Abstract
Social work students experience high levels of stress, which makes them vulnerable to stress-related disorders such as depression. Attachment security has been associated with better stress regulation. Another factor that is closely associated with attachment is mentalization, i.e., the ability to reflect about one's own and others’ mental states, which may also influence the way people cope with stress. The main aim of the study was to investigate the impact of attachment and mentalization on stress, depression, and anxiety in social work students. 460 social work students completed the short version of the "Experiences in Close Relationships-Revised questionnaire” (ECR-RD8), “Relationship Questionnaire” (RQ-2), “Certainty About Mental States Questionnaire” (CAMSQ), “Perceived Stress Scale” (PSS-10) as well as the “Patient Health Questionnaire” (PHQ-9) and the “Generalized Anxiety Disorder Scale” (GAD-7) in a cross-sectional research design. The majority of the current social work students (71.1%) were assigned to an insecure attachment style and reported noticeably high levels of stress, depression, and anxiety. Insecurely attached students showed even higher levels of stress, depression, and anxiety compared to securely attached students. Moreover, the results indicate that securely attached students have better mentalizing skills and that mentalizing skills (partially) mediated the effect of attachment security on perceived stress, depression, and anxiety. Due to the importance of mentalization for stress regulation, mental health, and the quality of relationships, programs promoting mentalization in social work students should be implemented in social work education programs.
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Introduction
Previous studies have shown that students enrolled in social work and other healthcare programs report disproportionately high levels of stress (Enns et al., 2018; Hoying et al., 2020; Kriener et al., 2018; Palomino Coila & Nuñez Palomino, 2020; Weinberg, 2020). Social work and healthcare students are exposed to stressors resulting from clinical field internships or training that are part of their education programs (Mayer et al., 2018), in addition to general stressors for college or university students (such as the transition to a new environment, academic workload, financial concerns, and uncertainty about the future). In Germany, social work is understood as a “practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people” (International Federation of Social Workers, 2023). Therefore, social work students have to complete 100 days of supervised practice as part of their bachelor’s degree in order to work as a state-approved social worker. During these internships social work students work both in the social welfare as well as the healthcare system with clients of different ages and backgrounds who are often confronted with different kinds of problems such as physical and mental illness, drug addiction, poverty, or homelessness. There is overwhelming evidence that psychosocial stressors increase the risk for stress-related mental and physical health disorders (J. I. Cohen, 2000), which makes social work and healthcare students more vulnerable to developing stress-related mental health disorders, such as anxiety or depression (Chang et al., 2012; Dyrbye et al., 2006). In Germany, Kriener et al. (2018) found that 33.2% of social work students report high levels of stress. Therefore, successful coping with stress is important to the mental health and well-being of social work students and will be critical to their mental health upon entering clinical social work practice, as social workers in the field are exposed to many psychosocial stressors that increase their risk for stress-related disorders (Coyle et al., 2005; Kim et al., 2011; Lloyd et al., 2002). Hence, it is of particular interest to investigate factors that may affect stress levels in social work students. Previous studies have shown that attachment and mentalizing may influence how people cope with stress (Cooke et al., 2019; Safiye et al., 2022).
Attachment
Attachment, the emotional bond from the infant to the primary caregiver, is formed in the first years of life (Bowlby, 1969). The quality of attachment is based on the infant’s relational experiences with the primary caregiver (Ainsworth et al., 1978). Infants who experience consistent sensitive caregiving develop secure attachment patterns characterized by an inner sense of safety and effective stress and emotion regulation (Ainsworth et al., 1978; Cooke et al., 2019; De Wolff & van IJzendoorn, 1997). In contrast, infants whose primary caregivers are unresponsive to their needs and distress signals develop an insecure attachment pattern characterized by hyperactivation or deactivation of their attachment behavioral system in times of distress (Abrams et al., 2006; Ainsworth et al., 1978; Beebe et al., 2010; Moran et al., 2008). Early childhood interactions with the main caregiver are represented in internal working models (Bowlby, 1969) that influence later aspects of interpersonal relationships (Treboux et al., 2004) and intrapersonal functioning (Sroufe, 2005). While attachment security is associated with well-being (Borelli et al., 2019), attachment insecurity is associated with higher levels of stress (Bugaj et al., 2016; Eckstein-Madry et al., 2021; Halpern et al., 2012; Tironi et al., 2021), depression, and anxiety (Dagan et al., 2018; Green et al., 2021; Mickelson et al., 1997; Mikulincer & Shaver, 2007).
Adults’ mental representation regarding early childhood experiences with the primary caregiver is commonly assessed by the Adult Attachment Interview (AAI) (George et al., 1985). Based on the AAI adults can be classified as having a secure (secure-autonomous) or insecure (dismissing, preoccupied, or unresolved/disorganized) working model of attachment (Main & Goldwyn, 1985). Interestingly, research using the AAI has shown that adults can overcome negative early childhood experiences with their primary caregiver by developing an earned-secure attachment style through positive and supportive relationships later in life (Roisman et al., 2002; Saunders et al., 2011). However, there is also an ongoing debate about whether attachment in adults should be measured categorically or dimensionally (Fraley et al., 2015). As pointed out above, the categorical approach classifies into secure and insecure attachment styles. From a dimensional perspective, attachment is often conceptualized as a construct involving two dimensions: Attachment anxiety, which is associated with being afraid of being rejected by others, and attachment avoidance, which is associated with discomfort with close relationships (Mikulincer et al., 2003). Individuals scoring low on both dimensions may be considered as securely attached while those scoring high on attachment anxiety and/or attachment avoidance may be considered as insecurely attached, which negatively affects neurobiological systems underlying stress and emotion regulation (Moutsiana et al., 2014; Rigon et al., 2016; Vrtička et al., 2012).
Mentalization
Early infant-caregiver attachment relationships also serve as a foundation for the development of reflective functioning or mentalization (Bateman & Fonagy, 2010). Mentalization describes the ability to think about one’s mental states, such as emotions, thoughts, desires, and beliefs, as well as to reflect on the mental states of others (Bateman & Fonagy, 2010; Fonagy et al., 2004). It is assumed that the sensitivity of the caregiver to infants’ mental states not only fosters the development of attachment security but also promotes the infant's rapidly developing understanding of minds (Fonagy & Allison, 2014; Fonagy et al., 2011; Steele et al., 2002). In line with this, previous studies have shown that parental reflective functioning influences children’s ability to mentalize (Rosso & Airaldi, 2016). Hence, caregiver-infant attachment relationships affect mentalizing capacity (Katznelson, 2014). Mentalization is organized around four polarities. According to these polarities, mentalizing can be (a) controlled (explicit) or automatic (implicit), (b) in regard to the self or others, (c) internally or externally focused, and (d) cognitive or affective (Luyten et al., 2020). Explicit mentalizing describes a mode of controlled decoding of one’s mental states which requires conscious, verbal efforts, while implicit mentalizing is a reflexive, automatic process (Nolte et al., 2013).
