own way. At
the same time, Penny’s autism called for vigilance to prevent
	 Contemporary Family Therapy
1 3
meltdowns, but her mother found it painful to attend to her
harmed child.
Because Penny’s mother was unaware of her conflicting
dispositional representations and transformed information,
she could not be responsive and predictable. Penny became
frustrated when limited in any way; her emotional displays
escalated very quickly. This triggered anxiety in her mother
that, in turn, fueled Penny’s arousal in a self-maintaining,
reciprocally escalating process (i.e., a circular, self-maintaining
process). The unpredictable responses of Penny’s
mother were mirrored between her parents where her father
attempted to enforce discipline while her mother was more
laissez–faire. This controlling/passive dynamic enabled
Penny’s use of coercion. In addition, Penny became angry
when her mother tried to protect her sister from Penny’s
aggression, both envying her well sister and resenting her
mother’s ‘favoritism.’
Penny’s coercive strategy, including meltdowns, was
attributed to ‘autism’, thus reducing her mother’s sense
of agency and helping her to avoid the guilt she felt about
Penny’s birth. As Penny reached school-age, she began to
employ the notion of ‘autism’ as a strategy that allowed her
to seem unable to control her emotions, thus augmenting her
ability to coerce her parents. Doing this, however, indicated
that she did have control over her behavior. For example,
she claimed to have ‘sensory issues’ to avoid unpleasant
activities.
Penny’s mother showed some indication of reflection in
her AAI, but it was only about understanding the influence
that her parents’ childhood experiences had had on their
parenting of her. She was not able to reflect on her own
behavior.
Treatment Planning and Implementation
with DMM FFFs
FFFs permit individualized planning of interventions,
including hypotheses about the priority of therapeutic
actions and about counter-indicated approaches. FFFs lead
to treatment hypotheses that can be tested and modified during
the session-by-session treatment process. Thus diagnosis,
treatment and feedback become a recursive family-specific
process. For each of our topics and associated cases, we
discuss how the General Functional Formulation informs the
specific Family Functional Formulation and its application
to the case example. We focus particularly on exposure to
danger, developmental capacity to transform information at
the time of exposure, reorganization following the danger,
developmental timing of treatment, and inclusion of family
members in the treatment process.
Treating Child Abuse Through DMM FFF
In spite of a marked reluctance to offer relational therapy in
cases of family violence, individual work has several constraints.
These include limited opportunity to discover and
disarm the triggers of violence, to learn to repair difficult
interactions and to balance the ‘seesaw’ of emotions within
violent relationships. These limitations suggest the need for
relational work. Safety and protection are top priority in relational
work. Contra-indications for relational therapy include
the violent person’s unwillingness to take responsibility for
their violent actions (Sammut Scerri et al. 2017). Together
with the therapists, all family members make a safety plan,
based on past violent episodes, and a no-violence contract.
These help family members learn to predict and prevent
dangerous arousal, de-escalate arousal, and expand their
repertoire of coping strategies. The DMM provides us with
a powerful explanatory framework for describing the development
of family members’ self-protective strategies as well
as a model of triggering traumas (Crittenden 2016).
To elicit representations of trauma, we ask for an episode
of violence, then ‘walk around in it’, exploring thought, feeling,
intention, escalation into violence, and consequences.
We support family members to repair and heal their relationships
by co-regulating arousal, acknowledging and repairing
shame, hurt and disappointment, and communicating
straight forwardly. We listen carefully to how people talk
about their behavior that harms others and about safety. Put
another way, we use live discourse analysis (cf. Crittenden
and Landini 2011), and behave in ways that reduce the need
for self-protective strategies. This helps family members ‘to
stand in the emotional shoes’ of others. Accepting responsibility
for one’s actions while being comforted is often very
new for most people who have acted violently. It becomes
the basis for thinking about why humans harm the people
we love, and who love us.
We asked Pete and his family to describe the episode of
violence that sent him to prison, and then slowly tracked
what happened—thought, feeling, action and intention of all
family members. When Pete said, ‘I only hit him’, we noticed
the use of the minimizing word ‘only’ in the context of agentic
speech. We explored the word ‘only’ by asking what we
would see if we were there, how you hit him, where you hit
him, and so on. At the same time, we underlined Pete’s need
for agency held in the words ‘I hit him’. When we asked
what we would see, Pete slowly revealed his vulnerability—
and need for an aggressive response. We also listened for the
triggers, such as ‘the smell of sawdust’, that threatened Pete.
Pete was supported by the therapist’s empathic response that
avoided exonerating him while concurrently acknowledging
that his fear of being powerlessness to protect his son
underlay his action.
