Emotion Regulation and Existential Meaning-Making in Young Women with Mental Ill-Health Concerns–A Qualitative Study

1Area of Psychology of Religion, Public Mental Health Promotion Research Area, Impact Research Programme, Uppsala University, Sweden 2Public Mental Health Promotion Clinical Research, Innlandet Hospital Trust, Norway 3Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Sweden 4Department of Women’s and Children’s Health, Karolinska Institutet, Sweden 5Department of Psychology, Stockholm University, Sweden


Introduction
Since the economic recession in Sweden in the 1990s, repeated nation wide studies report on the deteriorating mental and psychosomatic health among young people in Sweden [1][2][3][4][5][6]. The increasing rates of psychiatric problems, like anxiety, worry, and anguish, are particularly confirmed among youths and young adults, especially among females [4]. This is considered a serious and growing public health concern, with causation and gender differences still under investigation [5,[7][8][9]. In a systematic review, Bor et al. [10] found that recent cohorts of adolescent girls in Europe are experiencing increases in internalizing symptoms, as anxiety and depression, compared with previous cohorts, where externalized symptoms seem to be more stable, among both girls and boys. From adolescence through adulthood, females have nearly a double risk for depression than males [11][12][13]. Adolescent depression is reported to have a multifactorial causation [11,14]. Further, Hankin [12] proposes a multi-dimensional vulnerability-stress framework, including environmental risk factors and gender-specific dimensions.
Psychological-and existential vulnerability is manifested in different ways for young people in Sweden [5,[15][16][17][18][19][20]. Adamson and colleagues found [15,16,21] in studies among non-clinical student populations that a positive self-concept was strongly related to the subjects' believing adults to be genuinely interested in their existential questions. The subjects rated the importance of their existential questions in the following order: concerns for the future, meaning of life in general, death, and one's own identity. The feeling that one belonged in a life context was significantly related to a positive self-concept [15]. A negative and unstable self-concept was significantly related to low self-The concepts Emotion regulation and Existential meaningmaking represent growing research fields. Emotion regulation functions as a trans-diagnostic approach [23]. Psychotherapy research shows that problems in emotion regulation are at the core of many different psychiatric disorders [23][24][25], and diagnostically, depression is widely conceptualized as a consequence of dysfunctional emotion regulation [26][27][28]. Longitudinal research shows that positive expectations about the ability to modify negative affect predict reductions in depression [29], and dysfunctional emotion-regulation strategies predict depression levels two years after initial assessment [30]. Existential meaning-making, as developed within the highly secularized Scandinavian context, especially in health-care research, includes approaching everyday existential meaningmaking choices and ultimate concerns as interwoven categories of general patient information [31,32]. Contemporary Sweden is understood as one of the most secularized countries in the world, with very low church-oriented religion in the majority culture [33,34]. This picture is confirmed among Swedish youths in a recent nationwide study (N =1 316, 16-24 years) [35], where religion seemed to have had little importance in their lives or for their identity commitments. From a public mental health perspective DeMarinis [36] underscores that many ethnic-Swedish youth experience dysfunction in existential meaningmaking, indicating a crisis of meaning in terms of access to cultural knowledge or existential resources. For the present study, a working-definition for existential meaning-making was used building on DeMarinis [36], and Ulland and DeMarinis [32]: existential meaning-making is lived experiences leading to a fundamental sense of belonging, significance, and meaning in everyday life as well as in relation to critical events and ultimate concerns as life and death.
As a qualitative study following a larger, quantitative study with this population [20], the present study's aim was to examine in-depth the interview material, exploring inter-and intrapersonal processes related to Emotion regulation and Existential meaning-making in young women with mental illhealth concerns. The central research question was: Are emotion regulation and existential meaning-making as lived experiences in everyday life, critical life-events, and ultimate concerns interrelated processes among young women with mental illhealth concerns, and if so, how?