Genuine mentalizing is characterized by the ability to form relatively accurate models of one's own and other‘s minds while acknowledging the opaqueness of mental states and not being too certain about those (Fonagy et al., 2016; Luyten et al., 2012). Conversely, hyper- and hypomentalizing are both maladaptive forms of mentalizing. Hypermentalizing (also referred to as pseudomentalizing (Luyten et al., 2020) or excessive theory of mind) is characterized by the overinterpretation and -attribution of mental states of and to others (Sharp et al., 2011, 2013). Individuals who hypermentalize tend to mis- and overinterpret social cues in others and have difficulties in the regulation of their emotional responses to social situations (Sharp et al., 2011). In other words, hypermentalizing is characterized by being too certain about mental states (Müller et al., 2023). While hypermentalizing is seen as an alternative, dysfunctional strategy of mentalizing, hypomentalizing (also referred to as undermentalizing) and non-mentalizing are characterized by the loss of mentalizing capacity per se (Sharp et al., 2011). Individuals who hypomentalize show a lack of or reduced ability to recognize their own or others’ complex mental states (Fonagy et al., 2016). Hence, it is characterized by little certainty about mental states (Müller et al., 2023). Thus, impaired mentalizing (i.e., hyper- or hypomentalizing) may lead to misinterpretation of behaviors or situations because one’s own or other’s mental states are mis- or overinterpreted, which in turn can result in intrapersonal and interpersonal problems (Euler et al., 2021). Further, impaired mentalizing skills are associated with emotional exhaustion, stress coping, and burn-out (Manzano-García et al., 2021; Safiye et al., 2022, 2023; Schwarzer et al., 2022) and even psychopathology (Fonagy & Luyten, 2009; Fonagy et al., 2011; Luyten et al., 2020), while genuine levels of mentalizing have been associated with well-being (Borelli et al., 2019; Schwarzer et al., 2022, 2023).
The Relationship Between Stress, Attachment, and Mentalization
When under intense emotional arousal and psychosocial distress, the activation of the attachment system is linked to the deactivation of the mentalization system, and a neurological switch from cortical to subcortical systems, thus from explicit to implicit mentalizing, followed by non-mentalizing modes, ensues (Luyten et al., 2012; Mayes, 2006). Non-mentalizing modes are characterized by reasoning about mental states without any real connection with reality (pretend mode), concrete understanding (psychic equivalence mode), or reduction of internal states of mind to observable behavior (teleological mode) (Luyten et al., 2012). It can be assumed that the threshold for the neurological switch is individually variable and that one’s attachment history has a significant effect on when this point is reached, i.e., when the mentalizing system switches into an automatic mode, which is characterized by inhibited attention and elevated vigilance for attachment-related rejection and abandonment (Fonagy et al., 2011; Fonagy & Luyten, 2009; Mayes, 2006). Particularly, it is attachment-related stress that has shown to neurologically affect mentalizing capacity negatively (Bateman & Fonagy, 2013; Nolte et al., 2013). Impaired mentalizing capacity is correlated with low well-being and high levels of stress (Borelli et al., 2019; Schwarzer et al., 2022), whereas genuine mentalizing skills may help us regulate stress and emotions and thereby protect us from mental health problems. Studies have shown that a genuine mentalizing capacity serves as a protective factor (Borelli et al., 2019; Schwarzer et al., 2022), which may be of high relevance for social work students who have reported perceiving high levels of stress (Kriener et al., 2018; Palomino Coila & Nuñez Palomino, 2020).
Current Study
Based on the previously described findings that suggest social work students are at high risk for stress and stress-related mental health disorders, such as depression or anxiety, it is of major importance to investigate factors that influence stress levels in social work students. To date, to the best of our knowledge, there is no data on the impact of attachment on mentalizing skills and the direct and/or indirect effect of mentalization on stress, depression, and anxiety in social work students. However, if a significant impact of mentalization on stress, depression, and anxiety is shown, this may have important implications for social work education.
Given the association between attachment and mentalization with stress levels and mental health in general, the overall aim of the current study was to investigate the impact of attachment and mentalization on stress, depression, and anxiety in social work students. More specifically, we hypothesized that: (1) insecurely attached social work students report lower mentalizing skills than securely attached students and higher levels of stress as well as more symptoms of depression and anxiety than securely attached students; (2) mentalization would mediate the relationship between attachment and stress, depression, and anxiety.
Methods
Participants and Data Collection
Social work students at the Catholic University of Applied Sciences North Rhine-Westphalia, Germany were invited to participate in this questionnaire-based online survey using LimeSurvey between December 2nd, 2021, and February 13th, 2022. While Bachelor’s degree programs usually take a generalist approach, teaching relevant scientific basic knowledge, methodology, theories, and models and enabling graduates to practice professionally in the field of social work, consecutive Master’s degree programs are optional and can help students to expand their knowledge and skills in specific fields of social work (e.g., clinical social work). At the time of the survey, 1770 students were enrolled in a bachelor's degree program in social work at the departments of Aachen and Münster at the Catholic University of Applied Sciences. 406 students were enrolled in a master’s degree program in social work at the departments of Aachen, Cologne, Paderborn, and Münster. Bachelor students at the departments of Aachen and Münster as well as master students at all four departments were contacted once via their institutional email address by their local students’ registry and were asked to participate in the survey. Additionally, the study was advertised on the university’s digital notice board which is only visible to enrolled students. Student representatives in Aachen and Münster also promoted the study via their social media accounts. In total, 460 students participated in the survey, making an estimated response rate of 21%. Participants were on average 25.96 years old (SD = 7.91, age range 18—56). Demographic variables with respect to gender, relationship status, children, academic level, and income are presented in Table 1.
Ethical Statement
The current study adhered to the ethical guidelines of the Catholic University of Applied Sciences North Rhine-Westphalia in accordance with the Declaration of Helsinki and was approved by the Institutional Ethical Review Board (approval number: AZ 2021-03). To ensure maximum anonymity, participants’ IP details were not collected. Participation was voluntary and participants could discontinue at any time. There were no disadvantages associated with non-participation. Participants gave informed consent before they were directed to the survey.
Measures
Attachment
To assess students’ attachment styles, the Relationship Questionnaire (RQ-2; Bartholomew & Horowitz, 1991) was used. The RQ-2 includes four items, each item contains statements about one of the attachment styles. Based on two dimensions (inner model of self and model of others), students were assigned to one of the four attachment styles according to Griffin and Bartholomew (1994): secure, dismissing, preoccupied and fearful. In the current study, insecure attachment styles (dismissing, preoccupied and fearful) were grouped. There is strong evidence for the construct validity of the attachment dimensions of the model of self and model of other (Griffin & Bartholomew, 1994). The construct validity of the RQ-2 has been examined in a cross-cultural study in 62 different cultures (including Germany) with evidence for good convergent and discriminant validity of the RQ-2 across cultures (Schmitt et al., 2004). The RQ-2 has also widely been used in Germany to assess attachment styles (e.g., Bugaj et al., 2016; Ehrenthal et al., 2009).
Additionally, participants answered the German short eight-item version of the inventory Experiences in Close Relationships-Revised (ECR-RD8; Ehrenthal et al., 2021). The ECR-RD8 measures attachment insecurity on two scales: attachment-related anxiety and attachment-related avoidance. In line with the original version of the ECR-R (Fraley et al., 2000), the ECR-RD8 proves to be a valid and reliable instrument to measure attachment insecurity (Ehrenthal et al., 2021). Cronbach’s alpha was 0.77 for the anxiety scale and 0.79 for the avoidance scale.
Mentalization
To measure mentalizing capacity, the Certainty About Mental States Questionnaire (CAMSQ; Müller et al., 2023) was used. The CAMSQ measures mentalizing concerning one’s self and others on two scales with ten items each: Other-Certainty and Self-Certainty. Low scores on the scale Self-Certainty indicate hypomentalizing, a form of maladaptive mentalizing where individuals show comparatively low certainty about their mental states. Hypermentalizing is measured as an imbalance between Self- and Other-Certainty with a maladaptive profile when Other-Certainty exceeds the level of Self-Certainty (Other-Self-Discrepancy scores > 0). If Other-Self-Discrepancy scores are lower than zero, individuals are more certain about their own mental states than about others’ mental states. This generally hints at a genuine mentalizing capacity. The developers found this instrument to be a valid and reliable instrument to assess mentalization in non-clinical samples in the US and Germany (Müller et al., 2023). Cronbach’s alpha was 0.86 for the Other-Certainty scale and 0.86 for the Self-Certainty scale.
