Clin Psychology and Psychoth - 2024 - Bryde Christensen - Emotion Regulation and Mentalization in Patients With Depression

Clinical Psychology & Psychotherapy
RESEARCH ARTICLE
Emotion Regulation and Mentalization in Patients With

Depression and Anxiety
Anne Bryde Christensen1,2 | Stig Poulsen2 | Trine Munk Højberg2,3 | Stine Bech Jessen2 | Nina Reinholt4 |
Morten Hvenegaard | Anita Eskildsen6 | Mikkel Arendt6,7 | Sidse Arnfred4,8
5
1Centerfor Eating and feeding Disorders Research, Mental Health Center Ballerup, Copenhagen University Hospital – Mental Health Services Capital
Region of Denmark, Copenhagen, Denmark | 2Department of Psychology, University of Copenhagen, Copenhagen, Denmark | 3Child and Adolescent
Mental Health Centre, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark | 4Psychiatric Research Unit, Psychiatry Region
Zealand, Copenhagen University Hospital, Slagelse, Denmark | 5Department of Crisis Psychology, Rigshospitalet, Copenhagen University Hospital,
Copenhagen, Denmark | 6Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark | 7Department of Clinical Medicine, Aarhus
University, Aarhus, Denmark | 8Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Correspondence: Anne Bryde Christensen ([email protected])
Received: 4 January 2023 | Revised: 29 February 2024 | Accepted: 15 April 2024
Keywords: emotion regulation | ERSQ | mentalization | psychopathology | RFQ
ABSTRACT
Objective: Theoretical conceptualizations of emotion and affect regulation have a considerable common ground. However, men-
talization theory considers the ability to regulate affects as being contingent on the ability to mentalize. The aim of the present
study is to examine the association between emotion regulation and mentalization, operationalized as reflective functioning, in
a sample of patients with depression and/or anxiety.
Methods: The study used data from the TRAns-diagnostic Cognitive behavioural Therapy versus standard cognitive behav-
ioural therapy (TRACT-RCT) trial. Patients with depression and/or anxiety (N = 291; 64.4% female; Mage = 32.2; SD = 11.0)
completed the Emotion Regulation Strategies Questionnaire (ERSQ) and the Reflective Functioning Questionnaire (RFQ-6).
Correlation and regression analyses were performed to determine associations of the measures of ERSQ and RFQ-6 in relation
to the outcome variables, global well-being (World Health Organization Well-being Index; WHO-5) and social functioning (Work
and Social Adjustment Scale; WSAS).
Results: Overall, the patients had a reduced level of emotion regulation (MERSQ_Total = 1.77; SD = 0.59). However, only mildly
impaired reflective functioning was found (MRFQ-6 = 3.57; SD = 1.26). ERSQ correlated significantly with RFQ-6 (r = −0.31), that
is, more frequent use of emotion regulation strategies was associated with less hypomentalization. ERSQ was a stronger predictor
of well-being and social function than RFQ-6.
Conclusion: In patients with anxiety and/or depression, hypomentalization as measured by the RFQ-6 is not a major problem,
but emotion regulation is. It seems that these two, theoretically related constructs, do not necessarily co-occur. Alternatively, the
RFQ-6 scale might not capture the mentalization construct in a valid way. Emotion regulation strategies are highly related to
symptomatology; therefore, they are likely to be an important target for psychotherapy.
1   |   Introduction expression of individual human emotions (Rottenberg and

