The results of this study indicate that the coding system for H/H states of mind captures features of discourse on the AAI that are associated with infant disorganization. Contrary to our hypotheses, the aspects of discourse that indexed an H/H state of mind did not overlap substantially with the standard criteria for assigning the classifications for U, CC, or E3 in the standard Main and Goldwyn (1998)
system. The CC category is currently applied to transcripts in which the discourse characteristics change over the course of the interview (dismissing to preoccupied) or change from parent to parent or in which coherence is low but no particular state of mind scale is elevated. Although we had expected otherwise, the results indicate that these CC indicators were independent of the HH indicators. There appear to be many ways to manifest contradictory strategies on the AAI, not all of which are included in the U or CC coding criteria.
Rather than elaborating on the current criteria for those existing classifications, the H/H codes appear to delineate additional trauma-related ways in which a contradictory or pervasively unintegrated state of mind can be manifested on the AAI. The HH system both codes new elements that do not overlap with the traditional system, and combines those new elements with elements of the existing rare classifications (Ds2, E3) into more elaborated profiles associated with the intergenerational transmission of disorganization. Thus, the H/H system is an important augmentation to the current system for capturing indicators of a pervasively unintegrated state of mind.As is evident, however, this work exists within the Main and Goldwyn theoretical framework regarding integrated and unintegrated states of mind and expands the existing Main and Goldwyn system to include additional ways that incoherence manifests itself in more disturbed samples.
Consistent with standard AAI coding, it is not the content of the participant's experiences that is used to classify the participant's state of mind. Instead, it is the way the participant organizes his or her discourse about these experiences, that is, how the participant tells the story. The discourse of H/H mothers when describing relational experiences with their own caregivers was characterized by global devaluation of attachment figures, continued identification with those devalued figures, a sense of self as bad, fearful affect, and laughter at pain, as well as contradictory and unintegrated evaluations of central caregivers over the course of the interview (see also Steele, 2003
, for similar features in the AAIs of severely dissociative abused patients).
It is important to note that a number of the simple frequency codes were also significantly related to infant disorganization. Although capturing only specific and limited aspects of the H/H conceptualization, the frequency codes were retained for analysis because they are more closely tied to objectively specifiable features of the transcript than are the overall rating scale and classification, which allow the coder to weight more global features of the transcript that cannot easily be coded as frequency data. Given the limited and specific nature of the frequency codes, their generally robust associations with infant disorganization were somewhat surprising.
It is also important to note that because of the importance of assessing lack of resolution of abuse in this sample, the standard AAI protocol was augmented with a set of questions developed by trauma researchers to ask about the occurrence of physical abuse, sexual abuse, and witnessed violence (Herman et al., 1989
; see also Appendix A
). These questions were added to the protocols to enhance the ability to detect and code U states of mind and are not necessary for the coding of the H/H system. In contrast to coding U states of mind, coding for H/H states of mind does not rely on portions of the interview that relate to experiences of loss or abuse. Similar to traditional coding procedures for organized states of mind, HH states of mind are coded from discourse over the entire interview and the sections of the AAI that elicit the most relevant material for H/H coding are the early adjectives and examples describing the quality of the parent–child relationship and the later questions asking the parent to reflect on childhood experiences. In support of the applicability of the HH coding system to standard AAI protocols (without additional probes for abuse experiences), the coding system has also been applied to the standard AAI interviews of borderline and dysthymic patients reported on by Patrick et al. (1994
; Melnick & Patrick, 2003)
. Those protocols did not include additional questions about abuse and the HH system significantly differentiated between dysthymic and borderline patients, with no problem applying the system.
Recent evidence indicates that the primary gain from the additional questions is likely to lie in increased reporting of sexual abuse experiences. Bailey, Moran, and Forbes (2003)
reported that physical abuse experiences were reported at about the same rate on the standard format of the AAI as on a structured traumatic experiences questionnaire; however, sexual abuse experiences were underreported on the AAI compared to the traumatic experiences questionnaire. Therefore, the additional questions are likely to result in increased identification of sexual abuse experiences compared to the standard AAI format. The validity of the AAI in relation to the prediction of infant disorganization depends on accurate identification of abuse experiences so that lack of resolution of such experiences can be assessed. Therefore, the additional probes should have maximized the potential for experiences of abuse to be identified during the interview and coded for U status.
Despite these attempts to identify abuse and provide opportunity for abuse-related discourse, however, and despite the high rates of childhood abuse and infant disorganization in the sample (47% of mothers, n
= 21, had experienced physical or sexual abuse during childhood using state criteria; Lyons–Ruth & Block, 1996
), only three protocols met criteria for unresolved abuse using the standard coding criteria. Thirteen percent of women considered abused by the AAI coder (n
= 23) were coded U for abuse, while 22% of women who had suffered a loss (n
= 45) were coded U for loss. Greater difficulty resolving loss than abuse experiences is unexpected and difficult to justify given existing theory and research on sequellae of abuse. In addition, most losses had not occurred prior to age 16, and did not involve nuclear family members, while abuse experiences were all prior to adulthood.