Contemporary Family Therapy	
1 3
Treating Behavioral Disorders in Children Through
DMM FFF
The key to treatment for many behavioral disorders in children
is understanding the structure of family self-protective
strategies. The Doyle family dynamics illustrate that children’s
disruptive externalizing behavior can have origins in
both an inhibitory protective strategy and also an exhibitory
coercive protective strategy. That is, disruptive behavior can
function differently for different children.
The Doyle FFF suggested how their sons’ opposite strategies
evolved and where intervention could result in positive
change for the whole family. The therapeutic focus shifted
to the parents, helping them to feel their anger and recognize
it as a source of important guiding information, thus
enabling them to feel confident in their own authority. As
they increased the clarity and predictability of their behavior,
they became appropriately responsive without reinforcing
either inhibited or coercive behavior in the boys. The
goal was for their children to feel safer, with Pavi inhibiting
negative feelings less and Stefan inhibiting them more. The
greatest resistance to change came from the therapists who
feared having to change their focus on one child to working
collaboratively with the whole family and each other.
Treating‘Psychotic’States Through DMM FFF
Treatment approaches for psychosis include psychotherapy
(Garety 2003) and pharmacological therapy (Patel et al.
2014), but only 20% of patients report favorable treatment
outcomes (American Psychiatric Association (APA) 2013;
Crismon et al. 2014). We propose that a DMM FFF might
yield more success.
A DMM GFF can inform work with families with a member
displaying psychotic states by revealing that: (a) past
dangers that are unthinkable or unspeakable have resulted in
rigid use of extreme strategies by one or more family members
so as to protect the vulnerable person; (b) the current
protective organization of the family, that appears to protect
the ‘psychotic’ person, actually protects other ‘normal’ family
members, thus explaining why treatment is ineffective;
and (c) the function of high arousal states to motivate ‘psychotic’
behavior (that counters the depression of inhibition)
actually achieves protective escape for the family until the
crisis passes.
The last point is important because the GFF for psychosis
indicates that the information disposing the psychotic
behavior has been transformed to omitted, denied, displaced,
and delusional information, often differently for each family
member. Having a guide to these complex transformations
might make possible the progressive restoration of the communicative
function of symptoms. Of course, this action is
possible only after defusing the danger that this forbidden
information could trigger.
Giovanni’s psychotic behavior pointed to the danger of
desire for comfort being expressed through sexuality, while
also signaling that his need to find ways to build relationships
outside the family was urgent. Therapeutic work
needed to address how the parents’ possible sexual abuse of
their sons contributed to the dilemma of needing help while
precluding admission of the reason for needing help. Consequently,
the family had to refuse help when it threatened to
uncover dangerous information. Repetition of this cycle led
to Giovanni’s increasingly somaticized and negative symptoms.
Professionals’ attempts to address Giovanni’s need to
establish relationships outside the family were stalled by the
mother’s desire to keep her children at home and the parents’
need to avoid charges of sexual abuse. It is unclear when a
protected extra-familial placement might become available.
Until then—or until the parents are safe from prosecution—
the death of the now elderly parents is the next predictable
destabilizing transition.
Treating Meltdowns Tied to Autism Through DMM
FFF
An unfortunate outcome of genetic explanations of autism is
that treatment is directed toward management of presumed
hard-wired symptoms rather than toward their reduction or
elimination. One of the most distressing symptoms is ‘meltdowns’
or severe explosions of anger and anxiety. In DMM
terms, this suggests that the children are either (a) extremely
anxiously inhibited and unable to prevent trauma-elicited
disinhibition or (b) highly anxious and using a coercive
strategy to manage uncertainty in relationships. The difference
between these two GFFs is, in the first case, the parents’
consistent rejection of the child in response to negative
behavior versus, in the second case, parents’ rapid arousal as
a meltdown commences (thus, causing children to escalate
their meltdowns). Both processes are encompassed by the
diagnosis of ‘autism’ but require different treatments. Penny
and her mother best fit the second GFF.
When Penny’s mother sought help with Penny’s meltdowns,
we mapped a ‘circularity’, that is, we mapped the
sequence of procedural actions and emotions that maintained
the problem. Subsequently, we explored how Penny’s mother’s
conscious semantic and episodic accounts conflicted
with observed procedural processes. See Fig. 2 for an example
of a circularity in Penny’s family.
Mapping and discussing this circularity helped everyone
to see that Penny’s meltdowns were embedded in a procedural
family process. When Penny’s mother tried changing
the morning routine, it reduced the meltdowns. We then
discussed other causes of Penny’s meltdowns, such as her
frustration with her cerebral palsy. Over time, changes with
	 Contemporary Family Therapy
1 3
Penny positively affected other members of the family. A
negative circularity was transformed into a virtuous cycle of
increasing attunement of procedural behavior and semantic
understanding, in each family member’s zone of proximal
development.
