All resourcesFamily Functional Formulations as Guides to Psychological Treatment
Abstract
The 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 family functional formulations is proposed based on exposure to danger, developmental competence regarding 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 been difficult to understand and treat 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. Key words: assessment/diagnosis, treatment, adaptation, attachment, developmental psychopathology, DMM
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 reflect gaps in the conceptual knowledge base. There has been a tradition in systemic family therapy of attempting to address these issues by therapists developing formulations to link family typologies to different clinical presentations (Minuchin, et al. 1978; Dallos and Draper 2015). 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 medical illness discourse inevitably permeates the relationship between 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.
We propose that DMM assessments and DMM-informed formulations might enhance formulations and treatment outcomes in family therapy and systemic interventions by focusing on danger, developmental processes, and learned patterns of information processing. Family therapy approaches already draw on multiple theories, including behaviorism, social learning theory, attachment, and ecological systems theory. The DMM also draws on these theories and adds cognitive neuroscience, information processing, and evolutionary theories of human adaptation. A set of formal DMM assessments exists, including especially, the DMM-Adult Attachment Interview (AAI, Crittenden and Landini, 2011). We think that the DMM has the potential to augment family therapy’s already strong theory base in ways that will improve treatment efficacy by refining the process of formulation to address response to danger.
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, Boscolo, Cecchin & Prata 1980; Perkins, Glass, and D’Aniello 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 family members. The DMM is an integrative expansion of the Bowlby-Ainsworth theory of attachment. A crucial contribution of DMM theory to understanding harmful behavior 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 to help the child to understand how to protect themselves. For example, studies of people diagnosed in adulthood with chronic PTSD (Heller, 2002) and eating disorder (Ringer & 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, sex, and protective strengths. 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 and
emphasizes protective strengths rather than mental health deficits.
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, 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
Figure 1. These influences are dynamically interactive.
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.
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
6Running Head: FAMILY FUNCTIONAL FORMULATION
feelings) can focus therapists on the full range of available information. This information can be
derived from a life-span set of assessments of attachment.
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.
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 protective strategies, (c) seeking both individual strategies appropriate for the person’s age
and maturation and also a 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., learning to update protective
strategies to fit changing contexts.
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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 family functional formulations
based on these ideas from DMM attachment theory can inform therapeutic response to harmful
behavior.
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 threats that create
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 specific 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 family-specific
treatment actions, feedback, and reformulation.
Four Examples of DMM FFFs
To illustrate our model of family functional formulation using the DMM, we examine
four clinical issues, in order from transparent to increasingly 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 is described
in the final section of this paper.
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Physical abuse (frequent transformations: omitted feelings and images with acquired
prescriptive semantic rules).
Child abuse appears 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 (e.g., separations, intense discord) 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 past dangerous experience and is often
known only in a preconscious imaged way. Protective resources, such as times when problems
were resolved or family members were protective, can facilitate the treatment (Flåm and
Handegård 2015).
Many people who are aggressive use self-protective strategies organized on the basis of
prescriptive semantic rules and omit information about their own negative feelings from
awareness. 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). These transformations impede 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 his stepson 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 behavior,
sometimes even excessively so, without considering exonerating circumstances or others’ partial
9Running Head: FAMILY FUNCTIONAL FORMULATION
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 had 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 omitted 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.
The problem was obviously in the father, but its basis was unclear. Treatment needed to
discover Pete’s hidden triggers and the means of disarming them.
Disruptive behavior in children (ODD & ADHD) (frequent complex patterning of
transformations: Parents: Denial of negative affect plus substitution of prescriptive semantic
guides for denied feelings; First-born child: massive omission of ‘forbidden’ negative affect with
10Running Head: FAMILY FUNCTIONAL FORMULATION
uncontrolled intrusions; Second-born child: 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).