Gross 2003). Research has identified ER as a central fac-
Emotion regulation (ER) refers to a set of neurocognitive tor across psychopathological disorders (Berenbaum et al.
processes that regulate the time trajectory, intensity, and 2003; McRae and Gross 2020) and as a result it has become a
© 2024 John Wiley & Sons Ltd.
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as defined by Berking, seem well established in patients with
Summary depression and anxiety, while the findings regarding reflective
function are inconclusive.
• Emotion regulation, but not reflective function, is
diminished in patients with depression and anxiety,
and it could be useful to target them differently in Therefore, we aim to investigate the relationship between
psychotherapy. emotion regulation strategies and hypomentalization within
a clinical population of patients with depression and anxiety,
something not previously done. We hypothesize (1) that emo-
tion regulation and hypo-mentalization scores will be inversely
transdiagnostic treatment target (e.g., Barlow 2011). Berking correlated and (2) that the scores will correlate with symptoms
and colleagues' emotion regulation theory focuses on of well-being and social function and their association will be
how adaptive emotion regulation emerges as a situation- so strong that they will be mutually constrained in combined
dependent interaction between various strategies (Berking analyses.
and Lukas 2015; Berking and Whitley 2014). Several empiri-
cal studies indicate that there is a positive correlation between
emotion dysregulation and the development and mainte- 2   |   Methods
nance of symptoms of both depression and anxiety (Aldao,
Nolen-Hoeksema, and Schweizer 2010; Berking et al. 2014; 2.1   |   Design
Ehring et al. 2010; Wirtz et al. 2014).
This study extracted data from the TRAns-diagnostic Cognitive
Mentalization has been defined as the ability to conceive and behavioural Therapy versus standard cognitive behavioural
interpret conscious and unconscious mental states of oneself therapy (TRACT-RCT) trial—a pragmatic, multicentre, parallel,
and others (Fonagy 1991). Reflective functioning refers to the single-blinded non-inferiority trial comparing transdiagnostic
operationalization of the psychological processes that are at versus diagnosis-specific group cognitive behavioural therapy
the core of mentalization (Fonagy et al. 2004). According to for anxiety disorders and depression in mental health services
mentalization theory, the individual must concurrently men- (Reinholt et al. 2021).
talize themselves and others in order to regulate affects and
emotions. In other words, adaptive mentalization and emotion
regulation goes hand in hand. The term mentalized affectivity 2.2   |   Sample
describes mature emotion regulation, where the individual
has the capability to make sense of emotional states (Fonagy Participants were recruited from three Danish hospital-based
et al. 2004). The abilities to mentalize and regulate emotions outpatient mental health clinics from 13 December 2016 to 9
adaptively are impaired across a wide range of mental disor- November 2018 (Reinholt et al. 2021). Included patients were
ders (Luyten et al. 2012). 18 to 65 years old, fluent in Danish and with a primary DSM-5
(American Psychiatric Association 2013) diagnosis of major de-
Fischer-Kern et al. (2013) found that reflective functioning pressive disorder (MDD), social anxiety disorder (SAD), agora-
was reduced in patients with depression, whereas others phobia (Ag), or panic disorder (PD). Exclusion criteria included a
have found that there were no differences between patients range of co-morbidities (for details about inclusion and exclusion
with depression and reflective functioning in control groups. criteria, see Reinholt et al. 2021).
The diverging findings may reflect that the impaired reflec-
tive functioning is not necessarily global (Luyten et al. 2012,
388). Thus, Rudden et al. (2006) found that patients with 2.3   |   Measures
panic disorder have problems mentalizing their own symp-
toms, while general reflective functioning was not reduced The following measures were collected digitally at study entry.
(Katznelson 2014).
Some researchers have suggested that there is a reciprocal re- 2.3.1   |   Emotion Regulation Strategy Questionnaire
lationship between mentalization and emotion regulation (ERSQ)
(Marszał and Jańczak 2018). Yet research into the relation-
ship between emotion regulation and mentalization is sparse. ERSQ is a 27 item self-report questionnaire measuring the pa-
Several studies have indicated associations between reduced tient's use of emotion regulation skills within the past week on a
reflective functioning and emotion dysregulation (Marszał and 5-point Likert scale ranging from 0 (not at all) to 4 (almost always).
Jańczak 2018; Schultheis, Mayes, and Rutherford 2019), although Higher scores reflect adaptive emotion regulation by the frequent
the opposite has also been found (Morel and Papouchis 2015). use of emotion regulation skills. Mean scores are calculated for the
Sharp et al. (2011) found that the relationship between border- total scale and nine subscales, respectively (Grant, Salsman, and
line personality disorder features and reduced reflective func- Berking 2018). The questionnaire has satisfying convergent and
tioning was partially mediated through emotion dysregulation. discriminative validity, and change sensitivity properties (Berking
The same study suggested, in accordance with mentalization and Znoj 2008). The mean total score of the ERSQ in a student
theory, that impaired reflective functioning causes problems sample was 2.53 (SD = 0.68) with mean subscale scores ranging
with emotion regulation as seen in borderline personality disor- between 2.45 and 3.53 (Grant, Salsman, and Berking 2018). In the
der. Summing up, dysfunctional emotion regulation strategies, present study, McDonald's omega for the total score was 0.92.
2 of 7 Clinical Psychology & Psychotherapy, 2024