Stress
To assess stress, the German adaptation of the Perceived Stress Scale (PSS-10; Klein et al., 2016) was used. It is a ten-item questionnaire measuring how uncontrollable, unpredictable, and overloading individuals experienced their life in the last month (S. Cohen et al., 1983). It has been shown that the PSS-10 is a reliable and valid instrument to measure stress in clinical and non-clinical samples (S. Cohen et al., 1983; Klein et al., 2016; Schneider et al., 2020). Cronbach’s alpha was 0.85.
Depression and Anxiety
To assess mental health, two questionnaires were answered by the students. The German version of the Patient Health Questionnaire (PHQ-9; Löwe et al., 2002) was used to test the severity of depressive symptoms with a maximum score of 27. A score of 10 or above on the scale indicates at least moderate levels of clinical depression. The German version of the Generalized Anxiety Disorder Scale (GAD-7; Löwe et al., 2008) was used to measure symptoms of anxiety with a maximum score of 21. A score of 10 or above indicates at least moderate levels of anxiety. Both questionnaires have been proven to be valid and reliable instruments to measure depression (Gräfe et al., 2004; Löwe et al., 2004) respectively anxiety (Löwe et al., 2008; Spitzer et al., 2006). Cronbach’s alpha was 0.88 for the depression scale and 0.88 for the anxiety scale.
Statistical Analyses
Complete data were available for n = 307. Using Little’s MCAR Test, values proved to be missing completely at random (χ2 = , p > 0.05). Therefore, missing values in the questionnaires were replaced using the expectation maximization (EM) algorithm implemented in IBM SPSS Statistics 28. Missing data for demographic characteristics were not imputed. All subsequent analyses used this imputed data set (N = 460). Based on their scores on the RQ-2 scales, students were split into two groups with either a secure or insecure (dismissing, preoccupied, fearful) attachment style. If students’ attachment styles were unstable (in between two styles), they were assigned to the insecure attachment group for further analyses. All statistical analyses were performed using IBM SPSS Statistics 28.
Descriptive statistics were employed to explore attachment style, stress levels, depression, and anxiety in the current population of social work students. To test our first hypothesis whether insecurely attached students have higher levels of stress, depression, and anxiety than securely attached students and lower mentalizing skills than insecurely attached students, we employed independent samples t-tests. To check for sociodemographic differences between attachment groups, chi-square tests, and independent-sample t-tests were run and analyses of variance and covariance were used to control for possible confounding effects. To test our second hypothesis that mentalization (partly) mediates the effect of attachment on stress, depression, and anxiety, we first conducted correlational analyses using the Pearson product-moment correlation to explore the association between attachment, mentalizing, stress, depression, and anxiety. In the next step, mediation analyses were conducted using the PROCESS procedure for SPSS v4.1 by Hayes (2022) which uses ordinary least squares regression, yielding unstandardized path coefficients for total, direct, and indirect effects. Bootstrapping with 5000 samples together with heteroscedasticity consistent standard errors (Davidson & MacKinnon, 1993) were employed to compute the confidence intervals and inferential statistics. Effects were deemed significant when the confidence interval did not include zero. Separate mediation models were run with attachment style, anxiety, and avoidance to examine the differential effects of these attachment dimensions. The level of significance for all analyses was set at p < 0.05.
Results
Attachment Style, Stress, Depression, and Anxiety in Social Work Students
Based on the RQ-2, 28.9% of the social work students were assigned a secure attachment style and 71.1% an insecure attachment style (9.8% dismissing, 25.4% preoccupied, 22.6% fearful and 13.3% showed an unstable pattern). Students with a secure attachment style showed significantly lower scores on the attachment dimensions (ECR-RD8) anxiety (t(458) = 6.13, p < 0.001, d = 0.63) and avoidance (t(272.44) = 6.98, p < 0.001, d = 0.68) compared to students with an insecure attachment style validating group assignment (Table 2). Regarding students’ mental health, 31.3% of the participants reported mild, 33% moderate, 18% moderately severe, and 7% severe depressive symptoms (PHQ-9). Scores above a cut-off score of ≥ 11 indicate clinically relevant depression symptoms, which applied to 51.7% of our sample. Further, 36.1% of the participants reported mild, 33% moderate, and 11.5% severe symptoms of general anxiety (GAD-7). 7.6% of the participants showed low, 65% moderate, and 27.4% high levels of perceived stress (PSS-10).
Differences in Stress, Depression, Anxiety, and Mentalization Between Attachment Styles
In line with our expectation, students with a secure attachment style experienced significantly less stress than those with an insecure attachment style (t(458) = 5.55, p < 0.001, d = 0.57). They also reported significantly lower scores on the PHQ-9 (t(458) = 6.09, p < 0.001, d = 0.62) and GAD-7 (t(458) = 5.42, p < 0.001, d = 0.56). Descriptive statistics are presented in Table 2.
Regarding mentalization, social work students with a secure attachment style showed significantly higher scores on the CAMSQ Self-Certainty scale (t(458) = −6.31, p < 0.001, d = −0.65) and Other-Certainty scale (t(458) = −2.01, p = 0.045, d = −0.21). Securely attached students had also significantly lower Other-Self-Discrepancy scores (t(458) = 3.81, p < 0.001, d = 0.39). The results are visualized in Fig. 1.
Mentalizing scores for insecurely and securely attached students. Note Mean scores for Self-Certainty and Other-Certainty are shown for insecurely and securely attached students (error bars show standard errors). Attachment style was assessed by the RQ-2 (Relationship Questionnaire). Self-Certainty and Other-certainty were assessed using the CAMSQ (Certainty About Mental States Questionnaire)
It should be noted that men were more likely to be securely attached than women (χ2(1) = 6.01, p = 0.019, φ = −0.134) and singles were more likely to be insecurely attached than people in a relationship (χ2(1) = 7.37, p = 0.007, φ = −0.149). No other significant differences were found concerning attachment style and age, academic level, weekly working time, monthly income, and parenting status. To test whether gender or relationship status affected the main effect of attachment style, analyses of variance with attachment, gender, and relationship status on the dependent variables were run, yielding no main effect of gender or relationship status or any interaction with attachment style (all p > 0.05).
The Mediating Role of Mentalization Between Attachment and Stress, Depression and Anxiety
Before mediation analyses were conducted, we first explored correlations between the measures. The results of the correlational analyses can be found in Table 3. Then, mediation analyses were performed to analyze whether the association between attachment and perceived stress, depression, and anxiety was mediated by Self-Certainty or Other-Self-Discrepancy.
As shown in Fig. 2, Other-Self-Discrepancy partially mediated the effect of attachment style (RQ-2) and attachment anxiety (ECR-RD8) on stress (PSS-10), depression (PHQ-9), and anxiety (GAD-7). However, Other-Self-Discrepancy did not mediate the effect of attachment avoidance (ECR-RD8) on these variables. As shown in Fig. 3, Self-Certainty partially mediated the effect of attachment style, attachment anxiety, attachment avoidance on stress, depression, and anxiety.