There is concern that some therapists treating children with disruptive behavior only target
symptoms (often with stimulant medications) without identifying the function of the behavior
and parental processes that maintain the behavior (Sayal, Mills, White, Merrell, and Tymms
2015; Timimi, Gardner, and McCabe 2011). Here we consider one family with two adopted
children whose similar disruptive behaviors were reinforced similarly in spite of their different
interpersonal functions within the family. 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) and that first- and second-born children experience their parents
differently (Farnfield, 2017). Further, the symptoms of ADHD can draw distracted parents’
attention to the children or distract their attention from spousal problems or both. Either way,
parents’ inconsistent responses can lead to escalating demands by the child that frustrate the
parents, leading to a cycle of increasing distress. This familial explanation fits many cases of
comorbid ADHD and ODD; the Doyle family is an example. Because the parents spontaneously
sought treatment for their children and had been approved to adopt the children, the therapists
accepted the assumption that the problem resided in the children.
The Doyles. Pavi, age 6, had been in therapy for two 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.
Pavi’s problems (biting, hitting, attacking his younger brother, and dangerous behavior
such as running into the street) began after the family moved far away from relatives. Some
months after Pavi’s treatment had begun, Stefan’s teacher reported he had become
uncooperative, aggressive, and had difficulty calming down when aroused. The teacher
recommended that Stefan be evaluated for medication. Mrs. Doyle reported being exhausted with
managing the boys’ aggression toward each other and sometimes even to her.
Assessment of attachment. The family members participated in individual DMM
assessments of attachment and a whole-family interview. Mrs. Doyle’s protective attachment
11Running Head: FAMILY FUNCTIONAL FORMULATION
strategy was idealizing her parents, not doing the wrong thing (i.e., inhibit before acting), and
trying to do the right thing (follow prescriptions from her parents and parenting books). Mrs.
Doyle openly missed her family, but denied feeling angry. 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. He rigidly inhibited anger, sadness and fear until he could not -
and then he exploded in unpredictable angry aggression. Younger Stefan used the opposite
strategy; he predictably alternated coercive displays of vulnerability and disarming coyness with
sudden displays of intense anger. Sometimes he openly challenged his parents. Nevertheless,
both parents maintained modulated, even pleading, demeanors; their responses to Stephan were
non-contingent and modulated, whether he was charmingly coy 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, did not assert their hierarchical
authority, and often deferred to their children. Pavi tried to create a protective parent hierarchy
by being excessively obedient, but when his inhibitory strategy broke down explosively, it
frightened the parents. 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. Their sons’ 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
so destabilized the family that all family members entered treatment. (c) With treatment focused
on disruptive behavior rather than on its function, the basis of the problems in the parents’
inhibition of anger and abdication of parental authority had been overlooked all together.
12Running Head: FAMILY FUNCTIONAL FORMULATION
The problem to be resolved was differentiating the functions of the brothers’ use of
disruptive behavior and discovering how the parents could respond productively.
Psychosis (frequent transformations: displaced, denied, and delusionally transformed
information). Psychotic disorders are disabling for patients and their families and require
extensive treatment resources. They are relatively frequent with an estimated 12-month
prevalence of 0.4% (Moreno-Küstner, Martin, and Pastor 2018). The symptoms include (a)
delusions, hallucinations, and thought disorders (“positive” symptoms), (b) inhibition of
initiative (“negative” symptoms), and (c) anomalies of cognitive functioning (American
Psychiatric Association (APA), 2013). Nevertheless, there is lack of consensus regarding the
diagnostic criteria, etiology and pathophysiology of the psychoses (Patel, Cherian, Gohil, and
Atkinson 2014). Psychotic episodes can recur, become chronic, or remit completely (Crismon,
Argo, and Buckley 2014). We note the similarity between the symptoms of psychosis and DMM
inhibitory strategies when these are accompanied by explosively disinhibited negative affect (as
in Pavi, in the previous case).
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’ actions. Because developmental transitions (for example, the transition to
adulthood or the birth of a child) require a radical re-shaping of family attachment structures,
such periods can threaten families when their structure is rigid and based on denied information
about danger. In such cases, a family member behaves as if the transition would destroy them.
Because transitions are developmentally unavoidable and culturally regarded as 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 describes them as a response to irresolvable
developmental conflict between the approaching context that requires new behavior and the prior
context that requires incompatible behavior. The DMM contribution is the idea is that maturation
(a genetically-based process of change) creates developmental conflict in family contexts with
13Running Head: FAMILY FUNCTIONAL FORMULATION
hidden information explaining the conflict. The inability to resolve the (hidden) 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. However, 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 explicitly, all family members denied sexual abuse with outrage. The
family terminated the psychiatric support for Giovanni without professional agreement.