2.3.2   |   Reflective Functioning Questionnaire (RFQ-6) A total score was calculated as the mean of all 25 items. HSCL-
25 have demonstrated satisfying internal consistency, conver-
The RFQ is a self-report scale measuring reflective function- gent validity, sensitivity and specificity (Müller et al. 2010;
ing. Originally, the scoring of the scale yielded two subscales, Strand et al. 2003; Winokur et al. 1984). The mean score in
RFQ_C and RFQ_U (Fonagy et al. 2016). However, in a re- a Norwegian general population sample was 1.33 (SE = 0.004)
cent validation study by Müller et al. (2022), concerns were (Strand et al. 2003). In the present study, McDonald's omega for
raised with respect to the validity, more specifically item the total score was 0.91.
content, dimensionality, scoring procedures and associations
with psychopathology. The study found that the RFQ mea-
sures a unidimensional construct, that is, hypomentalization, 2.4   |   Statistical Analysis
where higher scores reflect lower levels of mentalization.
Consequently, they proposed that one total mean score should Analyses were conducted using IBM SPSS Statistics 25. Missing
be calculated from the psychometrically optimized RFQ-8 or data was handled by pairwise deletion. We report means and
RFQ-6. We followed the scoring procedure proposed by Müller standard deviations of the included scales, including subscales
et al. (2022) and calculated a total score for the RFQ-6. In a of ERSQ, and Pearson correlations for ERSQ with RFQ-6 as well
general population sample from the United States, the mean of as ERSQ and RFQ-6 with WHO-5 and WSAS. Prior to regres-
the RFQ-6 was 3.31 (SD = 1.37) (Müller, personal communica- sion analyses, we examined differences in scores related to sex
tion). McDonald's omega for the RFQ-6 total score was 0.79 in by t-tests and associations between scores on the instruments
the present sample. and age with Pearson's correlations. Because sex was not sig-
nificantly related to any of the scales and Pearson correlations
between age and WSAS (r = 0.14, p ≤ 0.05), WHO-5 (r = −0.12,
2.3.3   |   WHO Well-Being Index (WHO-5) p = 0.06) and ERSQ (r = −0.12, p = 0.06) were very small, age
and sex were not included in the regression analyses. Simple
WHO-5 (Bech et al. 2003) is a 5-item self-rating instrument and hierarchical regression analyses were used for prediction
measuring the positive dimension of well-being. The statements of WHO-5, WSAS, ERSQ and RFQ-6. The hierarchical anal-
about subjective well-being over the past two weeks are scored yses were carried out with ERSQ and RFQ-6 in alternating
on a 6-point Likert-scale ranging from 0 (at no time) to 5 (all order (Model A:ERSQ entered first; Model B:RFQ-6 entered
the time). The raw scores are transformed to a percentage score first). The mean score of the HSCL-25 was included in ad-
ranging from 0 (worst possible well-being) to 100 (best possible ditional regression analyses to control for the main effect of
well-being). In a Danish general population sample, the mean psychopathology.
score was 68.7 (SD = 19.0) (Bech et al. 2003). A score below 50
suggests poor well-being and scores ≤28 are indicative of depres-
sion (Löwe et al. 2004). The WHO-5 has demonstrated high re- 2.5   |   Ethics
liability and validity (Newnham, Hooke, and Page 2010). In the
present study, McDonald's omega was 0.85. The Danish Data Protection Agency Region Zealand (registra-
tion #REG-104-2016) and the Ethics Committee Region Zealand
(registration #3084871-S J-582) approved the study.
2.3.4   |   Work and Social Adjustment Scale (WSAS)
WSAS is a 5-item self-report measure of functional impair- 3   |   Results