Simple mediator models with Other-Self Discrepancy as mediator. Note Bootstrapped 95%-confidence intervals for the indirect effects are considered significant when the confidence interval does not include zero. Unstandardized beta coefficients are presented for all paths. Attachment style was assessed by the RQ-2 (Relationship Questionnaire). Attachment anxiety and avoidance were assessed by the ECR-RD8 (Experiences in Close Relationships-Revised questionnaire). Stress was assessed by the PSS-10 (Perceived Stress Scale). Depression was assessed by the PHQ-9 (Patient Health Questionnaire) and anxiety was assessed by the GAD-7 (Generalized Anxiety Disorder Scale). Other-Self-Discrepancy was assessed using the CAMSQ (Certainty About Mental States Questionnaire). ab = indirect effect, c = total effect, c' = direct effect. *p < 0.05, **p < 0.01, ***p < 0.001
Simple mediator models with Self-Certainty as mediator. Note Bootstrapped 95%-confidence intervals for the indirect effects are considered significant when the confidence interval does not include zero. Unstandardized beta coefficients are presented for all paths. Attachment style was assessed by the RQ-2 (Relationship Questionnaire). Attachment anxiety and avoidance were assessed by the ECR-RD8 (Experiences in Close Relationships-Revised questionnaire). Stress was assessed by the PSS-10 (Perceived Stress Scale). Depression was assessed by the PHQ-9 (Patient Health Questionnaire) and anxiety was assessed by the GAD-7 (Generalized Anxiety Disorder Scale). Self-certainty was assessed using the CAMSQ (Certainty About Mental States Questionnaire). ab = indirect effect, c = total effect, c' = direct effect. *p < 0.05, **p < 0.01, ***p < 0.001
Discussion
In line with our first hypothesis, insecurely attached students based on the RQ-2 reported more stress, depressive symptoms, and anxiety and had less mentalizing skills (i.e., significantly lower scores regarding the certainty about their own mental states, while showing significantly higher Other-Self-Discrepancy scores (Müller et al., 2023)) than securely attached students. In line with our second hypothesis, we found that hypermentalizing, understood as being more certain about the mental states of others than about one’s own (Other-Self-Discrepancy), partially mediated the effect of attachment style on perceived stress, symptoms of depression, and anxiety. Additionally, Self-Certainty, which is associated with genuine mentalizing capacities (if it is not exceeded by being too certain about the mental states of others), also mediated the effect of attachment style on the outcome variables.
Attachment Style, Stress, Depression, and Anxiety in Social Work Students
In the current study, the majority of the students (71.1%) were assigned to an insecure attachment style based on the RQ-2. Previous research on the distribution of attachment representations in non-clinical samples found that 52–58% were classified as having secure attachment representations (Bakermans-Kranenburg & van IJzendoorn, 2009). In line with our findings, Trost et al. (2014) found in a sample of social work students that the majority had an insecure or only partly-secure attachment representation using the Bielefeld Partnership Expectations Questionnaire (BFPE). A recent work by Schröder et al. (2022) also found only 25.3% secure attachment representations in social workers using the Adult Attachment Projective Picture System. One explanation for the high distribution of attachment insecurity in social work students and social workers is a connection between one's biography and career choice. People with insecure attachment representations may be more likely to develop an interest in professions that deal with client problems to better deal with their own negative childhood experiences. In line with this assumption, it was found that clinical psychology students more often report adverse childhood experiences than business students (Nikčević et al., 2007). This is of importance because previous studies have suggested that attachment security might influence therapeutic working alliance and therapy outcomes (Degnan et al., 2016). Moreover, attachment insecurity has been associated with enhanced stress reactivity (Pierrehumbert et al., 2012; Thompson et al., 2018) and impaired mental health (Green et al., 2021; Mickelson et al., 1997; Mikulincer & Shaver, 2007).
In the current study, 27.4% of the students reported high levels of stress, which is similar to findings by Kriener et al. (2018) who also assessed perceived stress in social work students in Germany and is in line with evidence of high stress levels in social work and health care students outlined before (e.g., Enns et al., 2018; Hoying et al., 2020; Palomino Coila & Nuñez Palomino, 2020; Weinberg, 2020). Regarding depression and anxiety, 51.7% of the present study’s population scored above the cut-off for clinical depression and 44.5% of the sample reported moderate to severe anxiety. Securely attached students experienced significantly less stress than insecurely attached students and had lower levels of depression and anxiety, which is in line with previous studies on the impact of attachment on stress and mental health (Bugaj et al., 2016; Tironi et al., 2021).
The Role of Mentalization in Attachment, Stress, Depression, and Anxiety
In line with previous findings showing that attachment insecurity is associated with impaired mentalizing capacity (Fonagy et al., 2011; Fonagy & Luyten, 2009; Mayes, 2006; Rizq & Target, 2010), we found that securely attached students have more genuine mentalizing skills and show lower hypermentalizing than insecurely attached students. Moreover, hypermentalizing partially mediated the effect of attachment insecurity on perceived stress, symptoms of depression, and anxiety. Thus, securely attached individuals might hypermentalize less, which in turn reduces perceived stress and enhances mental well-being. Additionally, Self-Certainty also mediated the effect of attachment style on the outcome variables. These findings are supported by Brugnera et al. (2021) who found that mentalizing mediates the association between attachment insecurity and well-being in psychotherapists. In line with findings by Müller et al. (2023), neither hypermentalizing regarding one's self nor hypomentalizing regarding others were found to be maladaptive.
To further investigate the differential effects of attachment avoidance and attachment anxiety, we repeated the mediation analyses for attachment anxiety and attachment avoidance separately. The findings showed that the effect of attachment anxiety on stress and mental health was partially mediated by Self-Certainty and Other-Self-Discrepancy indicating that in anxious people hypermentalizing concerning other mental states and hypomentalizing concerning their own mental states may affect stress perception and mental health. In contrast, the effect of attachment avoidance on stress and mental health was only mediated by hypomentalizing concerning their own mental states. Since attachment-related anxiety is associated with a strong need for closeness and a fear of being rejected (Mikulincer et al., 2003), it may be associated with being too certain about what partners think and feel. On the other hand, being avoidant is characterized by being compulsively self-reliant and preferring emotional distance from others (Mikulincer et al., 2003), which is why people with avoidance tendencies may not attribute mental states to others as much as anxiously attached individuals do. This is also in line with neuroimaging findings showing differential activations in limbic and prefrontal areas in response to social-emotional stimuli in attachment-avoidant and -anxious individuals (Vrtička et al., 2012).
Limitations
The current study provides evidence for the role of mentalization and attachment in stress perception, depression, and anxiety in social work students. Nevertheless, several limitations have to be considered when interpreting the findings. The first limitation of the present study is its cross-sectional study design and therefore the limited possibility to explore how mentalizing capacity, attachment dimensions, stress, depression, and anxiety levels change over time. It is thus difficult to certainly say whether e.g., high stress is a result of poor mentalizing capacity or if one’s mentalizing capacity is affected by experiencing high stress. Second, the present study did not distinguish between general stress and attachment-related stress. This would have been interesting to investigate since the latter is hypothesized to have a greater adverse effect on mentalizing capacity (Nolte et al., 2013). Third, the current sample of social work students scored significantly higher on depression and anxiety than the general (German) population (Kroenke et al., 2009; Löwe et al., 2008), which indicates that the social work students in the current study are struggling with significant levels of depression and anxiety. However, the results should be interpreted against the background of the Covid-19 pandemic, which has been shown to have a significant impact on mental health among the general population (Bäuerle et al., 2020; Deimel et al., 2022) as well as students (Lee et al., 2021; Schröpfer et al., 2021; Werner et al., 2021). Fourth, the representativeness of the study sample might be limited. In the current study, the percentage of individuals identifying as women was higher compared to the overall proportion of 76.85% female social work students in Germany (Statistisches Bundesamt, 2023). Further, we did not collect information about ethnicity, migration background, or sexual orientation, which may also affect stress and mental health in social work students. In Germany, the collection of data on ethnicity is a sensitive and complex issue given the historical abuse of ethnicity-based categories. However, previous studies have shown that ethnic, gender, or sexual minority students report more mental health problems (Campbell et al., 2022; Kneale & Bécares, 2021; Kunyu et al., 2020), which has been associated with high levels of minority stress (Elmer et al., 2022). Therefore, future studies should address the impact of these factors on stress levels and mental health in social work students also in Germany. Fifth, it must be noted that, to our knowledge, this is the first study to use the CAMSQ after its initial development and evaluation by Müller et al. (2023). Comparisons with other studies assessing individuals’ mentalizing capacities must be interpreted with caution since they usually use other questionnaires which operationalize mentalizing as a one-dimensional construct, while the CAMSQ differentiates between Self-Certainty and Other-Certainty. Last, the current study is based on self-report data which may be prone to social desirability, which should be considered when interpreting the results.