Sample and data collection procedures
The sample representing young women with mental ill-health concerns was composed of ten voluntary female subjects (21-25 y, M=22.7) on the waiting list (n=34) for psychotherapy at a large metropolitan outpatient psychodynamic psychotherapy clinic for young adults in Sweden, with depression as the most common preliminary diagnosis, self-rated by the Symptom Checklist (SCL-90) [37,38] at intake. The present qualitative deep-interview study was the second part of a sequential mixed methods research design [39]. The first part, a quantitative study, was directed towards all women at the clinic, both women on the waiting list and in therapy (N=100), and comprised an on-line questionnaire aiming at measuring psychological-and existential vulnerabilities among clinical young women, by a quantitative comparison of depression-related subgroups. In total, 63 women logged on to the questionnaire. In all, 25 from the waiting list and 28 already in psychotherapy completed the questionnaire sufficiently to score all scales (n = 53, 17-30 years, M = 22.4 years; SD = 2.4) [20]. The present study included semi-structured deep-interviews with ten women from the waiting list, all of whom had answered the initial questionnaire sufficiently to score all scales, and in the questionnaire had said 'yes' to an in-depth interview, i.e. a convenience sample. The total sample (n=53) had an overall significant aberrant KSP T-profile, indicating mental ill-health and negative childhood experiences, and a High inhibition of aggression group even more so [20]. This subgrouping was linked to Perris' and colleagues' findings in repeated studies [40,41] that depressed patients differ from healthy volunteers in several stable personality traits, with high values especially on inhibition of aggression. The total KSP T-score values for the present study's group of ten were close to the main sample's High inhibition of aggression-group. For a comparison with the total sample (n=53) see Figure 1.

Measures
Demographics included information on background and lifestyle [35], and questions pertaining to existential meaning, including view on life and religious/spiritual belief [42,43].
Karolinska Scales of Personality (KSP) was used to measure personality traits. KSP is a self-report inventory constructed for research purposes [44,45]. It focuses on personality traits that are assumed to have a biological basis and to be related to vulnerability to psychopathology. The scales are constructed on a rational-theoretical basis rather than on empirical-statistical grounds. The inventory comprises 135 questions grouped into 15 scales (Figure 1). The scales have been demonstrated to have long-term stability [46].
The semi-structured qualitative deep-interview guide [20] was organized by questions pertaining to the empiricallygrounded Systems Model of Interaction [47][48][49], with three principal question areas for emotion regulation: There are various approaches to defining emotion regulation [24]. This present study used the Systems Model of Interaction, mentioned above, to delineate how experiences are organized internally and emotions regulated from infancy and onward. These three principles address the question, 'How do transformations come about?' [49]. Emotion regulation goes in the systems model principal areas on in two fields: Interactive regulation; and Self-regulation. For the present study, the subjects' own lived experiences and descriptions were analyzed in relation to these principal areas.
Using the working-definition of existential meaning-making for this present study where everyday existential questions and ultimate concerns interact, the interview questions explored lived experiences related to belonging, loneliness, the sacred (as a signifier of significance [32,50,51]), sense of meaning, and death.
To explicitly combine the salient emotion regulation principle heightened affective moments and sense of meaning the following questions were included [20]: Please, give an example of a strong emotional moment with another person/other people that felt deeply meaningful? (Interactive regulation); and Please, give an example of a strong emotional moment that felt deeply meaningful when you were by yourself? (Self-regulation).
Significant others were in the present study defined as persons the subjects referred to in relation to Ongoing regulation, and Disruption and repair in a life-trajectory perspective.

Data analyses
The analysis of the qualitative interviews was conducted in different steps by a theoretically-informed analysis for coding and categorizing the material [39,52], using the Atlas.ti 7 data program [53]. The interviews were taped and transcribed verbatim. Thereafter systematic analyses focusing on emotion regulation and existential meaning-making were done by:

Psychology and Behavioral Science International Journal
The condensation of meaning was done inductively in accordance with Giorgi's four steps to develop abstracted knowledge about the subjects lived experiences in the focused areas [52,54]. Similarities and differences between informants were examined, and the interviews were explored both vertically and horizontally through the material. The coding and condensation processes were checked by two of the authors, with high agreement.

Ethics
Ethical approval was obtained from the Regional Ethics Committee in Uppsala (Dnr 2012/219). The subjects could be referred to professional support if needed.

