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Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families
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Child Abuse & Neglect
Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families夽 Tristan Milot a,∗ , Andra Lorent b , Diane St-Laurent b , Annie Bernier c , George Tarabulsy d , Jean-Pascal Lemelin e , Louise S. Éthier b a b c d e
Département de psychoéducation, Université du Québec à Trois-Rivières, Canada Département de psychologie, Université du Québec à Trois-Rivières, Canada Département de psychologie, Université de Montréal, Canada École de psychologie, Université Laval, Canada Département de psychoéducation, Université de Sherbrooke, Canada
a r t i c l e
i n f o
Article history: Received 16 October 2013 Received in revised form 14 February 2014 Accepted 26 February 2014 Available online xxx
Keywords: Neglecting mothers Hostile-Helpless state of mind Disorganized states of mind Childhood trauma Physical neglect
a b s t r a c t This study aimed to assess disorganized states of mind in a sample of neglecting and at-risk of neglecting mothers using the recently developed Hostile-Helpless (HH) coding system (Lyons-Ruth et al., 2006) for the Adult Attachment Interview (Main & Goldwyn, 1998). The relation between HH states of mind and mothers’ childhood traumas was also examined. Participants were 70 neglecting mothers and at-risk of neglecting mothers. Childhood traumas were assessed using the Childhood Trauma Questionnaire. HH states of mind were coded from Adult Attachment Interview transcripts by two reliable coders. Results revealed a high prevalence of disorganized states of mind in this sample. Forty-five mothers were classified HH, representing 64% of the entire sample. Most mothers reported at least one form of childhood trauma, with a mean of 2.9 different forms of trauma. Mothers classified HH reported having been emotionally abused, sexually abused and physically neglected more frequently than non-HH mothers. There was no difference between neglecting and at-risk of neglect mothers on HH states of mind and childhood experiences of trauma. These findings are in line with theorization on maltreating mothers’ psychological background and they provide further empirical support to the validation of the HH classification system with at-risk populations. © 2014 Elsevier Ltd. All rights reserved.
Introduction According to attachment theory, a disorganized state of mind with respect to attachment in a parent is related to a higher risk of difficulties in the parent-child relationship (Hesse, 2008; Main & Hesse, 1990). Traditionally, disorganized states of mind in adulthood are assessed through the Adult Attachment Interview (AAI; Main & Goldwyn, 1998) using the Unresolved state of mind classification (U/d). The AAI is a widely used semi-structured interview documenting thoughts, feelings, and memories related to early experiences with caregivers and assessing adults’ state of mind with respect to attachment relationships. During the AAI, adults showing slippage in their discourse when talking about either a specific loss or trauma
夽 This research was supported by grants from the Social Sciences and Humanities Research Council of Canada (410-2010-2532). ∗ Corresponding author address: Département de psychoéducation, Université du Québec à Trois-Rivières, 3351, boul. des Forges, Trois-Rivières, QC, Canada G9A 5H7. http://dx.doi.org/10.1016/j.chiabu.2014.02.015 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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experience are considered unresolved with respect to either loss or trauma. It has been theoretically proposed and empirically demonstrated that these unresolved experiences interfere with normative parenting (e.g., Abrams, Rifkin, & Hesse, 2006; Madigan, Bakermans-Kranenburg, van IJzendoorn, Moran, Pederson, & Benoit, 2006; Schuengel, Bakermans-Kranenburg, & van IJzendoorn, 1999). Given these findings, one may expect U/d state of mind to be particularly prevalent among highly dysfunctional families, such as those in which there is child maltreatment. Surprisingly, however, only a handful of studies have assessed caregivers’ state of mind in maltreating families, where childhood disorganized attachment is widely documented. Frigerio, Costantino, Ceppi, and Barone (2013) conducted a study involving three different samples among which eight were maltreating mothers and seven were mothers at high risk for maltreatment. Out of these 15 mothers, only 3 maltreating mothers (38%) and 2 high-risk mothers (29%) were classified as U/d with respect to loss or trauma. In another study involving 23 mothers for whom child neglect was substantiated, Lindhiem, Bernard, and Dozier (2011) reported only 3 (13%) mothers classified as U/d. The low rates of U/d state of mind in maltreating caregivers appear to challenge current thinking about the relation between this state of mind and dysfunctional parenting. In comparison, prevalence of U/d state of mind is estimated at 18% in normal populations, 32% in high-risk samples (e.g., low SES or adolescent parents) and 43% in other clinical samples (e.g., depressed mothers, borderline personality, criminal offenders; Bakermans-Kranenburg & van Ijzendoorn, 2009). Moreover, the relatively low rates of U/d found in maltreating samples are particularly surprising considering the great proportion of maltreating parents (up to 81%) reporting childhood trauma experiences (Cort, Toth, Cerulli, & Rogosch, 2011; Éthier, Couture, & Lacharité, 2004). Thus, there appears to be a mismatch between the relational difficulties of maltreating parents, their own past traumatic experiences and the sensitivity of the U/d classification to tap into disorganized states of mind with regard to attachment. The purpose of this study is to examine the contribution of a newly developed classification of adult disorganized states of mind, namely the Hostile-Helpless state of mind (HH; Lyons-Ruth, Yellin, Melnick, & Atwood, 2005), to further investigate disorganized states of mind among neglectful parents. According to Lyons-Ruth et al. (2005), HH state of mind expands the current concept of U/d state of mind and provides a useful alternative for more accurately identifying disorganized states of mind in high-risk samples. The Hostile-Helpless state of mind coding system The Hostile-Helpless state of mind coding system for the AAI was developed in order to capture disorganized attachment states of mind that would result from childhood relational trauma (Lyons-Ruth et al., 2005). This new parallel system is distinct and independent from the traditional Main and Goldwyn’s (1998) AAI coding system. The HH coding system is largely based on the clinical concepts of dissociation and splitting, which are psychopathological processes which may accompany or follow traumatic experiences. The system is aimed at capturing globally contradictory and unintegrated mental representations of caregivers often observed in adults severally abused or neglected in childhood. According to Lyons-Ruth et al. (2005), while the Main and Goldwyn’s coding system “classifies participants as U when they show