Implications for Social Work Education and Clinical Social Work Practice
Given the association between mentalization, stress, depression, and anxiety, promoting mentalizing skills in social work students might be important to enhance stress resilience and mental health. A recent systematic review on psychological interventions to foster stress resilience in health care and social work students only found small to moderate effects on stress perception but no effects on depressive symptoms or well-being (Kunzler et al., 2020). Most interventions were based on mindfulness-based approaches, cognitive-behavioral therapy, or psychoeducation. None of the interventions targeted mentalization, although a previous study showed that mentalization has a significant impact on stress resilience in healthcare workers (Hosgoren Alıcı et al., 2022). Interestingly, mentalization-based interventions and training have been shown to improve the ability to mentalize in patients (Asen & Fonagy, 2012; Bateman & Fonagy, 2010, 2013; Brockmann & Kirsch, 2010; Sharp et al., 2013). A randomized controlled trial by Ensink et al. (2013) has shown that the implementation of mentalization training within the curriculum for novice clinicians can improve their mentalization abilities. Trowell et al. (2008) suggest that training courses in which students in the field of mental health are encouraged to reflect on their emotional reactions in stressful situations might be helpful to improve stress resilience and well-being. Therefore, social work education institutions are advised to develop and evaluate effective mentalization-based programs and implement those in their curricula. In Germany, social work programs often include training for reflection of one's own professional identity as a prospective social worker against the background of one's own biography, which may be expanded by the integration of mentalization-based training to help students achieve a deeper understanding for their emotional reactions to (attachment-related) stress and to enhance their stress resilience. Given the high distributions of attachment insecurity in the current sample and previous samples of social work students (Trost et al., 2014) and social workers (Schröder et al., 2022), promoting mentalizing skills in prospective social workers may also counteract the negative influence of attachment on stress and mental health. This is highly relevant as not only during their studies but also in social work practice, professionals report high levels of stress and mental health-related problems (Bauknecht & Wesselborg, 2022; Coyle et al., 2005; Lloyd et al., 2002). Therefore, it seems even more important to implement mentalization-based approaches already in the education of future social workers, which may enhance stress resilience during their study and also when entering clinical social work practice. Moreover, mentalizing skills might enhance the quality of (professional) relationships (Camoirano, 2017; Fonagy & Allison, 2014). In line with this, therapists with higher mentalization skills show better therapeutic outcomes (Cologon et al., 2017). Nevertheless, current data are scarce and further research is needed.
Conclusion
The present study aimed to investigate the impact of attachment and mentalization on stress and mental health in social work students. Our findings show that social work students have high levels of stress, depression, and anxiety. Insecurely attached students reported even higher levels compared to securely attached students. Interestingly, mentalizing skills mediated the association between attachment and stress, depression, and anxiety. Thus, mentalization might play an important role in the well-being of social work students. Therefore, mentalizing skills should be addressed in social work education. Fostering mentalization in social work students might not only make them more stress-resilient but also enhance the quality of their (professional) relationships and make them more resilient to psychosocial stressors upon entering clinical social work practice, as social workers in the field are exposed to many psychosocial stressors that increase their risk for stress-related disorders.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
References
Abrams, K. Y., Rifkin, A., & Hesse, E. (2006). Examining the role of parental frightened/frightening subtypes in predicting disorganized attachment within a brief observational procedure. Development and Psychopathology, 18(2), 345–361. https://doi.org/10.1017/S0954579406060184
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Erlbaum.
Asen, E., & Fonagy, P. (2012). Mentalization-based therapeutic interventions for families. Journal of Family Therapy, 34(4), 347–370. https://doi.org/10.1111/j.1467-6427.2011.00552.x
Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 adult attachment interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & Human Development, 11(3), 223–263. https://doi.org/10.1080/14616730902814762
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226–244. https://doi.org/10.1037/0022-3514.61.2.226
Bateman, A., & Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9(1), 11–15. https://doi.org/10.1002/j.2051-5545.2010.tb00255.x
Bateman, A., & Fonagy, P. (2013). Mentalization-based treatment. Psychoanalytic Inquiry, 33(6), 595–613. https://doi.org/10.1080/07351690.2013.835170
Bäuerle, A., Teufel, M., Musche, V., Weismüller, B., Kohler, H., Hetkamp, M., Dörrie, N., Schweda, A., & Skoda, E.-M. (2020). Increased generalized anxiety, depression and distress during the COVID-19 pandemic: A cross-sectional study in Germany. Journal of Public Health, 42(4), 672–678. https://doi.org/10.1093/pubmed/fdaa106
Bauknecht, J., & Wesselborg, B. (2022). Psychische Erschöpfung in sozialen Interaktionsberufen von 2006 bis 2018: Ein Vergleich der Bereiche Pflege, frühkindliche Bildung, Schule, Soziale Arbeit und Polizei [Mental exhaustion in social interaction professions from 2006 to 2018: A comparison of the areas of care, early childhood education, school, social work, and the police]. Prävention Und Gesundheitsförderung, 17(3), 328–335. https://doi.org/10.1007/s11553-021-00879-0
Beebe, B., Jaffe, J., Markese, S., Buck, K., Chen, H., Cohen, P., Bahrick, L., Andrews, H., & Feldstein, S. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother–infant interaction. Attachment & Human Development, 12(1–2), 3–141. https://doi.org/10.1080/14616730903338985
Borelli, J. L., Brugnera, A., Zarbo, C., Rabboni, M., Bondi, E., Tasca, G. A., & Compare, A. (2019). Attachment comes of age: Adolescents’ narrative coherence and reflective functioning predict well-being in emerging adulthood. Attachment & Human Development, 21(4), 332–351. https://doi.org/10.1080/14616734.2018.1479870
Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). Basic Books.
Brockmann, J., & Kirsch, H. (2010). Konzept der Mentalisierung: Relevanz für die psychotherapeutische Behandlung [Concept of mentalization: Relevance for psychotherapeutic treatment]. Psychotherapeut, 55(4), 279–290. https://doi.org/10.1007/s00278-010-0751-x
Brugnera, A., Zarbo, C., Compare, A., Talia, A., Tasca, G. A., de Jong, K., Greco, A., Greco, F., Pievani, L., Auteri, A., & Lo Coco, G. (2021). Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists. Psychotherapy Research, 31(2), 247–257. https://doi.org/10.1080/10503307.2020.1762946
Bugaj, T. J., Müksch, C., Ehrenthal, J. C., Köhl-Hackert, N., Schauenburg, H., Huber, J., Schmid, C., Erschens, R., Junne, F., Herzog, W., & Nikendei, C. (2016). Stresserleben bei Medizinstudierenden: Welche Rolle spielen Bindungserleben und Persönlichkeitsaspekte? Eine Querschnittsanalyse [Stress in medical students: A cross-sectional study on the relevance of attachment style and structural integration]. Psychotherapie Psychosomatik Medizinische Psychologie, 66(2), 88–92. https://doi.org/10.1055/s-0035-1569285
Camoirano, A. (2017). Mentalizing makes parenting work: A review about parental reflective functioning and clinical interventions to improve it. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2017.00014
Campbell, F., Blank, L., Cantrell, A., Baxter, S., Blackmore, C., Dixon, J., & Goyder, E. (2022). Factors that influence mental health of university and college students in the UK: A systematic review. BMC Public Health. https://doi.org/10.1186/s12889-022-13943-x
Chang, E., Eddins-Folensbee, F., & Coverdale, J. (2012). Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Academic Psychiatry, 36(3), 177–182. https://doi.org/10.1176/appi.ap.11040079
Cohen, J. I. (2000). Stress and mental health: A biobehavioral perspective. Issues in Mental Health Nursing, 21(2), 185–202. https://doi.org/10.1080/016128400248185
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. https://doi.org/10.2307/2136404
Cologon, J., Schweitzer, R. D., King, R., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style and therapist effectiveness. Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 614–625. https://doi.org/10.1007/s10488-017-0790-5
Cooke, J. E., Kochendorfer, L. B., Stuart-Parrigon, K. L., Koehn, A. J., & Kerns, K. A. (2019). Parent–child attachment and children’s experience and regulation of emotion: A meta-analytic review. Emotion, 19(6), 1103–1126. https://doi.org/10.1037/emo0000504
Coyle, D., Edwards, D., Hannigan, B., Fothergill, A., & Burnard, P. (2005). A systematic review of stress among mental health social workers. International Social Work, 48(2), 201–211. https://doi.org/10.1177/0020872805050492
Dagan, O., Facompré, C. R., & Bernard, K. (2018). Adult attachment representations and depressive symptoms: A meta-analysis. Journal of Affective Disorders, 236, 274–290. https://doi.org/10.1016/j.jad.2018.04.091
Davidson, R., & MacKinnon, J. G. (1993). Estimation and inference in econometrics. Oxford University Press.