There is almost no published data for comparison from other studies on the relative rates of subjects with abuse histories who are classified U for abuse compared to rates of subjects with loss histories who are classified U for loss. Such a breakdown would be valuable in future reports. To date, however, there is no reason to consider these data atypical. Because the criteria for U states of mind were originally developed for loss experiences and only subsequently extended to abuse experiences, current criteria for lack of resolution may be more sensitive to processes involved in integrating loss and less sensitive to processes involved in integrating abuse. Abused mothers of D infants who were not captured by the U abuse scale included those who either consistently denied occurrence of abusive events, for example, “She abused all the other kids but she didn't hit me because I was too fast” (not a believable statement to those who work with abusive families), or those who fit the profile described above where negative experiences are frankly and vividly and concisely described, for example, “Did you consider it abusive?” “Sure, it was abusive.” The essential problem is likely to be that “unresolved” abuse presents in discourse in very different ways than does unresolved loss. In contrast, a high proportion of abused women were classified as H/H, and the severity of both sexual and physical abuse experiences were related to HH states of mind (Lyons–Ruth et al., 2003
It seems unlikely that including the few additional questions about the occurrence of abuse experiences altered the process of the AAI for the participant. First, for the large group who have not experienced abuse, the questions do not apply. Second, recent data indicate that the group who has experienced physical abuse is already reporting those experiences on the standard AAI interview at the same rates as any structured questionnaires, as noted above. Therefore, the AAI process for this group is also unlikely to be different. Only for the small group who have experienced sexual abuse would we expect the AAI process to be different, in that those experiences are often not elicited in the usual AAI format (Bailey et al., 2003
) and would be more likely to be elicited and discussed with the additional questions. However, the opportunity to hear how such experiences are discussed in the interview should result in a gain rather than a loss of coding validity for the AAI and, particularly, for the coding of lack of resolution of abuse.
Given that the AAI data were gathered 5.5 years after the infant attachment and mother–infant interaction data, the significant associations between state of mind and maternal and infant behavior are especially notable. These predictive associations over time from infant attachment to maternal state of mind were also evident in the original Berkeley study data where AAIs were gathered when the children were age 6 (Main et al., 1985
In addition to being associated with infant disorganization and maternal disrupted communication, an H/H state of mind has been associated with the severity of childhood trauma in other analyses (Lyons–Ruth et al., 2003
). Both exposure to physical violence and sexual abuse alone, but not severity of loss experiences, were significantly associated with increased indicators of a H/H state of mind. Severity of trauma was not directly associated with infant disorganization, however. Therefore, the parent's H/H state of mind provided one indirect path through which the parent's traumatic experiences were associated with disorganized attachment in the next generation.
An H/H state of mind was not theoretically conceived as related only to trauma, however. An important impetus for developing the current coding system was the view that parental emotional unavailability, whether due to chronic hostility, role reversal, or withdrawal from the child, responses that do not meet current criteria for abuse, constitutes a primary relational trauma. The serious relational deviations inherent in parental hostility, role reversal, and withdrawal can now be coded reliably from early infancy onward, and are robust predictors of infant disorganization, as noted earlier (e.g., Goldberg et al., 2003
; Kelly et al., 2003
; Lyons–Ruth et al., 1999
; Madigan et al., 2003
). According to this conceptualization, such primary early relational trauma would be expected to impact overall symptom severity by adulthood through at least three mechanisms. First, serious early relational deviations create early impairments in the sense of safety and protection of the infant and young child, with concomitant impact on neurobiological stress responses and psychological symptom formation. Second, these parental stances are also likely to be correlated with the child's exposure to physically threatening events over time. Third, unresponsive parental stances are likely to contribute to more pronounced symptom formation around particular traumatic events, due to the lack of parental comfort and help in integrating the traumatic experience. In this light, it should be noted that despite the increased prevalence of H/H states of mind among parents with a history of childhood abuse (Lyons–Ruth et al., 2003
), such trauma histories were neither necessary nor sufficient for the occurrence of H/H states of mind in this sample.
Given the relation between U states of mind and infant disorganization repeatedly found in low-risk samples (van IJzendoorn et al., 1999
), we view the lack of prediction from U to D in this sample as resulting from the high prevalence of parenting dysfunction and adverse events experienced during childhood by mothers in the current clinical sample. The standard coding system for the AAI may be most sensitive to identifying lapses of monitoring of reason and discourse related to family disruption and loss, while the H/H coding system was specifically designed to detect the more pervasively unintegrated states of mind that accompany experiences of relational trauma, including the cumulative traumas of consistently hostile or withdrawn parenting, as well as the episodic traumas of abuse events.