lapses of monitoring of reason or discourse in regard to experiences of loss or trauma, the coding system for pervasively unintegrated HH states of mind examines discourse patterns throughout the whole protocol regardless of relevance to particular experiences” (Lyons-Ruth et al., 2005; p. 7). A Hostile-Helpless state of mind is present when the individual displays signs in his/her discourse of conflicting or extremely negative thoughts and emotions toward a primary caregiver, while also identifying with this caregiver (LyonsRuth et al., 2005). Many adults with a Hostile-Helpless state of mind are believed to display a mix of hostile and helpless features representing a breakdown in organized strategies of attachment (Lyons-Ruth, Melnick, Yellin, & Atwood 2006). However, some individuals may be polarized toward either a punitive (hostile) or a caregiving (helpless) stance. Individuals with a hostile state of mind tend to depict their caregivers as malevolent, while also showing indications in their discourse that they identify with them. Also, when they talk about past trauma, they may focus on reporting the facts while leaving out emotional or painful content. Adults in the hostile range may also idealize malevolent caregivers, while also displaying anger or a desire of vengeance and control toward them. Individuals with a helpless state of mind, on the other hand, are more likely to identify with a helpless attachment figure and to report having displayed a caregiving attitude toward them during their childhood. They may struggle to develop a better understanding of their past relationships with the caregiver, without achieving a coherent representation of these relationships. They may also depict themselves as victims or be engaged in abusive relationships with others and be overwhelmed by feelings of fear and guilt. The HH coding system is increasingly being used in research with clinical samples. In a longitudinal study involving 45 low-income mothers and their child, Lyons-Ruth et al. (2005) found that 51% of mothers met criteria for Hostile-Helpless state of mind. Moreover, in that sample, HH state of mind was found to be related to maternal history of childhood trauma, to the adoption of atypical behaviors toward children (e.g., withdrawal, negative-intrusive behaviors, role confusion), and to infant disorganization (assessed at 18 months). In another study conducted with 12 women with borderline personality disorder (BPD) and 20 women with dysthymia, Lyons-Ruth and colleagues (Lyons-Ruth, Melnick, Patrick, & Hobson, 2007) found that 100% of BDP and 55% of dysthymic participants were classified as HH. Results of this study also indicated strong relations between Hostile-Helpless state of mind and borderline phenomenology. In another study, Finger (2006) compared attachment state of mind of 62 substance-abusing Afro-American mothers and 87 matched control low-income mothers. Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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Mothers in the substance abusing group were significantly more likely to be classified HH (56%) than mothers in the control group (37%). Finally, evidence of validity of the HH classification system has also been provided by Frigerio et al. (2013). The authors found that HH states of mind were highly prevalent (75%) among mothers in the maltreating group, whereas 43% of mothers at-risk of maltreating their children were classified HH. In comparison, proportions of HH state of mind in their low-risk and poverty samples were 9% and 20%, respectively. Thus, research that has relied on the HH coding scheme of the AAI suggests that this measure is highly sensitive in identifying disorganized attachment states of mind in adulthood, particularly in at-risk and clinical populations. Aim of the study In view of (a) the rarity of studies which have examined disorganized attachment state of mind among maltreating parents and (b) the surprisingly low rates in this population of disorganized attachment state of mind using the U/d classification, it is important to pursue research efforts to better understand attachment states of mind among maltreating parents. In this study, we propose to document the proportion of disorganized state of mind, using the HH coding system, in a sample of physically neglecting mothers and mothers at-risk of neglecting their children. Also, considering the proposed traumatic etiology of disorganized attachment state of mind, we examine if disorganized states of mind, as measured by the HH classification, are related to mothers’ reports of childhood traumatic experiences. If such relations were to be found, they would serve to further validate the use of the HH coding system to tap into disorganized states of mind in maltreating parents. Method Participants Seventy mothers participated in this study. They were recruited over a 10-year period through child protection agencies and social services to participate in a longitudinal study on physically neglecting families. Physical neglect was defined as a failure to provide, lack of supervision, and moral-legal-educational maltreatment (Barnett, Manly, & Cicchetti, 1993). Child physical neglect was substantiated by child protection agencies for 48 mothers. The remaining 22 were considered by social services as at high risk for physically neglecting their children. Families were considered at-risk if they met at least four risk factors, such as adolescent mother, depressed mother, or lack of social support (Éthier et al., 2004). Mothers were Caucasian and French-speaking (mean age at the time of recruitment = 29 years, SD = 5.4) and were living in an urban area of the Province of Québec, Canada. All mothers came from a low socioeconomic background. Mothers had an average of 9.8 years of education (SD = 1.95), with 60% of participants not having completed a high-school degree. Most participants (81%) earned less than $20,000/year, with 75% reporting state welfare as their main source of income. Only 31% of participants reported being employed. Finally, mothers had an average of 2.1 children at home (SD = 1.20). Measures Hostile-Helpless states of mind. Hostile-Helpless states of mind were coded using the Hostile-Helpless coding system for the Adult Attachment Interview (Lyons-Ruth et al., 2006). The Adult Attachment Interview (AAI, Main & Goldwyn, 1998) includes 20 questions and follow-up probes on early attachment-related experiences (e.g., relationships with caregivers, separation from parents, frightening or traumatic experiences, significant losses). Individuals are also prompted to evaluate the impact of these experiences on their personality. Finally, additional questions document the quality of the current relationships with parents, as well as participants’ relationships with their own children. Interviews were audio recorded and transcribed verbatim for coding purposes. The Hostile-Helpless state of mind coding system focuses on a series of disorganization indicators leading up to an overall Disorganization score (1–9). Participants with a Disorganization score of 5 or above are classified HH with regards to attachment, and those with a Disorganization