De Wolff, M. S., & van IJzendoorn, M. H. (1997). Sensitivity and attachment: A meta-analysis on parental antecedents of infant attachment. Child Development, 68(4), 571–591. https://doi.org/10.1111/j.1467-8624.1997.tb04218.x
Degnan, A., Seymour-Hyde, A., Harris, A., & Berry, K. (2016). The role of therapist attachment in alliance and outcome: A systematic literature review. Clinical Psychology and Psychotherapy, 23(1), 47–65. https://doi.org/10.1002/cpp.1937
Deimel, D., Firk, C., Stöver, H., Hees, N., Scherbaum, N., & Fleißner, S. (2022). Substance use and mental health during the first COVID-19 lockdown in Germany: Results of a cross-sectional sevaluurvey. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph191912801
Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine: Journal of the Association of American Medical Colleges, 81(4), 354–373. https://doi.org/10.1097/00001888-200604000-00009
Eckstein-Madry, T., Piskernik, B., & Ahnert, L. (2021). Attachment and stress regulation in socioeconomically disadvantaged children: Can public childcare compensate? Infant Mental Health Journal, 42(6), 839–850. https://doi.org/10.1002/imhj.21878
Ehrenthal, J. C., Dinger, U., Lamla, A., Funken, B., & Schauenburg, H. (2009). Evaluation der deutschsprachigen Version des Bindungsfragebogens “Experiences in close relationships—revised” (ECR-RD) [Evaluation of the German version of the attachment questionnaire “Experiences in close relationships—revised” (ECR-RD)]. Psychotherapi Psychosomatik Medizinische Psychologie, 59(6), 215–223. https://doi.org/10.1055/s-2008-1067425
Ehrenthal, J. C., Zimmermann, J., Brenk-Franz, K., Dinger, U., Schauenburg, H., Brähler, E., & Strauß, B. (2021). Evaluation of a short version of the experiences in close relationships-revised questionnaire (ECR-RD8): Results from a representative German sample. BMC Psychology. https://doi.org/10.1186/s40359-021-00637-z
Elmer, E. M., van Tilburg, T., & Fokkema, T. (2022). Minority stress and loneliness in a global sample of sexual minority adults: The roles of social anxiety, social inhibition, and community involvement. Archives of Sexual Behavior, 51(4), 2269–2298. https://doi.org/10.1007/s10508-021-02132-3
Enns, A., Eldridge, G. D., Montgomery, C., & Gonzalez, V. M. (2018). Perceived stress, coping strategies, and emotional intelligence: A cross-sectional study of university students in helping disciplines. Nurse Education Today, 68, 226–231. https://doi.org/10.1016/j.nedt.2018.06.012
Ensink, K., Maheux, J., Normandin, L., Sabourin, S., Diguer, L., Berthelot, N., & Parent, K. (2013). The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial. Psychotherapy Research, 23(5), 526–538. https://doi.org/10.1080/10503307.2013.800950
Euler, S., Nolte, T., Constantinou, M., Griem, J., Montague, P. R., & Fonagy, P. (2021). Interpersonal problems in borderline personality disorder: Associations with mentalizing, emotion regulation, and impulsiveness. Journal of Personality Disorders, 35(2), 177–193. https://doi.org/10.1521/pedi_2019_33_427
Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51(3), 372–380. https://doi.org/10.1037/a0036505
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2004). Affect regulation, mentalization, and the development of the self. Karnac Books.
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. https://doi.org/10.1017/S0954579409990198
Fonagy, P., Luyten, P., Moulton-Perkins, A., Lee, Y.-W., Warren, F., Howard, S., Ghinai, R., Fearon, P., & Lowyck, B. (2016). Development and validation of a self-report measure of mentalizing: The reflective functioning questionnaire. PLoS ONE, 11(7), e0158678. https://doi.org/10.1371/journal.pone.0158678
Fonagy, P., Luyten, P., & Strathearn, L. (2011). Borderline personality disorder, mentalization, and the neurobiology of attachment. Infant Mental Health Journal, 32(1), 47–69. https://doi.org/10.1002/imhj.20283
Fraley, R. C., Hudson, N. W., Heffernan, M. E., & Segal, N. (2015). Are adult attachment styles categorical or dimensional? A taxometric analysis of general and relationship-specific attachment orientations. Journal of Personality and Social Psychology, 109(2), 354–368. https://doi.org/10.1037/pspp0000027
Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item response theory analysis of self-report measures of adult attachment. Journal of Personality and Social Psychology, 78(2), 350–365. https://doi.org/10.1037/0022-3514.78.2.350
George, C., Kaplan, N., & Main, M. (1985). Adult Attachment Interview [Unpublished manuscript]. University of California, Berkeley.