Results
The interviews being 3-4 hours each, provided very rich information. Only the main and sub-categories explicitly relevant for emotion regulation and existential meaning-making are presented here. Background factors are summarized from the questionnaire and the interviews.

Background Factors
Demographics All ten subjects were born in Sweden, and almost all of their parents. Six subjects were working, four were studying, and both subjects and parents were educated, with a high school, college or university degree. Only one woman still lived with the parents. Seven had a boyfriend, four lived with their boyfriend. None had children. Nine had siblings, six were the family's oldest child. Seven had experienced economic hardship sometime in life. They followed the Swedish belief profile, seven believed in something (spirit/life force/did not know), but no one considered religion important.

Psychotherapy issues and critical life events-a summary
The majority felt that they had performed over their limits, pushing aside their own feelings and needs, which recently had started to surface, and in some cases even lead to severe 'panic attacks'. All gave different examples of conflict, crisis, separation, bereavement, and abuse that had not been processed or mourned. Unsolved relational ruptures with family members were common, due to mental ill-health, neuropsychiatric diagnosis, addictions and/or violence among parents and/or siblings. The majority experienced losses and death, however no suicidal attempts. In therapy they wanted help with various things, like difficulties around parents/family, managing own anxiety, and negative feelings/thoughts. All had multiple and/or long-lasting strains. All were high achievers.

Emotion regulation
The results are presented in relation to the main emotion regulation principal categories:

1) Ongoing regulation
2) Disruption and repair, however 3) Heightened affective moments, is only presented in relation to a deeply felt sense of meaning (see Moments of significant meaning and Table 3).

Ongoing regulation, regulating emotions in everyday life
The subjects regulated emotions in different ways in everyday life. The following sub-categories in everyday life were found: Social engagement; Safe places; Physical/ordering activities; Intellectual/creative activities; and Intrapersonal activities (an overview of sub-categories and examples of condensed citations are presented in Table 1).

Social engagement
The majority consciously withhold disturbing feelings from family and friends, using different strategies such as shutting down, withdrawing, or distractions. The majority found recurring security and strength from friends and boyfriend. These relationships provided a 'reboot place', where one could be pampered, be yourself, and express emotions. Many described how they felt good about the helping others in need and how it gave them a meaning of life.

Safe places
Examples of safe places included the own home, a friends room, the family's summer cottage, the library, and the church. Here you can be yourself and have a sense of continuity in life. Some described how nature provides strength and space to think, make decisions and cry or scream, for others hot baths and riding the bus provided spaces for serenity and thinking.

Physical/ordering activities
Several of the women expressed how they took advantage of everyday small joys, like good food, a sunset, and how it strengthens them, giving life meaning and a sense of 'peace of mind'. Some collected things associated with childhood and/or special events, to always have something left if all relatives die or relations with parents were broken, and for marking that good things had happened in their life.

Intellectual/creative activities
The majority of the women strived to perform at a high level, even when not feeling well. They engaged in some form of pursuit that evoked emotions or expressed feelings, like reading, writing, listening to music, dancing, to be in an 'existential bubble' by yourself or together with others. They often switched between their different pursuits to express or let go of their feelings. The majority repeatedly used a particular book, TV-show or movie that expresses something emotionally important, to control anxiety. TV-shows and music were also used as companions, to not feel alone. The specific TV-shows were downloaded to the cellular phone, and always available. A common existential theme in these shows was a development from a misery or crisis situation to a life where the protagonist felt better and had found herself, focusing on internal development. They valued the opportunity to identify with a person in a similar situation and got a sense of the importance of belonging. Other existential themes included: death, what we do with our time, and the world's end.