score lower than 5 are classified not HH (Lyons-Ruth et al., 2006). The Disorganization score is based on the coder’s judgment on how well the participant’s state of mind fits the theoretical description of the coding manual. To do so, coders must also take into account six other HH indicators, referred to as individual frequency codes: Global devaluation of a caregiver, Identification with a hostile caregiver, Recurrent references to fearful affect, Sense of self as bad, Laughter at pain, and Ruptured attachment. According to discourse features, participants are classified in one of the following HH subtypes: Hostile, Helpless, or Mixed. To be classified as Hostile, a discourse is expected to include global devaluation toward at least one primary attachment figure throughout the transcript. Participants may also display a range of aggressive thoughts or behaviors consistent with those of the devaluated caregiver and may punctuate these negative experiences with inappropriate laughter. The discourse may be concise and may include constricted speech patterns or straightforward descriptions of traumatic events. In the transcript classified as Helpless, one or more caregivers are depicted as helpless and abdicating their parental role. The transcript is often punctuated by recurrent references to fearful affect in various traumatic as well as non-traumatic situations. Helpless individuals may also orient their discourse toward a vulnerable stance, using negative words in order to describe themselves or identifying with the helpless attachment figure in terms of thoughts and behaviors. Their discourse may be passive, although punctuated by an honest desire to Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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contemplate on negative past experiences. Finally, a transcript is assigned to the Mixed subtype when the discourse includes fluctuations between hostile and helpless indicators, with elements of both inner aggressiveness and vulnerability being clearly displayed. More detailed information concerning HH classification criteria and on how this coding system differs from the Main and Goldwyn’s (1998) classification system is available elsewhere (Lyons-Ruth, Melnick, Atwood, & Yellin, 2006; Lyons-Ruth et al., 2005). AAIs were coded by two reliable coders who were trained by a certified trainer. In order to be reliable with the H/H coding system, an intra-class correlation or a kappa of .70 or above with criterion codes is required. The first coder (second author of this report) scored all 70 AAIs and the second independently scored 22 AAIs. Interrater reliability for these 22 interviews (31%) was as follows: ri = .92 for the HH Disorganization score, kappa = .91 for the HH dichotomous score, and kappa = .72 for HH subtypes. Although coders were aware that participants came from a high-risk population, they were blind to group status (neglecting vs. at-risk of neglect) and any other information concerning participants. Childhood trauma exposure. The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998), is a 28-item retrospective self-report questionnaire measuring exposure to childhood adverse events. The instrument yields scores for five forms of child maltreatment: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Each subscale is comprised of five items that participants rate from 1 (never true) to 5 (very often true), according to the frequency with which traumatic events occurred. Cut-off scores are provided for none, mild, moderate, and severe exposure levels for each subscale. As suggested by the authors, in this study, we used a dichotomous score reflecting presence (be it low, moderate or severe) versus absence of trauma. The CTQ has good psychometric properties (Bernstein & Fink, 1998). For the present study, internal consistency indices (Cronbach’s alpha) ranged from .70 to .90. Procedure Mothers were recruited over a 10-year period. Most mothers were administered the AAI in a follow-up study (about 4 years after their recruitment) during a home visit. The CTQ was completed about 4 years after the AAI. Because of attrition, the CTQ was available for only 42 out of the 70 participants. Analyses showed that the sample of 28 mothers lost to attrition were not significantly different from the 42 remaining participants on any of the sociodemographic variables. Results Data analysis Analyses were conducted using SPSS 20.0 software. Presence of HH states of mind was documented using descriptive statistics, including proportion of mothers classified HH, distribution of HH subtypes, and mean HH Disorganization scores. Descriptive statistics for childhood trauma experiences (presence vs. absence for each form of trauma and total number of trauma forms) were also examined. In addition, relations between HH states of mind and childhood trauma experiences were evaluated. We first looked at proportions of HH and non-HH mothers having experienced childhood trauma (presence vs. absence) using chi-square contingency tables. Then, using t-test analyses, we examined if the total number of trauma forms experienced varied as a function of HH status. Also, we examined whether Disorganization level varied as a function of the presence or absence of childhood trauma experiences. Finally, a correlation analysis was conducted to examine if level of disorganization was related to total number of childhood trauma forms. Hostile-Helpless state of mind Forty-five of the 70 mothers were classified Hostile-Helpless, representing 64% of the entire sample. Mean Disorganization scores were 6.7 in the HH subgroup and 3.3 in the non-HH subgroup (t = 19.8, p < .001). In the HH subgroup, 12 (27%) were classified Hostile, 19 (42%) were Mixed, and 14 (31%) were Helpless. There was no difference between neglecting mothers and at-risk of neglecting mothers on any HH variables. Childhood trauma experiences Out of the 42 mothers who completed the CTQ, 38 (90%) reported at least one form of childhood trauma: 24 (57%) experienced emotional abuse, 17 (40%) experienced physical abuse, 24 (57%) experienced sexual abuse, 34 (81%) experienced emotional neglect, and 21 (50%) experienced physical neglect. Participants experienced a mean of 2.9 forms of childhood abuse. There was no difference between neglecting mothers and at-risk of neglecting mothers on all CTQ variables. Hostile-Helpless state of mind and childhood trauma Mothers classified HH reported having been emotionally abused, sexually abused, and physically neglected more frequently than non-HH mothers (see Table 1). Moreover, mothers in the HH group experienced almost twice as many forms of childhood trauma than non-HH mothers (M = 3.4 vs. M = 1.8; t(40) = 3.54, p < .001). Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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Table 1 Proportion of mothers who experienced childhood trauma as a function of Hostile/Helpless status. 2
HH (N = 27)
Non-HH (N = 15)
Emotional abuse N %
20 74
4 27
9.90**
Physical abuse N %
13 48
4 27
1.85
Sexual abuse N %
19 70
5 33
5.40*
Emotional neglect N %
24 89
10 67
3.09†
Physical neglect N %
17 63
4 27
5.71*
† * **
p < .10. p < .05. p < .01.