Gräfe, K., Zipfel, S., Herzog, W., & Löwe, B. (2004). Screening psychischer Störungen mit dem „Gesundheitsfragebogen für Patienten (PHQ-D)“ [Screening for psychiatric disorders with the patient health questionnaire (PHQ). Results from the German validation study]. Diagnostica, 50(4), 171–181. https://doi.org/10.1026/0012-1924.50.4.171
Green, J., Berry, K., Danquah, A., & Pratt, D. (2021). Attachment security and suicide ideation and behaviour: The mediating role of reflective functioning. International Journal of Environmental Research and Public Health, 18(6), 3090. https://doi.org/10.3390/ijerph18063090
Griffin, D. W., & Bartholomew, K. (1994). Models of the self and other: Fundamental dimensions underlying measures of adult attachment. Journal of Personality and Social Psychology, 67(3), 430–445. https://doi.org/10.1037/0022-3514.67.3.430
Halpern, J., Maunder, R. G., Schwartz, B., & Gurevich, M. (2012). Attachment insecurity, responses to critical incident distress, and current emotional symptoms in ambulance workers. Stress and Health, 28(1), 51–60. https://doi.org/10.1002/smi.1401
Hayes, A. F. (2022). PROCESS macro for SPSS and SAS, and R. http://processmacro.org/
Hosgoren Alıcı, Y., Hasanli, J., Saygılı, G., & Koçak, O. M. (2022). The importance of mentalization, coping mechanisms, and perceived stress in the prediction of resilience of healthcare workers. Psychology, Health & Medicine. https://doi.org/10.1080/13548506.2022.2131855
Hoying, J., Melnyk, B. M., Hutson, E., & Tan, A. (2020). Prevalence and correlates of depression, anxiety, stress, healthy beliefs, and lifestyle behaviors in first-year graduate health sciences students. Worldviews on Evidence-Based Nursing, 17(1), 49–59. https://doi.org/10.1111/wvn.12415
International Federation of Social Workers. (2023). Global Definition of Social Work. https://www.ifsw.org/what-is-social-work/global-definition-of-social-work/
Katznelson, H. (2014). Reflective functioning: A review. Clinical Psychology Review, 34(2), 107–117. https://doi.org/10.1016/j.cpr.2013.12.003
Kim, H., Ji, J., & Kao, D. (2011). Burnout and physical health among social workers: A three-year longitudinal study. Social Work, 56(3), 258–268. https://doi.org/10.1093/sw/56.3.258
Klein, E. M., Brähler, E., Dreier, M., Reinecke, L., Müller, K. W., Schmutzer, G., Wölfling, K., & Beutel, M. E. (2016). The German version of the perceived stress scale—psychometric characteristics in a representative German community sample. BMC Psychiatry, 16, 159. https://doi.org/10.1186/s12888-016-0875-9
Kneale, D., & Bécares, L. (2021). Discrimination as a predictor of poor mental health among LGBTQ+ people during the COVID-19 pandemic: Cross-sectional analysis of the online Queerantine study. BMJ Open, 11, e049405. https://doi.org/10.1136/bmjopen-2021-049405
Kriener, C., Schwertfeger, A., Deimel, D., & Köhler, T. (2018). Psychosoziale Belastungen, Stressempfinden und Stressbewältigung von Studierenden der Sozialen Arbeit: Ergebnisse einer quantitativen Studie [Psychosocial stress, stress perception and stress management of students of social work: A quantitative study]. Das Gesundheitswesen, 80(S01), 37–43. https://doi.org/10.1055/s-0042-108643
Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1–3), 163–173. https://doi.org/10.1016/j.jad.2008.06.026
Kunyu, D., Juang, L. P., Schachner, M. K., & Schwarzenthal, M. (2020). Discrimination among youth of immigrant descent in Germany: Do school and cultural belonging weaken links to negative socioemotional and academic adjustment? Zeitschrift Für Entwicklungspsychologie Und Pädagogische Psychologie, 52(3–4), 88–102. https://doi.org/10.1026/0049-8637/a000231
Kunzler, A. M., Helmreich, I., König, J., Chmitorz, A., Wessa, M., Binder, H., & Lieb, K. (2020). Psychological interventions to foster resilience in healthcare students. The Cochrane Database of Systematic Reviews, 7, CD013684. https://doi.org/10.1002/14651858.CD013684
Lee, J., Solomon, M., Stead, T., Kwon, B., & Ganti, L. (2021). Impact of COVID-19 on the mental health of US college students. BMC Psychology, 9, 95. https://doi.org/10.1186/s40359-021-00598-3
Lloyd, C., King, R., & Chenoweth, L. (2002). Social work, stress and burnout: A review. Journal of Mental Health, 11(3), 255–265. https://doi.org/10.1080/09638230020023642
Löwe, B., Spitzer, R. L., Zipfel, S., & Herzog, W. (2002). PHQ-D. Gesundheitsfragebogen für Patienten [Prime MD Patient Health Questionnaire (PHQ) – German version] (2nd ed.). Pfizer. https://www.klinikum.uni-heidelberg.de/fileadmin/Psychosomatische_Klinik/download/PHQ_Manual1.pdf
Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46(3), 266–274. https://doi.org/10.1097/MLR.0b013e318160d093
Löwe, B., Kroenke, K., Herzog, W., & Gräfe, K. (2004). Measuring depression outcome with a brief self-report instrument: Sensitivity to change of the patient health questionnaire (PHQ-9). Journal of Affective Disorders, 81(1), 61–66. https://doi.org/10.1016/S0165-0327(03)00198-8
Luyten, P., Campbell, C., Allison, E., & Fonagy, P. (2020). The mentalizing approach to psychopathology: State of the art and future directions. Annual Review of Clinical Psychology, 16(1), 297–325. https://doi.org/10.1146/annurev-clinpsy-071919-015355
Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). Assessment of mentalization. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (pp. 43–65). American Psychiatric Publishing Inc.
Main, M., & Goldwyn, R. (1985). Adult attachment scoring and classification system [Unpublished manuscript]. University of California, Berkeley.
Manzano-García, G., Ayala-Calvo, J. C., & Desrumaux, P. (2021). Entrepreneurs’ capacity for mentalizing: Its influence on burnout syndrome. International Journal of Environmental Research and Public Health, 18(1), 3. https://doi.org/10.3390/ijerph18010003
Mayer, S. E., Lopez-Duran, N. L., Sen, S., & Abelson, J. L. (2018). Chronic stress, hair cortisol and depression: A prospective and longitudinal study of medical internship. Psychoneuroendocrinology, 92, 57–65. https://doi.org/10.1016/j.psyneuen.2018.03.020
Mayes, L. C. (2006). Arousal regulation, emotional flexibility, medial amygdala function, and the impact of early experience: Comments on the paper of Lewis et al. Annals of the New York Academy of Sciences, 1094, 178–192. https://doi.org/10.1196/annals.1376.018
Mickelson, K. D., Kessler, R. C., & Shaver, P. R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology, 73(5), 1092–1106. https://doi.org/10.1037/0022-3514.73.5.1092
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. Guilford Press.
Mikulincer, M., Shaver, P. R., & Pereg, D. (2003). Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motivation and Emotion, 27(2), 77–102.
Moran, G., Forbes, L., Evans, E., Tarabulsy, G. M., & Madigan, S. (2008). Both maternal sensitivity and atypical maternal behavior independently predict attachment security and disorganization in adolescent mother-infant relationships. Infant Behavior and Development, 31(2), 321–325. https://doi.org/10.1016/j.infbeh.2007.12.012
Moutsiana, C., Fearon, P., Murray, L., Cooper, P., Goodyer, I., Johnstone, T., & Halligan, S. (2014). Making an effort to feel positive: Insecure attachment in infancy predicts the neural underpinnings of emotion regulation in adulthood. Journal of Child Psychology and Psychiatry, 55(9), 999–1008. https://doi.org/10.1111/jcpp.12198
Müller, S., Wendt, L., & Zimmermann, J. (2023). Development and validation of the certainty about mental states questionnaire (CAMSQ): A self-report measure of mentalizing oneself and others. Assessment, 30(3), 651–674. https://doi.org/10.1177/10731911211061280
Nikčević, A. V., Kramolisova-Advani, J., & Spada, M. M. (2007). Early childhood experiences and current emotional distress: What do they tell us about aspiring psychologists? The Journal of Psychology, 141(1), 25–34. https://doi.org/10.3200/JRLP.141.1.25-34
Nolte, T., Bolling, D., Hudac, C., Fonagy, P., Mayes, L., & Pelphrey, K. (2013). Brain mechanisms underlying the impact of attachment-related stress on social cognition. Frontiers in Human Neuroscience, 7, 816. https://doi.org/10.3389/fnhum.2013.00816