Intrapersonal activities
The majority used fantasy and imagination to a high degree and in many different ways. Several identified with and fantasized about fictional characters and stories in books, films etc. They often also reported to be engaged in internal conversations with and/or fantasies about fictional characters, own imaginary fantasy figures, fictional characters, or real celebrities in an extended way, to release feelings and not feel lonely. Some daydreamed about a fulfilling future, were you get what you long for or never had. Daydreams about a joint home and life with the boyfriend, were common. Some used a safe inner imaginary place to calm themselves or fall asleep. Some savored good vivid memories. Some used suicidal fantasies, because it is soothing to just know that you can do it if you really want to. The majority reported having regular inner conversations with themselves, with significant others, with the deceased, and with those with whom they have unresolved emotional conflicts. Several described how they intrapersonally practice saying 'no' and setting boundaries. Some heard encouraging comments from related persons, however seldom from parents. Parents were usually not included in the internal dialogue, the inner conversations with others were usually about situations concerning the parents. Three used some degree of prayer or meditation to calm themselves, to feel safe, and gather strength. Two were sometimes worried that God was angry with them, because they were not sure in their faith.

Disruption and repair, regulating emotions in critical lifeevents
All gave examples of critical events that have not been resolved, processed or mourned, even if some gave example of solutions and support facing difficulties in life. The following sub-categories of critical events were found: conflicts, crisis, separations, deaths and abuse (according to sub-categories below and examples of condensed citations included in Table 2).

Abuse
During my upbringing adults and authorities failed when we as exposed children and youth's needed help and support to find a place to feel safe in It helps to learn about how the brain and conditioned behavior work when you have been sexually abused, and why you 'turn-on' sexually on what you have been exposed to

Conflicts
Several gave examples of conflicts with parents and siblings that never were resolved, instead changing of subject, silence, or built-up emotional discharge was common. Several had a hard time showing disappointment and speaking-up for themselves, personality traits connected with depression, which created problems in close relations. Some gave examples of how they could show anger, argue, and solve conflicts with their father or boyfriend. No one gave an example of such behavior with their mother. Several expressed a longing to feel understood even when you have a conflict, and to have the ability to share the experience with someone who recognizes what you feel and think.

Crises
All experienced different crisis, caused by emotional pressure, confusion, or insecurities around life-choices. Some had experiences of solving the crises on there own and/or with significant others or in counseling. Several experienced problems getting adequate help, due to the parent's neglect and/ or the subjects own fear of asking for help.

Separations
Several experienced longer separations from parents which had not been resolved or processed. Some had chosen to break contact with parents due to unsolved conflicts. Two experienced painful separations, from a boyfriend and an organized group.
One found it helpful to learn about unsafe ambivalent attachment to better understand her experiences.

Deaths
The majority had experienced death, by sudden deaths caused by suicides, sickness or age. In most cases they did not mourn together with parents or other family members. Several talked internally to those who died, to sort out the relation or just keep the contact alive. One women chosed actively to seize life and every day joys to cope with a parent's suicide.

Abuse
One had recurring experiences of adults and authorities who failed to provide a safe living context. It helped to learn about how the brain and conditioned behavior works when you have been sexually abused, and effects in sexual encounters.

Existential meaning-making
Existential Meaning-making categories are described in relation to the sub-categories: belonging, loneliness, death, the sacred and sense of meaning as Moments of significant meaning, Inter-and Intrapersonally respectively (an overview of sub categories and examples of condensed citations included in Table  3). A general observation, several reported that this interview was the first time they shared their feelings and thoughts about questions around existential concerns experienced in daily living (Table 3).

Belonging
The majority experienced alienation, to not belong to a particular group and/or not belong to the society at large. Some felt more alienated from the world when feeling down. Several felt they belonged in a family, to be in a safe and relaxed family context was also experienced as the most meaningful in life. Many expressed how close friends were important and these friendships might even be perceived as sacred. The closest friends were mostly young women in the same age-group, known since their teenage years. Several were part of a larger peer group that had been linked to their school and/or interest area. Having a country house to come back to provided a strong emotional connection, and to the relatives and friends there. One was part of a cultural-and religious community connected to the parent's birth country, which played an important role.

Loneliness
The sense of alienation was closely related to feeling lonely. The majority felt alone quite often, sometimes even when they were with others, and some were afraid of loneliness. Boyfriends often softened the feeling of loneliness.