Analyses using Disorganization scores (from 1 to 9) revealed that the level of disorganization was significantly higher for mothers reporting experiences of emotional abuse, physical abuse, sexual abuse, and physical neglect than for mothers who reported no such experiences (see Table 2). Also, there was a significant correlation between mothers’ Disorganization score and number of trauma forms experienced by mothers (r = .55, p < .001). Discussion This aim of this study was to assess disorganized states of mind in a sample of neglecting mothers and at-risk of neglecting mothers using the recently developed Hostile/Helpless coding system for the Adult Attachment Interview. This study is one of the very few to have assessed adult attachment states of mind in maltreating parents and the first to use the HH state of mind classification with neglecting mothers. Forty-five mothers out of 70 (64%) were classified Hostile/Helpless, revealing a high prevalence of disorganized states of mind in this sample. These results are consistent with Frigerio et al.’s (2013) findings in which 75% of the maltreating mothers were classified HH. It is also important to note that the proportion of mothers with a disorganized attachment state of mind in our study, using the HH coding system, was much higher than what was reported in previous studies using the Unresolved classification (Frigerio et al., 2013; Lindhiem et al., 2011), which is more in line with current theorization on maltreating mothers’ psychological and relational functioning. Results also revealed that most mothers in our sample experienced at least one form of childhood trauma. This finding is concordant with the literature Table 2 Disorganization Score as a function of presence and absence of childhood trauma experiences. Presence
Absence
Emotional abuse M SD
6.29 1.68
4.18 1.29
4.36***
Physical abuse M SD
6.24 1.86
4.96 1.72
2.29*
Sexual abuse M SD
6.04 1.60
4.72 1.97
2.40*
Emotional neglect M SD
5.68 1.79
4.63 2.07
1.46
Physical neglect M SD
6.24 1.70
4.55 1.61
3.27**
* ** ***
t(40)
p < .05. p < .01. p < .001.
Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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on the intergenerational transmission of maltreatment which has shown that experiences of childhood maltreatment is an important risk factor for adopting neglecting or abusive parenting practices with one’s own children in adulthood (e.g., Cort et al., 2011; Heyman & Slep, 2002; Pears & Capaldi, 2001). Moreover, our results revealed a significant association between the HH classification and childhood experiences of emotional abuse, sexual abuse, and physical neglect and a strong correlation between the number of different types of maltreatment experienced by mothers and overall Disorganization scores. These findings provide further empirical evidence supporting the validity of the HH classification system with at-risk samples. Finally, the fact that neglecting mothers and at risk of neglecting mothers did not significantly differ on either HH state of mind or childhood experiences of maltreatment suggests that the at-risk mothers in our sample may also be a very high-risk group. However, it is also possible that at-risk of neglecting mothers differ from neglecting mothers on other variables not assessed in our study, such as psychological and ecological protective factors. Further research is needed to address this particular issue. Taken together, these findings underline the impact of childhood trauma on latter psychological functioning. Accordingly, childhood experiences of abuse and neglect should be considered as chronic stressors that may profoundly impact development and psychosocial functioning, including a higher risk of intergenerational transmission of traumatic experiences. These results have important clinical implications because they highlight the need to provide psychological therapeutic support to the parent when intervening with neglecting families. Several neglecting mothers have experienced childhood traumas, and it is likely that they still struggle with these past traumas if nothing has been done to address them. According to Moran et al. (2008), this therapeutic emotional support should include an acknowledgment of the parents’ trauma history and helping them realize how these past experiences might exert an influence on their capacity to engage and interact with significant others, in particular with their own child. One important aspect of the intervention should be to “assist parents in reflecting on how past experiences trigger defensive processes that materialize within the mother-child relationship, so that they can use this insight to change their responses” (Moran et al., 2008Moran et al., 2008, p. 390). Intervention programs such as STEEP (Steps Toward Effective, Enjoyable Parenting; Egeland & Erickson, 2004), which focus on both parent’s behaviors and mental representations, provide relevant treatment guidelines for enhancing mothers’ ability to reflect on their own experiences and the quality of parent-child relationships. These guidelines include identifying the parents’ coping strategies and defenses, challenging all-or-nothing thinking, helping parents understand their child’s motives and feelings and support them in finding and implementing solutions by themselves (Egeland & Erickson, 2004). Considering the unbalanced victim/aggressor representational patterns characterizing HH mothers (Lyons-Ruth et al., 2005), it is essential for the therapist to establish a secure therapeutic alliance as a stepping stone for healing past attachment experiences (Lyons-Ruth & Spielman, 2004). Treatments such as Transference-Focused Psychotherapy (TFP), which focus on the consolidation of an attachment relationship to the therapist as well as on the development of the ability to think in mental state terms (to understand the intentions, thoughts, feelings, beliefs and motivations of self and others), might be particularly useful with adults presenting HH states of mind. TFP has proven to be successful in enhancing reflective functioning and attachment security in patients with borderline personality disorder (Levy et al., 2006), a condition theoretically and empirically related to Hostile/Helpless states of mind (Lyons-Ruth et al., 2006, Lyons-Ruth et al., 2007). Limits of the study This study has some limitations that should be noted. Firstly, mothers completed the measure of childhood trauma (CTQ) a few years after they were administered the Adult Attachment Interview. It is possible that the timing of the measure of childhood maltreatment might have had an impact on the information that was collected: their reports of past trauma might have been slightly different had they been obtained concurrently to the administration of the AAI. Yet, one should keep in mind that, in our study, HH state of mind as an overall Disorganization score was strongly related to childhood trauma experiences, even if they were not assessed at the same time. Secondly, considering the relatively small sample size, findings should be replicated with a bigger sample. Finally, considering both the absence of a healthy comparison group and the fact that coders were aware of the high-risk nature of the sample, we cannot totally rule out the possibility that HH states of mind might have been slightly overestimated. Future directions According to attachment theory, the way a caregiver has processed his/her own attachment history is a significant determinant of how he/she will interact with his/her own child. In this study, we provided evidence that neglecting mothers were at very high-risk of having disorganized states of mind, as measured by the HH classification, and that these states of mind were related to childhood trauma. However, many questions remain unanswered, such as: How do HH states of mind interfere with mother-child daily interactions? 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Contents lists available at ScienceDirect