Theoretically, we view a hostile adult stance, either as captured by the HH coding system or as revealed in parent–infant interaction, as a likely outgrowth of a controlling/punitive stance in childhood (Cassidy, Marvin, & the MacArthur Working Group, 1991
). Additional codes for controlling/punitive or controlling/caregiving stances in childhood and adulthood have been added to the coding system since this study was completed. In the only work to date to use those additional codes, Melnick and Patrick (2003)
found that references to caregiving or punitive stances in childhood, as well as other H/H codes, differentiated adult borderline patients from adult dysthymic patients.
Although the description of a hostile stance has features in common with a dismissing stance, it is notable that none of the protocols classified H/H were classified dismissing by Main and Goldwyn criteria, despite such indicators of denial of vulnerability as “laughter at pain.” These protocols were not coded as dismissing because of the low or inconsistent levels of idealization displayed in the devaluations of caregivers and the frankness with which negative experiences were discussed. They were also not often coded as preoccupied because the negative evaluations were usually not presented in the context of angry, entangled speech patterns but as closed judgments in the context of a concise or even constricted discourse structure. In addition, a number of these clinical protocols have features that are rare in normative samples, including normative low-income samples, such as “hot” but concise devaluation, and those features provide a poor fit to any of the existing category descriptions. Protocols like these in which negative experiences were vividly related but the vulnerability and pain normally associated with such experiences were distanced by laughter and discourse style tended to be coded F1 or F4 in the Main and Goldwyn system, but to the clinician's eye these represent tough, “street-kid” stances. It appears that the difficulties in early relationships were too encompassing to be dealt with by lack of memory or by consistent idealization and caregivers were often too frightening or vulnerable to risk any anger, so the difficulties are presented as matter of fact or even as having a certain entertainment or shock value.
The H/H protocols closer to a helpless prototype were characterized most often by repeated references to fearful affects, as well as global devaluation of caregivers, a sense of self as bad, laughter at pain, and often frank reporting of negative experiences. Protocols of the helpless subtype were not coded E3, however, because in many cases traumatic events were not the topic of the fearful statements and/or were not identified or could not be inferred. Instead, fearful statements were made about a variety of different topics throughout the interview. The discourse of Helpless protocols was also likely to convey an attitude of lack of autonomy of thought, although not necessarily through childlike or passive speech forms, in combination with active role reversal in regard to a caregiver. Some participants classified in the Helpless category described caregivers who were frightened or victimized and at the same time showed identification with the victimized caregiver.
Theoretically, we view a helpless adult state of mind as a potential outgrowth of a caregiving stance in childhood, organized around the (largely impossible) goal of helping an impaired parent to function more effectively. At the most basic level, we would view the child's sense of helplessness as grounded in a primary failure to receive effective care around attachment needs in infancy. This sense of helplessness would be further elaborated in childhood as a function of the inability to ease the parent's vulnerability, as well as by the identification with and modeling of the parent's anxiety and dysfunction. Converging with this formulation, Solomon and George (1999)
described mothers of disorganized/controlling children as “… helpless, in the sense of feeling themselves to be without strategies” (p. 19).
Although these hostile or helpless profiles anchor the two extremes of the distribution captured by this coding system, it should be reiterated that these hostile or helpless states of mind often occur in mixed rather than pure form. Consistent with the view that hostile and helpless working models represent complementary roles in an unbalanced dyadic relational structure (Lyons–Ruth et al., 1999
), it is not surprising that women in the sample often displayed aspects of both hostile and helpless discourse features, as well as mixed references to both caregiving and punitive stances in childhood.
The H/H codes add to the Main and Goldwyn system in three ways. First, the coding system for H/H states of mind examines discourse patterns throughout the whole interview. Second, H/H codes can be assigned regardless of the occurrence of particular experiences in childhood, so that coding does not depend on the identification of an experience of loss or abuse. Third, the H/H coding system is informed by descriptions of defensive functions among clinical populations, thus extending the potential of the codes for capturing variations in attachment-related states of mind within clinical groups.
Given the initial promise of these results, additional work is needed exploring the concurrent correlates and predictive validity of these codes in a wider range of clinical samples with concurrent infant attachment data. Data from one recent study of clinically referred outpatients indicates that H/H states of mind (as well as U states of mind) are more prevalent among women with borderline personality disorder than those with dysthymic disorders (Melnick & Patrick, 2003
). However, no infant data from clinical samples are yet available to assess the intergenerational transmission of H/H states of mind among specific diagnostic groups. Assessing the factors associated with infant disorganization among clinical populations now constitutes a critical agenda if adequate early prevention programs are to be designed for the parents and infants at greatest risk.