ment. Each item is rated on an 8-point Likert-scale ranging
from 0 (not at all) to 8 (very severely). A score of 40 reflects 3.1   |   Sample Description
maximum functional impairment, whereas a score below 10
indicates belonging to a subclinical population. The measure Missing data (RFQ-6 = 4.1%, ERSQ = 12.7%, HSCL = 14.1%,
has demonstrated satisfying reliability, validity and sensitiv- WSAS = 12.4% and WHO-5 = 9.6%) involved 16.2% of the initial
ity to treatment response in anxiety and depression (Mundt sample (N = 291; 64.4% female; Mage = 32.2; SD = 11.0). Previous
et al. 2002; Zahra et al. 2014). In the present study, McDonald's episodes of the primary diagnosis (n = 158) and allowed co-
omega for the WSAS was 0.79. morbid disorders (n = 160) were found in more than half of the
patients, and more than half of the patients (n = 175) were not
working or studying (see Table 1). Means and SD for ERSQ,
2.3.5   |   Hopkins Symptom Checklist (HSCL-25) RFQ-6, HSCL-25, WHO-5 and WSAS are reported in Table 2.
Hopkins Symptom Checklist (Derogatis et al. 1974) is a self-

report measure of psychological symptoms and distress. A 3.2   |   Associations Between ERSQ and RFQ-6
Danish 25-item version (HSCL-25) of the validated Danish
SCL-92 scale (Olsen, Mortensen, and Bech 2004) was used in ERSQ correlated significantly with RFQ-6 (r = −0.31, p < 0.001),
the current study. Items included eight of 10 anxiety subscale that is, more frequent use of emotion regulation strategies was
items (excluding feelings that something bad will happen and associated with less hypomentalization. This inverse associ-
scary thoughts/ideas), all depression subscale items, two so- ation persisted when controlling for symptom level; however,
matization subscale items (headaches; dizziness or faintness), only 3.4% of the RFQ-6 variance was explained after including
and two global items (poor appetite; difficulty falling asleep). HCSL-25.
3 of 7
TABLE 1    |    Demographic and diagnostic characteristics of the TABLE 2    |    Questionnaire scores.
sample.
Standard
Patient characteristicsa N = 291 Questionnaire Mean deviation
Age, mean (SD) 32.2 (11.0) ERSQ_Total (n = 254)a 1.77 0.59
Female sex 188 (64.4) ERSQ_Awareness 1.91 0.79
Employment* ERSQ_Sensations 2.13 0.80
Fulltime/part time/student 106 (37.7) ERSQ_Clarity 2.04 0.85
Sick leave (≥3 months) 120 (42.7) ERSQ_Understanding 1.91 0.88
Retired or job seeking 27 (9.6) ERSQ_Acceptance 1.41 0.79
Other 28 (10.0) ERSQ_Tolerance 1.52 0.79
Previous episode(s) with primary diagnosis* 158 (54.3) ERSQ_Readiness to confront 1.75 0.91
Previous hospitalization 45 (15.5) ERSQ_Self-support 1.79 0.84
Previous psychotherapy (≥5 sessions) 251 (86.3) ERSQ_Modification 1.41 0.71
Current psychotropic medication* 202 (69.4) RFQ-6 (n = 279) 3.57 1.26
For Yes HSCL-25 (n = 250) 2.00 0.71
Antidepressants (SSRI) 150 (51.5) WHO-5 (n = 263) 31.63 18.74
Otherb 52 (17.9) WSAS (n = 255) 24.99 7.95
Co-morbid diagnosesc a n = 254 for all subscales of ERSQ.
Any 160 (55.0)