Death
The majority thought of death often, in periods daily, and anxiety around death was severe. Some were most afraid of others dying, some had periods of suicidal urges. Due to fear and a feeling of helplessness in the face of the uncertainty about death, some tried to avoid thinking of death, and some wanted to find a meaning in death and an answer to what would happen after death. Several reported feelings of 'deadliness' that trigger a strong emotional response, like panic attacks, sever headache, and self-harming behavior. Fear of death was connected to fear of loneliness, in this lifetime or after death.

The sacred
What several of them considered sacred were closely related to what they considered to be meaningful in life, like friendship, sisterhood, a newborn baby. Several used a cross as jewelry and/or a significant symbol for friendship considered sacred or significant, without considering themselves Christians. Several wore rings or other jewelries that they had received as a gift from grandparents/parents, such things were important and loaded with meaning and used as power objects at special occasions. Symbolically charged acts, like a moment of belonging when eating together, birth of a baby, weddings, funerals, to make it better for coming generations, as well as coming home to a beautiful and symbolically-charged place provided a sense of sacredness. The sacred was considered as something 'irreplaceable and very important emotionally.'

Moments of significant meaning-interpersonal
The majority experienced moments of significant meaning generally together with close friends and/or boyfriend. These moments were experienced as safe, relaxed, happy, being alive, close, feeling understood, and having somebody to love, with which even hard feelings could be shared. Several mentioned that the relation to the first boyfriend was very meaningful because they for the first time felt really understood. To feel understood was experienced as very important. Some experienced moments Psychology and Behavioral Science International Journal of significant meaning related more specifically to love and a deep intimate connection with their boyfriend. Four gave examples of very strong moments of significant meaning in relation to losses and funerals, where they cried and shared feelings with parents and siblings in a new way. The sense of belonging to both the dead and the living was strong at those moments, and something to be comforted by, and the importance to get a chance to say goodbye in a personally significant way was underscored. For one a moment of significant meaning was attending church with a family when abroad, and experiencing a type of believing atmosphere and a sense of safety that she never experienced in Sweden. Other moments of significant meaning included: sharing with someone something that you created from within yourself, and making that person feel strongly about your art work, being invited to hold a newborn baby in a stranger's family when alone far away from home on Christmas Eve, and, being present at the birth of a new sibling.

Moments of significant meaning-intrapersonal
The majority gave example of intrapersonal moments of significant meaning when they in some way were in deep contact with themselves, their innermost feelings and thoughts about themselves and their lives. These experiences were either charged by a strong positive, like euphoria or self-gratitude, or a strong negative feeling, like panic or heavy cry. The moments were for some connected to life choices or life goals, a sense of faith in life and one's personal strength, agency, and mastery. Summed up as: 'short moments when you have faith and believe in things, so you don't totally give up'.

Emotion regulation and existential meaning-makingconsidered interrelations
The results show that emotion regulation and existential meaning-making appear to be highly related in this sample. Frequent experiences of losses and disruptions without repair seemed to have fueled existential issues like fear of death, loneliness, and alienation. Several had felt lonely throughout life, some more alienated and lonely when together with others. Losses and deaths were part of their lives in a very literal way. They often thought of death, and thoughts of death and human mortality triggered very strong emotional reactions, in some cases even panic attacks and self-harming behavior. To handle those emotional and existential strains, they seemed to use everything available in their relational-and cultural contexts to regulate emotions and make meaning, for example close friendships as safe 'Reboot places', a popular TV-show as a regular comfort, or a Christian cross, without being Christian, loaded with their own secular meaning. To a great extent their intrapersonal strategies, seized ideations and identifications from contemporary popular culture, engaging in elaborated fantasies around fictional characters who developed from situations of misery to happiness, mainly through internal changes. The intraspersonal strategies seemed to be somewhat helpful and comforting on an everyday basis. However, in conflicts, crises, separations, deaths and abuse situations they appeared to have few functional emotion regulation strategies to handle and work through disturbing thoughts and emotions together with significant others or by themselves. To a high degree they withheld disturbing emotions and withdrew into their 'bubble'. Signs of dysfunctional existential meaningmaking were specifically present as unresolved thoughts and feelings around death, loneliness, and alienation, adding to the vulnerability for mental-ill health. Sharing strong emotions with significant others in moments related to birth, death, and love, or sharing a common moment or work in a community lessened the sense of loneliness. Having a deep authentic contact with yourself, feeling your innermost feelings and/or a faith in life and yourself were associated with a deep sense of meaning, and being alive. The sacred was related to the perceived sense of meaning in life and considered as something 'irreplaceable and very important emotionally', like friendship, sisterhood, a newborn baby, weddings, and funerals. Despite the deficiencies in long-term strategies for emotion regulation and existential meaning-making they experienced and valued the moments of significant meaning. Even if just for short periods, they experienced a fundamental sense of belonging, significance, and meaning that for a brief time countered the fear of death, loneliness, and alienation.

