We conducted a cross-cultural survey using standardized questionnaires in online format (see below) via the specialized survey platform among psychotherapists from 12 European countries: Austria, Bulgaria, Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden and Switzerland. Data collection across all countries was conducted in parallel between June 2020 and June 2021, during the second and third waves of the COVID-19 pandemic. The online set of survey questionnaires was sent in each country to the professional psychotherapy associations of the different treatment modalities, which distributed them to their members.
Finally, 2915 psychotherapists from the 12 countries representing various psychotherapeutic modalities participated in this study. Eligibility criteria included certification (or being in the process of certification) in a particular psychotherapeutic modality and psychotherapeutic practice for at least 1 year. Participants completed the online versions of the questionnaires, which were preceded by detailed socio-demographic and professional questions, including items on the impact of the COVID-19 pandemic on their practice and on potential psychological distress associated with the pandemic. In each country, participation was anonymous and voluntary, and participants received no compensation for participating in the survey. Informed consent was obtained from all participants in this study. The study protocol was accepted by the ethics committee of the Faculty of Psychology of the University of Warsaw in Poland. Sociodemographic and work-related variables and COVID-19-related distress among psychotherapists in each country are presented in the supplementary tables. Finally, it is important to emphasize that this manuscript contains unique data, which have not been published in any other journal.
As can be seen in all the tables, the age distributions were generally similar in all countries (M = 45.5 years, min. 21 years – max. 82 years). Regarding the sex of the participants, female psychotherapists were overrepresented (83%) in all countries. A significant number of participants were also in some form of stable relationship (75%). In terms of education, most participants held degrees in psychology. However, Finnish and Swedish participants were almost evenly split between having a degree in psychology or a different degree such as social work, counseling or nursing. In all 12 countries, most psychotherapists worked with adult clients. Nevertheless, a significant number of Polish and Bulgarian psychotherapists have also worked with children. Having a private workplace was almost universal for therapists in all countries. Most psychotherapists in all countries had already undergone their own psychotherapy. Coaching was provided once a month to participants in most countries. However, Austrian psychotherapists used quarterly supervision, and most Spanish therapists did not use it at all. Results regarding treatment modalities vary by country. Cognitive-behavioral therapy seemed to be the most common therapeutic approach in Cyprus, Spain, Poland and Romania. Then, psychodynamic therapy was the dominant modality in Bulgaria, Norway and Sweden. Austria and Switzerland seemed to favor Gestalt therapy. Finally, integrative psychotherapy was the most common approach in the UK. On average, psychotherapists in Bulgaria, Cyprus, Finland, Poland, Romania and Serbia had between 6 and 11 years of experience in the profession. On the other hand, the psychotherapists who worked in Austria, Spain, Norway, Switzerland, Sweden and the United Kingdom had between 12 and 18 years of experience. In eight of the countries included (Austria, Cyprus, Finland, Spain, Norway, Romania, Switzerland and the United Kingdom), most psychotherapists reported having certification in psychology (80% or more). Figures seemed lower in Bulgaria, Poland, Serbia and Sweden, with only around 35-65% of psychotherapists obtaining a certificate. The psychotherapists worked between a few hours a week and more than 20 hours a week. Specifically, the average weekly workload in Bulgaria, Cyprus, Romania and Serbia was between 1 and 10 h. In Sweden and the United Kingdom, the average was between 10 and 20 ha per week. The psychotherapists who worked more than 20 hours per week came from Finland, Norway and Poland. Austrian, Spanish and Swiss psychotherapists were evenly distributed between the latter two workload categories. Finally, a general tendency to work partially online during the COVID-19 pandemic has been observed, which is the case for psychotherapists in 11 countries (Austria, Bulgaria, Cyprus, Finland, Spain, Norway, Poland, Romania, Serbia, Switzerland and Sweden). At the time of data collection, UK therapists still mainly provided their services online only.