≥2 diagnoses 68 (23.4) 4   |   Discussion
Anxiety or depression* 110 (37.8)
Other diagnosesd* 20 (6.9) We found that emotion regulation scores were associated with
well-being and social function, while hypomentalization mea-
Principal diagnosis
sured by the RFQ-6 showed a relatively weak association with
Major depressive disorder 146 (50.2) these measures, which disappeared when controlling for symp-
Social anxiety disorder 80 (27.5) tom level. The two scales were only slightly (r = −0.18) inversely
Panic disorder/agoraphobia 65 (22.3) associated, when controlling for symptom level.
Panic disorder 51 (17.5)
The association between ERSQ scores and global well-being
Agoraphobia 14 (4.8) and social functioning, was reduced, but not obliterated,
Abbreviation: SSRI, selective serotonin reuptake inhibitors. after adjusting for symptom level measured by the HSCL-
a Data are presented as number (percentage) or mean (SD) unless otherwise
indicated.
25. The shared variance suggests either that symptom level
bOther medications: benzodiazepines (according-to-need), anxiolytics, other and emotion regulation strategies are closely associated, or
medications (maximum of three).
c DSM-5 diagnoses assessed using the Mini-I nternational Neuropsychiatric
both affected by a latent variable, something which is not
Interview Version 7.0.2 at intake. surprising as emotion dysregulation is seen in many psychi-
dOther diagnoses: binge eating disorder, bulimia nervosa, obsessive-c ompulsive atric disorders (Gross 1998). A pivotal question is whether re-
disorder, posttraumatic stress disorder. duced emotion regulation is the cause or consequence of other
*Missing values = 10: Employment. Missing values = 2: previous episodes with
primary diagnosis. Missing values = 1: current medication, co-morbidity anxiety symptoms. Berking et al. (2008) found that higher levels of
or depression, co-morbidity other diagnoses. emotion regulation predicted higher levels of positive affect
and reduced levels of negative affect and anxiety after adjust-
ment for earlier emotional adjustment over a two-week period.
Their findings suggest that emotion dysregulation may pre-
3.3   |   Prediction of Well-Being and Social Function cede symptoms and decreased emotional adjustment, and that
emotion regulation strategies not simply decreased in associa-
ERSQ scores were correlated with both WHO-5 (r = 0.49, tion with increased symptom levels.
p < 0.001) and WSAS scores (r = −0.46, p < 0.001). Overall, the
correlations between RFQ-6 and WHO-5/WSAS, while statis- The patients in our study displayed lower levels of emotion reg-
tically significant, were smaller than the correlations between ulation, compared with non-clinical samples (Grant, Salsman,
ERSQ and WHO-5/WSAS (Table 3). In model A (ERSQ entered and Berking 2018). This is consistent with evidence showing
first), when controlling for symptom level, ERSQ and HSCL-25 that patients with internalizing disorders, such as depression
separately predicted WHO-5 and WSAS, while RFQ-6 was non- or anxiety, have lower levels of emotion regulation (Aldao,
significant. Likewise, in model B (RFQ-6 entered first), when Nolen-Hoeksema, and Schweizer 2010). It is also consistent with
controlling for symptom level, RFQ-6 neither predicted WHO-5 results from a study by Radkovsky et al. (2014), which showed
nor WSAS, while ERSQ predicted both WHO-5 and WSAS (see ERSQ total scores comparable to ours in a sample of patients
Table 3 for regression parameters). suffering from depression.