Discussion
DMM FFFs offer a systemic model that describes the interdependence
of family members’ developing minds around
strategies for protection from danger (Crittenden et al. 2014).
The model is based on a layered array of causal conditions
from genes to culture (see Fig. 1), but centers on how the
psychological development of each family member is shaped
by and contributes to the adaptation of all family members.
Families are seen as progressively enabling children to recognize,
prevent, and recover from threatening events. When
parents are unable to do that, in each child’s zone of proximal
development, treatment may be needed.
More than other approaches to formulation, DMM FFFs
address the role of danger in eliciting protection and comfort
and the implications of the absence of these to immediate
and long-term adaptation. By addressing the development of
information processing about danger, the DMM adds focus
and granularity to understanding distress in families while
retaining family systems theory’s conceptualization of the
family as a functional whole and sharpening the selection
of treatment strategies.
As compared to psychiatric diagnoses or categorization
by type of harmful behavior, our cases demonstrate equifinality,
whereby different family processes yield similar
symptoms, for example, inhibitory and coercive protective
attachment strategies can both yield ‘acting out’ behavior.
This suggests the need for different treatment strategies for
what might appear to be the ‘same’ problems. Our cases
also show multifinality, wherein the same family process
can yield different outcomes. For example, sudden disinhibition
can display as both ‘psychosis’ and parental abuse;
similarly, unpredictable parental behavior can lead to both
autistic meltdowns and disruptive behavior problems. DMM
FFF helps to clarify problems of co-morbid and changing
psychiatric diagnoses.
The DMM conceptualization of adaptation to danger
offers a paradigm shift away from categorizing deficits
toward identifying strategic strengths, albeit sometimes past
strengths have stood in the way of on-going adaptation. The
Fig. 2  Example of recurrent
daily circularity in Penny’s
family Girls nearly
ready for
school, Mum
waits by the
door
Mum and
Dad feed
chickens
and girls
start playing
Mum came
in and called
them.. They
came down
Penny
reading list
of toys
Dad
frustrated
trying to get
Penny ready,
ShoutingNo effect,
David tried to
take list and
tore it
Penny
screaming.
got list back
Mum tried to
stay out of
it… packed
lunch…
Penny tries to
get May to
smuggle the
list in her bag
David had
enough..
Leaves..
Plays
piano…
Contemporary Family Therapy	
1 3
DMM’s developmental framework promotes capturing the
crest of maturation to maximize the possibility of change.
Families come to therapy because they do not understand
why they have problems or how to resolve the problems.
They expect skill from their therapist. Being able to formulate
based on DMM theory and assessments can jumpstart
the beginning of therapy by giving the therapist a preliminary
guide to a family’s functioning. Although family
therapy has tended to eschew formal assessment, formulation
improves when therapists have a source of information
that is not constrained by family members’ psychological
transformations. With such information, therapists can work
efficiently to highlight those transformations of information
that unnecessarily place family members in conflict. In this
process, therapists act as transitional attachment figures for
family members, attuning their work to each family member’s
zone of proximal development. This enables therapists
to progressively assist family members to discover implicit
aspects of their experience, including those outside of conscious
awareness. An especially auspicious aspect of DMM
formulation is the recursive, systemic, and interpersonal process
through which formulations emerge, suggest actions,
and are modified by feedback. Thus, DMM formulations
are emergent phenomena generated through a collaborative
process of making meaning about safety and comfort among
people who begin with different perspectives. Repeatedly
enacting the process of learning from examined experience
becomes a central outcome of therapy.
We propose that DMM FFFs provide a way to gather
information, integrate it as a formulation, and test familyspecific
hypotheses regarding causation and change. DMM
formulations aim to illuminate the causes of human distress
and generate empirically sound means of reducing harm to
the self and others. The examples given in this paper suggest
the breadth of problems to which DMM formulation
can be applied. DMM FFFs both reflect the complexity of
individuals’ life circumstances and also suggest the most
advantageous timing and sequencing of potential treatment
approaches. DMM formulations make symptoms meaningful,
thus offering self-respect to troubled people who have
struggled with adversity too early in life and with too little
protection and comfort. This is in contrast to treatment
intended to reduce symptoms, which can inadvertently perpetuate
family suffering, as in our examples of disruptive
behavior problems and psychosis. Consequently, patients
who do not benefit from treatment are not seen as being
‘resistant’, rather the emphasis turns to formulating the problem
better and adapting treatment to fit each person’s needs
and development.