Several years later, Giovanni came to professional attention again with gait anomalies
indicative of a possible neurological dysfunction; in hospital, no neurological problems were
found, but Giovanni said hospitalization was 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. During a two-month psychiatric
hospitalization, Giovanni’s mother was tender and affectionate to him, unlike at home.
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 Giovanni’s intense anger (which was displaced to hostile people who spread
defamatory lies about his family). This crisis was formulated as Giovanni’s recurrent need to
both say and also not to say that he and his brother had been sexually abused by their father
14Running Head: FAMILY FUNCTIONAL FORMULATION
while continuing to live at home so as to stabilize marital conflict. This unspeakable information
was transformed somatically in ways that elicited external support for Giovanni while not
revealing the problem. Attempts to address the sexual abuse had generated further ‘psychosis’ by
threatening the family with dissolution rather than facilitating alternative developmental
pathways.
Several other hidden conditions in the family made the situation more complex. The
parents’ marriage was fragile because it was based on denying 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 that could easily be labeled sexual abuse. The
DMM-informed therapists understood the situation as Giovanni experiencing conflict between
establishing relationships outside the family and protecting his family.
The psychiatric diagnosis of psychosis had relieved the immediate crisis while
maintaining, and further obscuring, the underlying family problem that family members actively
hid. 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 was children’s inability to leave home without harming their
parents and, possibly, exposing sexual abuse.
Autism (frequent transformations: two generations of multiple transformations, including
falsification and denial).
A DMM GFF autism. 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 manifested psychological trauma for childhood events (Roberts,
strategies (Brewerton, Robson, and Crittenden 2017; Crittenden, Dallos, Landini, and Kozlowska
2014; Crittenden, Landini, and Zhang 2019). Like other psychiatric diagnoses, the central
indicators of autism (limited social and linguistic communication and repetitive behaviors)
Lyall, Rich-Edwards, Ascherio, and Weisskopf 2013) and the children often displayed inhibitory
15Running Head: FAMILY FUNCTIONAL FORMULATION
overlap with other conditions, such as anxiety, self-harm, and eating disorders. Further, the
diagnosis as now applied probably refers to several different conditions (Timimi et al. 2011) and
severe cases of autism, with strong evidence for neurological differences and inhibitory
strategies, no longer constitute the majority of samples (Stedman, Taylor, Erard, Peura, and
Siegel 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. The cerebral palsy was a result of a home birth in which Penny had suffered brain
damage from anoxia. 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.
Because Penny’s mother believed that ‘autism’ explained Penny’s behavior, she felt 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 own
parents’ unavailability and consequent emotional neglect of her. 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); she did not
notice this discrepancy. On the other hand, she repeatedly emphasized a prescriptive semantic
intention of being reliable and present for her own daughters.
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
experiences of being protected 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.
16Running Head: FAMILY FUNCTIONAL FORMULATION
Many family conditions contributed to Penny using a coercive strategy that included
meltdowns. Penny’s mother had conflicting experiences and prescriptive 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 attempts to get her own way. At the same time, Penny’s meltdowns required preventive
vigilance, but her mother found it painful to attend to her harmed child.
Because Penny’s mother used aspirational psychological short-cuts and was unaware of
her transformations of information and conflicting representations, she could not be responsive
and predictable. Penny became frustrated when limited in any way; her emotional displays
escalated very quickly. This triggered her mother’s anxiety that, in turn, fueled Penny’s arousal
in a self-maintaining, reciprocally escalating process (i.e., a vicious cycle). The unpredictable
process was mirrored between her parents where her father attempted to enforce discipline while
her mother was more laissez–faire. This dynamic enabled Penny’s use of coercion.
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 herself 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.
The problem to be resolved was enabling Penny’s mother address two past generations of
denied neglect so as to transform the vicious cycle into a virtuous cycle of increasing acceptance
by Penny of her mother’s protective authority.
In closing this section, we note that all our cases had important information that was
transformed to keep it out of mind. Across the sequence of cases, the transformations became
more extreme and moved from the child’s generation to the parents’ generation to the
grandparents’ generation. Such obscured information is very difficult to discern without a DMM-
informed approach to gathering the history.