To assess burnout, we used the Maslach Burnout Inventory-Human Service Survey (MBI-HS)6. The 12 language adaptations of the MBI-HS were purchased from Mind Garden, the official distributor of the MBI-HS. The MBI-HS consists of 22 items and assesses burnout and its three components: (1) Emotional Exhaustion (EE), nine items; (2) Personal Achievement (PA), eight items; and (3) Depersonalization (DP), five items. For each item, the respondent indicated the frequency of symptoms on a Likert-type scale ranging from 0 (never) to 6 (every day). ). All the answers added together form an overall index, with higher values indicating higher burnout. We decided to use the MBI-HS in our study for two reasons: first, it is the most popular and widely used burnout inventory, focusing particularly on helping professions, which which was the case in our research.7.38. Second, the MBI-HS is the only tool available for burnout assessment with a wide range of different language adaptations; as such it is valuable in cross-cultural studies38.
To measure cultural values, participants completed a revised version of the Portrait Values Questionnaire (PVQ-R) developed by Schwartz et al.24. The PVQ-R consists of 57 short, gender-matched verbal portraits of different people, each representing an important goal for a person. For each portrait, respondents rate the person’s resemblance to themselves on a 6-point Likert-type scale defined as follows: 1—not at all like me, 2—not like me, 3—somewhat like me, 4—moderately like me, 5—like me, and 6—very like me. Participants’ values are inferred from the values of other people they describe as similar to themselves. For example, a respondent who points out that a person described as “Enjoying the pleasures of life is important to her” is similar to herself and probably values hedonic values. The PVQ-R assesses 19 values that can be combined into higher-order values, which was the case in our study: self-transcendence (universalism-nature, universalism-concern, universalism-tolerance, benevolence-care and benevolence- addiction), self-enhancement (achievement, power domination and power resources), openness to change (self-directing thought, self-directing action, stimulation and hedonism), conservation (personal-safety, societal-safety , tradition, conformity-rules, and interpersonal conformity). All language versions of the PVQ-R were provided by the author of this tool, S. Schwartz.
COVID-19-related distress was assessed via a short but reliable operationalization of this variable based on other studies published at the time when we began our research.39.40. Namely, we asked participants on a 1-5 point Likert scale how stressful they found the situation in their role as a psychotherapist caused by the COVID-19 pandemic. Responses range from 1 (“not at all”) to 5 (“very much”). We also considered the issue of changes in psychotherapy settings (i.e., online setting) imposed by the pandemic situation.
The data obtained had a two-level structure with people (2915 units) nested in countries (12 units); thus, a cross-sectional multilevel model was adopted41. The dependent variable was the burnout level of psychotherapists, which was operationalized as an overall burnout indicator. The explanatory variables at Level 1 were the four higher-order values rated by each person (see Measures section), centered on their means (centered on the group mean). Level 2 variables were aggregates of the individual person’s scores on four higher-order values to form a national average of each value, which was then centered on the average of all countries at a given value (see, centered on the grand average). The maximum likelihood (ML) estimation method was used. For the random effects (the random intercept model), the covariance structure of the variance components (VC) was assumed.
Unconditional modeling (i.e. at the intersection only) was the first step in the analysis. It was also used to obtain the interclass correlation coefficient (ICC)42, which provides information on the proportion of variance in the level of burnout explained by a grouping variable, ie a country in which a participant is a psychotherapist. ICC values as low as 0.01 were treated as non-trivial43. Next, sociodemographic and work-related characteristics and COVID-19-related distress were added to the model. Continuous variables were centered on the group mean (e.g., age, work experience, and pandemic-related stress), while categorical variables were transformed into two dummy coded categories (gender: female = 0, male = 1; relationship status: single = 0, in stable relationship = 1; weekly workload: 0 = less than 20 h, 1 = 20 h and more; supervision: 0 = quarterly or less, 1 = once a month or more). In the following steps, only the variables judged to be significantly related to the explained variable were taken into account.44. In the third step, level 1 personal values were added, followed by the introduction of level 2 aggregates of these values for each country in the fourth step. Finally, interactions between levels of all values were tested45.46. For significant interactions between levels, simple slopes, significant regions and confidence bands were established using computational tools developed by Preacher et al.47. Statistical analysis was performed using IBM SPSS Statistics version 2748. Only the final hypothesis testing models are presented in the article.
For model comparison, the deviance statistics, based on χ2 distribution with the degrees of freedom equal to the difference in the number of estimated parameters in the nested models, and Akaike’s information criterion were used41.
All procedures performed in studies involving human participants complied with institutional and/or national research committee ethical standards and the 1964 Declaration of Helsinki and subsequent amendments or comparable ethical standards.