Child Abuse & Neglect
Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families夽 Tristan Milot a,∗ , Andra Lorent b , Diane St-Laurent b , Annie Bernier c , George Tarabulsy d , Jean-Pascal Lemelin e , Louise S. Éthier b a b c d e
Département de psychoéducation, Université du Québec à Trois-Rivières, Canada Département de psychologie, Université du Québec à Trois-Rivières, Canada Département de psychologie, Université de Montréal, Canada École de psychologie, Université Laval, Canada Département de psychoéducation, Université de Sherbrooke, Canada
a r t i c l e
i n f o
Article history: Received 16 October 2013 Received in revised form 14 February 2014 Accepted 26 February 2014 Available online xxx
Keywords: Neglecting mothers Hostile-Helpless state of mind Disorganized states of mind Childhood trauma Physical neglect
a b s t r a c t This study aimed to assess disorganized states of mind in a sample of neglecting and at-risk of neglecting mothers using the recently developed Hostile-Helpless (HH) coding system (Lyons-Ruth et al., 2006) for the Adult Attachment Interview (Main & Goldwyn, 1998). The relation between HH states of mind and mothers’ childhood traumas was also examined. Participants were 70 neglecting mothers and at-risk of neglecting mothers. Childhood traumas were assessed using the Childhood Trauma Questionnaire. HH states of mind were coded from Adult Attachment Interview transcripts by two reliable coders. Results revealed a high prevalence of disorganized states of mind in this sample. Forty-five mothers were classified HH, representing 64% of the entire sample. Most mothers reported at least one form of childhood trauma, with a mean of 2.9 different forms of trauma. Mothers classified HH reported having been emotionally abused, sexually abused and physically neglected more frequently than non-HH mothers. There was no difference between neglecting and at-risk of neglect mothers on HH states of mind and childhood experiences of trauma. These findings are in line with theorization on maltreating mothers’ psychological background and they provide further empirical support to the validation of the HH classification system with at-risk populations. © 2014 Elsevier Ltd. All rights reserved.
Introduction According to attachment theory, a disorganized state of mind with respect to attachment in a parent is related to a higher risk of difficulties in the parent-child relationship (Hesse, 2008; Main & Hesse, 1990). Traditionally, disorganized states of mind in adulthood are assessed through the Adult Attachment Interview (AAI; Main & Goldwyn, 1998) using the Unresolved state of mind classification (U/d). The AAI is a widely used semi-structured interview documenting thoughts, feelings, and memories related to early experiences with caregivers and assessing adults’ state of mind with respect to attachment relationships. During the AAI, adults showing slippage in their discourse when talking about either a specific loss or trauma
夽 This research was supported by grants from the Social Sciences and Humanities Research Council of Canada (410-2010-2532). ∗ Corresponding author address: Département de psychoéducation, Université du Québec à Trois-Rivières, 3351, boul. des Forges, Trois-Rivières, QC, Canada G9A 5H7. http://dx.doi.org/10.1016/j.chiabu.2014.02.015 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
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experience are considered unresolved with respect to either loss or trauma. It has been theoretically proposed and empirically demonstrated that these unresolved experiences interfere with normative parenting (e.g., Abrams, Rifkin, & Hesse, 2006; Madigan, Bakermans-Kranenburg, van IJzendoorn, Moran, Pederson, & Benoit, 2006; Schuengel, Bakermans-Kranenburg, & van IJzendoorn, 1999). Given these findings, one may expect U/d state of mind to be particularly prevalent among highly dysfunctional families, such as those in which there is child maltreatment. Surprisingly, however, only a handful of studies have assessed caregivers’ state of mind in maltreating families, where childhood disorganized attachment is widely documented. Frigerio, Costantino, Ceppi, and Barone (2013) conducted a study involving three different samples among which eight were maltreating mothers and seven were mothers at high risk for maltreatment. Out of these 15 mothers, only 3 maltreating mothers (38%) and 2 high-risk mothers (29%) were classified as U/d with respect to loss or trauma. In another study involving 23 mothers for whom child neglect was substantiated, Lindhiem, Bernard, and Dozier (2011) reported only 3 (13%) mothers classified as U/d. The low rates of U/d state of mind in maltreating caregivers appear to challenge current thinking about the relation between this state of mind and dysfunctional parenting. In comparison, prevalence of U/d state of mind is estimated at 18% in normal populations, 32% in high-risk samples (e.g., low SES or adolescent parents) and 43% in other clinical samples (e.g., depressed mothers, borderline personality, criminal offenders; Bakermans-Kranenburg & van Ijzendoorn, 2009). Moreover, the relatively low rates of U/d found in maltreating samples are particularly surprising considering the great proportion of maltreating parents (up to 81%) reporting childhood trauma experiences (Cort, Toth, Cerulli, & Rogosch, 2011; Éthier, Couture, & Lacharité, 2004). Thus, there appears to be a mismatch between the relational difficulties of maltreating parents, their own past traumatic experiences and the sensitivity of the U/d classification to tap into disorganized states of mind with regard to attachment. The purpose of this study is to examine the contribution of a newly developed classification of adult disorganized states of mind, namely the Hostile-Helpless state of mind (HH; Lyons-Ruth, Yellin, Melnick, & Atwood, 2005), to further investigate disorganized states of mind among neglectful parents. According to Lyons-Ruth et al. (2005), HH state of mind expands the current concept of U/d state of mind and provides a useful alternative for more accurately identifying disorganized states of mind in high-risk samples. The Hostile-Helpless state of mind coding system The Hostile-Helpless state of mind coding system for the AAI was developed in order to capture disorganized attachment states of mind that would result from childhood relational trauma (Lyons-Ruth et al., 2005). This new parallel system is distinct and independent from the traditional Main and Goldwyn’s (1998) AAI coding system. The HH coding system is largely based on the clinical concepts of dissociation and splitting, which are psychopathological processes which may accompany or follow traumatic