Discussion
This study explored Emotion regulation and Existential meaning-making in young women with mental ill-health concerns. Results indicated that emotion regulation, and existential meaning-making were interrelated processes in this sample. For these young women, existential meaning-making was associated with the degree of function of their emotion regulation and perceived mental health. A dysfunction in any of the processes seemed to influence the other negatively, increasing the vulnerability for mental ill-health. The overall picture indicates that this sample experienced a crisis of meaning in terms of access to sufficient cultural knowledge or existential resources in intergenerational, emotionallynurturing relationships, as earlier enlightened by DeMarinis (2008). However, lived experiences of functional existential meaning-making, even if just as a short moment of significant meaning, inter-or intrapersonally, seemed to lessen the emotional pain activated by existential issues as fear of death, loneliness, and alienation. Death was a recurring theme in the present study's interview material. Adamson and colleagues (1996;1999;2007) found, as others, that suicidal thoughts generally were quite common among their non-clinical subjects, even if suicidal thoughts and attempts were more frequent among those with a negative and unstable self-concept. 'Death' as an existential question was also considered quite important Psychology and Behavioral Science International Journal in their sample. One of the most striking findings in the present study was the subjects' occupation with thoughts of death as an existential issue and fear of death, due to as it seemed unmourned and unprocessed losses, suicides and deaths. Some had periods of suicidal urges, and some used suicidal fantasies to regulate emotions, but they seemed less occupied by thoughts on committing suicide, than on thoughts and emotions related to fear of death, indicating impairments in both emotion regulation and existential meaning-making. Further, their tendency to internalize confirmed their KSP-profile and is in line with the increase in internalizing symptoms, anxiety and depression, among adolescent girls in Europe, as recently reported.

Implication for clinical practice
This mental ill-health related group showed signs of dysfunctional emotion regulation as well as existential meaning-making. Clinically, this points to the need to include and provide openings for experiences and their narratives related to emotional regulation and existential information in therapies with mental ill-health related females. Over time this information may possibly contribute to better identifying the problem areas. For identifying possible resources and new positive expectations, functional emotion regulation patterns, and a more functional sense of meaning in life is needed. The importance of addressing questions around existential concerns being experienced in daily living, is strengthened by the fact that several reported that this interview was the first time they shared their feelings and thoughts about those areas with someone else. They experienced as especially important the opportunity to talk about Moments of significant meaning. Loneliness aspects were found to be interrelated to death, and belonging aspects to the sacred and sense of meaning, so those areas and interconnections need to be explicitly addressed and worked with to lessen the vulnerability for mental ill-health in young adults.

Strengths and limitations of the study
Since this is a qualitative study, and the sample was small, generalizations are not possible. However, due to the lack of studies combining these topics, the difficulty for this subject group to talk about these issues, the growing concern for young women's mental ill-health, the results might, if cautiously interpreted, be of use especially in secular contexts for further research -and for clinical practice. The findings contribute new information on emotion regulation and existential meaning-making. One important area for further study is also the intrapersonal use of ideations and identifications from contemporary culture in relation to both personal emotion regulation and existential meaning-making strategies in daily living, and the consequences of such use.

Conclusion
Emotion regulation and existential meaning-making as lived experiences were interrelated in function for young females with psychological and existential vulnerability, and thus need to be addressed as two equally important domains in psychotherapy with this group, not least in the secular Swedish culture.