Palomino Coila, M. R., & Nuñez Palomino, M. (2020). Stress, anxiety, and depression in social work students from Peru. Revista de Salud Pública, 22(6), 601–608. https://doi.org/10.15446/rsap.v22n6.95151
Pierrehumbert, B., Torrisi, R., Ansermet, F., Borghini, A., & Halfon, O. (2012). Adult attachment representations predict cortisol and oxytocin responses to stress. Attachment & Human Development, 14(5), 453–476. https://doi.org/10.1080/14616734.2012.706394
Rigon, A., Duff, M. C., & Voss, M. W. (2016). Structural and functional neural correlates of self-reported attachment in healthy adults: Evidence for an amygdalar involvement. Brain Imaging and Behavior, 10(4), 941–952. https://doi.org/10.1007/s11682-015-9446-9
Rizq, R., & Target, M. (2010). “We had a constant battle”. The role of attachment status in counseling psychologists’ experiences of personal therapy: Some results from a mixed-methods study. Counselling Psychology Quarterly, 23(4), 343–369. https://doi.org/10.1080/09515070.2010.534327
Roisman, G. I., Padrón, E., Sroufe, L. A., & Egeland, B. (2002). Earned-secure attachment status in retrospect and prospect. Child Development, 73(4), 1204–1219. https://doi.org/10.1111/1467-8624.00467
Rosso, A. M., & Airaldi, C. (2016). Intergenerational transmission of reflective functioning. Frontiers in Psychology, 7, 1903. https://doi.org/10.3389/fpsyg.2016.01903
Safiye, T., Vukčević, B., Gutić, M., Milidrag, A., Dubljanin, D., Dubljanin, J., & Radmanović, B. (2022). Resilience, mentalizing and burnout syndrome among healthcare workers during the COVID-19 pandemic in Serbia. International Journal of Environmental Research and Public Health, 19(11), 6577. https://doi.org/10.3390/ijerph19116577
Safiye, T., Vukčević, B., Milidrag, A., Dubljanin, J., Cikotić, A. G., Dubljanin, D., Lačković, M., Rodić, I., Nikolić, M., Čolaković, G., Mladenović, T., & Gutić, M. (2023). Relationship between mentalizing and teacher burnout: A cross sectional study. PLoS ONE, 18(1), e0279535. https://doi.org/10.1371/journal.pone.0279535
Saunders, R., Jacobvitz, D., Zaccagnino, M., Beverung, L. M., & Hazen, N. (2011). Pathways to earned-security: The role of alternative support figures. Attachment & Human Development, 13(4), 403–420. https://doi.org/10.1080/14616734.2011.584405
Schmitt, D. P., Alcalay, L., Allensworth, M., Allik, J., Ault, L., Austers, I., Bennett, K. L., Bianchi, G., Boholst, F., Cunen, M. A. B., Braeckman, J., Brainerd, E. G., Caral, L. G. A., Caron, G., Casullo, M. M., Cunningham, M., Daibo, I., De Backer, C., De Souza, E., & ZupanÈiÈ, A. (2004). Patterns and universals of adult romantic attachment across 62 cultural regions: Are models of self and of other pancultural constructs? Journal of Cross-Cultural Psychology, 35(4), 367–402. https://doi.org/10.1177/0022022104266105
Schneider, E. E., Schönfelder, S., Domke-Wolf, M., & Wessa, M. (2020). Measuring stress in clinical and nonclinical subjects using a German adaptation of the perceived stress scale. International Journal of Clinical and Health Psychology, 20(2), 173–181. https://doi.org/10.1016/j.ijchp.2020.03.004
Schröder, M., Bürgin, D., Hutzenthaler, N., Buchheim, A., & Schmid, M. (2022). Zu Bindungsrepräsentationen und Burnout bei sozialpädagogischen Fachpersonen [On attachment representations and burnout among social pedagogical professionals]. Praxis der Kinderpsychologie und Kinderpsychiatrie, 71(1), 72–93. https://doi.org/10.13109/prkk.2022.71.1.72
Schröpfer, K., Schmidt, N., Kus, S., Koob, C., & Coenen, M. (2021). Psychological stress among students in health-related fields during the COVID-19 pandemic: Results of a cross-sectional study at selected Munich universities. International Journal of Environmental Research and Public Health, 18(12), 6611. https://doi.org/10.3390/ijerph18126611
Schwarzer, N.-H., Nolte, T., Fonagy, P., & Gingelmaier, S. (2022). Self-rated mentalizing mediates the relationship between stress and coping in a non-clinical sample. Psychological Reports, 125(2), 742–762. https://doi.org/10.1177/0033294121994846
Schwarzer, N.-H., Nolte, T., Fonagy, P., Griem, J., Kieschke, U., & Gingelmaier, S. (2023). The relationship between global distress, mentalizing and well-being in a German teacher sample. Current Psychology, 42(2), 1239–1248. https://doi.org/10.1007/s12144-021-01467-3
Sharp, C., Ha, C., Carbone, C., Kim, S., Perry, K., Williams, L., & Fonagy, P. (2013). Hypermentalizing in adolescent inpatients: Treatment effects and association with borderline traits. Journal of Personality Disorders, 27(1), 3–18. https://doi.org/10.1521/pedi.2013.27.1.3
Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., & Fonagy, P. (2011). Theory of mind and emotion regulation difficulties in adolescents with borderline traits. Journal of the American Academy of Child & Adolescent Psychiatry, 50(6), 563-573.e1. https://doi.org/10.1016/j.jaac.2011.01.017
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth to adulthood. Attachment & Human Development, 7(4), 349–367. https://doi.org/10.1080/14616730500365928
Statistisches Bundesamt. (2023). Studierende an Hochschulen—Sommersemester 2022 [Students at universities—Summer semester 2022]. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bildung-Forschung-Kultur/Hochschulen/Publikationen/Downloads-Hochschulen/studierende-hochschulen-ss-2110410227314.pdf?__blob=publicationFile
Steele, M., Steele, H., & Johansson, M. (2002). Maternal predictors of children’s social cognition: An attachment perspective. Journal of Child Psychology and Psychiatry, 43(7), 861–872. https://doi.org/10.1111/1469-7610.00096
Thompson, G., Wrath, A., Trinder, K., & Adams, G. C. (2018). The roles of attachment and resilience in perceived stress in medical students. Canadian Medical Education Journal, 9(4), e69–e77.
Tironi, M., Charpentier Mora, S., Cavanna, D., Borelli, J. L., & Bizzi, F. (2021). Physiological factors linking insecure attachment to psychopathology: A systematic review. Brain Sciences, 11(11), 1477. https://doi.org/10.3390/brainsci11111477
Treboux, D., Crowell, J. A., & Waters, E. (2004). When “new” meets “old”: Configurations of adult attachment representations and their implications for marital functioning. Developmental Psychology, 40(2), 295–314. https://doi.org/10.1037/0012-1649.40.2.295
Trost, A., Bochynek, A., Kreutz, D., & Weisleder, S. (2014). Ein Aachener Bindungsblick auf Herz und Verstand—Bindungsstile von Studierenden des Maschinenbaus und der Sozialen Arbeit—Ergebnisse und Konsequenzen [An Aachen attachment view on heart and mind—Attachment styles of mechanical engineering and social work students—Results and consequences]. In A. Trost (Ed.), Bindungsorientierung in der Sozialen Arbeit. Grundlagen—Forschungsergebnisse—Anwendungsbereiche (pp. 197–210). Borgmann.
Trowell, J., Davids, Z., Miles, G., Shmueli, A., & Paton, A. (2008). Developing healthy mental health professionals: What can we learn from trainees? Infant Observation, 11(3), 333–343. https://doi.org/10.1080/13698030802553583
Vrtička, P., Bondolfi, G., Sander, D., & Vuilleumier, P. (2012). The neural substrates of social emotion perception and regulation are modulated by adult attachment style. Social Neuroscience, 7(5), 473–493. https://doi.org/10.1080/17470919.2011.647410
Weinberg, M. (2020). Differences in the association of spirituality, forgiveness, PTSD and stress among social workers and social work students treating trauma survivors. Social Work in Health Care, 59(6), 430–444. https://doi.org/10.1080/00981389.2020.1781739
Werner, A. M., Tibubos, A. N., Mülder, L. M., Reichel, J. L., Schäfer, M., Heller, S., Pfirrmann, D., Edelmann, D., Dietz, P., Rigotti, T., & Beutel, M. E. (2021). The impact of lockdown stress and loneliness during the COVID-19 pandemic on mental health among university students in Germany. Scientific Reports, 11, 22637. https://doi.org/10.1038/s41598-021-02024-5
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Jansen, N., Kühl, J., Eller, N. et al. Mentalizing Capacity Partially Mediates the Relationship Between Attachment and Stress, Depression, and Anxiety in Social Work Students. Clin Soc Work J 51, 339–353 (2023). https://doi.org/10.1007/s10615-023-00882-2
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DOI: https://doi.org/10.1007/s10615-023-00882-2