experiences. The system is aimed at capturing globally contradictory and unintegrated mental representations of caregivers often observed in adults severally abused or neglected in childhood. According to Lyons-Ruth et al. (2005), while the Main and Goldwyn’s coding system “classifies participants as U when they show lapses of monitoring of reason or discourse in regard to experiences of loss or trauma, the coding system for pervasively unintegrated HH states of mind examines discourse patterns throughout the whole protocol regardless of relevance to particular experiences” (Lyons-Ruth et al., 2005; p. 7). A Hostile-Helpless state of mind is present when the individual displays signs in his/her discourse of conflicting or extremely negative thoughts and emotions toward a primary caregiver, while also identifying with this caregiver (LyonsRuth et al., 2005). Many adults with a Hostile-Helpless state of mind are believed to display a mix of hostile and helpless features representing a breakdown in organized strategies of attachment (Lyons-Ruth, Melnick, Yellin, & Atwood 2006). However, some individuals may be polarized toward either a punitive (hostile) or a caregiving (helpless) stance. Individuals with a hostile state of mind tend to depict their caregivers as malevolent, while also showing indications in their discourse that they identify with them. Also, when they talk about past trauma, they may focus on reporting the facts while leaving out emotional or painful content. Adults in the hostile range may also idealize malevolent caregivers, while also displaying anger or a desire of vengeance and control toward them. Individuals with a helpless state of mind, on the other hand, are more likely to identify with a helpless attachment figure and to report having displayed a caregiving attitude toward them during their childhood. They may struggle to develop a better understanding of their past relationships with the caregiver, without achieving a coherent representation of these relationships. They may also depict themselves as victims or be engaged in abusive relationships with others and be overwhelmed by feelings of fear and guilt. The HH coding system is increasingly being used in research with clinical samples. In a longitudinal study involving 45 low-income mothers and their child, Lyons-Ruth et al. (2005) found that 51% of mothers met criteria for Hostile-Helpless state of mind. Moreover, in that sample, HH state of mind was found to be related to maternal history of childhood trauma, to the adoption of atypical behaviors toward children (e.g., withdrawal, negative-intrusive behaviors, role confusion), and to infant disorganization (assessed at 18 months). In another study conducted with 12 women with borderline personality disorder (BPD) and 20 women with dysthymia, Lyons-Ruth and colleagues (Lyons-Ruth, Melnick, Patrick, & Hobson, 2007) found that 100% of BDP and 55% of dysthymic participants were classified as HH. Results of this study also indicated strong relations between Hostile-Helpless state of mind and borderline phenomenology. In another study, Finger (2006) compared attachment state of mind of 62 substance-abusing Afro-American mothers and 87 matched control low-income mothers. Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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Mothers in the substance abusing group were significantly more likely to be classified HH (56%) than mothers in the control group (37%). Finally, evidence of validity of the HH classification system has also been provided by Frigerio et al. (2013). The authors found that HH states of mind were highly prevalent (75%) among mothers in the maltreating group, whereas 43% of mothers at-risk of maltreating their children were classified HH. In comparison, proportions of HH state of mind in their low-risk and poverty samples were 9% and 20%, respectively. Thus, research that has relied on the HH coding scheme of the AAI suggests that this measure is highly sensitive in identifying disorganized attachment states of mind in adulthood, particularly in at-risk and clinical populations. Aim of the study In view of (a) the rarity of studies which have examined disorganized attachment state of mind among maltreating parents and (b) the surprisingly low rates in this population of disorganized attachment state of mind using the U/d classification, it is important to pursue research efforts to better understand attachment states of mind among maltreating parents. In this study, we propose to document the proportion of disorganized state of mind, using the HH coding system, in a sample of physically neglecting mothers and mothers at-risk of neglecting their children. Also, considering the proposed traumatic etiology of disorganized attachment state of mind, we examine if disorganized states of mind, as measured by the HH classification, are related to mothers’ reports of childhood traumatic experiences. If such relations were to be found, they would serve to further validate the use of the HH coding system to tap into disorganized states of mind in maltreating parents. Method Participants Seventy mothers participated in this study. They were recruited over a 10-year period through child protection agencies and social services to participate in a longitudinal study on physically neglecting families. Physical neglect was defined as a failure to provide, lack of supervision, and moral-legal-educational maltreatment (Barnett, Manly, & Cicchetti, 1993). Child physical neglect was substantiated by child protection agencies for 48 mothers. The remaining 22 were considered by social services as at high risk for physically neglecting their children. Families were considered at-risk if they met at least four risk factors, such as adolescent mother, depressed mother, or lack of social support (Éthier et al., 2004). Mothers were Caucasian and French-speaking (mean age at the time of recruitment = 29 years, SD = 5.4) and were living in an urban area of the Province of Québec, Canada. All mothers came from a low socioeconomic background. Mothers had an average of 9.8 years of education (SD = 1.95), with 60% of participants not having completed a high-school degree. Most participants (81%) earned less than $20,000/year, with 75% reporting state welfare as their main source of income. Only 31% of participants reported being employed. Finally, mothers had an average of 2.1 children at home (SD = 1.20). Measures Hostile-Helpless states of mind. Hostile-Helpless states of mind were coded using the Hostile-Helpless coding system for the Adult Attachment Interview (Lyons-Ruth et al., 2006). The Adult Attachment Interview (AAI, Main & Goldwyn, 1998) includes 20 questions and follow-up probes on early attachment-related experiences (e.g., relationships with caregivers, separation from parents, frightening or traumatic experiences, significant losses). Individuals are also prompted to evaluate the impact of these experiences on their personality. Finally, additional questions document the quality of the current relationships with parents, as well as participants’ relationships with their own children. Interviews were audio recorded and transcribed verbatim for coding purposes. The Hostile-Helpless state of mind coding system focuses on a series of disorganization indicators leading up to an overall