As enthusiastic as we are about DMM FFFs, they are not
a panacea. They require more training, expertise, and precision
than other forms of formulation. The training includes
having more information about child development than most
clinicians have and learning to deliver and interpret DMM
assessments. Worryingly, the assessments can mislead if
applied without expertise. One can hope that, through the
treatment process, therapists would discover their errors,
but this is not always the case. In addition, the DMM itself
would benefit from more research. Nevertheless, the conceptual
framework underlying DMM FFFs helps conscientious
work by grounding clinical practice in a focused and coherent
way, which can improve treatment success. Addressing
the function of maladaptive behavior, how it was learned,
and how it can be changed emphasizes strengths and generates
hope. Doing this together in therapy creates a model of
adapting that family members can use long after the close
of treatment.
Compliance with Ethical Standards 
Conflict of interest  The authors declare that they have no conflict of
interest.
Informed Consent  No single person formed the basis for the 4 case
studies, but all the people in the anonymized composites signed
informed consents as designated by the governing authority where
they lived (in three different countries).
Research Involving Human Participants and/or Animals  No research
data are reported.
References
American Psychiatric Association (APA). (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Washington, DC:
American Psychiatric Association (APA).
Barkley, R. A., & Murphy, K. R. (2006). Attention deficit hyperactivity
disorder: A clinical workbook (3rd ed.). New York: Guilford
Publications.
Bowen, M. (1971). The use of family theory in clinical practice. In
J. Haley (Ed.), Changing families: A family therapy reader (pp.
159–192). New York: Grune & Stratton.
Bowlby, J. (1969/1982). Attachment and Loss: Vol 1. Attachment. New
York: Basic Books.
Brewerton, N., Robson, K., & Crittenden, P. M. (2017). Formulating
autism systemically: Part 2—A 12-year prospective case
study. Clinical Child Psychology and Psychiatryhttps​://doi.
org/10.1177/13591​04517​71438​1.
Centers for Disease Control and Prevention. (2016). About the CDCKaiser
ACE Study. Retrieved from https​://www.cdc.gov/viole​
ncepr​event​ion/child​abuse​andne​glect​/acest​udy/about​.html
Crismon, L., Argo, T. R., & Buckley, P. F. (2014). Schizophrenia. In J.
T. DiPiro, R. L. Talbert, & G. C. Yee (Eds.), Pharmacotherapy: A
pathophysiologic approach (9th ed., pp. 1019–1046). New York:
McGraw-Hill.
Crittenden, P. M. (1992). Children’s strategies for coping with
adverse home environments: An interpretation using attachment
theory. Child Abuse and Neglect. https​://doi.org/10.1016/0145-
2134(92)90043​-Q.
	 Contemporary Family Therapy
1 3
Crittenden, P. M. (1997). Patterns of attachment and sexuality: Risk
of dysfunction versus opportunity for creative integration. In L.
Atkinson & K. J. Zuckerman (Eds.), Attachment and psychopathology
(pp. 47–93). New York: Guilford Press.
Crittenden, P. M. (2016). Raising parents: Attachment, representation,
and treatment (2nd ed.). London: Routledge.
Crittenden, P. M. (2017). Formulating autism systemically: Part 1—A
review of the published literature and case assessments. Clinical
Child Psychology and Psychiatry. https​://doi.org/10.1177/13591​
04517​71324​1.
Crittenden, P. M., Dallos, R., Landini, A., & Kozlowska, K. (2014).
Attachment and family therapy. London: McGraw-Hill.
Crittenden, P. M., & Heller, M. B. (2017). The roots of chronic PTSD:
Childhood trauma, information processing, and self-protective
strategies. Chronic Stress. https​://doi.org/10.1177/24705​47016​
68296​5.
Crittenden, P. M., & Landini, A. (2011). Assessing adult attachment: A
dynamic-maturational approach to discourse analysis. New York:
W.W. Norton.
Crittenden, P. M., Landini, A., & Zhang, W. (2018). The roots of the
DMM and DMM Integrative Treatment: Autism as an example.
In G. Crocetti (Ed.) La psicoterapia psicoanalitica per l’infanzia
e l’adolescenza nei contesti socio-culturali attuali. Roma:
Armando.
Crittenden, P. M., & Spieker, S. J. (2018). Dynamic-maturational
model of attachment and adaptation versus ABC+D assessments
of attachment in child protection and treatment: Reply to Van
IJzendoorn, Bakermans, Steele, & Granqvist (2018). Infant Mental
Health Journal. https​://doi.org/10.1002/imhj.21750​.