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
17Running Head: FAMILY FUNCTIONAL FORMULATION
hypotheses that can be tested and modified during the treatment process based on session-by-
session feedback regarding change or lack thereof. 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 treatment. We emphasize how the DMM focus on exposure to
danger, developmental capacity to transform information, and developmental timing of treatment
can help family therapists to address problems more efficiently.
Treating child abuse through a DMM FFF
In spite of reluctance to offer relational therapy in cases of family violence, individual
work has several constraints including limited opportunity to discover and disarm the triggers of
violence, learn to repair difficult interactions, and balance the ‘seesaw’ of emotions within
violent relationships. These limitations suggest the need for relational work. Safety is a priority
in relational work with contra-indications for relational therapy including the violent person’s
failure to take responsibility for their actions (Sammut Scerri, Vetere, Abela, and Cooper 2017).
Working together, therapists and family members make a safety plan and a no-violence contract.
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 harmful behavior and safety. Put
another way, we use live discourse analysis (cf. Crittenden and Landini 2011), and behave in
empathic ways to reduce the need for self-protection. 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 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
18Running Head: FAMILY FUNCTIONAL FORMULATION
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. These questions identified the
psychological short-cuts implicit in Pete’s transformations of information. 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.
Treating behavioral disorders in children through a 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 inhibitory strategies and also
exhibitory coercive strategies. 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 a DMM FFF
Only 20% of patients report favorable treatment outcomes (APA 2013; Crismon et al.
2014). We propose that DMM FFFs might yield more success. The DMM GFF revealed that: a)
past dangers that are unthinkable or unspeakable can result 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 actually achieves protective escape for all
family members until the crisis passes.
19Running Head: FAMILY FUNCTIONAL FORMULATION
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 and across two generations. Having a guide to these complex
transformations might make possible the progressive elimination of psychological short-cuts and
restoration of the communicative function of symptoms. Of course, this action requires defusing
the danger that the forbidden information could trigger.
Giovanni’s psychotic behavior pointed to the danger of desire for comfort being
expressed through sexuality, while also signaling his need to build relationships outside the
family. 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; this forced the family to refuse help when it threatened to uncover dangerous information.
Repetition of this cycle had led to Giovanni’s increasingly somaticized symptoms. Professionals’
attempts to help Giovanni move out of the family were stalled by the parents’ need to limit what
the children said. Until a place in a community for mentally ill patients became available or until
the parents were safe from prosecution, the death of the elderly parents was the next predictable
transition that could free Giovanni from the family trap.
Treating meltdowns tied to autism through a 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.’ In DMM terms, meltdowns
suggest 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.
20Running Head: FAMILY FUNCTIONAL FORMULATION
Subsequently, we explored how Penny’s mother’s conscious semantic and episodic accounts
conflicted with observed procedural processes. See Figure 2 for the 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 her
responses, 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 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 FFs 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 how children learn to process 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. The outcome can
sharpen 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 behavior
problems. 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 parental abuse, behavior
21Running Head: FAMILY FUNCTIONAL FORMULATION
problems, and psychosis. DMM FFFs help 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 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 reveals family members’ psychological transformations. With such information, therapists
can work efficiently to highlight those transformations 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 aspects of their experience that
have been outside their 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, in each person’s zone of proximal
development. Thus, DMM formulations are emergent phenomena generated through a
collaborative process of making meaning about safety and comfort among family members with
different perspectives. Learning to enact the process of examining 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 family-specific hypotheses regarding causal processes 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,
22Running Head: FAMILY FUNCTIONAL FORMULATION
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’; the DMM turns the emphasis to formulating problems 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 such
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 promotes
conscientious work by grounding clinical practice in a focused and coherent way; this can
increase 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.
23Running Head: FAMILY FUNCTIONAL FORMULATION
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Figure 1: The dynamic interplay of influences on adaptation (Used with permission, Crittenden,
2016).
29Running Head: FAMILY FUNCTIONAL FORMULATION
Figure 2. Example of recurrent daily circularity in Penny’s family.
Girls nearly
ready for
school, Mum
waits by the
door
David had
enough..
Leaves..
Plays
piano…
Mum and
Dad feed
chickens
and girls
start playing
Penny tries to
get May to
smuggle the
list in her bag
Mum tried to
stay out of
it… packed
lunch…
Penny
screaming.