Our study indicated that the participants' level of reflective func-
Model 3
0.063***
0.051***
tioning was only mildly reduced compared with the population
ERSQ
ΔR2
means found by Müller et al. (2022). This is consistent with at
least two other studies, both using the interview-based Reflective
Functioning Scale (Fonagy et al. 1998). Taubner et al. (2011)
Analysis B found no differences in reflective functioning between patients
Model 2
RFQ-6
0.000
0.002
ΔR2
suffering from chronic depression and a control group, and
Karlsson and Kermott (2006) reported that reflective function-
ing was not severely reduced among patients suffering from
major depression. Accordingly, Karlsson and Kermott (2006)
HSCL-25
Model 1
0.384***
0.256***
proposed that reflective functioning might be a measure bet-
R2
ter suited for patients suffering from other mental disorders

With HSCL-25
such as borderline personality disorder (BPD). Studies on other

mental disorders appear to indicate that reflective functioning
may be relatively unimpaired, even if ER is affected (Pedersen
Model 3
RFQ-6
et al. 2012; Pedersen, Poulsen, and Lunn 2015). Furthermore,

0.000
0.001
ΔR2
Müller et al. (2022) reported that the RFQ had strong associa-
tions with personality pathology, but much weaker associations
with symptom distress.
Analysis A
Hierarchical regression
Model 2
0.062***
0.053***
ERSQ
It is possible that the findings of our study reflect psychometric

ΔR2
weaknesses in the RFQ-6. Müller et al. (2022) suggested that

the strong associations with personality pathology reported
in studies of the RFQ might be inflated as several RFQ items
HSCL-25
Model 1
0.384***
0.256***
concern impulsivity and emotional lability, thereby capturing

R2
central characteristics of BPD psychopathology rather than

mentalizing per se. This might explain previous findings of
high scores on the RFQ in BPD populations and rather mixed
findings within other populations. Furthermore, this is likely
Model 2
0.192***
0.183***
ERSQ
to inflate the correlation between RFQ-6 and ERSQ, as im-

ΔR2
pulsivity and emotional lability are indicators of difficulties

Analysis B
in emotion regulation, thereby overlapping the content of the

ERSQ. Finally, Müller et al. (2022) found no evidence that the
RFQ could assess hypermentalization, only the hypomental-
Model 1
0.057***
0.033**
RFQ-6
ization part of the RFQ was related to lower mental health.

R2
Overall, Müller et al. (2022) questioned the convergent validity

of the RFQ and called for alternative mentalization self-report
scales to be developed. Accordingly, it is hard to determine,
Model 2
whether our results indicate that patients with anxiety and de-
RFQ-6
0.008
0.002
ΔR2
pression do not have substantially lower reflective functioning

Analysis A
or whether they reflect the psychometric and conceptual con-

cerns outlined by Müller et al. (2022). However, the present
Without HSCL-25
TABLE 3    |    Correlations and hierarchical regression analysis.
study adds to the literature indicating that reflective function-

Model 1
0.240***
0.214***
ERSQ
ing, measured by both interview-based and self-report instru-

R2
ments, may not be consistently linked to general symptoms of

distress, anxiety or depression that are state based.
−0.25***
RFQ-6
0.18**
4.1   |   Limitations
R
Correlation
It is a limitation of the current study that because mentalization

seems to be less affected in patients with depression and anxiety,
−0.46***
compared with the more frequently assessed patients with BPD,

0.49***
ERSQ
*p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001.
associations between mentalization and emotion regulation are

r
more difficult to detect. In general, the questionnaire format for

assessment of ER and reflective functioning might be problem-
atic as subjects might not have the ability to report their own
Parameter
capacities for emotion regulation and mentalization in a valid

WHO-5
manner due to either inherent limitations or contextual distur-

WSAS
bance (Grant, Salsman, and Berking 2018; Luyten et al. 2012;