Disorganization score (1–9). Participants with a Disorganization score of 5 or above are classified HH with regards to attachment, and those with a Disorganization score lower than 5 are classified not HH (Lyons-Ruth et al., 2006). The Disorganization score is based on the coder’s judgment on how well the participant’s state of mind fits the theoretical description of the coding manual. To do so, coders must also take into account six other HH indicators, referred to as individual frequency codes: Global devaluation of a caregiver, Identification with a hostile caregiver, Recurrent references to fearful affect, Sense of self as bad, Laughter at pain, and Ruptured attachment. According to discourse features, participants are classified in one of the following HH subtypes: Hostile, Helpless, or Mixed. To be classified as Hostile, a discourse is expected to include global devaluation toward at least one primary attachment figure throughout the transcript. Participants may also display a range of aggressive thoughts or behaviors consistent with those of the devaluated caregiver and may punctuate these negative experiences with inappropriate laughter. The discourse may be concise and may include constricted speech patterns or straightforward descriptions of traumatic events. In the transcript classified as Helpless, one or more caregivers are depicted as helpless and abdicating their parental role. The transcript is often punctuated by recurrent references to fearful affect in various traumatic as well as non-traumatic situations. Helpless individuals may also orient their discourse toward a vulnerable stance, using negative words in order to describe themselves or identifying with the helpless attachment figure in terms of thoughts and behaviors. Their discourse may be passive, although punctuated by an honest desire to Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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contemplate on negative past experiences. Finally, a transcript is assigned to the Mixed subtype when the discourse includes fluctuations between hostile and helpless indicators, with elements of both inner aggressiveness and vulnerability being clearly displayed. More detailed information concerning HH classification criteria and on how this coding system differs from the Main and Goldwyn’s (1998) classification system is available elsewhere (Lyons-Ruth, Melnick, Atwood, & Yellin, 2006; Lyons-Ruth et al., 2005). AAIs were coded by two reliable coders who were trained by a certified trainer. In order to be reliable with the H/H coding system, an intra-class correlation or a kappa of .70 or above with criterion codes is required. The first coder (second author of this report) scored all 70 AAIs and the second independently scored 22 AAIs. Interrater reliability for these 22 interviews (31%) was as follows: ri = .92 for the HH Disorganization score, kappa = .91 for the HH dichotomous score, and kappa = .72 for HH subtypes. Although coders were aware that participants came from a high-risk population, they were blind to group status (neglecting vs. at-risk of neglect) and any other information concerning participants. Childhood trauma exposure. The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998), is a 28-item retrospective self-report questionnaire measuring exposure to childhood adverse events. The instrument yields scores for five forms of child maltreatment: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Each subscale is comprised of five items that participants rate from 1 (never true) to 5 (very often true), according to the frequency with which traumatic events occurred. Cut-off scores are provided for none, mild, moderate, and severe exposure levels for each subscale. As suggested by the authors, in this study, we used a dichotomous score reflecting presence (be it low, moderate or severe) versus absence of trauma. The CTQ has good psychometric properties (Bernstein & Fink, 1998). For the present study, internal consistency indices (Cronbach’s alpha) ranged from .70 to .90. Procedure Mothers were recruited over a 10-year period. Most mothers were administered the AAI in a follow-up study (about 4 years after their recruitment) during a home visit. The CTQ was completed about 4 years after the AAI. Because of attrition, the CTQ was available for only 42 out of the 70 participants. Analyses showed that the sample of 28 mothers lost to attrition were not significantly different from the 42 remaining participants on any of the sociodemographic variables. Results Data analysis Analyses were conducted using SPSS 20.0 software. Presence of HH states of mind was documented using descriptive statistics, including proportion of mothers classified HH, distribution of HH subtypes, and mean HH Disorganization scores. Descriptive statistics for childhood trauma experiences (presence vs. absence for each form of trauma and total number of trauma forms) were also examined. In addition, relations between HH states of mind and childhood trauma experiences were evaluated. We first looked at proportions of HH and non-HH mothers having experienced childhood trauma (presence vs. absence) using chi-square contingency tables. Then, using t-test analyses, we examined if the total number of trauma forms experienced varied as a function of HH status. Also, we examined whether Disorganization level varied as a function of the presence or absence of childhood trauma experiences. Finally, a correlation analysis was conducted to examine if level of disorganization was related to total number of childhood trauma forms. Hostile-Helpless state of mind Forty-five of the 70 mothers were classified Hostile-Helpless, representing 64% of the entire sample. Mean Disorganization scores were 6.7 in the HH subgroup and 3.3 in the non-HH subgroup (t = 19.8, p < .001). In the HH subgroup, 12 (27%) were classified Hostile, 19 (42%) were Mixed, and 14 (31%) were Helpless. There was no difference between neglecting mothers and at-risk of neglecting mothers on any HH variables. Childhood trauma experiences Out of the 42 mothers who completed the CTQ, 38 (90%) reported at least one form of childhood trauma: 24 (57%) experienced emotional abuse, 17 (40%) experienced physical abuse, 24 (57%) experienced sexual abuse, 34 (81%) experienced emotional neglect, and 21 (50%) experienced physical neglect. Participants experienced a mean of 2.9 forms of childhood abuse. There was no difference between neglecting mothers and at-risk of neglecting mothers on all CTQ variables. Hostile-Helpless state of mind and childhood trauma Mothers classified HH reported having been emotionally abused, sexually abused, and physically neglected more frequently than non-HH mothers (see Table 1). Moreover, mothers in the HH group experienced almost twice as many forms of childhood trauma than non-HH mothers (M = 3.4 vs. M = 1.8; t(40) = 3.54, p < .001). Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015
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Table 1 Proportion of mothers who experienced childhood trauma as a function of Hostile/Helpless status. 2
HH (N = 27)
Non-HH (N = 15)
Emotional abuse N %
20 74
4 27
9.90**
Physical abuse N %
13 48
4 27
1.85
Sexual abuse N %
19 70
5 33
5.40*
Emotional neglect N %
24 89
10 67
3.09†
Physical neglect N %
17 63
4 27
5.71*
† * **
p < .10. p < .05. p < .01.