Dallos, R. (2019). Don’t blame the parents: Intention and change in
family therapy. Maidenhead: Mcgraw Hill.
Dallos, R., & Draper, R. (2010). An introduction to family therapy:
Systemic theory and practice. London: McGraw-Hill Education.
Felitti, V. J. (2009). Adverse childhood experiences and adult health.
Academic Pediatrics. https​://doi.org/10.1016/j.acap.2009.03.001.
Flåm, A. M., & Handegård, B. H. (2015). Where is the child in family
therapy service after family violence? A study from the Norwegian
Family Protection Service. Contemporary Family Therapy.
https​://doi.org/10.1007/s1059​
Garety, P. A. (2003). The future of psychological therapies for psychosis.
World Psychiatry, 2, 147–152.
Heller, M. B. (2002). An accident waiting to happen. Bulletin of the
British Psychoanalytic Society, 38, 76–80.
Insel, T. R. (2014). The NIMH Research Domain Criteria (RDoC)
Project: precision medicine for psychiatry. American Journal of
Psychiatry. https​://doi.org/10.1176/appi.ajp.2014.14020​138.
Johnson, M. (1995). Patriarchal terrorism and common couple violence:
Two forms of violence against women. Journal of Marriage
and the Family. https​://doi.org/10.2307/35368​3.
Johnstone, L., & Dallos, R. (2013). Formulation in psychology and
psychotherapy: Making sense of people’s problems. Abingdon:
Routledge.
Kaslow, F., & Patterson, T. (2006). Relational diagnosis—A brief
historical overview: Comment on the special section. Journal of
Family Psychology. https​://doi.org/10.1037/0893-3200.20.3.428.
Marvin, R. S., & Stewert, R. B. (1990). A family systems framework
for the study of attachment. In M. T. Greenberg, D. Cicchetti, & E.
M. Cummings (Eds.), Attachment in the preschool years: Theory,
research, and intervention (pp. 51–86). Chicago, IL: University
of Chicago Press.
Minuchin, S., Rosman, B., & Baker, L. (1978). Psychosomatic families:
Anorexia Nervosa in context. Cambridge: Harvard University
Press.
Moreno-Küstner, B., Martín, C., & Pastor, L. (2018). Prevalence
of psychotic disorders and its association with methodological
issues. A systematic review and meta-analyses. PLoS ONE. https​
://doi.org/10.1371/journ​al.pone.01956​87.
Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia:
Overview and treatment options. P & T: A Peer-Reviewed
Journal for Formulary Management, 39(9), 638–645.
Perkins, S. N., Glass, V. Q., & D’Aniello, C. (2019). It’s all about
the balance: Therapists’ experience of systemic alliance development.
Contemporary Family Therapy. https​://doi.org/10.1007/
s1059​1-019-09500​-1.
Ringer, F., & Crittenden, P. (2007). Eating disorders and attachment:
The effects of hidden processes on eating disorders. European
Eating Disorders Review. https​://doi.org/10.1002/erv.761.
Roberts, A. L., Lyall, K., Rich-Edwards, J. W., Ascherio, A., & Weisskopf,
M. G. (2013). Association of maternal exposure to childhood
abuse with elevated risk for autism in offspring. JAMA Psychiatry.
https​://doi.org/10.1001/jamap​sychi​atry.2013.447.
Sammut Scerri, C., Vetere, A., Abela, A., & Cooper, J. (2017). Intervening
after violence: Therapy with couples and families. Berlin:
Springer.
Sayal, K., Mills, J., White, K., Merrell, C., & Tymms, P. (2015). Predictors
of and barriers to service use for children at risk of ADHD:
longitudinal study. European Child & Adolescent Psychiatry.
https​://doi.org/10.1007/s0078​7-014-0606-z.
Selvini, M. P., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing—circularity—neutrality:
Three guidelines for the conductor
of the session. Family Process. https​://doi.org/10.111
1/j.1545-5300.1980.00003​.x.
Stedman, A., Taylor, B., Erard, M., Peura, C., & Siegel, M. (2018).
Are children severely affected by autism spectrum disorder underrepresented
in treatment studies? An analysis of the literature.
Journal of Autism and Developmental Disorders. https​://doi.
org/10.1007/s1080​3-018-3844-y.
Timimi, S., Gardner, N., & McCabe, B. (2011). The myth of autism.
Basingstoke: Palgrave MacMillan.
von Bertalanffy, L. (1968). General system theory. New York: Braziller.
Wampold, B. E. (2015). How important are the common factors
in psychotherapy? An update. World Psychiatry. https​://doi.
org/10.1002/wps.20238​.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.