Murphy and Lilienfeld 2019).
5 of 7
5   |   Conclusion Reappraisal.” Emotion 10, no. 4: 563–572. https://doi.org/10.1037/
a0019010.
The study only found a very small association between mental- Fischer-Kern, M., P. Fonagy, N. D. Kapusta, et al. 2013. “Mentalizing in
ization and emotion regulation thereby challenging the assump- Female Inpatients With Major Depressive Disorder.” Journal of Nervous
tion that these constructs are related in patients with anxiety and Mental Disease 201, no. 3: 202–207. https://doi.org/10.1097/N MD.
and depression. Patients with anxiety and depression have diffi- 0b013e31828 45c0a.
culties with emotion regulation and this is associated with their Fonagy, P. 1991. “Thinking About Thinking: Some Clinical and
well-being and social function. Hypo-mentalization was not Theoretical Considerations in the Treatment of a Borderline Patient.”
found to be related to well-being and social function. The International Journal of Psycho-Analysis 72, no. 4: 639–656.
Fonagy, P., G. Gergely, E. L. Jurist, and M. Target. 2004. Affect

Regulation, Mentalization, and the Development of Self. 2nd ed. New
York: Routledge.
Data Availability Statement
Fonagy, P., P. Luyten, A. Moulton-Perkins, et al. 2016. “Development
No data is available for the current study.
and Validation of a Self-Report Measure of Mentalizing: The Reflective
Functioning Questionnaire.” PLoS ONE 11, no. 7: 1–28. https://doi.org/
10.1371/journal.pone.0158678.
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Clinical Psychology & Psychotherapy

Emotion Regulation and Mentalization in Patients With

Correspondence: Anne Bryde Christensen ([email protected])

Received: 4 January 2023 | Revised: 29 February 2024 | Accepted: 15 April 2024

Keywords: emotion regulation | ERSQ | mentalization | psychopathology | RFQ

1 | Introduction expression of individual human emotions (Rottenberg and

© 2024 John Wiley & Sons Ltd.

Clinical Psychology & Psychotherapy, 2024; 31:e2995 1 of 7

2 of 7 Clinical Psychology & Psychotherapy, 2024

WSAS is a 5-­item self-­report measure of functional impair- 3 | Results

Hopkins Symptom Checklist (Derogatis et al. 1974) is a self-­

Any 160 (55.0)

4 of 7 Clinical Psychology & Psychotherapy, 2024

ter suited for patients suffering from other mental disorders

such as borderline personality disorder (BPD). Studies on other

et al. 2012; Pedersen, Poulsen, and Lunn 2015). Furthermore,

It is possible that the findings of our study reflect psychometric

weaknesses in the RFQ-­6. Müller et al. (2022) suggested that

concern impulsivity and emotional lability, thereby capturing

central characteristics of BPD psychopathology rather than

to inflate the correlation between RFQ-­6 and ERSQ, as im-

pulsivity and emotional lability are indicators of difficulties

in emotion regulation, thereby overlapping the content of the

ization part of the RFQ was related to lower mental health.

Overall, Müller et al. (2022) questioned the convergent validity

pression do not have substantially lower reflective functioning

or whether they reflect the psychometric and conceptual con-

study adds to the literature indicating that reflective function-

ing, measured by both interview-­based and self-­report instru-

ments, may not be consistently linked to general symptoms of

It is a limitation of the current study that because mentalization

compared with the more frequently assessed patients with BPD,

*p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001.

associations between mentalization and emotion regulation are

more difficult to detect. In general, the questionnaire format for

capacities for emotion regulation and mentalization in a valid

manner due to either inherent limitations or contextual distur-

bance (Grant, Salsman, and Berking 2018; Luyten et al. 2012;

Fonagy, P., G. Gergely, E. L. Jurist, and M. Target. 2004. Affect

6 of 7 Clinical Psychology & Psychotherapy, 2024

Reinholt, N., M. Hvenegaard, A. B. Christensen, et al. 2021.

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1   |   Introduction expression of individual human emotions (Rottenberg and

WSAS is a 5-item self-report measure of functional impair- 3   |   Results

Hopkins Symptom Checklist (Derogatis et al. 1974) is a self-

weaknesses in the RFQ-6. Müller et al. (2022) suggested that

to inflate the correlation between RFQ-6 and ERSQ, as im-

ing, measured by both interview-based and self-report instru-

p ≤ 0.05, p ≤ 0.01, p ≤ 0.001.