Analyses using Disorganization scores (from 1 to 9) revealed that the level of disorganization was significantly higher for mothers reporting experiences of emotional abuse, physical abuse, sexual abuse, and physical neglect than for mothers who reported no such experiences (see Table 2). Also, there was a significant correlation between mothers’ Disorganization score and number of trauma forms experienced by mothers (r = .55, p < .001). Discussion This aim of this study was to assess disorganized states of mind in a sample of neglecting mothers and at-risk of neglecting mothers using the recently developed Hostile/Helpless coding system for the Adult Attachment Interview. This study is one of the very few to have assessed adult attachment states of mind in maltreating parents and the first to use the HH state of mind classification with neglecting mothers. Forty-five mothers out of 70 (64%) were classified Hostile/Helpless, revealing a high prevalence of disorganized states of mind in this sample. These results are consistent with Frigerio et al.’s (2013) findings in which 75% of the maltreating mothers were classified HH. It is also important to note that the proportion of mothers with a disorganized attachment state of mind in our study, using the HH coding system, was much higher than what was reported in previous studies using the Unresolved classification (Frigerio et al., 2013; Lindhiem et al., 2011), which is more in line with current theorization on maltreating mothers’ psychological and relational functioning. Results also revealed that most mothers in our sample experienced at least one form of childhood trauma. This finding is concordant with the literature Table 2 Disorganization Score as a function of presence and absence of childhood trauma experiences. Presence
Absence
Emotional abuse M SD
6.29 1.68
4.18 1.29
4.36***
Physical abuse M SD
6.24 1.86
4.96 1.72
2.29*
Sexual abuse M SD
6.04 1.60
4.72 1.97
2.40*
Emotional neglect M SD
5.68 1.79
4.63 2.07
1.46
Physical neglect M SD
6.24 1.70
4.55 1.61
3.27**
* ** ***
t(40)
p < .05. p < .01. p < .001.
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on the intergenerational transmission of maltreatment which has shown that experiences of childhood maltreatment is an important risk factor for adopting neglecting or abusive parenting practices with one’s own children in adulthood (e.g., Cort et al., 2011; Heyman & Slep, 2002; Pears & Capaldi, 2001). Moreover, our results revealed a significant association between the HH classification and childhood experiences of emotional abuse, sexual abuse, and physical neglect and a strong correlation between the number of different types of maltreatment experienced by mothers and overall Disorganization scores. These findings provide further empirical evidence supporting the validity of the HH classification system with at-risk samples. Finally, the fact that neglecting mothers and at risk of neglecting mothers did not significantly differ on either HH state of mind or childhood experiences of maltreatment suggests that the at-risk mothers in our sample may also be a very high-risk group. However, it is also possible that at-risk of neglecting mothers differ from neglecting mothers on other variables not assessed in our study, such as psychological and ecological protective factors. Further research is needed to address this particular issue. Taken together, these findings underline the impact of childhood trauma on latter psychological functioning. Accordingly, childhood experiences of abuse and neglect should be considered as chronic stressors that may profoundly impact development and psychosocial functioning, including a higher risk of intergenerational transmission of traumatic experiences. These results have important clinical implications because they highlight the need to provide psychological therapeutic support to the parent when intervening with neglecting families. Several neglecting mothers have experienced childhood traumas, and it is likely that they still struggle with these past traumas if nothing has been done to address them. According to Moran et al. (2008), this therapeutic emotional support should include an acknowledgment of the parents’ trauma history and helping them realize how these past experiences might exert an influence on their capacity to engage and interact with significant others, in particular with their own child. One important aspect of the intervention should be to “assist parents in reflecting on how past experiences trigger defensive processes that materialize within the mother-child relationship, so that they can use this insight to change their responses” (Moran et al., 2008Moran et al., 2008, p. 390). Intervention programs such as STEEP (Steps Toward Effective, Enjoyable Parenting; Egeland & Erickson, 2004), which focus on both parent’s behaviors and mental representations, provide relevant treatment guidelines for enhancing mothers’ ability to reflect on their own experiences and the quality of parent-child relationships. These guidelines include identifying the parents’ coping strategies and defenses, challenging all-or-nothing thinking, helping parents understand their child’s motives and feelings and support them in finding and implementing solutions by themselves (Egeland & Erickson, 2004). Considering the unbalanced victim/aggressor representational patterns characterizing HH mothers (Lyons-Ruth et al., 2005), it is essential for the therapist to establish a secure therapeutic alliance as a stepping stone for healing past attachment experiences (Lyons-Ruth & Spielman, 2004). Treatments such as Transference-Focused Psychotherapy (TFP), which focus on the consolidation of an attachment relationship to the therapist as well as on the development of the ability to think in mental state terms (to understand the intentions, thoughts, feelings, beliefs and motivations of self and others), might be particularly useful with adults presenting HH states of mind. TFP has proven to be successful in enhancing reflective functioning and attachment security in patients with borderline personality disorder (Levy et al., 2006), a condition theoretically and empirically related to Hostile/Helpless states of mind (Lyons-Ruth et al., 2006, Lyons-Ruth et al., 2007). Limits of the study This study has some limitations that should be noted. Firstly, mothers completed the measure of childhood trauma (CTQ) a few years after they were administered the Adult Attachment Interview. It is possible that the timing of the measure of childhood maltreatment might have had an impact on the information that was collected: their reports of past trauma might have been slightly different had they been obtained concurrently to the administration of the AAI. Yet, one should keep in mind that, in our study, HH state of mind as an overall Disorganization score was strongly related to childhood trauma experiences, even if they were not assessed at the same time. Secondly, considering the relatively small sample size, findings should be replicated with a bigger sample. Finally, considering both the absence of a healthy comparison group and the fact that coders were aware of the high-risk nature of the sample, we cannot totally rule out the possibility that HH states of mind might have been slightly overestimated. Future directions According to attachment theory, the way a caregiver has processed his/her own attachment history is a significant determinant of how he/she will interact with his/her own child. In this study, we provided evidence that neglecting mothers were at very high-risk of having disorganized states of mind, as measured by the HH classification, and that these states of mind were related to childhood trauma. However, many questions remain unanswered, such as: How do HH states of mind interfere with mother-child daily interactions? 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Please cite this article in press as: Milot, T., et al. Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.015